Clinical response after laparoscopic fenestration of symptomatic hepatic cysts: a systematic review and meta-analysis

Abstract

Background: Laparoscopic fenestration is one of the treatment options for symptomatic hepatic cysts, either solitary or in context of polycystic liver disease (PLD), but indications, efficacy and surgical techniques are under debate.

Methods: A systematic literature search (1950-2017) of PubMed, Embase, Web of Science and the Cochrane Library was performed (CRD42017071305). Studies assessing symptomatic relief or symptomatic recurrence after laparoscopic fenestration in patients with symptomatic, non-parasitic, hepatic cysts were included. Complications were scored according to Clavien-Dindo. Methodological quality was assessed by Newcastle-Ottawa scale (NOS) for cohort studies. Pooled estimates were calculated using a random effects model for meta-analysis.

Results: Out of 5277 citations, 62 studies with a total of 1314 patients were included. Median NOS-score was 6 out of 9. Median follow-up duration was 30 months. Symptomatic relief after laparoscopic fenestration was 90.2% (95% CI 84.3-94.9). Symptomatic recurrence was 9.6% (95% CI 6.9-12.8) and reintervention rate was 7.1% (95% CI 5.0-9.4). Post-operative complications occurred in 10.8% (95% CI 8.1-13.9) and major complications in 3.3% (95% CI 2.1-4.7) of patients. Procedure-related mortality was 1.0% (95% CI 0.5-1.6). In a subgroup analysis of PLD patients (n = 146), symptomatic recurrence and reintervention rates were significantly higher with respective rates of 33.7% (95% CI 18.7-50.4) and 26.4% (95% CI 12.6-43.0). Complications were more frequent in PLD patients, with a rate of 29.3% (95% CI 16.0-44.5).

Conclusions: Laparoscopic fenestration is an effective procedure for treatment of symptomatic hepatic cysts with a low symptomatic recurrence rate. The symptomatic recurrence rate and risk of complications are significantly higher in PLD patients.

Keywords: Clinical outcomes; Hepatic cysts; Laparoscopic fenestration; Polycystic liver disease.

Fig. 1

A PRISMA diagram. Flow chart representing literature search and elements of systematic review (identification and screening). B Illustrative schematic of country of origin of included studies. The number of inclusions per continent is shown

Fig. 2

A –E Analysis of continuous data: reported medians and means, N_s, number of studies. For reported means, the vertical line represents the median of means. C Preoperative cyst size, diameter in centimetres. F Scoring of post-operative complications according to Clavien–Dindo. G Timeframes wherein patients were included (study periods) are shown per study, sorted chronologically on first inclusion

Fig. 3

Funnel plots of meta-analysis outcomes. The modelled standard error is plotted against the double arcsine transformed estimates of individual studies. Luis Furuya-Kanamori asymmetry index (LFK-index) is also shown

Fig. 4

Subgroup analyses. N_s: number of studies. N_p: number of patients. Interrupted lines: pooled estimates. Error bars: 95% confidence intervals. A Outcomes for the polycystic liver disease (PLD) subgroup and overall results. B Percentage of patients that underwent omentopexy per included cohort. C, D Outcomes for omentopexy subgroups (Group 1: no omentopexy, Group 2: omentopexy). E Outcomes for mean follow-up subgroups (Group I: ≤38 months, Group II: >38 months). F Percentage of patients that underwent concomitant cholecystectomy per included cohort. G, H Outcomes for concomitant cholecystectomy subgroups (Group A: ≤ 21.5%, Group B: > 21.5%). I–L Outcomes for publication year subgroups (1994–2005 and 2006–2017). M–O Outcomes for data collection subgroups (prospective and retrospective)