Conversion of Minimally Invasive Liver Resection for HCC in Advanced Cirrhosis: Clinical Impact and Role of Difficulty Scoring Systems

Abstract

Background: Minimally invasive liver resections (MILRs) in cirrhosis are at risk of conversion since cirrhosis and complexity, which can be estimated by scoring systems, are both independent factors for. We aimed to investigate the consequence of conversion of MILR for hepatocellular carcinoma in advanced cirrhosis. Methods: After retrospective review, MILRs for HCC were divided into preserved liver function (Cohort-A) and advanced cirrhosis cohorts (Cohort-B). Completed and converted MILRs were compared (Compl-A vs. Conv-A and Compl-B vs. Conv-B); then, converted patients were compared (Conv-A vs. Conv-B) as whole cohorts and after stratification for MILR difficulty using Iwate criteria. Results: 637 MILRs were studied (474 Cohort-A, 163 Cohort-B). Conv-A MILRs had worse outcomes than Compl-A: more blood loss; higher incidence of transfusions, morbidity, grade 2 complications, ascites, liver failure and longer hospitalization. Conv-B MILRs exhibited the same worse perioperative outcomes than Compl-B and also higher incidence of grade 1 complications. Conv-A and Conv-B outcomes of low difficulty MILRs resulted in similar perioperative outcomes, whereas the comparison of more difficult converted MILRs (intermediate/advanced/expert) resulted in several worse perioperative outcomes for patients with advanced cirrhosis. However, Conv-A and Conv-B outcomes were not significantly different in the whole cohort where “advanced/expert” MILRs were 33.1% and 5.5% in Cohort A and B. Conclusions: Conversion in the setting of advanced cirrhosis can be associated with non-inferior outcomes compared to compensated cirrhosis, provided careful patient selection is applied (patients elected to low difficulty MILRs). Difficulty scoring systems may help in identifying the most appropriate candidates.

Robo-Lap Approach Optimizes Intraoperative Outcomes in Robotic Left and Right Hepatectomy

“…In fact, conversion represents the epiphenomenon of an intraoperative complication that cannot be managed by minimally invasive methods; [21][22][23] however, most intraoperative events do not compromise the minimally invasive feasibility of the operation and in this perspective the analysis of intraoperative complications according to Satava has great clinical significance. In the Robo-Lap approach, in fact, a significantly lower incidence of minor complications is recorded, which are not the cause of conversion, but which influence intraoperative management.…”

Feasibility and oncologic efficacy of robotic vs. open liver resection for large and huge hepatocellular carcinoma

“…The inclusion of converted patients could have attenuated (possibly) the advantage of RLR, and conversely, their exclusion could have contributed to the very good results of RLR. Furthermore, conversion could be an important prognostic factor in HCC patients with cirrhosis 3 . We would kindly ask the authors to comment on this.…”