Skip to main content
SpringerLink
Log in

Impact of liver cirrhosis on the difficulty of minimally-invasive liver resections: a 1:1 coarsened exact-matched controlled study

  • Published:
Surgical Endoscopy Aims and scope Submit manuscript

Abstract

Introduction

The impact of liver cirrhosis on the difficulty of minimal invasive liver resection (MILR) remains controversial and current difficulty scoring systems do not take in to account the presence of cirrhosis as a significant factor in determining the difficulty of MILR. We hypothesized that the difficulty of MILR is affected by the presence of cirrhosis. Hence, we performed a 1:1 matched-controlled study comparing the outcomes between patients undergoing MILR with and without cirrhosis including the Iwate system and Institut Mutualiste Montsouris (IMM) system in the matching process.

Methods

Between 2006 and 2019, 598 consecutive patients underwent MILR of which 536 met the study inclusion criteria. There were 148 patients with cirrhosis and 388 non-cirrhotics. One-to-one coarsened exact matching identified approximately exact matches between 100 cirrhotic patients and 100 non-cirrhotic patients.

Results

Comparison between MILR patients with cirrhosis and non-cirrhosis in the entire cohort demonstrated that patients with cirrhosis were associated with a significantly increased open conversion rate, transfusion rate, need for Pringles maneuver, postoperative, stay, postoperative morbidity and postoperative 90-day mortality. After 1:1 coarsened exact matching, MILR with cirrhosis were significantly associated with an increased open conversion rate (15% vs 6%, p = 0.03), operation time (261 vs 238 min, p  < 0.001), blood loss (607 vs 314 mls, p  = 0.002), transfusion rate (22% vs 9%, p  = 0.001), need for application of Pringles maneuver (51% vs 34%, p  = 0.010), postoperative stay (6 vs 4.5 days, p  = 0.004) and postoperative morbidity (26% vs 13%, p  = 0.029).

Conclusion

The presence of liver cirrhosis affected both the intraoperative technical difficulty and postoperative outcomes of MILR and hence should be considered an important parameter to be included in future difficulty scoring systems for MILR.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  1. Cucchetti A, Ercolani G, Vivarelli M et al (2006) Impact of model for end-stage liver disease (MELD) score on prognosis after hepatectomy for hepatocellular carcinoma on cirrhosis. Liver Transpl 12:966–971

    Article  Google Scholar 

  2. Hackl C, Schlitt HJ, Renner P, Lang SA (2016) Liver surgery in cirrhosis and portal hypertension. World J Gastroenterol 22:2725–2735

    Article  CAS  Google Scholar 

  3. Goh BK, Teo JY, Lee SY et al (2018) Critical appraisal of the impact of individual surgeon experience on the outcomes of laparoscopic liver resection in the modern era: collective experience of multiple surgeons at a single institution with 324 consecutive cases. Surg Endosc 32:1802–1811

    Article  Google Scholar 

  4. Ciria R, Cherqui D, Geller DA et al (2016) Comparative short-term benefits of laparoscopic liver resection: 9000 cases and climbing. Ann Surg 263:761–777

    Article  Google Scholar 

  5. Fretland AA, Dagenborg VJ, Bjornelv GM et al (2018) Laparoscopic versus open resection for colorectal liver metastases: the OSLO-COMET randomized controlled trial. Ann Surg 267:199–207

    Article  Google Scholar 

  6. Meng X, Xu Y, Pan Y et al (2019) Open versus laparoscopic hepatic resectionf or hepatocellular carcinoma: a systematic review and meta-analysis. Surg Endosc 33:2396–2418

    Article  Google Scholar 

  7. Goh BK, Lee SY, Teo JY et al (2018) Changing trends and outcomes associated with the adoption of minimally invasive hepatectomy: a contemporary single-institution experience with 400 consecutive resections. Surg Endosc 32:4658–4665

    Article  Google Scholar 

  8. Wakabayashi G, Cherqui D, Geller DA, Buell JF, Kaneko H, Han HS et al (2015) Recommendations for laparoscopic liver resection: a report from the second international consensus conference held in Morioka. Ann Surg 261:619–629

    PubMed  Google Scholar 

  9. Wakabayashi G (2016) What has changed after the Morioka consensus conference 2014 on laparoscopic liver resection? HBSN 5:281–2819

    PubMed  PubMed Central  Google Scholar 

  10. Kawaguchi Y, Fuks D, Kokudo N, Gayet B (2018) Difficulty of laparoscopic liver resection: proposal for a new classification. Ann Surg 267:13–17

    Article  Google Scholar 

  11. Halls MC, Berardi G, Cipriani F, Barkhatov L, Lainas P, Harris S, D’Hondt M, Rotellar F, Dagher I, Aldrighetti L, Troisi RI, Adwin B, Abu HM (2018) Development and validation of a difficulty score to predict intraoperative complications during laparoscopic liver resection. BJS 105:1182–1191

    Article  CAS  Google Scholar 

  12. Hasegawa Y, Wakabayashi G, Nitta H, Takahara T, Katagiri H, Umemura A, Makabe K, Sasaki A (2017) A novel model for prediction of pure laparoscopic liver resection surgical difficulty. Surg Endosc 31:5356–5363

    Article  Google Scholar 

  13. Yamamoto M, Kobayashi T, Oshita A, Abe T, Kohashi T, et al. Laparoscopic versus open limited liver resection for hepatocellular carcinoma with liver cirrhosis: a propensity score matching study with the Hiroshima Surgical study group of Clinical Oncology (HiSCO). Surg Endosc 2019 in press

  14. Xing L, Guo HB, Kan JL et al (2020) Clinical outcome of open surgery versus laparoscopic surgery for cirrhotic hepatocellular carcinoma patients: a meta-analysis. Eur J Gastroenterol Hepatol 32:239–245

    Article  Google Scholar 

  15. Haber PK, Wabitsch S, Krenzien F et al (2019) Laparoscopic liver surgery in cirrhosis- addressing lesions in posterosuperior segments. Surg Oncol 28:140–144

    Article  Google Scholar 

  16. Morise Z, Ciria R, Cherqui D et al (2015) Can we expand the indications for laparoscopic liver resection? a systematic review and meta-analysis of laparoscopic liver resection for patients with hepatocellular carcinoma and chronic liver disease. J Hepatobiliary Pancreat Sci 22:342–352

    Article  Google Scholar 

  17. Wang C, Huang Z, Huang X et al (2018) Surgical outcomes between patients with and without a cirrhotic liver undergoing laparoscopic liver resection: a meta-analysis. Clin Res Hepatol Gastronterol 42:553–563

    Article  Google Scholar 

  18. Cipriani F, Fantini C, Ratti F et al (2018) Laparoscopic liver resections for hepatocellular carcinoma. Can we extend the surgical indication in cirrhotic patients? Surg Endosc 32:617–626

    Article  Google Scholar 

  19. Hobeika C, Fuks D, Cauchy F, Goumard C, Soubrane O, Gayet B et al (2020) Impact of cirrhosis in patients undergoing laparoscopic liver resection in a nationwide multicentre survey. BJS 107:277

    Article  Google Scholar 

  20. Goh BK, Chan CY, Wong JS, Lee SY, Lee VT, Cheow PC et al (2015) Factors associated with and outcomes of open conversion after laparoscopic minor hepatectomy. Surg Endosc 29:2636–2642

    Article  Google Scholar 

  21. Goh BK, Lee SY, Koh YX et al (2020) Minimally-invasive major hepatecomies: a Southeast Asia single institution contemporary experience with its first 120 consecutive cases. ANZ J Surg 90:553–557

    Article  Google Scholar 

  22. Dindo D, Demartines N, Clavien PA (2004) Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 240:205–213

    Article  Google Scholar 

  23. Strasberg SM, Belghiti J, Clavien PA et al (2000) Terminology Committee of the International Hepato-Pancreato-Biliary Association: the Brisbane 2000 terminology of liver anatomy and resections. HPB 2(3):333–339

    Article  Google Scholar 

  24. Blackwell M, Iacus S, King G et al (2009) CEM: coarsened exact matching in STATA. Stata J 9:524–546

    Article  Google Scholar 

  25. Hicks CW, Hashmi ZG, VElopulos C, et al (2014) Association between race and age in survival after trauma. JAMA Surg 149:642–647

    Article  Google Scholar 

  26. Glauser G, Osiemo B, Goodrich S et al (2019) Association of overlapping, nonconcurrent, surgery with patient outcomes at a large academic medical center. A Coarsened exact matching study. Ann Surg 270:620–629

    Article  Google Scholar 

  27. Hallet J, Pessaux P, Beyfuss K et al (2019) Critical appraisal of predictive tools to access the difficulty of laparoscopic liver resection: a systematic review. Surg Endosc 33:366–376

    Article  Google Scholar 

  28. Ban D, Tanabe M, Ito H et al (2014) A novel difficulty scoring system for laparoscopic liver resection. J Hepatobilliary Pancreat Sci 21:745–753

    Article  Google Scholar 

  29. Halls MC, Cherqui D, Taylor MA et al (2018) Are the current difficulty scores for laparoscopic liver surgery telling the whole stody? an international survey and recommendations for the future. HPB 20:231–236

    Article  Google Scholar 

  30. Abe H, Midorikawa Y, Mitsula Y et al (2017) Predicting postoperative outcomes of liver resection by magnetic resonance elastography. Surgery 162:248–255

    Article  Google Scholar 

  31. Cauchy F, Fuks D, Nomi T et al (2015) Risk factors and consequences of conversion in laparoscopic major liver resection. Br J Surg 102:785–795

    Article  CAS  Google Scholar 

  32. Berardi G, Morise Z, Sposito C et al (2020) Development of a nomogram to predict outcome after liver resection for hepatocellular carcinoma in Child-Pugh B cirrhosis. J Hepatol 72:75–84

    Article  Google Scholar 

  33. Beard RE, Wang Y, Khan S, Marsh JW, Tsung A, Geller DA (2018) Laparoscopic liver resection for hepatocellular carcinoma in early and advanced cirrhosis. HPB 20:521–529

    Article  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Level 5, 20 College Road, Academia, Singapore, 169856, Singapore

    Brian K. P. Goh, Ser-Yee Lee, Ye-Xin Koh, Jin-Yao Teo, Juinn-Huar Kam, Peng-Chung Cheow, Prema-Raj Jeyaraj, Pierce K. Chow, London L. Ooi, Alexander Y. Chung & Chung-Yip Chan

  2. Duke-National University of Singapore Medical School, Singapore, Singapore

    Brian K. P. Goh, Ser-Yee Lee, Ye-Xin Koh, Juinn-Huar Kam, Peng-Chung Cheow, Prema-Raj Jeyaraj, Pierce K. Chow, London L. Ooi & Chung-Yip Chan

  3. Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore

    Nicholas Syn

Authors
  1. Brian K. P. Goh
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Nicholas Syn
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Ser-Yee Lee
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Ye-Xin Koh
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Jin-Yao Teo
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Juinn-Huar Kam
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Peng-Chung Cheow
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Prema-Raj Jeyaraj
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Pierce K. Chow
    View author publications

    You can also search for this author in PubMed Google Scholar

  10. London L. Ooi
    View author publications

    You can also search for this author in PubMed Google Scholar

  11. Alexander Y. Chung
    View author publications

    You can also search for this author in PubMed Google Scholar

  12. Chung-Yip Chan
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Brian K. P. Goh.

Ethics declarations

Disclosures

Dr Brian Goh, Nicholas Syn, Ser Yee Lee, Ye Xin Koh, Jin Yao Teo, Juinn Huar Kam, Peng Chung Cheow, Prema Raj Jeyaraj, Pierce Chow, London Ooi, Alexander Chung and Chung Yip Chan have no conflicts of interest or financial ties to disclose.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Goh, B.K.P., Syn, N., Lee, SY. et al. Impact of liver cirrhosis on the difficulty of minimally-invasive liver resections: a 1:1 coarsened exact-matched controlled study. Surg Endosc 35, 5231–5238 (2021). https://doi.org/10.1007/s00464-020-08018-0

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00464-020-08018-0

Keywords

Search

Navigation