Minimally Invasive versus Open Liver Resection for Stage I/II Hepatocellular Carcinoma

Abstract

Minimally invasive liver resection (MILR) is increasingly used as a surgical treatment for patients with hepatocellular carcinoma (HCC). However, there is no large scale data to compare the effectiveness of MILR in comparison to open liver resection (OLR). We identified patients with stage I or II HCC from the National Cancer Database using propensity score matching techniques. Overall, 1931 (66%) and 995 (34%) patients underwent OLR or MILR between 2010 and 2015. After propensity matching, 5-year OS was similar in the MILR and OLR group (51.7% vs. 52.8%, p = 0.766). MILR was associated with lower 90-day mortality (5% vs. 7%, p = 0.041) and shorter length of stay (4 days vs. 5 days, p < 0.001), but higher rates of positive margins (6% vs. 4%, p = 0.001). An operation at an academic institution was identified as an independent preventive factor for a positive resection margin (OR 0.64: 95% CI 0.43-0.97) and 90-day mortality (OR 0.61; 95% CI 0.41-0.91). MILR for HCC is associated with similar overall survival to OLR, with the benefit of improved short term postoperative outcomes. The increased rate of positive margins after MILR requires further investigation, as do the differences in perioperative outcomes between academic and nonacademic institutions.

Keywords: hepatectomy; laparoscopic surgery; liver cancer; robotic surgery; survival.

Figure 1

Flow diagram. AJCC, American Joint Committee on Cancer; MILR, minimally invasive liver resection; OLR, open liver resection.

Figure 2

Trends of minimally invasive liver resection utilization for stage I/II HCC treatment. Use of minimally invasive surgery (laparoscopic and robotic) versus open hepatectomy for stage I or II hepatocellular carcinoma over time in the unmatched study population from the National Cancer Center Database 2010-2015 (A) and stratified by the facility type (B).

Figure 3

Overall survival in (A) the unmatched and (B) the propensity score matched study cohort with stage I or II hepatocellular carcinoma (log-rank test). MILR, minimally invasive liver resection; OLR, open liver resection.

Figure 4

Forest plot depicting hazard ratio of minimally invasive liver resection versus open liver resection in the matched study cohort using the tests of interaction in the following subgroups: age, sex, CDCS (Charlson Deyo Comorbidity Index Score), facility type, tumor size, stage, surgery, and year. The open liver resection group was used as reference. Black squares represent hazard ratios (and 95% confidence intervals by the corresponding horizontal lines).