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ORIGINAL ARTICLE
Year : 2017  |  Volume : 13  |  Issue : 5  |  Page : 849-855

Meta-analysis of efficacy of laparoscopic hepatectomy versus open hepatectomy for hepatocarcinoma


1 Department of Hepatopancreatobiliary Surgery, China-Japan Union Hospital of Jilin University, Changchun 130033, China
2 Department of Breast Surgery, The Second Hospital of Jilin University, Changchun 130041, China
3 Department of General Surgery, China-Japan Union Hospital of Jilin University, Changchun 130033, China
4 Department of Colorectal Surgery, The Second Hospital of Jilin University, Changchun 130041, China
5 Department of Hepatopancreatobiliary Surgery, China-Japan Union Hospital of Jilin University; Department of General Surgery, China-Japan Union Hospital of Jilin University, Changchun 130033, China

Date of Web Publication13-Dec-2017

Correspondence Address:
Tao Jiang
Department of Hepatopancreatobiliary Surgery, Department of General Surgery, China-Japan Union Hospital of Jilin University, Changchun 130033
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcrt.JCRT_533_17

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 > Abstract 


Objective: The aim of this study was to summarize the current evidence to evaluate the effects of laparoscopic hepatectomy (LH) and open hepatectomy (OH) in the treatment of hepatocarcinoma.
Methods: A comprehensive literature search was performed using PubMed, Embase, and Google Scholar to identify all relevant studies. After we screened further, 22 published studies were included in this meta-analysis. We pooled the odds ratios (ORs), standardized mean difference (SMD) and conducted heterogeneity, quality assessment.
Results: The outcomes of treatment effects included surgical blood loss, surgical time, postoperative complications, perioperative mortality, 3-year survival rate, and 5-year survival rate. Comparing OH for liver cancer patients, the pooled SMD of surgical blood loss was −0.65 (95% confidential index [confidence interval (CI)] = [−0.80, −0.50]), the pooled SMD of surgical time was −0.12 (95% CI = [−0.25, −0.00]), the pooled OR of postoperative complications was 0.48 (95% CI = [0.38, 0.62]), the pooled OR of perioperative mortality was 0.34 (95% CI = [0.14, 0.84]), the pooled OR of 3-year survival rate was 1.03 (95% CI = [0.76, 1.39]), and the pooled OR of 5-year survival rate was 0.99 (95% CI = [0.75, 1.30]).
Conclusion: LH was found to significantly decrease patients' blood loss. LH slightly decreases surgical time. In addition, LH appears not to affect 3- and 5-year survival rate, but it offers less postoperative complications and perioperative mortality.

Keywords: Hepatocarcinoma, laparoscopic hepatectomy, meta-analysis, open hepatectomy


How to cite this article:
Liu H, Wang D, Yu Y, Ren H, Jiang T. Meta-analysis of efficacy of laparoscopic hepatectomy versus open hepatectomy for hepatocarcinoma. J Can Res Ther 2017;13:849-55

How to cite this URL:
Liu H, Wang D, Yu Y, Ren H, Jiang T. Meta-analysis of efficacy of laparoscopic hepatectomy versus open hepatectomy for hepatocarcinoma. J Can Res Ther [serial online] 2017 [cited 2018 Oct 24];13:849-55. Available from: http://www.cancerjournal.net/text.asp?2017/13/5/849/220478




 > Introduction Top


Hepatocellular carcinoma is one of the most common malignant tumors around the world.[1] Meanwhile, liver cancer ranks third among all cancers in mortality.[2] At present, the traditional open hepatectomy (OH) is still the most important means for the treatment of liver cancer, but the traditional open surgery is often accompanied by greater trauma and pain. With the development of minimally invasive surgery, laparoscopic equipment and technology is gradually popular in a lot of surgical centers. The laparoscopic hepatectomy (LH) has been used by many hospitals. Compared with OH, LH may have some advantages for reducing tissue damage, alleviating pain, and shortening the recovery time.[3],[4],[5],[6] However, previous studies were retrospective single-center studies, and their sample size and evidence intensity are low. Therefore, this study aims to conduct a meta-analysis to compare the perioperative safety and clinical effects of LH and OH and to provide proofs for choosing optimal treatment project. We found that LH significantly decreases patients' blood loss and slightly decreases surgical time.


 > Methods Top


Searching method

We conducted a search of PubMed, Embase, and Google Scholar databases that were published between 2005 and 2017. We limited the search to study published in English. The medical subject heading terms and keywords used included “laparoscopic hepatectomy,” “LH,” “open hepatectomy,” “OH,” “liver cancer,” and “hepatocarcinoma.” Duplicate articles and unpublished studies from international meetings were excluded from the study.

Inclusion criteria

Studies were selected carefully on the basis of following criteria: compared studies the effects of LH with OH in the treatment of hepatocarcinoma prospective and retrospective controlled studies; patients with hepatocarcinoma; information collected including surgical blood loss, surgical time, postoperative complications, perioperative mortality, and 3- and 5-year survival rate; the LH referring to liver is resected or dissociated by endoscope; the OH indicates OH without using endoscope.

Excluding standard

Nonclinical controlled trials; non-liver cancer research; to accept other surgical treatment; data description is not clear.

Data extraction

Two authors independently assessed each literature and then downloaded and extracted all the data using standardized data abstraction forms. The data extracted included year of publication, surgical blood loss, surgical time, postoperative complications, perioperative mortality, and 3- and 5-year survival rate.

Statistical analysis

We used RevMan (version 5.3, Cochrane Collaboration, Oxford, UK) to perform all the statistical analyses. To obtain the pooled odds ratios (ORs) and standardized mean difference (SMD) with 95% confidence intervals (CIs), a random effects model was applied. The heterogeneity between and within trials was evaluated using Chi-square test, P < 0.1 or an I2 measure >50%, based on a statement from the Cochrane Handbook.


 > Results Top


Literature searches and characteristics of eligible study

[Figure 1] shows the flow diagram of study selection process. After a further screening, we obtained 22 studies. The detailed characteristics for the 22 eligible studies are summarized in [Table 1].
Figure 1: The study selection process

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Table 1: Baseline characteristics of included studies

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Quality assessment

We assessed the quality of included studies using Newcastle–Ottawa scale (NOS).[27] Each study was evaluated, respectively, by two independent investigators. NOS contains three characters: how to select the involved groups, the similarity between the groups, and how to assess follow-up and outcomes. The number of total scores was recorded to evaluate the quality of included studies in our study. Full marks of NOS are nine scores.

Meta-analysis of the surgical blood loss of laparoscopic hepatectomy and open hepatectomy

The surgical blood loss was reported in 12 studies [Figure 2]. Compared with OH, LH was associated with a 0.39 reduction in blood loss (95% CI = [−0.77, −0.01]). Significant heterogeneity was found among these studies (I2 = 83%, P < 0.00001). Due to significant heterogeneity of the data, we performed a sensitivity analysis for included studies where we sequentially excluded each study from our meta-analysis. Using this approach, we found that heterogeneity was mainly caused by the study of Belli 2009, Ben-Shun 2011, and Kim 2014. Subsequently, the literature was excluded and the heterogeneity of the data was moderate (P = 0.04) while the I2 estimate of the variance between the studies was 51%. The pooled OR from these nine studies was −0.64 (95% CI = [−0.88, −0.39]). According to our analysis, the difference between LH and OH was significant (P < 0.00001). LH significantly decreases patients' blood loss.
Figure 2: The forest plot for the surgical blood loss between laparoscopic hepatectomy and open hepatectomy groups

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Meta-analysis of the surgical time of laparoscopic hepatectomy and open hepatectomy

The surgical time was reported in 14 studies [Figure 3]. The pooled SMD from these 14 studies was 0.06 (95% CI = [−0.21, 0.34], P = 0.65). We performed a sensitivity analysis for included studies where we sequentially excluded each study from our meta-analysis. Using this approach, we found that heterogeneity was mainly caused by the studies of Belli 2007, Lai 2016, Laurent 2003, and Lesurtel 2003. Subsequently, the I2 estimate of the variance between the studies is 56% and P = 0.02, which showed moderate heterogeneity. According to our analysis, the surgical time of between LH and OH was significant (P = 0.25) and the surgical time of LH was less than OH.
Figure 3: The forest plot for the surgical time between laparoscopic hepatectomy and open hepatectomy groups

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Meta-analysis of the postoperative complications of laparoscopic hepatectomy and open hepatectomy

The number of postoperative complications was reported in 17 studies [Figure 4]. Data from 17 studies were analyzed in a random effects model, and the pooled OR was 0.51 (95% CI = [0.35, 0.74]). The I2 estimate of the variance between the studies is 46% and P = 0.01, which showed low heterogeneity. According to our analysis, the postoperative complications between LH and OH were significant (P = 0.0005).
Figure 4: The forest plot for the postoperative complications between laparoscopic hepatectomy and open hepatectomy groups

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Meta-analysis of the perioperative mortality of laparoscopic hepatectomy and open hepatectomy

The perioperative mortality was reported in 15 studies [Figure 5]. Fifteen studies were selected. Random effects meta-analysis demonstrated that patients with LH had significantly lower perioperative mortality compared with OH (OR = 0.38; 95% CI = [0.14, 0.99]). The I2 estimate of the variance between these studies is 0% and P = 0.91, which showed no significant heterogeneity. According to our analysis, the perioperative mortality of LH was lower than OH (P = 0.05).
Figure 5: The forest plot for the perioperative mortality between laparoscopic hepatectomy and open hepatectomy groups

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Meta-analysis of the 3-year survival rate of laparoscopic hepatectomy and open hepatectomy

The 3-year survival rate was reported in ten studies [Figure 6]. Random effects meta-analysis shows that the 3-year survival rate of LH and OH was not significant (P = 0.72) and the pooled OR was 1.09 (95% CI = [0.67, 1.80]). The I2 is 44% and P = 0.06, which indicated low heterogeneity.
Figure 6: The forest plot for the 3-year survival rate between laparoscopic hepatectomy and open hepatectomy groups

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Meta-analysis of the 5-year survival rate of laparoscopic hepatectomy and open hepatectomy

The 5-year survival rate was reported in ten studies [Figure 7]. The pooled OR from these ten studies was 0.98 (95% CI = [0.75, 1.29]). The I2 estimate of the variance between the studies is 0% and P = 0.66, which showed low heterogeneity. According to our analysis, the 5-year survival rate of LH and OH was not significant (P = 0.91).
Figure 7: The forest plot for the 5-year survival rate between laparoscopic hepatectomy and open hepatectomy groups

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 > Discussion Top


In 1992, LH was first reported by Gagner et al. Then, LH is gradually applied around the world.[29] However, LH is one of the most complex laparoscopic operations. However, because of technical difficulties, such as hemostasis from the transection plane, controlling hemorrhage from intrahepatic vessels and exploration of deep regions, LH is considered to be one of the most complex laparoscopic operations. Studies have reported that laparoscopic extrahepatic lobectomy had advantages of shorter surgery time and less surgical blood loss compared with OH. However, LH also has some limitations. For example, LH cannot accurately detect location of those small tumors which are located in the liver parenchyma; LH may increase the risk of serious complications due to inconvenience operation. Recent years, with the development of intraoperative ultrasound, Da Vinci robot, and other new surgical equipment, the LH has a great breakthrough. This meta-analysis was designed to further assess safety and efficacy of LH versus OH.

First, in terms of perioperative mortality, this meta-analysis showed that perioperative mortality of LH was less than OH. At the time of surgery, the results of this meta-analysis showed that the LH group had less operative time. In recent years, with the development of laparoscopic technology, combined with LH itself saves the time of the switch belly. Thus, LH is more advantage than OH for shortening the operation time. The results of this meta-analysis showed that the LH group showed significant advantages in reducing surgical blood loss and postoperative complications, which is similar to previous study.[30] For the reasons for high heterogeneity, we believe that the surgical methods of each group (such as regular liver resection and local hepatectomy) may be different; the difference of selection criteria may lead to the difference of surgical time and postoperative complications, even affect the outcome of the operation. In addition, the definition of surgical time in each study may also lead to heterogeneity.

In summary, this meta-analysis showed that LH compared with OH significantly reduced the operation time, surgical blood loss, perioperative complications, and perioperative mortality. Our study showed that LH is safe and effective. We believe that LH will benefit an increasing number of patients with the development of endoscopic techniques.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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