ARTICLE IN PRESS

Laparoscopic versus open liver resection for metastatic colorectal cancer: A metaanalysis of 610 patients Suzanne C. Schiffman, MD, Kevin H. Kim, PhD, Allan Tsung, MD, J. Wallis Marsh, MD, and David A. Geller, MD, Pittsburgh, PA

Background. Laparoscopic liver resection (LLR) for metastatic colorectal cancer (mCRC) remains controversial. The objective of this manuscript was to perform a metaanalysis comparing outcomes of LLR with open liver resection (OLR) in patients with hepatic mCRC, and to identify which patients were suitable candidates for LLR. Study design. A PubMed search identified 2,122 articles. When filtered for case-matched articles comparing LLR with OLR for mCRC, 8 articles were identified consisting of 610 patients (242 LLR, 368 OLR). A random effects metaanalysis was performed. Results. The 2 groups were well-matched for age, sex, American Society of Anesthesiologists score, tumor size, number of metastases, extent of major hepatectomy, and use of neoadjuvant/adjuvant chemotherapy. The mean number of metastases in the LLR and OLR groups were 1.4 and 1.5, respectively (P = .14). Estimated blood loss was less in LLR group (262 vs 385 mL; P = .049). Transfusion rate was significantly less in LLR group (9.9 vs 19.8%; P = .004). There was no difference in operative time (248.7 vs 262.8 min; P = .85). Length of stay (LOS) was less in the LLR group (6.5 vs 8.8 days; P = .007). The overall complication rate was less in LLR group (20.3% vs 33.2%; P = .03). Importantly, there was no difference in the 1-, 3-, and 5-year disease-free survival (DFS) or overall survival (OS) rates. Conclusion. In carefully selected patients with limited mCRC (1 or 2 tumors), LLR provides marked perioperative benefits without compromising oncologic outcomes or long-term survival. Specifically, LLR offers decreased blood loss, LOS, and overall complication rates with comparable 5-year OS and DFS. (Surgery 2014;j:j-j.) From the Department of Surgery, University of Pittsburgh, Pittsburgh, PA

The feasibility and safety of laparoscopic liver resection (LLR) have been demonstrated in multiple reports.1-26 A review of 2,804 patients who underwent LLR for benign and malignant indications demonstrated overall mortality of 0.3% and morbidity of 10.5% with no reported intraoperative deaths.1 Additionally, recent studies demonstrated patients undergoing LLR had improved cosmesis, lesser length of stay (LOS), less morbidity, and decreased postoperative pain.2,3,5,11 Resection is the standard of care for patients with resectable hepatic colorectal metastases (mCRC) with studies reporting 5-year survival rates Accepted for publication August 13, 2014. Reprint requests: David A. Geller, MD, UPMC Liver Cancer Center, University of Pittsburgh, 3459 Fifth Avenue, UPMC Montefiore, 7 South, Pittsburgh, PA 15213-2582. E-mail: [email protected]. 0039-6060/$ - see front matter Ó 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.surg.2014.08.036

of approximately 35–60%.27-33 Recent data demonstrated the superiority of liver resection compared with ablation for colorectal metastases.34,35 Along with improved chemotherapy regimens, improvements in operative technique have contributed to prolonged survival in patients with mCRC. LLR for malignant pathology has been slower to gain acceptance. Concerns remain regarding the oncologic adequacy of LLR compared with open liver resection (OLR) for mCRC. Theoretic concerns include the potential for an increase in positive margin rate and failure to detect occult metastases. Although recent studies suggest equivalent morbidity rates and achievement of oncologic goals of resection, these studies do not provide longterm, disease-free survival (DFS) or overall survival (OS) rates.36,37 Further, 2 studies of LLR for mCRC provided large series with >100 patients each, but did not include any comparison to case-cohort matched open patients.10,16 Nguyen et al10 presented an international, multi-institutional series of LLR for mCRC in 109 patients and demonstrated SURGERY 1

ARTICLE IN PRESS 2 Schiffman et al

oncologic negative margins in 95% of patients with 5-year OS rate of 50%. Similarly, Kazaryan et al16 reported LLR for mCRC in 107 patients with a 5-year OS rate of 47% on an intent-to-treat analysis. Although several metaanalyses have been reported comparing LLR to OLR for resection of hepatocellular carcinoma (HCC),38,39 at the time of this manuscript preparation, there were limited data comparing LLR with OLR for mCRC. Further, with regard to the number of hepatic CRC metastases, there is no consensus as to which patients should be offered a minimally invasive resection. Therefore, we were especially interested in identifying which subset of patients with mCRC were suitable candidates for LLR. The aim of this study was to systematically analyze the clinical evidence in case-matched studies comparing LLR with OLR in patients with mCRC for perioperative and oncologic outcomes, and to determine the number of tumors that are suitable for LLR based on case-matched evidence. In addition, we sought to analyze the long-term OS and DFS in these patient cohorts. METHODS Patients. Patients with metastatic colorectal cancer (mCRC) deemed surgically resectable were considered for LLR or OLR. Diagnosis was based on clinical presentation and radiographic imaging with liver-dedicated, triphasic computed tomography or magnetic resonance imaging. All resections were performed with the intent to cure. This study does not attempt to reiterate specific techniques of liver resection, which have been described previously by individual authors. A number of different techniques for performing major LLR have evolved in recent years. As with OLR, no single method of parenchymal transection has been shown to be superior, and techniques vary considerably among surgeons. Study selection. The protocol conformed to the ethical guidelines of the 1975 Declaration of Helsinki. The study methodology was carried out in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) recommendations for improving the standard metaanalysis.40 Two authors carried out electronic literature searches (SCS and DAG) independently using PubMed to identify studies comparing LLR with OLR in patients with mCRC. The following medical subject heading terms and key words were used: ‘‘Laparoscopic hepatectomy,’’ ‘‘laparoscopic liver resection,’’ ‘‘open hepatectomy,’’ and ‘‘open liver resection,’’ The related articles function was used to broaden

Surgery j 2014

the search, and all abstracts, citations, and studies retrieved were reviewed. Reference lists of all relevant publications were hand searched for additional studies. This method of cross-referencing was continued until no further relevant publications were identified. The latest date on which a literature search was conducted was April 6, 2013 (Fig 1). Inclusion criteria. We selected controlled clinical studies in which a laparoscopic approach for resection of mCRC was compared with open hepatectomy approach in terms of perioperative outcomes, oncologic outcomes, and long-term survival outcomes. The studies were case-matched in terms of age, gender, American Society of Anesthesiologists (ASA) score, tumor size and location, number of metastases, tumor presentation, and chemotherapy (neoadjuvant and adjuvant). To be included in this metaanalysis, studies had to: (1) compare LLR with OLR in patients undergoing resection for mCRC, (2) include $10 patients in each group (minimum of 20 patients), and (3) report on $1 of the outcomes mentioned herein. Exclusion criteria. We excluded the following studies from the metaanalysis: (1) Studies in which it was impossible to extract data specifically related to mCRC, (2) studies with

Laparoscopic versus open liver resection for metastatic colorectal cancer: a metaanalysis of 610 patients.

Laparoscopic liver resection (LLR) for metastatic colorectal cancer (mCRC) remains controversial. The objective of this manuscript was to perform a me...
1MB Sizes 2 Downloads 7 Views