Abstract
Background
Minimally invasive liver resections (MILR) offer potential benefits such as reduced blood loss and morbidity compared with open liver resections. Several studies have suggested that the impact of cirrhosis differs according to the extent and complexity of resection. Our aim was to investigate the impact of cirrhosis on the difficulty and outcomes of MILR, focusing on major hepatectomies.
Methods
A total of 2534 patients undergoing minimally invasive major hepatectomies (MIMH) for primary malignancies across 58 centers worldwide were retrospectively reviewed. Propensity score (PSM) and coarsened exact matching (CEM) were used to compare patients with and without cirrhosis.
Results
A total of 1353 patients (53%) had no cirrhosis, 1065 (42%) had Child-Pugh A and 116 (4%) had Child-Pugh B cirrhosis. Matched comparison between non-cirrhotics vs Child-Pugh A cirrhosis demonstrated comparable blood loss. However, after PSM, postoperative morbidity and length of hospitalization was significantly greater in Child-Pugh A cirrhosis, but these were not statistically significant with CEM. Comparison between Child-Pugh A and Child-Pugh B cirrhosis demonstrated the latter had significantly higher transfusion rates and longer hospitalization after PSM, but not after CEM. Comparison of patients with cirrhosis of all grades with and without portal hypertension demonstrated no significant difference in all major perioperative outcomes after PSM and CEM.
Conclusions
The presence and severity of cirrhosis affected the difficulty and impacted the outcomes of MIMH, resulting in higher blood transfusion rates, increased postoperative morbidity, and longer hospitalization in patients with more advanced cirrhosis. As such, future difficulty scoring systems for MIMH should incorporate liver cirrhosis and its severity as variables.
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Acknowledgements
The Collaborators list of International Robotic and Laparoscopic Liver Resection Study Group Investigators is Nicholas L. Syn (Yong Loo Lin School of Medicine, National University of Singapore); Mikel Prieto (Hepatobiliary Surgery and Liver Transplantation Unit, Biocruces Bizkaia Health Research Institute, Cruces University Hospital, University of the Basque Country, Bilbao, Spain); Celine De Meyere (Department of Digestive and Hepatobiliary/Pancreatic Surgery, Groeninge Hospital, Kortrijk, Belgium); Juul Meurs (Department of Digestive and Hepatobiliary/Pancreatic Surgery, Groeninge Hospital, Kortrijk, Belgium); Kelvin K. Ng (Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, New Territories, Hong Kong SAR, China); Kit-Fai Lee (Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, New Territories, Hong Kong SAR, China); Diana Salimgereeva (Department of Hepato-Pancreato-Biliary Surgery, Moscow Clinical Scientific Center, Moscow, Russia); Ruslan Alikhanov (Department of Hepato-Pancreato-Biliary Surgery, Moscow Clinical Scientific Center, Moscow, Russia); Nita Thiruchelvam (Hepatopancreatobiliary Unit, Department of Surgery, Changi General Hospital, Singapore); Jae Young Jang (Department of General Surgery, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea); Masayuki Kojima (Department of Surgery, Fujita Health University School of Medicine, Aichi, Japan); Jaime Arthur Pirola Kruger (Liver Surgery Unit, Department of Gastroenterology, University of Sao Paulo School of Medicine, Sao Paulo, Brazil); Victor Lopez-Lopez (Department of General, Visceral and Transplantation Surgery, Clinic and University Hospital Virgen de la Arrixaca, IMIB-ARRIXACA, El Palmar, Murcia, Spain); Margarida Casellas I Robert (Hepatobiliary and Pancreatic Surgery Unit, Department of Surgery, Dr. Josep Trueta Hospital, IdIBGi, Girona, Spain); Roberto Montalti (Department of Clinical Medicine and Surgery, Division of HPB, Minimally Invasive and Robotic Surgery, Federico II University Hospital Naples, Naples, Italy); Mariano Giglio (Department of Clinical Medicine and Surgery, Division of HPB, Minimally Invasive and Robotic Surgery, Federico II University Hospital Naples, Naples, Italy); Boram Lee (Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seoul, Korea); Mizelle D’Silva (Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seoul, Korea); Hao-Ping Wang (Department of Surgery, Chang Gung Memorial Hospital, Kaohsiung); Franco Pascual (Department of Hepatobiliary Surgery, Assistance Publique Hopitaux de Paris, Centre Hepato-Biliaire, Paul-Brousse Hospital, Villejuif, France); Mansour Saleh (Department of Hepatobiliary Surgery, Assistance Publique Hopitaux de Paris, Centre Hepato-Biliaire, Paul-Brousse Hospital, Villejuif, France); Shian Yu (Department of Hepatobiliary Surgery, Affiliated Jinhua Hospital, Zhejiang University School of Medicine, Jinhua, China); Zewei Chen (Department of Hepatobiliary Surgery, Affiliated Jinhua Hospital, Zhejiang University School of Medicine, Jinhua, China); Simone Vani (Hepatobiliary Surgery Unit, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Catholic University of the Sacred Heart, Rome, Italy); Francesco Ardito (Hepatobiliary Surgery Unit, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Catholic University of the Sacred Heart, Rome, Italy); Ugo Giustizieri (HPB Surgery, Hepatology and Liver Transplantation, Fondazione IRCCS Istituto Nazionale Tumori di Milano, Milan, Italy); Davide Citterio (HPB Surgery, Hepatology and Liver Transplantation, Fondazione IRCCS Istituto Nazionale Tumori di Milano, Milan, Italy); Federico Mocchegiani (HPB Surgery and Transplantation Unit, United Hospital of Ancona, Department of Experimental and Clinical Medicine Polytechnic University of Marche); Marco Colasanti (Division of General Surgery and Liver Transplantation, S. Camillo Forlanini Hospital, Rome, Italy); Giammauro Berardi (Division of General Surgery and Liver Transplantation, S. Camillo Forlanini Hospital, Rome, Italy); Yoelimar Guzmán (General & Digestive Surgery, Hospital Clínic, Barcelona, Spain); Kevin P. Labadie (Department of Surgery, University of Washington Medical Center. Seattle, USA); Maria Conticchio (Unit of Hepato-Pancreatc-Biliary Surgery, “F. Miulli” General Regional Hospital, Acquaviva delle Fonti, Bari, Italy); Epameinondas Dogeas (Department of Surgery, Division of Hepatobiliary and Pancreatic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA); Emanuele F. Kauffmann (Division of General and Transplant Surgery, University of Pisa, Pisa, Italy); Mario Giuffrida (Hepatobiliary Surgery Unit, Department of Medicine and Surgery, University of Parma, Parma, Italy); Daniele Sommacale (Department of Digestive and Hepatobiliary and Pancreatic Surgery, AP-HP, Henri-Mondor Hospital, Creteil, France); Alexis Laurent (Department of Digestive and Hepatobiliary and Pancreatic Surgery, AP-HP, Henri-Mondor Hospital, Creteil, France); Paolo Magistri (HPB Surgery and Liver Transplant Unit, University of Modena and Reggio Emilia, Modena, Italy); Kohei Mishima (Center for Advanced Treatment of Hepatobiliary and Pancreatic Diseases, Ageo Central General Hospital, Saitama, Japan); Moritz Schmelzle (Department of Surgery, Campus Charité Mitte and Campus Virchow-Klinikum, Charité-Universitätsmedizin, Corporate Member of Freie Universität Berlin, and Berlin Institute of Health, Berlin, Germany); Felix Krenzien (Department of Surgery, Campus Charité Mitte and Campus Virchow-Klinikum, Charité-Universitätsmedizin, Corporate Member of Freie Universität Berlin, and Berlin Institute of Health, Berlin, Germany); Prashant Kadam (Department of Hepatopancreatobiliary and Liver Transplant Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom); Chung-Ngai Tang (Department of Surgery, Pamela Youde Nethersole Eastern Hospital, Hong Kong SAR, China); Jacob Ghotbi (The Intervention Centre and Department of HPB Surgery, Oslo University Hospital, Institute of Clinical Medicine, University of Oslo, Oslo, Norway); Åsmund Avdem Fretland (The Intervention Centre and Department of HPB Surgery, Oslo University Hospital, Institute of Clinical Medicine, University of Oslo, Oslo, Norway); Fabio Forchino (Department of General and Oncological Surgery. Mauriziano Hospital, Turin, Italy); Bernardo Dalla Valle (General and Hepatobiliary Surgery, Department of Surgery, Dentistry, Gynecology and Pediatrics University of Verona, GB Rossi Hospital, Verona, Italy); Junhao Zheng (Department of General Surgery, Sir Run-Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China); Alessandro Mazzotta (Department of Digestive, Oncologic and Metabolic Surgery, Institute Mutualiste Montsouris, Universite Paris Descartes, Paris, France); Phan Phuoc Nghia (Department of Hepatopancreatobiliary Surgery, University Medical Center, University of Medicine and Pharmacy, Ho Chi Minh City, Vietnam); Francois Cauchy (Department of HPB Surgery and Liver Transplantation, Beaujon Hospital, Clichy, France)
Funding
Dr T. P. Kingham was partially supported by the US National Cancer Institute MSKCC Core Grant number P30 CA008747 for this study. Dr M. Yin was partially funded by the Research Project of Zhejiang Provincial Public Welfare Fund project in the Field of Social development (LGF20H160028). Dr Brian Goh was partially supported by the Intuitive Foundation Grant for this study. Any research findings, conclusions, or recommendations expressed in this work are those of the authors and not of the Intuitive Foundation.
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We confirm that all the authors are accountable for all aspects of the work. Dr Goh BK has received travel grants and honorarium from Johnson and Johnson, Olympus and Transmedic, the local distributor for the Da Vinci Robot. Dr Marino MV is a consultant for CAVA robotics LLC. Johann Pratschke reports a research grant from Intuitive Surgical Deutschland GmbH and personal fees or non-financial support from Johnson & Johnson, Medtronic, AFS Medical, Astellas, CHG Meridian, Chiesi, Falk Foundation, La Fource Group, Merck, Neovii, NOGGO, pharma-consult Peterson, and Promedicis. Moritz Schmelzle reports personal fees or other support outside of the submitted work from Merck, Bayer, ERBE, Amgen, Johnson & Johnson, Takeda, Olympus, Medtronic, and Intuitive. Asmund Fretland reports receiving speaker fees from Bayer. Fernando Rotellar reports speaker fees and support outside the submitted work from Integra, Medtronic, Olympus, Corza, Sirtex and Johnson & Johnson. Troisi R. I. reports speaker fees and support outside the submitted work from Integra, Stryker, Medtronic, Medistim, and MSD. Prof. Constantino Fondevila declares relevant financial activities with Guandong Shunde Innovative Design Institute.
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Cipriani, F., Aldrighetti, L., Ratti, F. et al. Impact of Liver Cirrhosis, Severity of Cirrhosis, and Portal Hypertension on the Difficulty and Outcomes of Laparoscopic and Robotic Major Liver Resections for Primary Liver Malignancies. Ann Surg Oncol 31, 97–114 (2024). https://doi.org/10.1245/s10434-023-14376-5
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DOI: https://doi.org/10.1245/s10434-023-14376-5