| Objectives: Laparoscopic right hepatectomy(LRH)with an anterior approach for large hepatocellular carcinoma(HCC)is a complicated procedure.Hepatic transection plane is difficult to expose in this complex procedure,which may lead to massive bleeding and unplanned conversion.During our practice,we implemented a modified liver hanging maneuver(LHM),which is built through the tunnel on the right side of inferior vena cava with the assistance of the Goldfinger,to help the exposure of hepatic transection plane and increase the safety of LRH.We aim to introduce this technique in LRH for large HCC and evaluate its feasibility in complex LRH.Methods: From January 2012 to June 2018,39 consecutive patients with large HCC underwent LRH were enrolled in this study.The first 27 cases didn't apply the LHM(the LHM group)while the next following 12 cases applied this technique(the non-LHM group).LHM was built in laparoscopic approach with a direct view.A posterior hepatic tunnel was separated along the right side of inferior vena cava,and the Goldfinger pass through this tunnel and emerge from the back of right hepatic vein.With the assistance of the Goldfinger,the hanging tape can easily pass through the tunnel to build the hanging system.We compared the perioperative variables and the long-term survival outcomes.Results: Preoperative variables,such as gender,age,liver function,cirrhosis,are comparable in the two groups.The median tumor size is similar between the LHM group and the non-LHM group((12.0 vs.12.6 cm,P=0.54).Ten cases(83.3%)in the non-LHM group had a tumor size larger than 10 cm,while 20 cases(74.1%)in the LHM group(P=0.693).Operative time in the non-LHM group was significantly longer than that in the LHM group(415 vs.312 min,P<0.001).The total blood loss in the non-LHM group was larger than that in the LHM group(460 vs.200 ml,P<0.001),especially during the procedure of hepatic parenchymal transection(300 vs.100 ml,P<0.001),resulting in a higher intraoperative transfusion requirement(55.6% vs.16.7%,P<0.001).Two cases(7.4%)in the non-LHM group need to conversion due to massive blood loss from hepatic veins,while no patients in the LHM group(P=1.000).The total surgical complications rate is relative high in both groups but had no difference(75.0% vs.85.2%,P=0.654).The most common complication was pleural effusion,8 patients(66.7%)in the LHM group and 15 patients(77.8%)in the non-LHM group were detected with this complication,and 3 patients in each group required thoracentesis(25.0% vs.11.1%,P=0.348).Conclusion: The posterior hepatic tunnel could be easily built through the right side of the inferior vena cava in a laparoscopic approach.The Goldfinger could guide the establishment of the LHM system quickly by dragging the hanging tape pass through this tunnel.During the procedure of complicated LRH,LHM could reduce the blood loss,shorten the operative time,and decrease the requirement of intraoperative transfusion.Background: Intracorporeal and extracorporeal Pringle maneuver(PM)are both applied in laparoscopic hepatectomy(LH)to minimize blood loss.We have implemented a simplified intracorporeal PM and compared its safety and efficacy with extracorporeal PM in a large volume cohort of LH for hepatocellular carcinoma.Methods: Between January 2012 and June 2018,708 consecutive patients with hepatocellular carcinoma underwent LH in our center.Of these,457 patients underwent PM(the PM group),and 251 patients did not experience PM(the non-PM group).Among PM patients,166 were offered extracorporeal PM(the EPM group),and 291 patients were given a simplified intracorporeal PM(the IPM group).The safety and efficacy of this modified intracorporeal PM were evaluated by comparing the perioperative outcomes.Results: Compared with patients in the non-PM group,patients in the PM had larger tumor size(3.9 vs.4.5 cm,P<0.001),higher proportion of posterolateral tumor location(4.8% vs.32.4%,P<0.001)and non-anatomical resection(38.2% vs.87.5%,P<0.001).Patients in the EPM and IPM group underwent similar number of clamping session(1.9 vs.2.0,P=0.495)and clamping time(19.1 vs.19.9 min,P=0.295).Operative time and intraoperative blood loss were also comparable in the two subgroups.Conversion rate was higher in the EPM group than that in the IPM group but there was no significant statistical difference(10.8% vs.8.9%,P=0.513).Peak transaminase levels after LH in the PM group were higher than that in the non-PM group,but comparable between the EPM group and the IPM group.Conclusions: PM is most likely recommended among patients with large tumor size,posterolateral tumor location,and non-anatomical resection.Both the intracorporeal and extracorporeal PM are effective in hepatic inflow occlusion,but the simplified intracorporeal PM does not require an additional trocar or incision and shows no interference with the visual field and the manipulation of laparoscopic instruments.Objectives: Previous studies have shown that surgical complications of laparoscopic hepatectomy(LH)in patients with hepatocellular carcinoma(HCC)and portal hypertension are significantly reduced,but fewer studies have focused on the role of laparoscopic techniques in patients with Child grade B liver function.We retrospectively collected all the surgically resectabl patients with HCC and Child grade B liver function in our center for nearly six years.Using a propensity score matching(PSM)method,we compared the incidence of postoperative surgical complications and long-term survival in Child-B patients who had performed open and laparoscopic hepatectomy for HCC.Methods: From January 2012 to June 2018,a total of 186 patients with HCC were identified as preoperative Child grade B liver function.According to the surgical approaches,we divided them into the open group(n=145)and the laparoscopic group(n=41).We used a 1:1 PSM with a caliper value of 0.05 to accurately match these patients between the two groups,and analyzed the impact of laparoscopic technique on postoperative complications and long-term survival in patients with HCC and Child grade B liver function.Results: Before the PSM,there were significant differences of preoperative characteristics between the open group and the laparoscopic group,such as age(50.9 vs.55.2 years,P=0.020),white blood cell counts(5.1 vs.4.0×109/L,P=0.003),platelet count(116.9 vs.79.2 ×109/L,P < 0.001),portal hypertension(46.9% vs.73.2%,P = 0004),tumor size(8.1 vs.4.1 cm,P < 0.001),major vascular invasion(24.8% vs.0,P < 0.001)and central tumor location(58.6% vs.78.0%,P = 0.036).After a precise 1:1 PSM,32 patients in each group were included in the final analysis,and there was no significant difference in all variables between the two groups.Patients in the open group had more massive intraoperative blood loss(487 vs.302 ml,P=0.062),and the intraoperative blood transfusion requirement was also higher(43.7% vs.15.6%,P=0.029).The total surgical complication rate(96.9% vs.71.9%,P=0016)and the incidence of major complications(50.0% vs.15.6%,P=0.008)in the open group were also significantly higher than those in the laparoscopic group,mainly in the surgical site infection,pleural effusion,thoracentesis,and respiratory dysfunction.Before PSM,the long-term survival in the laparoscopic group was significantly better than that in the open group.After PSM,there was no significant difference in the disease-free survival and overall survival between the two groups.The 1-,3-,and 5-year disease-free survival rates were 71.0%,48.2%,and 29.2% in the open group,and 72.5%,58.9%,and 50.5% in the laparoscopic group,respectively(P=0.477).While the 1-,3-,and 5-year overall survival rates were 81.3%,68.5%,and 47.25% in the open group and 83.2%,65.2%,and 65.2% in the laparoscopic group,respectively(P=0.793).Conclusions: Compared with an open approach,LH can reduce the intraoperative blood loss and blood transfusion,decrease the incidence of postoperative surgical site infection and respiratory-related complications,and shorten the postoperative hospital stay.There was no significant difference in the disease-free survival and overall survival in the two groups.Therefore,LH can reduce postoperative complications in patients with HCC and Child grade B liver function,but does not impair long-term survival.Objectives: As laparoscopic techniques are gradually implemented to hepatobiliary surgery,more and more centers are attempting to perform laparoscopic hepatectomy(LH).LH is more technically demanding than an open approach,and intraoperative bleeding is challenging to control and massive blood loss often leads to conversion.At present,only a few studies have investigated the impact of conversion on perioperative and survival outcomes in patients with hepatocellular carcinoma(HCC).Methods: All patients diagnosed with HCC and underwent LH in our hospital from January 2012 to June 2018 were retrospectively reviewed.Using a a 1:3 propensity score matching(PSM)method,these patients experienced conversion during LH were compared with those who successfully completed the LH.Postoperative complications and long-term survival between the two groups were analyzed.In addition,we performed a 1:8 PSM between patients experienced conversion and patients performed traditional open hepatectomy(from January 2012 to December 2016)to further analyze the impact of conversion on long-term prognosis.Results: A total of 708 patients underwent LH during the study period,of which 60 cases experienced conversion(conversion rate 8.5%).Multivariate regression analysis showed that a history of upper abdominal surgery(HR 2.520,95% CI 1.107-6.451;P=0.028),central tumor location(HR 2.188,95% CI 1.198-3.997;P=0.011)and major hepatectomy(HR 2.421,95% CI 1.255-4.670;P=0.008)were independent risk factors of conversion.Intraoperative excessive blood loss and a worse exposure of hepatic transection plane were the main causes of conversion.After a 1:3 PSM,patients in the conversion group(n=52)had a significantly higher incidence of minor complications(Clavien-Dindo Grade I and II)than those who successfully underwent LH(n=156)(48.1% vs.28.6%,P < 0.001),but there was no significant difference between the incidence of major complications and the 30-day mortality.The 1-,3-,and 5-year disease-free survival rates in the laparoscopic and conversion groups were 77.0%,63.6%,46.4% and 82.7%,58.4%,58.4%,respectively(P=0.698),while the overall survival rates in the two groups were 92.1%,77.5%,65.3% and 95.0%,79.3%,63.4%,respectively(P=0.822).There was no significant difference between disease-free survival and overall survival.After a 1:8 PSM with 1506 patients in the open group,the 1-,3-,and 5-year disease-free survival rates were 64.2%,49.6%,45.1%,respectively,in the open group(n=464),and 75.7%,49.4%,49.4%,respectively,in the conversion group(n=58)(P=0.276).The 1-,3-and 5-year overall survival rates in the two groups were 81.5%,64.2%,56.8% and 92.1%,73.4%,60.5%,respectively(P=0.195),there was also no significant difference in long-term survival between the two groups after eliminating the influence of confounding factors.Conclusions: A history of upper abdominal surgery,central tumor location,and major hepatectomy are independent risk factors for conversion,and massive blood loss and unclear hepatic transection plane are the main reasons for conversion.Once a conversion occurred,the operative time,the intraoperative blood loss,the proportion of intraoperative blood transfusion,mild postoperative complications and postoperative hospital stay would increase.Compared with patients who completed LH or underwent open hepatectomy at the beginning,there was no significant difference in long-term survival,indicating that timely conversion did not impact the long-term survival of patients with HCC.Objectives: Laparoscopic hepatectomy(LH)has been widely implemented in the surgical treatment for hepatocellular carcinoma(HCC).We summarized 648 cases of LH in our center,especially complicated LH,such as LH for large HCC,central HCC,and major hepatectomy,to further explore the feasibility of laparoscopic techniques in the surgical treatment for patients with HCC.Methods: The clinical data of 648 patients undergoing LH for HCC from January 2012 to June 2018 were retrospectively reviewed(the laparoscopic group).We also examined a total of 1506 cases with HCC who performed open hepatectomy from January 2012 to December 2016(the open group).Using a propensity score matching(PSM)method,we performed a 1:1 PSM between the laparoscopic group and open group to investigate the feasibility of the laparoscopic techniques in the surgical treatment of HCC.In addition,we further compared the perioperative complications and long-term survival outcomes among patients who performed LH for large HCC,central HCC,and major hepatectomy by a 1:1 PSM method.Results: After a 1:1 PSM,630 cases in each group were included in the final analysis.Compared with patients in the open group,patients in the laparoscopic group had longer operative time(245 vs.219 min,P<0.001)and less intraoperative blood loss(215 vs.295 ml,P<0.001).The incidence of severe surgical complications was lower(9.0% vs.2.5%,P<0.001)and postoperative hospital stay was shorter(9.4 vs.14.3 days,P<0.001)in the laparoscopic group.The 1-,3-,and 5-year disease-free survival rates were higher in the laparoscopic group than that in the open group(76.8% vs.73.5%,62.7% vs.56.4%,53.6% vs.50.4%,P=0.040),but the 1-,3-,and 5-year overall survival rates were similar between the two groups(93.1% vs.88.1%,77.4% vs.75.6%,67.4% vs.67.1%,P=0.141).In each subgroup analysis,the operative time of LH was also longer,but the mass of intraoperative blood loss during laparoscopic complex hepatectomy was similar to open complex hepatectomy,but the frequency of Pringle maneuver in the laparoscopic group is higher,the number of clamping is more,and the average clamping time is longer.Subgroup survival analysis showed no significant difference in disease-free survival and overall survival for large HCC and central HCC between the two groups.However,the disease-free survival rate among patients who underwent laparoscopic major hepatectomy is superior to its open counterpart,while there was no significant difference in overall survival between subgroups.Conclusions: Compared with patients who underwent open hepatectomy,patients performed LH have a better liver function,smaller tumor size,and most tumors are located in the superficial position of the liver.When LH is performed on strictly selected patients,the operative time is longer,intraoperative blood loss is less,and severe postoperative complications are lower.The disease-free survival rate of patients undergoing LH was better than that of patients performing open hepatectomy,but there was no significant difference in overall survival.The operative time is longer,intraoperative blood loss is similar,and postoperative complications are lower in patients with large and central HCC who performed LH when compared with patients in the open groups.The disease-free and overall survival of patients undergoing laparoscopic complex hepatectomy were not poor than their open counterpart,suggesting that laparoscopic complex hepatectomy is safe and reliable for patients who are strictly selected. |
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