Meta-Analysis
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World J Gastroenterol. Jul 7, 2014; 20(25): 8274-8281
Published online Jul 7, 2014. doi: 10.3748/wjg.v20.i25.8274
Laparoscopic vs open approach to resection of hepatocellular carcinoma in patients with known cirrhosis: Systematic review and meta-analysis
Ahmed Twaij, Philip H Pucher, Mikael H Sodergren, Tamara Gall, Ara Darzi, Long R Jiao
Ahmed Twaij, Philip H Pucher, Mikael H Sodergren, Ara Darzi, Department of Surgery and Cancer, QEQM Building, St Mary’s Hospital, Imperial College, London W2 1NY, United Kingdom
Tamara Gall, Long R Jiao, Department of Surgery, Hammersmith Hospital, Imperial College London, London SW7 2AZ, United Kingdom
Author contributions: Twaij A was involved with study design, data collection, data analysis, drafting of manuscript; Pucher PH contributed to study design, data collection, data analysis, drafting of manuscript; Sodergren MH performed study design, data analysis, and drafting of manuscript; Gall T, Darzi A and Jiao LR were involved with revision of the manuscript and final approval.
Correspondence to: Mikael H Sodergren, PhD, FRCS, Department of Surgery and Cancer, QEQM Building, St Mary’s Hospital, Imperial College, Praed Street, London W2 1NY, United Kingdom. m.sodergren@imperial.ac.uk
Telephone: +44-20-3312 6666 Fax: +44-20-33126309
Received: November 2, 2013
Revised: December 17, 2013
Accepted: March 19, 2014
Published online: July 7, 2014
Abstract

AIM: To review the currently available literature comparing laparoscopic to open resection of hepatocellular carcinoma (HCC) in patients with known liver cirrhosis.

METHODS: A literature search of MEDLINE, EMBASE, and Cochrane databases was conducted. The search terms used included (laparoscopic OR laparoscopy) AND (hepatic or liver) AND (surgery or resection) AND “hepatocellular carcinoma” AND (cirrhosis or cirrhotic). Furthermore, to widen the search, we also used the “related articles” section. Studies reporting a comparison of outcomes and methods of open vs laparoscopic hepatic resection for HCC in patients with liver cirrhosis were included. Meta-analysis of results was performed using a random effects model to compute relative risk (RR) and for dichotomous variables and standard mean differences (SMD) for continuous variables.

RESULTS: A total of 420 patients from 4 cohort studies were included in final analysis. Patients undergoing laparoscopic procedures had statistically less blood loss compared to the open cohort, SMD of -1.01 (95%CI: -1.23-0.79), P < 0.001, with a reduced risk of transfusion, RR = 0.19 (95%CI: 0.09-0.38), P < 0.001. A wider clearance at tumour resection margins was achieved following a laparoscopic approach, SMD of 0.34 (95%CI: 0.08-0.60), P = 0.011. No significant difference was noted between laparoscopic and open resection operative times, SMD of -0.15 (95%CI: 0.35-0.05), P = 0.142. The overall RR of suffering from postoperative morbidity is 0.25 in favour of the open surgery cohort (95%CI: 0.17-0.37), P < 0.001. Patients under-going laparoscopic surgery had significantly shorter length of stays in hospital compared to the open cohort, SMD of -0.53 (95%CI: -0.73 to -0.32), P < 0.001.

CONCLUSION: This review suggests that laparoscopic resection of hepatocellular carcinoma in patients with cirrhosis is safe and may provide improved patient outcomes when compared to the open technique.

Keywords: Laparoscopic, Hepatocellular carcinoma, Cirrhosis, Hepatic resection, Surgery, Hepatobiliary, Surgical oncology

Core tip: Laparoscopic surgery is now considered the gold standard for the majority of surgical procedures. Minimally invasive surgery in oncological cases has been shown to provide enhanced recovery and overall better outcomes compared to an open approach. Although slower to be implemented, laparoscopic hepatic surgery is now considered safe and, in many situations, better than an open technique. Cirrhotic livers have always been considered technically difficult to approach surgically. This review suggests that not only is laparoscopic surgery for patients with hepatocellular carcinoma and known known cirrhosis safe, it may have improved outcomes compared to the open technique.