Background This study evaluated the cost-effectiveness of open, laparoscopic, and robotic liver resection. Methods A comprehensive literature review and Bayesian network meta-analysis were conducted. Surface under cumulative ranking area values, mean difference, odds ratio, and 95% credible intervals were calculated for all outcomes. Cluster analysis was performed to determine the most cost-effective clustering approach. Costs-morbidity, costs-mortality, and costs-efficacy were the primary outcomes assessed, with postoperative overall morbidity, mortality, and length of stay associated with total costs for open, laparoscopic, and robotic liver resection. Results Laparoscopic liver resection incurred the lowest total costs (laparoscopic liver resection versus open liver resection: mean difference −2,529.84, 95% credible intervals −4,192.69 to −884.83; laparoscopic liver resection versus robotic liver resection: mean difference −3,363.37, 95% credible intervals −5,629.24 to −1,119.38). Open liver resection had the lowest procedural costs but incurred the highest hospitalization costs compared to laparoscopic liver resection and robotic liver resection. Conversely, robotic liver resection had the highest total and procedural costs but the lowest hospitalization costs. Robotic liver resection and laparoscopic liver resection had a significantly reduced length of stay than open liver resection and showed less postoperative morbidity. Laparoscopic liver resection resulted in the lowest readmission and liver-specific complication rates. Laparoscopic liver resection and robotic liver resection demonstrated advantages in costs-morbidity efficiency. While robotic liver resection offered notable benefits in mortality and length of stay, these were balanced against its highest total costs, presenting a nuanced trade-off in the costs-mortality and costs-efficacy analyses. Conclusion Laparoscopic liver resection represents a more cost-effective option for hepatectomy with superior postoperative outcomes and shorter length of stay than open liver resection. Robotic liver resection, though costlier than laparoscopic liver resection, along with laparoscopic liver resection, consistently exceeds open liver resection in surgical performance. 

Comparative cost-effectiveness of open, laparoscopic, and robotic liver resection: A systematic review and network meta-analysis.

Hepatocellular carcinoma (HCC) is the sixth commonest malignancy worldwide, and the fourth-leading cause of cancer related death. Partial liver resection (LR) forms the mainstay of therapy for suitable patients with preserved liver function. In recent years, significant advances in surgical technology, refinement of operative techniques and improvements in peri-operative care have facilitated the widespread adoption of laparoscopic liver resection (LLR) with encouraging outcomes. Liver cirrhosis (LC) is present in up to 80% of patients with HCC, and adds a further dimension of complexity to LR. Cirrhotic patients have a propensity for greater intraoperative blood loss as well as increased postoperative complications such as refractory ascites and posthepatectomy liver failure. Tumor localization within the fibrotic parenchyma is challenging, giving rise to concerns about resection margin status. Patients are also at higher risk of developing metachronous lesions, which affects long-term survival. Presently, the exact role of LLR in HCC patients with underlying LC is not well-defined. Current evidence suggests that LLR offers a multitude of benefits in the short-term such as reduced blood loss and blood transfusion requirements and lower morbidity, when compared to open resection. Oncologic adequacy and long-term survival do not appear to be compromised. Special consideration must be given for LLR in patients with advanced cirrhosis, or those who require extensive major hepatectomies. We present here a brief review of the literature surrounding LLR for HCC on a background of LC.

Laparoscopic versus open resection of hepatocellular carcinoma in patients with cirrhosis.

Zusammenfassung Hintergrund Das hepatozelluläre Karzinom (HCC) ist das fünfthäufigste Tumorleiden weltweit. Da viele HCCs bereits zum Zeitpunkt der Erstdiagnose nicht resektabel sind, haben sich in den letzten Jahrzenten perkutane Tumorablationen als kurativer Therapieansatz für das sehr frühe (BCLC 0) und frühe (BCLC A) HCC etabliert. Ziel dieser Arbeit ist es, einen kompakten Überblick über die aktuell zur Anwendung kommenden perkutanen lokalablativen Verfahren zu geben, basierend auf den technischen Besonderheiten sowie der klinischen Relevanz unter Berücksichtigung der aktuellen Studienlage. Methode Die Literaturrecherche umfasste alle über MEDLINE und PubMed verfügbaren Originalarbeiten, Reviews und Metaanalysen zu den jeweiligen perkutanen Ablationsverfahren, hierbei wurde vor allem ein Fokus auf randomisiert kontrollierte Studien und Veröffentlichungen aus den letzten 10 Jahren gelegt. Ergebnisse und Schlussfolgerung Die Radiofrequenzablation (RFA) und Mikrowellenablation (MWA) sind etablierte Verfahren, welche aufgrund ihrer starken Evidenz in internationalen und nationalen Leitlinien bei der Behandlung von HCCs im Stadium BCLC 0 und A mit einem Diameter bis zu 3 cm der chirurgischen Resektion gleichgestellt sind. Für HCCs mit einem Diameter zwischen 3 und 5 cm wird in den aktuellen S3-Leitlinien eine Kombination aus transarterieller Chemoembolisation (TACE) und Thermoablation mittels RFA oder MWA empfohlen, da bei HCCs dieser Größe die Kombinationstherapie der alleinigen Thermoablation überlegen ist und mit der chirurgischen Resektion vergleichbare Ergebnisse bezüglich des Gesamtüberlebens zeigt. Alternative, deutlich seltener eingesetzte thermische Verfahren sind die Kryotherapie (KT) und die Laserablation (LA). Zu den nicht thermischen Verfahren zählen die irreversible Elektroporation (IRE), die interstitielle Brachytherapie (IBT) und als neuestes Verfahren die Elektrochemotherapie (ECT). Aufgrund der noch nicht ausreichenden Evidenz kommen diese bis dato allerdings nur in Einzelfällen und im Rahmen von Studien zum Einsatz. Die nicht thermischen Verfahren stellen jedoch eine sinnvolle Alternative für die Ablation von HCCs in Nachbarschaft zu großen Blutgefäßen und Gallengängen dar, da sie diese Strukturen im Gegensatz zu den thermischen Ablationsverfahren deutlich weniger schädigen. Durch Fortschritte in der Technik der jeweiligen Verfahren, zunehmend gute Evidenz sowie Weiterentwicklungen bei unterstützenden Techniken wie Navigationsgeräten und Fusionsbildgebung könnten die perkutanen Ablationsverfahren in den kommenden Jahren ihre Indikationsstellung zur Behandlung größerer und weiter fortgeschrittener HCCs erweitern. 

Aktueller Stand zu perkutanen lokalablativen Verfahren beim hepatozellulären Karzinom

Journal of Laparoendoscopic & Advanced Surgical TechniquesVol. 33, No. 4 Full ReportsCommentary:Short- and Long-Term Outcomes in Laparoscopic Versus Open Hepatectomy for Hepatocellular Carcinoma in Elderly Patients: A Systematic Review and Meta-Analysis by Jiang et al.Peter Z. Berger and Kfir Ben-DavidPeter Z. BergerDepartment of Surgery, Mount Sinai Medical Center, Comprehensive Cancer Center, Miami Beach, Florida, USA.Search for more papers by this author and Kfir Ben-DavidAddress correspondence to: Kfir Ben-David, MD, FACS, Department of Surgery, Mount Sinai Medical Center, Comprehensive Cancer Center, 4306 Alton Road, 2nd Floor, Miami Beach, FL 33140, USA E-mail Address: kfir.bendavid@msmc.comDepartment of Surgery, Mount Sinai Medical Center, Comprehensive Cancer Center, Miami Beach, Florida, USA.Search for more papers by this authorPublished Online:4 Apr 2023https://doi.org/10.1089/lap.2023.29045.kbdAboutSectionsView articleView Full TextPDF/EPUB Permissions & CitationsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail View article"Commentary:Short- and Long-Term Outcomes in Laparoscopic Versus Open Hepatectomy for Hepatocellular Carcinoma in Elderly Patients: A Systematic Review and Meta-Analysis by Jiang et al.." Journal of Laparoendoscopic & Advanced Surgical Techniques, 33(4), pp. 335–336FiguresReferencesRelatedDetails Volume 33Issue 4Apr 2023 InformationCopyright 2023, Mary Ann Liebert, Inc., publishersTo cite this article:Peter Z. Berger and Kfir Ben-David.Commentary:Short- and Long-Term Outcomes in Laparoscopic Versus Open Hepatectomy for Hepatocellular Carcinoma in Elderly Patients: A Systematic Review and Meta-Analysis by Jiang et al..Journal of Laparoendoscopic & Advanced Surgical Techniques.Apr 2023.335-336.http://doi.org/10.1089/lap.2023.29045.kbdPublished in Volume: 33 Issue 4: April 4, 2023Online Ahead of Print:March 1, 2023PDF download 

Commentary:Short- and Long-Term Outcomes in Laparoscopic Versus Open Hepatectomy for Hepatocellular Carcinoma in Elderly Patients: A Systematic Review and Meta-analysis by Jiang et al.

Liver resection and liver transplantation are the mainstay of treatment for patients with hepatocellular carcinoma. Patient comorbidities, tumor resectability, and perioperative morbidity and mortality risk, specifically of post-hepatectomy liver failure, are determining factors when deciding between liver resection and liver transplantation in patients who do not have an obvious contraindication to either treatment. Liver resection is preferred in patients without cirrhosis , and it may be a reasonable choice in patient with cirrhosis but preserved liver function and no portal hypertension if the size and function of the future liver remnant are appropriate, especially if organ availability is scarce. 

Resection Versus Transplant for Hepatocellular Carcinoma: How to Offer the Best Modality.

Background The short- and long-term prognoses are unclear following laparoscopic major hepatectomy (LMH) for hepatocellular carcinoma (HCC). We performed a meta-analysis to compare the surgical and oncological outcomes of LMH vs. open major hepatectomy (OMH) in patients with HCC. Methods All studies comparing LMH with OMH for HCC published until April 2019 were identified independently by searching PubMed, Embase, Web of Science, and the Cochrane Central Register of Controlled Trials. We analyzed data for surgical and oncological outcomes, namely, operative time, intraoperative blood loss, blood transfusion rate, postoperative morbidity, major complications, mortality, hospital stay, margin distance, negative margin rate, long-term overall survival, and corresponding disease-free survival (DFS). Results We included 13 studies involving 1,225 patients with HCC (LMH: 534 patients; OMH: 691 patients) in the meta-analysis. Regarding short-term outcomes, the pooled data showed that LMH was associated with longer operative time [weighted mean difference (WMD): 72.14 min; 95% confidence interval (CI): 43.07–101.21; P<0.00001], less blood loss (WMD: −102.32 mL; 95% CI: −150.99 to −53.64; P<0.0001), shorter hospital stay (WMD: −3.77 d; 95% CI: −4.95 to −2.60; P<0.00001), lower morbidity [risk difference (RD): −0.01; 95% CI: −0.16 to −0.06; P<0.00001], and lower major complication rates (RD: −0.08; 95% CI: −0.11 to −0.05; P<0.00001). However, the need for blood transfusion (RD: −0.01; 95% CI: −0.06 to 0.05; P=0.78), mortality (RD: −0.01; 95% CI: −0.02 to 0.01; P=0.57), margin distance (WMD: 0.05 mm; 95% CI: −0.1 to 0.19; P=0.52), and negative margin rate (RD: 0.01; 95% CI: −0.03 to 0.05; P=0.65) were significantly comparable between the two groups. Regarding long-term outcomes, there was no difference in 3-year DFS [hazard ratio (HR): 0.99; 95% CI: 0.72–1.37; P=0.95], 3-year overall survival (HR: 1.25; 95% CI: 0.70–2.21; P=0.45), 5-year DFS (HR: 0.94; 95% CI: 0.64–1.38; P=0.76), and 5-year overall survival (HR: 0.94; 95% CI: 0.45–1.99; P=0.88). Conclusions LMH can be performed as safely as OMH in select patients and provides improved short-term surgical outcomes without affecting long-term survival. However, confirming our results requires more evidence from high-quality and prospective randomized controlled trials.

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Surgical and oncological outcomes after laparoscopic vs. open major hepatectomy for hepatocellular carcinoma: a systematic review and meta-analysis

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Surgical and oncological outcomes after laparoscopic vs. open major hepatectomy for hepatocellular carcinoma: a systematic review and meta-analysis