988 Letters to the Editors
the conclusion that PVR should be recommended routinely. Some authors even stated that “the “no-touch technique” introduced by Neuhaus et al. was never used, because it lacks scientific validation.”14 The Berlin authors criticized our complication rate. Interestingly, in the articles by Neuhaus et al, there is no mention of the complication rate, according to ClavienDindo.6,8,15-19 The authors, however, reported a considerable hospital mortality rate of 17% after PVR.6 It would be very interesting to learn about the complication rate, particularly if the reported mortality is within such a high range. The Berlin authors mentioned that Heidelberg has a low case load in advanced liver surgery. In the Neuhaus paper, however, the authors reported on 14 patients who underwent right trisectionectomy and PVR during a 10year observation period (1988–1998).6 This accounts for 1.4 patients per year and represents a very low case load. Furthermore, when referring to the case load, detailed information about the real rate of patients with HCA would be interesting to have, since it cannot be obtained from overlapping patient cohorts of the Berlin group: (Neuhaus et al 1999, n = 95 resected 1988– 1998; Neuhaus et al 2003, n = 133 resected 1988–2001; Thelen et al 2008, n = 60 resected 1996–2002; Thelen et al 2008, n = 60 resected 1996–2002; Neuhaus et al 2012, n = 100 resected 1990–2004; Kamphues et al 2015, n = 176 resected 1998–2008; Atanasov et al 2015, n = 47 resected 1996–2002).6,8,15-19 In summary, we have read, with great interest, the comments of the Berlin group regarding our recently published article in Surgery. They are all about selection, dogma, and survival figures of patients that have not been reproduced within the hepatobiliary community. Katrin Hoffmann, MD Peter Schemmer, MD Markus W. B€ u chler, MD Department of General and Transplant Surgery Ruprecht-Karls University, Heidelberg, Germany E-mail: [email protected]
References 1. Hoffmann K, Luible S, Goeppert B, Weiss KH, Hinz U, B€ uchler MW, et al. Impact of portal vein resection on oncologic long-term outcome in patients with hilar cholangiocarcinoma. Surgery 2015;158:1252-60. 2. Blumgart LH, Benjamin IS. Liver resection for bile duct cancer. Surg Clin North Am 1989;69:323-37. 3. Nimura Y, Hayakawa N, Kamiya J, Kondo S, Shionoya S. Hepatic segmentectomy with caudate lobe resection for bile duct carcinoma of the hepatic hilus. World J Surg 1990; 14:535-43. 4. Klempnauer J, Ridder GJ, von Wasielewski R, Werner M, Weimann A, Pichlmayr R. Resectional surgery of hilar cholangiocarcinoma: a multivariate analysis of prognostic factors. J Clin Oncol 1997;15:947-54. 5. Miyazaki M, Ito H, Nakagawa K, Ambiru S, Shimizu H, Okaya T, et al. Parenchyma-preserving hepatectomy in the surgical treatment of hilar cholangiocarcinoma. J Am Coll Surg 1999;189:575-83.
Surgery March 2016
6. Neuhaus P, Jonas S, Bechstein WO, Lohmann R, Radke C, Kling N, et al. Extended resections for hilar cholangiocarcinoma. Ann Surg 1999;230:808-19. 7. Yu W, Shao M, Gu Z, Shi S, Shen N, Zhang Y. Effect evaluation of vascular resection for patients with hilar cholangiocarcinoma: original data and meta-analysis. Hepatogastroenterology 2014;61:307-13. 8. Neuhaus P, Jonas S, Settmacher U, Thelen A, Benckert C, Lopez-H€anninen E, et al. Surgical managememt of proximal bile duct cancer: extended right lobe resection increases resectability and radicality. Langenbecks Arch Surg 2003;388:194-200. 9. Xiang S, Lau WY, Chen XP. Hilar cholangiocarcinoma: controversies on the extent of surgical resection aiming at cure. Int J Colorectal Dis 2015;30:159-71. 10. Tamoto E, Hirano S, Tsuchikawa T, Tanaka E, Miyamoto M, Matsumoto J, et al. Portal vein resection using the no-touch technique with a hepatectomy for hilar cholangiocarcinoma. HPB (Oxford) 2014;16:56-61. 11. Hirano S, Kondo S, Tanaka E, Shichinohe T, Tsuchikawa T, Kato K. No-touch resection of hilar malignancies with right hepatectomy and routine portal reconstruction. J Hepatobiliary Pancreat Surg 2009;16:502-7. 12. de Jong MC, Marques H, Clary BM, Bauer TW, Marsh JW, Ribero D, et al. The impact of portal vein resection on outcomes for hilar cholangiocarcinoma: a multi-institutional analysis of 305 cases. Cancer 2012;118:4737-47. 13. Abbas S, Sandroussi C. Systematic review and meta-analysis of the role of vascular resection in the treatment of hilar cholangiocarcinoma. HPB (Oxford) 2013;15:492-503. 14. Nagino M, Ebata T, Yokoyama Y, Igami T, Sugawara G, Takahashi Y, et al. Evolution of surgical treatment for perihilar cholangiocarcinoma: a single-center 34-year review of 574 consecutive resections. Ann Surg 2013;258:129-40. 15. Neuhaus P, Thelen A, Jonas S, Puhl G, Denecke T, VeltzkeSchlieker W, et al. Oncological superiority of hilar en bloc resection for the treatment of hilar cholangiocarcinoma. Ann Surg Oncol 2012;19:1602-8. 16. Kamphues C, Al-Abadi N, Bova R, Rademacher S, Al-Abadi H, Klauschen F, et al. The DNA index as a prognostic tool in hilar cholangiocarcinoma. J Surg Oncol 2015;112:214-8. 17. Thelen A, Scholz A, Benckert C, Schr€ oder M, Weichert W, Wiedenmann B, et al. Microvessel density correlates with lymph node metastases and prognosis in hilar cholangiocarcinoma. J Gastroenterol 2008;43:959-66. 18. Thelen A, Scholz A, Benckert C, Weichert W, Dietz E, Wiedenmann B, et al. Tumor-associated lymphangiogenesis correlates with lymph node metastases and prognosis in hilar cholangiocarcinoma. Ann Surg Oncol 2008;15:791-9. 19. Atanasov G, Hau HM, Dietel C, Benzing C, Krenzien F, Brandl A, et al. Prognostic significance of macrophage invasion in hilar cholangiocarcinoma. BMC Cancer 2015;15:790. http://dx.doi.org/10.1016/j.surg.2015.11.023
Comparison of laparoscopic versus open resection for colorectal liver metastases
To the Editors: We have read the paper of Schiffman et al1 with great interest and appreciate their efforts in presenting this interesting work. There are some important issues that were not reported in their study but need to be further explored. First, only 8 studies were considered quantified for the data extraction in their meta-analysis; our
Letters to the Editors 989
Surgery Volume 159, Number 3
literature survey shows that there are at least 3 important data sources2-4 that unfortunately are excluded from their meta-analysis. In our opinion, these 3 papers must be taken into account, because some important information can be obtained to optimize their meta-analysis. Blood loss, transfusion rate, and duration of stay of laparoscopic and open liver resections for colorectal liver metastasis are well presented in these studies. If these results had been included, the conclusion of their meta-analysis might have been different. Schiffman et al mentioned in the “Methods” section that review articles were excluded from their metaanalysis. If this was always the case, why was a review paper (reference 2) used in the meta-analysis? In addition, when the authors calculated the RRs and confidence intervals of the transfusion rate from the reference 44, an RR of 4.00 (95% confidence interval 0.90–17.68), which indicates the transfusion rate, was not significantly less in laparoscopic liver resection patients than that in open liver resection ones. The original data from reference 44, however, actually suggested that the transfusion rate in the laparoscopic liver resection group was significantly less than that of the open liver resection group (P = .040). We think the authors should describe why the results are contradictory. Finally, in the second paragraph of the results, the authors stated that these 8 studies were all retrospective, case-control studies. Actually, this is not correct, because
reference 47 was prospective. We believe that our suggestions may change the outcome of the study by Schiffman et al. Qian Cai, MBa Chao Dong, MDb Department of Pediatrics, The Third Xiangya Hospitala and Xiangya International Medical Center, Xiangya Hospital,b Central South University Changsha, China E-mail: [email protected]
References 1. Schisffman SC, Kim KH, Tsung A, Marsh JW, Geller DA. Laparoscopic versus open liver resection for metastatic colorectal cancer: a metaanalysis of 610 patients. Surgery 2015;157:211-22. 2. Abu Hilal M, Underwood T, Zuccaro M, Primrose J, Pearce N. Short- and medium-term results of totally laparoscopic resection for colorectal liver metastases. Br J Surg 2010;97:927-33. 3. Inoue Y, Hayashi M, Tanaka R, Komeda K, Hirokawa F, Uchiyama K. Short-term results of laparoscopic versus open liver resection for liver metastasis from colorectal cancer: a comparative study. Am Surg 2013;79:495-501. 4. Mala T, Edwin B, Gladhaug I, Fosse E, Søreide O, Bergan A, et al. A comparative study of the short-term outcome following open and laparoscopic liver resection of colorectal metastases. Surg Endosc 2002;16:1059-63. http://dx.doi.org/10.1016/j.surg.2015.07.033
the conclusion that PVR should be recommended routinely. Some authors even stated that “the “no-touch technique” introduced by Neuhaus et al. was never used, because it lacks scientific validation.”14 The Berlin authors criticized our complication rate. Interestingly, in the articles by Neuhaus et al, there is no mention of the complication rate, according to ClavienDindo.6,8,15-19 The authors, however, reported a considerable hospital mortality rate of 17% after PVR.6 It would be very interesting to learn about the complication rate, particularly if the reported mortality is within such a high range. The Berlin authors mentioned that Heidelberg has a low case load in advanced liver surgery. In the Neuhaus paper, however, the authors reported on 14 patients who underwent right trisectionectomy and PVR during a 10year observation period (1988–1998).6 This accounts for 1.4 patients per year and represents a very low case load. Furthermore, when referring to the case load, detailed information about the real rate of patients with HCA would be interesting to have, since it cannot be obtained from overlapping patient cohorts of the Berlin group: (Neuhaus et al 1999, n = 95 resected 1988– 1998; Neuhaus et al 2003, n = 133 resected 1988–2001; Thelen et al 2008, n = 60 resected 1996–2002; Thelen et al 2008, n = 60 resected 1996–2002; Neuhaus et al 2012, n = 100 resected 1990–2004; Kamphues et al 2015, n = 176 resected 1998–2008; Atanasov et al 2015, n = 47 resected 1996–2002).6,8,15-19 In summary, we have read, with great interest, the comments of the Berlin group regarding our recently published article in Surgery. They are all about selection, dogma, and survival figures of patients that have not been reproduced within the hepatobiliary community. Katrin Hoffmann, MD Peter Schemmer, MD Markus W. B€ u chler, MD Department of General and Transplant Surgery Ruprecht-Karls University, Heidelberg, Germany E-mail: [email protected]
References 1. Hoffmann K, Luible S, Goeppert B, Weiss KH, Hinz U, B€ uchler MW, et al. Impact of portal vein resection on oncologic long-term outcome in patients with hilar cholangiocarcinoma. Surgery 2015;158:1252-60. 2. Blumgart LH, Benjamin IS. Liver resection for bile duct cancer. Surg Clin North Am 1989;69:323-37. 3. Nimura Y, Hayakawa N, Kamiya J, Kondo S, Shionoya S. Hepatic segmentectomy with caudate lobe resection for bile duct carcinoma of the hepatic hilus. World J Surg 1990; 14:535-43. 4. Klempnauer J, Ridder GJ, von Wasielewski R, Werner M, Weimann A, Pichlmayr R. Resectional surgery of hilar cholangiocarcinoma: a multivariate analysis of prognostic factors. J Clin Oncol 1997;15:947-54. 5. Miyazaki M, Ito H, Nakagawa K, Ambiru S, Shimizu H, Okaya T, et al. Parenchyma-preserving hepatectomy in the surgical treatment of hilar cholangiocarcinoma. J Am Coll Surg 1999;189:575-83.
Surgery March 2016
6. Neuhaus P, Jonas S, Bechstein WO, Lohmann R, Radke C, Kling N, et al. Extended resections for hilar cholangiocarcinoma. Ann Surg 1999;230:808-19. 7. Yu W, Shao M, Gu Z, Shi S, Shen N, Zhang Y. Effect evaluation of vascular resection for patients with hilar cholangiocarcinoma: original data and meta-analysis. Hepatogastroenterology 2014;61:307-13. 8. Neuhaus P, Jonas S, Settmacher U, Thelen A, Benckert C, Lopez-H€anninen E, et al. Surgical managememt of proximal bile duct cancer: extended right lobe resection increases resectability and radicality. Langenbecks Arch Surg 2003;388:194-200. 9. Xiang S, Lau WY, Chen XP. Hilar cholangiocarcinoma: controversies on the extent of surgical resection aiming at cure. Int J Colorectal Dis 2015;30:159-71. 10. Tamoto E, Hirano S, Tsuchikawa T, Tanaka E, Miyamoto M, Matsumoto J, et al. Portal vein resection using the no-touch technique with a hepatectomy for hilar cholangiocarcinoma. HPB (Oxford) 2014;16:56-61. 11. Hirano S, Kondo S, Tanaka E, Shichinohe T, Tsuchikawa T, Kato K. No-touch resection of hilar malignancies with right hepatectomy and routine portal reconstruction. J Hepatobiliary Pancreat Surg 2009;16:502-7. 12. de Jong MC, Marques H, Clary BM, Bauer TW, Marsh JW, Ribero D, et al. The impact of portal vein resection on outcomes for hilar cholangiocarcinoma: a multi-institutional analysis of 305 cases. Cancer 2012;118:4737-47. 13. Abbas S, Sandroussi C. Systematic review and meta-analysis of the role of vascular resection in the treatment of hilar cholangiocarcinoma. HPB (Oxford) 2013;15:492-503. 14. Nagino M, Ebata T, Yokoyama Y, Igami T, Sugawara G, Takahashi Y, et al. Evolution of surgical treatment for perihilar cholangiocarcinoma: a single-center 34-year review of 574 consecutive resections. Ann Surg 2013;258:129-40. 15. Neuhaus P, Thelen A, Jonas S, Puhl G, Denecke T, VeltzkeSchlieker W, et al. Oncological superiority of hilar en bloc resection for the treatment of hilar cholangiocarcinoma. Ann Surg Oncol 2012;19:1602-8. 16. Kamphues C, Al-Abadi N, Bova R, Rademacher S, Al-Abadi H, Klauschen F, et al. The DNA index as a prognostic tool in hilar cholangiocarcinoma. J Surg Oncol 2015;112:214-8. 17. Thelen A, Scholz A, Benckert C, Schr€ oder M, Weichert W, Wiedenmann B, et al. Microvessel density correlates with lymph node metastases and prognosis in hilar cholangiocarcinoma. J Gastroenterol 2008;43:959-66. 18. Thelen A, Scholz A, Benckert C, Weichert W, Dietz E, Wiedenmann B, et al. Tumor-associated lymphangiogenesis correlates with lymph node metastases and prognosis in hilar cholangiocarcinoma. Ann Surg Oncol 2008;15:791-9. 19. Atanasov G, Hau HM, Dietel C, Benzing C, Krenzien F, Brandl A, et al. Prognostic significance of macrophage invasion in hilar cholangiocarcinoma. BMC Cancer 2015;15:790. http://dx.doi.org/10.1016/j.surg.2015.11.023
Comparison of laparoscopic versus open resection for colorectal liver metastases
To the Editors: We have read the paper of Schiffman et al1 with great interest and appreciate their efforts in presenting this interesting work. There are some important issues that were not reported in their study but need to be further explored. First, only 8 studies were considered quantified for the data extraction in their meta-analysis; our
Letters to the Editors 989
Surgery Volume 159, Number 3
literature survey shows that there are at least 3 important data sources2-4 that unfortunately are excluded from their meta-analysis. In our opinion, these 3 papers must be taken into account, because some important information can be obtained to optimize their meta-analysis. Blood loss, transfusion rate, and duration of stay of laparoscopic and open liver resections for colorectal liver metastasis are well presented in these studies. If these results had been included, the conclusion of their meta-analysis might have been different. Schiffman et al mentioned in the “Methods” section that review articles were excluded from their metaanalysis. If this was always the case, why was a review paper (reference 2) used in the meta-analysis? In addition, when the authors calculated the RRs and confidence intervals of the transfusion rate from the reference 44, an RR of 4.00 (95% confidence interval 0.90–17.68), which indicates the transfusion rate, was not significantly less in laparoscopic liver resection patients than that in open liver resection ones. The original data from reference 44, however, actually suggested that the transfusion rate in the laparoscopic liver resection group was significantly less than that of the open liver resection group (P = .040). We think the authors should describe why the results are contradictory. Finally, in the second paragraph of the results, the authors stated that these 8 studies were all retrospective, case-control studies. Actually, this is not correct, because
reference 47 was prospective. We believe that our suggestions may change the outcome of the study by Schiffman et al. Qian Cai, MBa Chao Dong, MDb Department of Pediatrics, The Third Xiangya Hospitala and Xiangya International Medical Center, Xiangya Hospital,b Central South University Changsha, China E-mail: [email protected]
References 1. Schisffman SC, Kim KH, Tsung A, Marsh JW, Geller DA. Laparoscopic versus open liver resection for metastatic colorectal cancer: a metaanalysis of 610 patients. Surgery 2015;157:211-22. 2. Abu Hilal M, Underwood T, Zuccaro M, Primrose J, Pearce N. Short- and medium-term results of totally laparoscopic resection for colorectal liver metastases. Br J Surg 2010;97:927-33. 3. Inoue Y, Hayashi M, Tanaka R, Komeda K, Hirokawa F, Uchiyama K. Short-term results of laparoscopic versus open liver resection for liver metastasis from colorectal cancer: a comparative study. Am Surg 2013;79:495-501. 4. Mala T, Edwin B, Gladhaug I, Fosse E, Søreide O, Bergan A, et al. A comparative study of the short-term outcome following open and laparoscopic liver resection of colorectal metastases. Surg Endosc 2002;16:1059-63. http://dx.doi.org/10.1016/j.surg.2015.07.033
