We read with great interest the study presented by Badawy and colleagues in the current issue of Journal of Investigative Surgery.Citation1 The dogma that laparoscopic surgery is not suitable for the frail and elderly has been present since the early days of laparoscopy. This study is therefore of important.
The authors present 40 patients operated with laparoscopic liver resection compared with 40 patients operated with open liver resection, analyzed with propensity scored matching. Operations took place between 2009 and 2016, in the Kyoto University Hospital. The authors report lower blood loss, shorter hospital stay, less complications and less recurrence in the laparoscopic group.
As with all matched analyses, biases might have affected the results of this study. Most importantly, this study is not suited for oncologic analyses due to its design, low number of cases and relatively short follow-up. The interesting observation that laparoscopic liver resection for HCC carries a lower recurrence rate than open liver resection, might thus be a matter of either selection or coincidence. For instance, more patients in the open group had recurrent tumors, hepatitis C, and cirrhosis. In a large, propensity scored analysis from a European collaborative group, no such difference could be seen, this analysis was, however, based only on colorectal liver metastases.Citation2
Nevertheless, there are theoretical mechanisms which may explain a possible oncologic benefit of laparoscopy. First and foremost, a reduced disturbance of the immunologic defense following laparoscopic surgery has been suggested.Citation3,4 The suggested benefit might be larger in cirrhotic patients, as reduced trauma to the abdominal wall might help preserve liver function, and as reduced adhesions might make a later liver transplantation or repeat liver resection safer.Citation5 Thus the proposed oncologic benefits of laparoscopic liver surgery require further studies, preferably prospective randomized trials or large scale cohort studies. A randomized trial of open and laparoscopic resection of primary HCC would be of great interest, as the published and ongoing randomized trials either involve only colorectal liver metastasesCitation6 or several types of liver tumors.Citation7
The reduced complication rates reported in the current study are in line with previous studies, including a recently published randomized, controlled trialCitation6 Despite of this, the very low blood loss and complication rate in the laparoscopic group could also suggest a possible bias towards easier cases in the laparoscopic group. Also, the inverse T-incision reported for open resections is larger than many other centers would use.
This being said, there is neither in this report, or in the literature, any indication that laparoscopic liver resection is harmful to elderly and frail patients. In the contrary, it might be the frail patients that benefit most from minimally invasive surgery—as suggested by Badawy and colleagues.
DECLARATION OF INTERESTS
The authors report no conflicts of interests.
REFERENCES
- Badawy A, Seo S, Toda R, et al. A propensity score-based analysis of laparoscopic liver resection for liver malignancies in elderly patients. J Invest Surg. 2017 ( in press).
- Martínez-Cecilia D, Cipriani F, Vishal S, et al. Laparoscopic Versus Open Liver Resection for Colorectal Metastases in Elderly and Octogenarian Patients: A Multicenter Propensity Score Based Analysis of Short- and Long-term Outcomes. Ann Surg. 2017 Jun;265(6):1192–1200.
- Fretland ÅA, Sokolov A, Postriganova N, et al. Inflammatory response after laparoscopic versus open resection of colorectal liver metastases: Data from the Oslo-CoMet trial. Medicine (Baltimore). 2015;94(42):e1786. doi:10.1097/MD.0000000000001786.
- Lacy AM, García-Valdecasas JC, Delgado S, et al. Laparoscopy-assisted colectomy versus open colectomy for treatment of non-metastatic colon cancer: A randomised trial. Lancet. 2002;359(9325):2224–2229.
- Yoon Y-I, Kim K-H, Kang S-H, et al. Pure laparoscopic versus open right hepatectomy for hepatocellular carcinoma in patients with cirrhosis: A propensity score matched analysis. Annals of Surgery. 2017;265(5):856–863.
- Fretland ÅA, Dagenborg VJ, Bjørnelv GMW, et al. Laparoscopic Versus Open Resection for Colorectal Liver Metastases: The OSLO-COMET Randomized Controlled Trial. Ann Surg. 2017 Jun 27. [Epub ahead of print].
- Wong-Lun-Hing EM, van Dam RM, van Breukelen GJP, et al. Randomized clinical trial of open versus laparoscopic left lateral hepatic sectionectomy within an enhanced recovery after surgery programme (ORANGE II study). Br J Surg. 2017;104(5):525–535.