Comparing the Clinical and Economic Impact of Laparoscopic Versus Open Liver Resection

Department of Surgery, Jewish General Hospital, McGill University, Montreal, Canada.
Annals of Surgical Oncology (Impact Factor: 3.93). 04/2010; 17(4):998-1009. DOI: 10.1245/s10434-009-0839-0
Source: PubMed

ABSTRACT Laparoscopic liver resection has thus far not gained widespread acceptance among liver surgeons. Valid questions remain regarding the relative clinical superiority of the laparoscopic approach as well as whether laparoscopic hepatectomy carries any economic benefit compared with open liver surgery.
The aim of this work is to compare the clinical and economic impact of laparoscopic versus open left lateral sectionectomy (LLS).
Between May 2002 and July 2008, 44 laparoscopic LLS and 29 open LLS were included in the analysis. Deviation-based cost modeling (DBCM) was utilized to compare the combined clinical and economic impact of the open and laparoscopic approaches.
The laparoscopic approach compared favorably with the open approach from both a clinical and economic standpoint. Not only was the median length of stay (LOS) shorter by 2 days in the laparoscopic group (3 versus 5 days, respectively, P = 0.001), but the laparoscopic cohort also benefited from a significant reduction in postoperative morbidity (P = 0.001). Because the groups differed significantly in age and ratio of benign to malignant disease, a subgroup analysis limited to patients with malignant disease was undertaken. The same reduction in LOS and postoperative morbidity was evident within the malignant subgroup undergoing laparoscopic LLS (P = 0.003). The economic impact of the laparoscopic approach was noteworthy, with the laparoscopic approach US$1,527-2,939 more cost efficient per patient compared with the open technique.
Our study seems not only to corroborate the safety and clinical benefit of the laparoscopic approach but also suggests a fiscally important cost advantage for the minimally invasive approach.

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Available from: T. Clark Gamblin, Jul 11, 2014
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    • "Hence, LLR may very likely outweigh the higher costs of the laparoscopic technique. Although we did not compare the costs between the two procedures due to inadequate data, a recent deviation-based cost modeling study compared the economic impact of laparoscopic versus open left lateral sectionectomy and found that the cost of each patient undergoing LLR was US$ 2,939 less than that of a patient undergoing a similar open operation on average [25]. "
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    ABSTRACT: The safety and efficacy of laparoscopic liver resection (LLR) for colorectal liver metastasis (CLM) remain to be established. A meta-analysis was undertaken to compare LLR and open liver resection (OLR) for CLM with respect to surgical and oncologic outcomes. An electronic search was performed to retrieve all relevant articles published in the English language by the end of March 2013. Data were analyzed using Review Manager version 5.0. A total of 8 nonrandomized controlled studies with 695 subjects were analyzsed. Intra-operative blood loss, the proportion of patients requiring blood transfusion, morbidity and the length of hospital stay were all significantly reduced after LLR. Postoperative recurrence, 5-year overall and disease-free survivals were comparable between two groups. LLR for CLM is safe and efficacious. It improves surgical outcomes and uncompromises oncologic outcomes as compared with OLR.
    BMC Surgery 10/2013; 13(1):44. DOI:10.1186/1471-2482-13-44 · 1.40 Impact Factor
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    • "Although LLR was initially described for the treatment of small, peripheral, benign lesions, experienced teams are now safely performing more advanced LLRs including right hemihepatectomy, left hemihepatectomy, central hepatectomy, and extended right and left hepatectomy for the treatment of both benign and malignant lesions. Paralleling these advances in the technical feasibility of LLR, there is increasing acceptance of the minimally invasive approach for the treatment of larger tumors [3]. "
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    ABSTRACT: Although laparoscopic liver resection has developed rapidly and gained widespread acceptance for the treatment of benign liver diseases and hepatocellular carcinoma with a small tumor size, its usefulness for the treatment of large tumors is less clear, due to concerns about compromising oncological principles and patient safety. The purpose of this study was to explore the safety and feasibility of laparoscopic liver resection for the treatment of hepatocellular carcinoma with a tumor size of 5-10 cm. From March 2007 to December 2011, we performed liver resection in 275 patients with hepatocellular carcinoma with a tumor size of 5-10 cm. Laparoscopic liver resection was performed in 97 patients (Lap-Hx group) and open liver resection was performed in 178 patients (Open-Hx group). Operative time, estimated intraoperative blood loss, blood transfusion rate, and length of postoperative hospital stay were compared between the two groups. Early and intermediate-term postoperative outcomes were also compared. Only one liver resection was performed for every patient with HCC in the present study.No operative deaths occurred in either group. Nine of the laparoscopic procedures were converted to open resection (conversion rate 9.28%). There were no significant differences in mean operative time (245±105 min vs 225±112 min; P = .469), mean estimated intraoperative blood loss (460±426 mL vs 454±365 mL; P = .913), or blood transfusion rate (4.6%, 4/88) vs (2.8%, 5/178)(P = .480) between the Lap-Hx and Open-Hx groups. However, postoperative hospital stay was shorter in the Lap-Hx group than the Open-Hx group (8.2±3.6 days vs 13.5±3.8 days; P = .028). There was a lower rate of postoperative complications in the Lap-Hx group than the Open-Hx group (9% vs 30%; P = .001), but there were no severe complications in either group. The median overall follow-up time was 21 months (range 2-50 months) and the median follow-up of time of survivors was 23 months. The median follow-up time was 25 months in the Lap-Hx group and 20 months in the Open-Hx group. The follow-up rate was 95% (84 patients) in the Lap-Hx group and 95% (169 patients) in the Open-Hx group, which was not a significant difference between the two groups (P = .20). Tumor recurrence occurred in 17 patients (20%) in the Lap-Hx group and 35 patients (21%) in the Open-Hx group, which was not a significant difference between the two groups (P = .876). A total of 33 patients (13%) died during the study period, including 12 patients (14%) in the Lap-Hx group and 21 patients (12%) in the Open-Hx group, which was not a significant difference between the two groups (P = .695). There were also no significant differences in the 1-year rates of overall survival (94% vs 95%; P = .942) or disease-free survival (93% vs 92%; P = .941), or the 3-year rates of overall survival (86% vs 88%; P = .879) or disease-free survival (66% vs 67%; P = .931), between the Lap-Hx and Open-Hx groups. Laparoscopic liver resection is safe and feasible in patients with hepatocellular carcinoma with a tumor size of 5-10 cm. Laparoscopic liver resection can avoid some of the disadvantages of open resection, and is beneficial in selected patients based on preoperative liver function, tumor size and location.
    PLoS ONE 08/2013; 8(8):e72328. DOI:10.1371/journal.pone.0072328 · 3.23 Impact Factor
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    • "Similarly, efforts examining laparoscopic versus open liver resection of benign and malignant tumors have demonstrated efficacy and safety in utilizing a laparoscopic approach [28-30]. Laparoscopic liver resection is associated with decreased hospitalization and costs [28,29,31,32], with the average postoperative hospital stay reported as 1.7 to 3.2 days [29,33-35]. "
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    ABSTRACT: Adoptive cell therapy (ACT) with tumor-infiltrating lymphocytes (TIL) in patients with metastatic melanoma has been reported to have a 56% overall response rate with 20% complete responders. To increase the availability of this promising therapy in patients with advanced melanoma, a minimally invasive approach to procure tumor for TIL generation is warranted. A feasibility study was performed to determine the safety and efficacy of laparoscopic liver resection to generate TIL for ACT. Retrospective review of a prospectively maintained database identified 22 patients with advanced melanoma and visceral metastasis (AJCC Stage M1c) who underwent laparoscopic liver resection between 1 October 2005 and 31 July 2011. The indication for resection in all patients was to receive postoperative ACT with TIL. Twenty patients (91%) underwent resection utilizing a closed laparoscopic technique, one required hand-assistance and another required conversion to open resection. Median intraoperative blood loss was 100 mL with most cases performed without a Pringle maneuver. Median hospital stay was 3 days. Three (14%) patients experienced a complication from resection with no mortality. TIL were generated from 18 of 22 (82%) patients. Twelve of 15 (80%) TIL tested were found to have in vitro tumor reactivity. Eleven patients (50%) received the intended ACT. Two patients were rendered no evidence of disease after surgical resection, with one undergoing delayed ACT with generated TIL after relapse. Objective tumor response was seen in 5 of 11 patients (45%) who received TIL, with one patient experiencing an ongoing complete response (32+ months). Laparoscopic liver resection can be performed with minimal morbidity and serve as an effective means to procure tumor to generate therapeutic TIL for ACT to patients with metastatic melanoma.
    World Journal of Surgical Oncology 06/2012; 10(1):113. DOI:10.1186/1477-7819-10-113 · 1.41 Impact Factor
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