Int J Clin Exp Med 2015;8(11):20679-20689 www.ijcem.com /ISSN:1940-5901/IJCEM0013725
Original Article The safety and efficacy of laparoscopic and open hepatectomy in hepatocellular carcinoma patients with liver cirrhosis: a systematic review Jie Chen1,2*, Tao Bai1,2*, Yu Zhang1,2*, Zhi-Bo Xie1,2, Xiao-Bo Wang1,2, Fei-Xiang Wu1,2, Le-Qun Li1,2 1 Department of Hepatobiliary Surgery, Affiliated Tumor Hospital of Guangxi Medical University, Nanning 530021, PR China; 2Guangxi Liver Cancer Diagnosis and Treatment Engineering and Technology Research Center, Nanning 530021, PR China. *Equal contributors.
Received July 31, 2015; Accepted October 3, 2015; Epub November 15, 2015; Published November 30, 2015 Abstract: Background: Compared with open hepatectomy (OH), laparoscopic hepatectomy (LH) had better shortterm outcomes in normal hepatocellular carcinoma (HCC) patients. Since liver cirrhosis is the major risk of HCC, serve postoperative complications can be observed after LH in HCC patients with cirrhosis. We conducted this systematic review to analysis the safety and the efficiency of LH in HCC patients with liver cirrhosis. Methods: MEDLINE, EMBASE, the Cochrane Library, the Chinese National Knowledge Infrastructure database, and clinical trial registries were searched through March 2015. Risk ratios (RRs), weigh mean difference (WMD) and 95% confidence intervals (CIs) were calculated. Results: The analysis included 7 retrospective trials, altogether involving 828 patients. Patients in LH group had wider tumor margin (WMD = 0.12, 95% CI 0.04 to 0.21, P = 0.003), less blood loss (WMD = -157.25, 95% CI -295.05 to -19.45, P = 0.03), less blood transfusion (RR = 0.41, 95% CI 0.22 to 0.74, P = 0.004), less postoperative mobility (RR = 0.48, 95% CI 0.35 to 0.66, P 50% was of a Int J Clin Exp Med 2015;8(11):20679-20689
Laparascopic vs. open hepatectomy for HCC with liver cirrhosis
Figure 1. Selection process for trials included in this meta-analysis.
high heterogeneity [31]. Subgroup was conducted depending on retrospective and retrospective matched trials. To evaluate the robustness of meta-analysis results, we repeated all meta-analyses using the other type of model (fixed- or random-effects); if both models gave the same meta-analysis results, we judged the result to be reliable. Results Characteristics of the included studies After searching the database and trial registries, 928 published trials and 310 registered studies were initially presented (Figure 1). We removed 250 duplicates, and left with 988 trials (887 published and 101 registered trials), 20681
which were potentially eligible. With the screening of the titles and abstracts, 856 published trials and 101 registered studies were excluded because the design or outcomes data were not satisfied with the inclusion criteria (not related with our topic). The remaining 37 published trials were fully read, and 30 published trials were excluded. It is because the trials were systematic reviews, or meta-analyses. Finally, 7 trials involving 828 patients were included (Belli et al. [22], Cheung et al. [23], Kanazawa et al. [7], Memeo et al. [24], Siniscalchi et al. [32], Truant et al. [8] and Yamashita et al. [33]). In 828 patients, 281 patients were with LH, another 547 patients were under OH. The number of HCC patients ranged from 56 to 179. A total of 605 patients were men. All HCC patients had liver cirrhosis. Conversion rate of LH to OH Int J Clin Exp Med 2015;8(11):20679-20689
Laparascopic vs. open hepatectomy for HCC with liver cirrhosis Table 1. Characteristics of included studies comparing LH and OH to treat HCC patients with liver cirrhosis No. of patients
Study design
Study Belli et al. Cheung et al. Kanazawa et al. Memeo et al. Siniscalchi et al. Truant et al. Yamashita et al.
LH (M, %)
OH (M, %)
R
54 (31, 57.4%)
125 (78, 62.4%)
RM
32 (22, 68.8%)
64 (50, 78.1%)
Mean age, y LH
Child-Pugh (A/B)
Convention to open, (n, %)
OH
LH
OH
63.3±6.1*
61.5±7.8
49/5
117/8
4, 7.0%
59.5 (39-79)**
61 (29-82)
32/0
62/4
3, 18.8% 3, 10.7%
R
28 (16, 57.1%)
28 (17, 60.7%)
69 (40-85)
68 (29-82)
20/8
21/7
RM
45 (37, 82.2%)
45 (35, 77.8%)
60 (43-80)
62 (34-75)
43/2
44/1
NA
R
23 (15, 65.2%)
133 (104. 78.2%)
57.9 (30-73)
63.3 (41-77)
NA
NA
NA
RM
36 (31, 86.1%)
53 (47, 88.7%)
60.6±10.2
63.3±7.6
36/0
53/0
7, 19.4%
R
63 (48, 76.2%)
99 (74, 74.7%)
67.5±9.5
65.2±10.1
59/4
96/3
NA
Abbreviations: LH = laparoscopic hepatectomy; OH = open hepatectomy; R = retrospective study; RM = retrospective matching study; NA = not available. *Mean ± SD. **Median (range).
Table 2. Intraoperative data and surgical results comparing LH and OH to treat HCC patients with liver cirrhosis Study
Outcomes
Tumor margin (cm)
Belli et al.
Operative time (min)
Blood loss (ml)
Blood transfusion (n, %)
LH
OH
LH
OH
LH
OH
LH
OH
NA
NA
167±36*
185±61.3
297±134
580±120
6 (11.1%)
32 (25.6%)
Cheung et al.
0.95 (0-3) 0.8 (0-3.5) 232.5 (70-450)** 204.5 (67-705) 150 (10-1460) 300 (50-2700) 0 (0.0%)
3 (4.7%)
Kanazawa et al.
0.5 (0-1.8) 0.3 (0-1.5)
4 (14.3%)
Memeo et al.
228 (69-515)
236 (95-376)
88 (0-900)
505 (80-1150) 0 (0.0%)
1 (0-5)
0.6 (0-5.8)
140 (45-360)
180 (90-360)
200 (0-1500)
200 (0-2000)
0 (0.0%)
0 (0.0%)
NA
NA
175±91
165±80
NA
NA
0 (0.0%)
36 (27.4%)
Siniscalchi et al. Truant et al.
0.95±0.28 0.86±0.17
193.4±104
215.8±88.7
452.2±442
447.2±449.8
1 (2.8%)
2 (3.8%)
Yamashita et al.
0.74±0.87 0.58±0.69
299.5±127.6
287.4±83.2
436.6±320.7
455.7±741.9
4 (6.3%)
2 (2.0%)
Abbreviations: LH = laparoscopic hepatectomy; OH = open hepatectomy; HCC = hepatocellular carcinoma; NA = not available. *Mean ± SD. **Median (range).
ranged 7.0% to 19.4%. The characteristics of the included studies are shown in Table 1. Quality assessment results were presented as Supplementary Table 1. NOS was used to assess the risk of bias for quality assessment of non-randomized studies. Overall quality of the included studies was of good quality that the NOS scores varied between 7 and 8 out of 9. Therapy outcomes Intraoperative outcomes: During surgery, tumor margin was significantly wider in LH than OH (WMD = 0.12, 95% CI 0.04 to 0.21, P = 0.002, I2 = 0%). Operating time seems to be similar between LH and OH (WMD = -10.36, 95% CI -26.21 to 5.49, P = 0.20, I2 = 36%). Patients in LH get less blood loss (WMD = -157.25, 95% CI -295.05 to -19.45, P = 0.03, I2 = 84%) and blood transfusion (RR = 0.41, 95% CI 0.22 to 0.74, P = 0.004, I2 = 40%) than patients in OH. (Tables 2 and 3; Supplementary Figure 1). Postoperative outcomes: Postoperative mobility was significantly decreased in LH (RR = 0.48, 20682
95% CI 0.35 to 0.66, P
Original Article The safety and efficacy of laparoscopic and open hepatectomy in hepatocellular carcinoma patients with liver cirrhosis: a systematic review Jie Chen1,2*, Tao Bai1,2*, Yu Zhang1,2*, Zhi-Bo Xie1,2, Xiao-Bo Wang1,2, Fei-Xiang Wu1,2, Le-Qun Li1,2 1 Department of Hepatobiliary Surgery, Affiliated Tumor Hospital of Guangxi Medical University, Nanning 530021, PR China; 2Guangxi Liver Cancer Diagnosis and Treatment Engineering and Technology Research Center, Nanning 530021, PR China. *Equal contributors.
Received July 31, 2015; Accepted October 3, 2015; Epub November 15, 2015; Published November 30, 2015 Abstract: Background: Compared with open hepatectomy (OH), laparoscopic hepatectomy (LH) had better shortterm outcomes in normal hepatocellular carcinoma (HCC) patients. Since liver cirrhosis is the major risk of HCC, serve postoperative complications can be observed after LH in HCC patients with cirrhosis. We conducted this systematic review to analysis the safety and the efficiency of LH in HCC patients with liver cirrhosis. Methods: MEDLINE, EMBASE, the Cochrane Library, the Chinese National Knowledge Infrastructure database, and clinical trial registries were searched through March 2015. Risk ratios (RRs), weigh mean difference (WMD) and 95% confidence intervals (CIs) were calculated. Results: The analysis included 7 retrospective trials, altogether involving 828 patients. Patients in LH group had wider tumor margin (WMD = 0.12, 95% CI 0.04 to 0.21, P = 0.003), less blood loss (WMD = -157.25, 95% CI -295.05 to -19.45, P = 0.03), less blood transfusion (RR = 0.41, 95% CI 0.22 to 0.74, P = 0.004), less postoperative mobility (RR = 0.48, 95% CI 0.35 to 0.66, P 50% was of a Int J Clin Exp Med 2015;8(11):20679-20689
Laparascopic vs. open hepatectomy for HCC with liver cirrhosis
Figure 1. Selection process for trials included in this meta-analysis.
high heterogeneity [31]. Subgroup was conducted depending on retrospective and retrospective matched trials. To evaluate the robustness of meta-analysis results, we repeated all meta-analyses using the other type of model (fixed- or random-effects); if both models gave the same meta-analysis results, we judged the result to be reliable. Results Characteristics of the included studies After searching the database and trial registries, 928 published trials and 310 registered studies were initially presented (Figure 1). We removed 250 duplicates, and left with 988 trials (887 published and 101 registered trials), 20681
which were potentially eligible. With the screening of the titles and abstracts, 856 published trials and 101 registered studies were excluded because the design or outcomes data were not satisfied with the inclusion criteria (not related with our topic). The remaining 37 published trials were fully read, and 30 published trials were excluded. It is because the trials were systematic reviews, or meta-analyses. Finally, 7 trials involving 828 patients were included (Belli et al. [22], Cheung et al. [23], Kanazawa et al. [7], Memeo et al. [24], Siniscalchi et al. [32], Truant et al. [8] and Yamashita et al. [33]). In 828 patients, 281 patients were with LH, another 547 patients were under OH. The number of HCC patients ranged from 56 to 179. A total of 605 patients were men. All HCC patients had liver cirrhosis. Conversion rate of LH to OH Int J Clin Exp Med 2015;8(11):20679-20689
Laparascopic vs. open hepatectomy for HCC with liver cirrhosis Table 1. Characteristics of included studies comparing LH and OH to treat HCC patients with liver cirrhosis No. of patients
Study design
Study Belli et al. Cheung et al. Kanazawa et al. Memeo et al. Siniscalchi et al. Truant et al. Yamashita et al.
LH (M, %)
OH (M, %)
R
54 (31, 57.4%)
125 (78, 62.4%)
RM
32 (22, 68.8%)
64 (50, 78.1%)
Mean age, y LH
Child-Pugh (A/B)
Convention to open, (n, %)
OH
LH
OH
63.3±6.1*
61.5±7.8
49/5
117/8
4, 7.0%
59.5 (39-79)**
61 (29-82)
32/0
62/4
3, 18.8% 3, 10.7%
R
28 (16, 57.1%)
28 (17, 60.7%)
69 (40-85)
68 (29-82)
20/8
21/7
RM
45 (37, 82.2%)
45 (35, 77.8%)
60 (43-80)
62 (34-75)
43/2
44/1
NA
R
23 (15, 65.2%)
133 (104. 78.2%)
57.9 (30-73)
63.3 (41-77)
NA
NA
NA
RM
36 (31, 86.1%)
53 (47, 88.7%)
60.6±10.2
63.3±7.6
36/0
53/0
7, 19.4%
R
63 (48, 76.2%)
99 (74, 74.7%)
67.5±9.5
65.2±10.1
59/4
96/3
NA
Abbreviations: LH = laparoscopic hepatectomy; OH = open hepatectomy; R = retrospective study; RM = retrospective matching study; NA = not available. *Mean ± SD. **Median (range).
Table 2. Intraoperative data and surgical results comparing LH and OH to treat HCC patients with liver cirrhosis Study
Outcomes
Tumor margin (cm)
Belli et al.
Operative time (min)
Blood loss (ml)
Blood transfusion (n, %)
LH
OH
LH
OH
LH
OH
LH
OH
NA
NA
167±36*
185±61.3
297±134
580±120
6 (11.1%)
32 (25.6%)
Cheung et al.
0.95 (0-3) 0.8 (0-3.5) 232.5 (70-450)** 204.5 (67-705) 150 (10-1460) 300 (50-2700) 0 (0.0%)
3 (4.7%)
Kanazawa et al.
0.5 (0-1.8) 0.3 (0-1.5)
4 (14.3%)
Memeo et al.
228 (69-515)
236 (95-376)
88 (0-900)
505 (80-1150) 0 (0.0%)
1 (0-5)
0.6 (0-5.8)
140 (45-360)
180 (90-360)
200 (0-1500)
200 (0-2000)
0 (0.0%)
0 (0.0%)
NA
NA
175±91
165±80
NA
NA
0 (0.0%)
36 (27.4%)
Siniscalchi et al. Truant et al.
0.95±0.28 0.86±0.17
193.4±104
215.8±88.7
452.2±442
447.2±449.8
1 (2.8%)
2 (3.8%)
Yamashita et al.
0.74±0.87 0.58±0.69
299.5±127.6
287.4±83.2
436.6±320.7
455.7±741.9
4 (6.3%)
2 (2.0%)
Abbreviations: LH = laparoscopic hepatectomy; OH = open hepatectomy; HCC = hepatocellular carcinoma; NA = not available. *Mean ± SD. **Median (range).
ranged 7.0% to 19.4%. The characteristics of the included studies are shown in Table 1. Quality assessment results were presented as Supplementary Table 1. NOS was used to assess the risk of bias for quality assessment of non-randomized studies. Overall quality of the included studies was of good quality that the NOS scores varied between 7 and 8 out of 9. Therapy outcomes Intraoperative outcomes: During surgery, tumor margin was significantly wider in LH than OH (WMD = 0.12, 95% CI 0.04 to 0.21, P = 0.002, I2 = 0%). Operating time seems to be similar between LH and OH (WMD = -10.36, 95% CI -26.21 to 5.49, P = 0.20, I2 = 36%). Patients in LH get less blood loss (WMD = -157.25, 95% CI -295.05 to -19.45, P = 0.03, I2 = 84%) and blood transfusion (RR = 0.41, 95% CI 0.22 to 0.74, P = 0.004, I2 = 40%) than patients in OH. (Tables 2 and 3; Supplementary Figure 1). Postoperative outcomes: Postoperative mobility was significantly decreased in LH (RR = 0.48, 20682
95% CI 0.35 to 0.66, P
