Hai-tao Jiangand Jing-yu Cao*

1Department of General Surgery, Ningbo No. 2 Hospital, Ningbo 315010, Zhejiang, China

2Department of Hepatobiliary Surgery, the Affiliated Hospital of Qingdao University, Qingdao, Shandong 266003, China

ORIGINAL ARTICLE

Impact of Laparoscopic Versus Open Hepatectomy on Perioperative Clinical Outcomes of Patients with Primary Hepatic Carcinoma

Hai-tao Jiang1and Jing-yu Cao2*

1Department of General Surgery, Ningbo No. 2 Hospital, Ningbo 315010, Zhejiang, China

2Department of Hepatobiliary Surgery, the Affiliated Hospital of Qingdao University, Qingdao, Shandong 266003, China

laparoscopy; laparotomy; primary hepatic carcinoma; perioperative outcomes

Objective To compare the perioperative outcomes of patients with primary hepatic carcinoma treated with laparoscopic hepatectomy (LH) with those treated with open hepatectomy (OH).

Methods From January 2010 to August 2014, 100 patients with primary hepatic carcinoma were randomly divided into the LH group and OH group respectively, 50 patients in each group. And the incision length, blood loss, operative time, postoperative liver function, anus exhaust time, complications, length of postoperative hospital stay, and cost measures were compared.

Results LH could achieve shorter incision length, less blood loss, more rapid recovery in liver function and gastrointestinal function, and shorter postoperative hospital stay length compared with OH for primary hepatic carcinoma patients (all p＜0.05). However, LH could not significantly shorten operative time, and reduce postoperative complications and hospitalization cost (all p＞0.05).

Conclusion Compared with OH, LH could improve perioperative outcomes of primary hepatic carcinoma patients.

Chin Med Sci J 2015; 30(2)： 80-83

LAPAROSCOPIC hepatectomy (LH), as an increasingly popular technique, has been proved to be safe and feasible for selective patients with primary hepatic carcinoma.1 It has been shown that compared with the conventional open hepatectomy (OH), patients undergoing LH had a less blood loss, fewer complications, shorter length of postoperative hospital stay, and a better subsequent quality of life.2, 3 The short-term outcome of patients who underwent LH is better than those who received OH.4 From January 2010 to August 2014, we performed LH for 50 patients with primary hepatic carcinoma, and compared their perioperative outcomes with those of 50 patients treated with OH.

PATIENTS AND METHODS

Patients

From January 2010 to August 2014, 100 patients diagnosed with primary hepatic carcinoma in the Affiliated Hospital of Qingdao University were randomly divided into two groups. The inclusive criteria were as follows: patients having a T1 stage primary hepatic carcinoma determined according to AJCC system; without major vascular invasion (portal vein,hepatic veins or inferior vena cava); with tumors involving two hepatic segments or fewer except the caudate lobe; with Child-Pugh’s classification A and B cirrhosis, whose model for end-stage liver disease (MELD) score less than 7.0 and postoperative remnant liver could meet physiological requirements of the patient’s body; without severe lesions in the heart, lung, brain, and kidney.

Of them, 50 patients were treated with LH (LH group), and other patients underwent OH (OH group). All patients did not receive other adjuvant therapies before operations. There were no statistical differences in preoperative baseline data between the two groups (all P＞0.05, Table 1).

Table 1. Preoperative clinical characteristics of primary hepatic carcinoma patients who undergoing LH or OH (n=50)

LH

After successful narcosis, the patients were placed in the supine position, whose position should be converted according to the operation needs. The first port (10 mm) placed on the navel was made by a trocar to gain access to the abdomen and establish pneumoperitoneum that was maintained at 12-14 mm Hg pressure (1 mm Hg=0.133 kPa). The main port was established by a 10-mm trocar under the left costal margin along the medioclavicular line or under the xiphoid. The auxiliary ports were established by 5-mm trocar under the left costal margin on the midaxillary line, under the right costal margin on the midaxillary line, or under the right costal margin on the collarbone midline, on the left midaxillary line or anterior axillary line crossing umbilical horizontal line according to the intraoperative situation. Intraoperative laparoscopic ultrasound was applied to confirm the number, size and location of nodules and guide the partial hepatectomy. The main vascular and biliary pedicles were anastomosed by a stapler (EndoGIA Covidien, CT, USA); smaller pedicles were closed by the use of haemoclip. Tumor and adjacent portion of the liver were cut completely.

OH

After successful narcosis, the patients were placed in the supine position. The right subcostal incision extended to the xiphoid process along the middle line was routinely used. The first porta hepatis was block if necessary. Intraoperative ultrasound was performed to guide liver resections. Regular hepatectomy was used to cut the liver along the lobe boundary, and partial irregular hepatectomy used to draw anatomical boundaries on the hepatic surface with an electric knife 1-2 cm from the tumor edge, then tumor was resected completely.

Short-term clinical outcomes

Parameters of clinical outcomes including incision length, blood loss, operative time, postoperative glutamic-pyruvic transaminase (ALT), glutamic oxalacetic transaminase (AST), total bilirubin (TBIL) levels, anus exhaust time, complications, length of postoperative hospital stay, and cost measures were reported .

Statistical analysis

Continuous variables were expressed as means±standard deviation and compared by using independent-samples t test. For category variables, comparisons were made by using Chi-square test or Fisher’s exact test. Statistical significance was defined as P＜0.05. All analyses were performed using SPSS 18.0.

RESULTS

The LH group had a shorter incision length (4.20±1.70 vs. 19.55±3.30 cm) and less blood loss (144.00±107.23 vs. 355.00±157.19 ml) than the OH group (all P＜0.05). There was no statistical differences in operative time between the two groups (LH: 120.90±34.03 minutes, OH: 130.70±35.66 minutes, P＞0.05).

Both postoperative anus exhaust time (1.50±0.61 vs. 2.40±0.50 days) and hospital stay length (6.00±1.45 vs. 8.75±2.15 days) of the LH group were significantly shorter than those of the OH group (all P＜0.05). ALT, AST and TBIL levels on the postoperative 1st, 3rd and 7th days in the LH group were much lower than those in the OH group (all P＜0.05, Table 2). Albumin levels on the postoperative 3th and 7th in the LH group were much higher than those in the OH group (all P＜0.05, Table 2). There were no statistical differences in postoperative complications (LH: 0, OH: 5 cases) and hospitalization cost (29 429.56±8562.35 vs. 32 859.86±5 002.97 ￥) between the two groups (all P＞0.05). Bile leakage occurred in 2 cases, pulmonary infection in 2 cases, and bleeding in 1 case with open surgery.

DISCUSSION

LH is a safe and feasible technique5-8to be applied worldwide. The surgical mortality of LH is about 0.3%, and occurrence of complication is about 10.3%.9

We observed the outcomes of LH for patients suffering from primary hepatic carcinoma in the perioperative period, which is the time period from about preoperative 5-7 days to postoperative 7-12 days. For this cohort, compared with OH group, LH could reduce operative blood loss, which was consistent with Dagher et al’s results.4Decreased blood loss might be attributed to full exposure of visual operative field that make surgery physician easy to operate; to the pressure maintained by pneumoperitoneum, which can reduce bleeding of small veins and blood flow of abdominal organs; to surgical instruments of LH that can effectively control bleeding of hepatic incision.

In conclusion, LH could improve short-term outcomes of patients with primary hepatic carcinoma.

Table 2. Comparison of postoperative hepatic function of the two groups§(n=50)

REFERENCES

1. Simillis C, Constantinides VA, Tekkis PP, et al. Laparoscopic versus open hepatic resections for benign and malignant neoplasms—a Meta analysis. Surgery 2007; 141:203-11.

2. Belli G, Fantini C, D’agostino A, et al. Laparoscopic versus open liver resection for hepatocellular carcinoma in patients with histologically proven cirrhosis: Short- and middle-term results. Surg Endosc 2007; 21:2004-11.

3. Kaneko H, Takagi S, Otsuka Y, et al. Laparoscopic liver resection of hepatocellular carcinoma. Am J Surg 2005; 189:190-4.

4. Dagher I, Di Giuro G, Dubrez J, et al. Laparoscopic versus open right hepatectomy: A comparative study. Am J Surg 2009; 198:173-7.

5. Dagher I, Belli G, Fantini C, et al. Laparoscopic hepatectomy for hepatocellular carcinoma: A European experience. J Am Coll Surg 2010; 211:16-23.

6. Tranchart H, Di Giuro G, Lainas P, et al. Laparoscopic resection for hepatocellular carcinoma: A matched-pair comparative study. Surg Endosc 2010; 24:1170-6.

7. Ito K, Ito H, Are C, et al. Laparoscopic versus open liver resection: A matched-pair case control study. J Gastrointest Surg 2009; 13:2276-8.

8. Nguyen KT, Marsh JW, Tsung A, et al. Comparative benefits of laparoscopic vs. open hepatic resection. Arch Surg 2011; 146:348-56.

9. Ishizawa T, Gumbs AA, Kokudo N, et al. Laparoscopic segmentectomy of the liver: From segmentIto Ⅷ. Ann Surg 2012; 256:959-64.

10. Zhang JH. Efficacy of laparoscopic and open hepatectomy on treatment of liver diseases. Chin Med Herald 2010; 7:30-2.

11. Liu TX, Fang DH, Guan BY, et al. Clinical evaluation of laparoscopic liver resection for liver tumor. Chin J Bases Clin Gen Surg 2012; 19:526-9.

12. Zhou YM, Xiao YQ, Wu LP, et al. Laparoscopic liver resection as a safe and efficacious alternative to open resection for colorectal liver metastasis: A Meta-analysis. BMC Surg 2013; 13:44.

13. Xi ZH. Advance of laparoscopic hepatectomy. Chin J New Clin Med 2008; 1:94-6.

14. Cherqui D, Laurent A, Tayar C, et al. Laparoscopic liver resection for peripheral hepatocellular carcinoma in patients with chronic liver disease: Midterm results and perspectives. Ann Surg 2006; 243:499-506.

for publication November 30, 2014.

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The patients who LH had better postoperative hepatic function, which indicated the degree of laparoscopic surgery-induced liver injury might be lower than that induced by OH. The short fasting time can accelerate the recovery of patient’s gastrointestinal function, so the LH group had a shorter postoperative anus exhaust time, which was consistent with Zhang’s report.10Because of the less intraoperative blood loss and the rapider recovery of hepatic and gastrointestinal function and incision healing, postoperative hospital stay of the LH group was less than that of OH group, which was consistent with Liu et al’s results.11,12No postoperative complications occurred in LH patients, which indicated LH did not increase the incidence of postoperative complications, such as bleeding, bile leakage, hypohepatia, lung infection and gas embolism, etc.13This study revealed that LH might excel OH in the short-term outcomes for patients with primary hepatic carcinoma, which was consistent with Cherqui et al’s reports.2,14