In the last years laparoscopic resection for colorectal liver metastases (CRLM) is my first option to treat hepatic lesions in the peripheral segments, with less than 5cm, and not touching/involving major hepatic vessels. Wedge resection or segmentectomies are performed laparoscopically. When surgeons dedicated to open liver resection pose concerns on minimally invasive approach, one question emerges in my mind. What are the results of minimally invasive liver resection and open liver resection?
CRLM are common and fatal if left untreated. Resection when possible is the best treatment option, since it offers the greatest potential for cure. Azagra described in 1993 one of the first minimally invasive liver resection (MILR). Since then, and contrary to other laparoscopic procedures, MILR did not received a widespread acceptance. Concerns regarding oncologic outcomes comparing to open liver resection (OLR), port-site metastases, and peritoneal spread, limited the used of laparoscopic approach in colorectal liver metastases resection. During the last 10 years several reports overwhelmed these concerns, and MILR is gaining supporters.
Georgios Karagkounis et al. from the Department of Surgery of the Cleveland Clinic published in 2016 in "Surgery" a retrospective review comparing MILR to OLR for colorectal liver metastases (CRLM). Between 2006 and 2015 two groups of 65 patients, one submitted to MILR and other to OLR, were analysed. Both groups were similar according to:
CRLM location (left lobe, right lobe, caudate lobe, bilobar)
CRLM size (2.0-4.0 cm for open surgery, 1.6-3.5 cm for minimally invasive surgery)
CEA
preoperative and postoperative chemotherapy
type of resection (wedge resections, segmentectomies, bisegmentectomies and hemihepatectomies)
Results were clear...
Operative time was similar, contradicting my preconceived idea that MILR would be slower. Blood loss was higher in OLR (p<0.001) with increased blood transfusion rate. Hospital stay was significant shorter (p<0.001) after MILR. While resecting a malignant diseased a complete resection is crucial for a good outcome. The authors report a R0 resection rate similar for both techniques (p=0.53), 83.1% after OLR and 78.5% after MILR. Additionally Karagkounis et al. report only two cases of recurrence in resection margin, and both cases occurred after open surgery. Overall complication rate was similar. However major complications (Clavien-Dindo III and IV) were in absolute number higher in open resection. Finally, disease free survival and 3- and 5-year overall survival were similar after MILR and OLR.
About their review, Karagkounis et al. say that the fact they have used three different minimally invasive techniques (laparoscopy, hand assisted, robot assisted) does not allow any specific conclusion for any of those techniques. Selection bias is a possibility since patient selection was not totally random, but surgeon specific skills was used to select approach. Additionally they compared a specific group of patients candidate to minimally invasive surgery based on tumor size (<7cm) and no major hepatic vessels involvement, which
along with the small number of major hepatectomies included do not allow the results to be generalized to the whole CRLM population.
Although the advantages inherent to laparoscopy are clear, oncologic adequacy is still less defined. Even though the authors make reference to several studies, including one meta-analysis published in 2015, that support the similar oncologic outcomes between the two techniques.
It looks clear that according to Karagkounis et al. MILR has advantages over OLR with the same oncologic outcomes. That is why the authors state that "these results are encouraging for the increasing use of minimally invasive approaches in the operative management of CRLM".
As one final conclusion the authors "recommend MILR to be considered a valid option for the treatment of CRLM in centers with adequate expertise." Does this mean that high volume centres for OLR cannot perform MIRL and must leave it for centers with expertise in laparoscopic surgery? Since I use minimally invasive surgery in several fields of surgery, I will keep using laparoscopy to treat CRLM...
Link to PubMed:
Dr. Carlos Eduardo Costa Almeida
General Surgeon