Background: Laparoscopic liver resection demands expertise and a long learning curve. Resection of the posterosuperior segments is challenging, and there are no data on the learning curve. The aim of this study was to evaluate the learning curve for laparoscopic resection of the posterosuperior segments.Methods: A cumulative sum (CUSUM) analysis of the difficulty score for resection was undertaken using patient data from four specialized centres. Risk-adjusted CUSUM analysis of duration of operation, blood loss and conversions was performed, adjusting for the difficulty score of the procedures. A receiver operating characteristic (ROC) curve was used to identify the completion of the learning curve.Results: According to the CUSUM analysis of 464 patients, the learning curve showed an initial decrease in the difficulty score followed by an increase and, finally, stabilization. More patients with cirrhosis or previous surgery were operated in the latest phase of the learning curve. A smaller number of wedge resections and a larger number of anatomical resections were performed progressively. Dissection using a Cavitron ultrasonic surgical aspirator and the Pringle manoeuvre were used more frequently with time. Risk-adjusted CUSUM analysis showed a progressive decrease in operating time. Blood loss initially increased slightly, then stabilized and finally decreased over time. A similar trend was found for conversions. The learning curve was estimated to be 40 procedures for wedge and 65 for anatomical resections.Conclusion: The learning curve for laparoscopic liver resection of the posterosuperior segments consists of a stepwise process, during which accurate patient selection is key.
Background Many patients with bi-lobar liver tumours are not eligible for liver resection due to an insufficient future liver remnant (FLR). To reduce the risk of posthepatectomy liver failure and the primary cause of death, regenerative procedures intent to increase the FLR before surgery. The aim of this systematic review is to provide an overview of the available literature and outcomes on the effectiveness of simultaneous portal and hepatic vein embolization (PVE/HVE) versus portal vein embolization (PVE) alone. Methods A systematic literature search was conducted in PubMed, Web of Science, and Embase up to September 2022. The primary outcome was resectability and the secondary outcome was the FLR volume increase. Results Eight studies comparing PVE/HVE with PVE and six retrospective PVE/HVE case series were included. Pooled resectability within the comparative studies was 75 per cent in the PVE group (n = 252) versus 87 per cent in the PVE/HVE group (n = 166, OR 1.92 (95% c.i., 1.13–3.25)) favouring PVE/HVE (P = 0.015). After PVE, FLR hypertrophy between 12 per cent and 48 per cent (after a median of 21–30 days) was observed, whereas growth between 36 per cent and 67 per cent was reported after PVE/HVE (after a median of 17–31 days). In the comparative studies, 90-day primary cause of death was similar between groups (2.5 per cent after PVE versus 2.2 per cent after PVE/HVE), but a higher 90-day primary cause of death was reported in single-arm PVE/HVE cohort studies (6.9 per cent, 12 of 175 patients). Conclusion Based on moderate/weak evidence, PVE/HVE seems to increase resectability of bi-lobar liver tumours with a comparable safety profile. Additionally, PVE/HVE resulted in faster and more pronounced hypertrophy compared with PVE alone.
Introduction: Most surgical treatments will cause a temporary decline in Health-Related Quality of Life (HRQoL). Laparoscopic surgery has been shown to reduce this decline. Evidence on HRQoL after laparoscopic liver resection (LLR) is however limited. The aim of this study was to compare HRQoL after open versus laparoscopic liver resection. Methods: This was a predefined sub-study of the OSLO-COMET trial (ClinicalTrials.gov NCT01516710). A total of 280 patients with colorectal liver metastases (CLM) were randomly assigned to open liver resection (OLR) (n=147) or LLR (n=133). HRQoL was assessed with the Short Form 36 (SF-36) at baseline, 1 month and 4 months after surgery. Results: A total of 272 patients underwent open (n=143) and laparoscopic (n=129) surgery. A total of 264 patients completed at least 2 questionnaires, and 671 (82%) questionnaires were available for analysis. The decline in HRQoL was compared between the groups. The decline from baseline was significantly smaller after LLR for Bodily Pain (p=0.001), Role Physical (p=0.003), Vitality (p=0.023) and Social Functioning (p=0.026) 1 month after surgery, and for Role Physical (p=0.019) at 4 months after surgery. The time from operation to initiation of adjuvant chemotherapy did not differ between the groups (46 vs 43 days, p=0.39), and the median number of courses given was 8 in both groups. Conclusion: Our results indicate that postoperative HRQoL is better after LLR compared to OLR. This difference lasts for up to four months. There was no difference in time to chemotherapy or number of courses given.
Within volume categories, 90-day mortality did not change over time. Conditional survival adjusted for confounding factors was significantly increased in the 40+ category compared to hospital volumes <5 and 5e19 procedures per year: HR 1.54 (95%CI 1.24e1.90) and HR 1.33 (1.15e 1.55). With increasing hospital volume, median survival was 19, 18, 21 and 26 months. Overall survival was significantly worse in all individual volume categories compared to the 40+ volume category: HR 1.65 (95%CI 1.35e2.01), HR 1.39 (1.21e1.60) and HR 1.19 (1.04e 1.37), respectively. Conclusions: In a nation-wide registry, improved postoperative mortality and long-term survival were found to extend beyond previously studied volume categories. To validate these findings future studies including more extensive case-mix correction are required.Aims: Despite the lack of randomized controlled trials, laparoscopic liver resections are performed in specialized centres all over the world. In this predefined sub study of the randomized «Oslo CoMet study», we examined patients' health related quality of life (HRQoL) after open and laparoscopic liver resection for colorectal metastases. Methods: From February 2012 to March 2014, 128 patients were randomly assigned to either open liver resection (OLR, n = 68) or laparoscopic liver resection (LLR, n = 60)). All the patients had parenchyma-sparing resection of one or more colorectal liver metastases. To assess patients' HRQoL, patients filled in the SF-36 questionnaire at baseline, at 1 month and 4 months after surgery. The Physical Component Summary (PCS) of the SF-36 is a validated measure of postoperative recovery after surgery. In total 330 forms from 122 patients were available for statistical analysis. The differences between means for OLR group and LLR group were estimated with linear mixed model analysis. The models included measurements from all time points and an adjustment for the use of adjuvant chemotherapy. Results: The groups were similar at baseline. In the laparoscopic group, the mean Physical Component SummaryPCS) changed from 47.4 [95% CI, 44.7e50.2] at baseline to 44.3 [95% CI, 41.5e47.2] at one month and 47.5 [95% CI, 45.1e49.8] at four months. In the open group the PCS changed from 48.5 [95% CI, 45.9e51.2] to 41.7 [95% CI, 38.9e44.5] at one month and 45.4 [95% CI, 43.1e47.6] at four months. The between groups difference (LLR to OLR) was 3.7 [95% CI, 7.1e0.35, p = 0.03] at one month, and 3.12 [95% CI, 6.4e0.05, p = 0.046] at four months. Conclusions: In this randomized study, patients operated with laparoscopic liver resection reported better postoperative HRQoL than patients operated with open liver resection. The difference was statistically significant at both one month and four months after surgery.
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