15018752330
发表时间:2015-11-03 浏览次数:461次
Introduction
Current literature reports significant efficacy of repeat hepatectomies in the treatment of recurrent malignant diseases (both primary and secondary) of the liver. The improved clinical outcomes after multidisciplinary treatment have led surgeons and oncologists to work on a new challenge - the management of recurrence. In hepatic surgery, the laparoscopic approach is becoming a widely accepted alternative to open approach especially for tumors located on anterior segments of the liver. Nevertheless, at the present, few studies have been done on repeat laparoscopic surgery of the liver because of some technical difficulties of repeated interventions, which is even more challenging if carried out by a minimally invasive approach.
We previously published data on laparoscopic re-interventions for hepatocellular carcinoma (HCC) in cirrhotic liver that described peri-operative outcomes, safety, and feasibility of this procedure. In this paper, our experience on repeat laparoscopic liver surgery for malignant primary and secondary diseases with a review of the literature is reported.
Methods
Patients and inclusion criteria
From January 2004 to
December 2013, 24 patients underwent a laparoscopic re-intervention (hepatic
resection and radiofrequency ablation [RFA]) for recurrent HCC in cirrhosis
(n = 17) and for recurrent metastases from colorectal carcinoma (n = 7) after a previous open or laparoscopic procedure. The primary surgical
interventions were 7 open and 18 laparoscopic procedures (a laparoscopic
segmentectomy was associated with a laparoscopic RFA in 1 patient). Details of
hepatic procedures are explained in A wedge resection (WR) was performed in
association with a laparoscopic left hemicolectomy in 1 case of synchronous
metastases; a left lateral sectionectomy with an open left hemicolectomy and a
cholecystectomy was performed for a similar case.
The inclusion criteria for the laparoscopic re-intervention were: A
well-compensated chronic liver disease (Child-Pugh Class A) without signs of
severe portal hypertension in cirrhotic patients, a performance status of
Karnosky ≥ 70, an American Society of Anesthesiology status ≤ 3, either a single
HCC (≤ 5 cm) or 1 or more metastases when located in the anterior hepatic
segments (segments II, III, IVb, V and VI), or a small (3 cm) deep HCC for
laparoscopic RFA in which major hepatectomy is not recommended. No tumor was
biopsied pre-operatively.
The patients were divided into two groups
according to the first surgical approach Group 1 underwent open resection (OR)
and laparoscopic procedure (7 patients), and Group 2 underwent laparoscopic
resection (LR) and laparoscopic procedure (17 patients). Results from the two
groups were compared in a retrospective study. Between the two groups, we
analyzed and compared operative time for re-intervention, blood loss, hospital
stay, post-operative morbidity, and mortality. Data were expressed as mean ±
standard deviation and represented in. Differences in means between the groups
were compared using Student's t-test. P < 0.05 was considered
statistically significant.
Surgical technique
The surgical technique for the repeat laparoscopic hepatic resection was
described elsewhere.In brief, continuous CO 2 pneumoperitoneum was
induced using access technique of open laparoscopy with the Hasson trocar. In
some cases, a safe access to the abdominal cavity was carried out by use of a
Visiport® (Covidien, Mansfield, MA, USA), opening the abdominal wall
layer by layer, after pneumoperitoneum was achieved with a Verres
needle.
During the exploratory laparoscopy, parietal and visceral
adhesions were dissected. Such adhesions had to be dissected carefully with the
use of specific surgical devices without causing any damage to the
gastrointestinal tract before obtaining surgical access to the liver. In this
phase, the pneumoperitoneum allowed adhesions to become strained to allow more
meticulous assessment and lysis of adherences. The Pringle maneuver was prepared
for all patients but was performed only in selected cases
(8/24).
Anatomical resections (segmentectomy, subsegmentctomy of IVb,
bisegmentectomy, and left lateral sectionectomy) were performed for treatment of
HCC, and WR was performed for liver metastases.
After an extensive
adhesiolysis has been performed, staging abdominal laparoscopy and laparoscopic
ultrasonography were carried out to confirm the extension of the lesions and
their relationships to the vasculature, to visualize their margins inside the
parenchyma, and to exclude a widespread peritoneal carcinosis that might hinder
the procedure. Laparoscopic transections were performed with a harmonic scalpel
(Harmonic Ace Shears® ; Ethicon, Endo-Surgery, Cincinnati, OH, USA)
or with a vessel sealer (Enseal Tissue Sealer® ; Ethicon,
Endo-Surgery, Cincinnati, OH, USA) or (Ligasure™; Covidien, Mansfield, MA, USA),
and was performed with reduced bleeding, due to a reduction of portal inflow of
up to 30% because of the pneumoperitoneum. The resection bed surfaces were
treated with a biologic fibrin glue (Tissucol; Baxter, Wien, Österreich), or a
hemostatic gel (Floseal; Baxter, Wien, Österreich), or a sealant patch
(TachoSil® ; Takeda, Linz, Österreich) to minimize risk of biliary
leak and to ensure hemostasis.
Bipolar electrocoagulation was used for
minor bleeding, and larger structures were secured with ties or either multiple
absorbable or nonabsorbable clips.
In order to facilitate the maneuver of
left lateral sectionectomy, the left hepatic vein was stapled, and the device
was introduced through the trocar located on the right of the patient, and then
angled toward the left.
Laparoscopic radiofrequency ablation
A three-trocar configuration was routinely used. A 12-mm port at the umbilicus
housed the 30° laparoscope. After an extensive adhesiolysis has been performed,
staging abdominal laparoscopy and laparoscopic ultrasonography were carried out
to identify the positions of the lesions.
As previously described, RFA
was carried out with multi-electrode 15-gauge radiofrequency probes (RITA
Medical Systems, Mountain View, CA, USA). Hook-shaped retractable electrodes
were deployed to a maximum diameter of 3 cm. After every electrode had reached a
temperature of 100 °C, the ablation was performed in a step-by-step fashion,
with a single step lasting approximately 8-10 min. In two patients with a deep
HCC, the size of the lesion was slightly larger than that recommended for a
standard RFA (35 and 33 mm, respectively). In these two cases, a Pringle
maneuver was carried out during laparoscopy causing vascular occlusion to reduce
blood flow and to increase the volume of the ablation.
After track
ablation, hemostasis of the liver surface was ensured by bipolar
electrocoagulation.
Results
Repeat laparoscopic hepatic procedures were performed in 24 patients: 6 were
treated by left lateral sectionectomy (1 associated with a WR), 4 by
segmentectomy, 4 by subsegmentectomy (1 had conversion to laparotomy), 1 by
bysegmentectomy associated with a WR, 4 by laparoscopic RFA of HCC, and 5 by WR.
Two patients were subjected to a third repeat procedure consisting of
laparoscopic WR of segment II and VI, respectively, for a second recurrence of
liver metastases.
The laparoscopic procedure was successfully completed
in 23 cases (95.9%). Adhesions were graded by the staff surgeons using the scale
presented in similar to that used in a multi-center study on adhesion
prevention. Grades 3 and 4 adhesions were present in 5 patients (71.4%) in Group
1 and 2 patients (11.7%) in the Group 2.
Of the 24 patients, one
underwent conversion to laparotomy in Group 1, not because of adhesions but due
to inadequate control of the resection margin for a HCC located in segment IV.
One patient, receiving a laparoscopic RFA of a HCC of 28 mm in VII segment after
primary intervention of segmentectomy associated with laparoscopic RFA, was
subjected to intestinal resection associated with ileostomy to treat peritonitis
from intestinal perforation that occurred during laparoscopic RFA.
The
mean operative time for re-intervention was significantly longer for Group 1
(220.14 ± 80.06 min) than for Group 2 (150 ± 56.18 min; P = 0.001),
whereas the mean blood loss was comparable in both groups: 297 ± 134 mL in Group
1 and 272.2 ± 120 mL in Group 2 (P > 0.05). The mean hospital stay was
6.4 ± 2.5 days in Group 1 and 5.2 ± 3 days in Group 2 (P > 0.05). The
resection margins were disease-free in all the patients.
The overall
post-operative morbidity and mortality rates were 29.1% (7/24) and 0%,
respectively. According to Dindo-Clavien classification, overall morbidity
varied between Grades I and IIIa. Morbidity rate was 29.4% in Group 1 and 28.5%
in Group 2. In Group 1, 2 patients had atelectasis treated by physical therapy
(Clavien's Grade II), 2 had pneumonia treated by antibiotics (Clavien's Grade
II) and 1 had bleeding from one trocar site treated by compression (Clavien's
Grade II). In Group 2, 1 patient presented post-operatively with moderate
ascites, 1 with atelectasis (Clavien's Grade I) and 1 presented with intestinal
perforation that occurred during a laparoscopic RFA, requiring a re-intervention
(Clavien's Grade IIIa).
Long-term outcomes in terms of hepatic recurrence
have not yet been evaluated.
Discussion
Recurrence rate for liver malignancy is estimated at 77-100% for HCC and 60% for metastasis from colorectal carcinoma. Nevertheless, current data report efficacy of repeat hepatectomies in the treatment of primary or secondary tumors of the liver. At present, studies on laparoscopic hepatic re-interventions are limited. Technical difficulties of both repeat hepatectomy and laparoscopic approach have slowed the spread of laparoscopic re-interventions on the liver. Few papers are available on this procedure, and investigations are biased due to the retrospective nature of these studies, and to the time differences between the series of open and laparoscopic interventions
Tsuchiya et al. reported a cohort of 14 patients affected by HCC,
who underwent laparoscopic repeat resection after a primary procedure
(laparoscopic hepatectomy, RFA, resection of extrahepatic metastasis, or
diagnostic assessment). They demonstrated that 2-year survival in patients with
intrahepatic recurrence (100%) is significantly higher than in those with the
extrahepatic recurrence (42.9%).
Indeed, the surgical strategy can be
changed, and survival can be impaired because of the presence of concomitant
peritoneal recurrence or because of extensive peritoneal adhesiolysis. Biopsies
of suspicious lesions are mandatory to identify carcinomatous foci in dense
adhesions to treat the extrahepatic recurrence if possible, or to abstain from a
surgical procedure.
Shafaee et al. analyzed the experience
of laparoscopic repeat liver resection of three institutions recruiting 76
patients (61 with liver metastasis, 3 with HCC, and 12 with benign lesions)
divided into two groups according to the first surgical approach. Peri-operative
outcomes (in terms of estimated blood loss and intra-operative transfusions)
were better in patients with previous LRs than in patient with previous ORs.
Furthermore, long-term outcomes in terms of hepatic recurrence and the need for
laparoscopic re-interventions were compared with those of open repeat resection
in other studies, and similar outcomes were observed.
Kanazawa et al. reported a series of 40 patients who underwent hepatic repeat
resection for HCC. Twenty patients were previously operated with the open
approach and 20 with the laparoscopic approach. Intra-operative blood loss and
the incidence of post-operative complications and consequently, post-operative
hospital stay were significantly lower in the laparoscopy group.
Shelat
et al. reported a series of 19 patients who underwent repeat
operated in whom peri-operative data of laparoscopic primary and repeated
hepatic resection were compared (outcomes from minor and major resections were
considered separately). Liver metastases were the most common indication for
repeat resections. The operative time and blood loss were both significantly
greater in laparoscopic repeat resection, whereas length of stay and
complications did not differ between the groups.
In previous papers that
reported our experience in repeat surgery for HCC in cirrhotic liver, we
highlighted that a minimally invasive approach applied during the first
hepatectomy determines minimal post-operative adhesions and faster and safer
adhesiolysis in terms of blood loss and risk of visceral injuries. These factors
highlight the advantages of the minimally invasive approach in the management of
oncological recurrence of selected cirrhotic or metastatic patients.
In
our study, patients with HCC on cirrhosis represent the most part of the cases.
This is because patients with multiple lesions in recurrent liver metastases are
less often selected for a multiple laparoscopic WR. The mean operative time for
re-intervention was significantly longer for the group with previous OR, whereas
the mean blood loss and the hospital stay were comparable in both groups. The
resection margins were disease-free in all the patients.
A good training
in laparoscopic adhesiolysis during minimally invasive incisional hernia repair
even in cirrhotic patients can accelerate the learning curve in the lysis of
hypervascularized adhesions, facilitated by laparoscopic pneumoperitoneum and
optical magnification.
The only case of severe complication in our study
was in a patient previously treated with a LR followed by a laparoscopic RFA for
a recurrent HCC. At the time of re-operation, he was affected by severe
thrombocytopenia. The need to perform a safe hemostasis by electrocoagulation on
the liver surface after extraction of the RFA probe from the hepatic parenchyma
induced us to perform a RFA with the laparoscopic approach. During laparoscopy,
the presence of a few thin adhesions (grade evaluated: 0-1) induced us to
consider the visceral damage not as a specific complication of adhesiolysis
per se, or of the re-operation, but a generic adverse event of
laparoscopy. Subsequently, we have restricted indications for the laparoscopic
approach of RFA that seems to increase morbidity of an otherwise safe
procedure.
In conclusion, this study suggests that repeat laparoscopic
surgery for recurrent hepatic malignant diseases in selected patients is a
feasible and safe procedure with good short-term outcomes, but further
prospective studies are needed to support these results.
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