Laparoscopic vs open approach to resection of hepatocellular carcinoma in patients with known cirrhosis: systematic review and meta-analysis

Abstract

Aim: To review the currently available literature comparing laparoscopic to open resection of hepatocellular carcinoma (HCC) in patients with known liver cirrhosis.

Methods: A literature search of MEDLINE, EMBASE, and Cochrane databases was conducted. The search terms used included (laparoscopic OR laparoscopy) AND (hepatic or liver) AND (surgery or resection) AND "hepatocellular carcinoma" AND (cirrhosis or cirrhotic). Furthermore, to widen the search, we also used the "related articles" section. Studies reporting a comparison of outcomes and methods of open vs laparoscopic hepatic resection for HCC in patients with liver cirrhosis were included. Meta-analysis of results was performed using a random effects model to compute relative risk (RR) and for dichotomous variables and standard mean differences (SMD) for continuous variables.

Results: A total of 420 patients from 4 cohort studies were included in final analysis. Patients undergoing laparoscopic procedures had statistically less blood loss compared to the open cohort, SMD of -1.01 (95%CI: -1.23-0.79), P < 0.001, with a reduced risk of transfusion, RR = 0.19 (95%CI: 0.09-0.38), P < 0.001. A wider clearance at tumour resection margins was achieved following a laparoscopic approach, SMD of 0.34 (95%CI: 0.08-0.60), P = 0.011. No significant difference was noted between laparoscopic and open resection operative times, SMD of -0.15 (95%CI: 0.35-0.05), P = 0.142. The overall RR of suffering from postoperative morbidity is 0.25 in favour of the open surgery cohort (95%CI: 0.17-0.37), P < 0.001. Patients under-going laparoscopic surgery had significantly shorter length of stays in hospital compared to the open cohort, SMD of -0.53 (95%CI: -0.73 to -0.32), P < 0.001.

Conclusion: This review suggests that laparoscopic resection of hepatocellular carcinoma in patients with cirrhosis is safe and may provide improved patient outcomes when compared to the open technique.

Keywords: Cirrhosis; Hepatic resection; Hepatobiliary; Hepatocellular carcinoma; Laparoscopic; Surgery; Surgical oncology.

Figure 1

Flow chart illustrating summary of literature search results.

Figure 2

Forest plot comparing tumour margins following open and laparoscopic approaches, standard mean difference with 95%CI, P = 0.011. I² measure of heterogeneity 0.0%, P = 0.631. SMD: Standard mean differences.

Figure 3

Forest plot comparing blood loss following open and laparoscopic approaches, standard mean difference with 95%CI, P < 0.001. I² measure of heterogeneity 96.2%, P < 0.001. SMD: Standard mean differences.

Figure 4

Forest plot comparing relative risk of blood transfusions following open and laparoscopic approaches, 95%CI, P < 0.001. I² measure of heterogeneity 0.0%, P = 0.845.

Figure 5

Forest plot comparing standard mean difference of operative times following open and laparoscopic approaches, with 95%CI, P = 0.142. I² measure of heterogeneity 24.2%, P = 0.266. SMD: Standard mean differences.

Figure 6

Forest plot comparing relative risk of post-operative morbidity following open and laparoscopic approaches, with 95%CI, P < 0.001. I² measure of heterogeneity 41.1%, P = 0.165.

Figure 7

Forest plot comparing standard mean difference of length of stay following open and laparoscopic approaches, with 95%CI, P < 0.001. I² measure of heterogeneity 59.8%, P = 0.058. SMD: Standard mean differences.