Abstract
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Luo et al. 1 performed a meta-analysis to investigate the potential benefits of laparoscopic hepatectomy in treating hepatic colorectal metastases. Colorectal cancer is the second most common cause of death in United States, and Stage IV disease has the highest mortality. The liver is the most common site of metastasis, and, in general terms, the standard of care for treating metastatic colorectal cancer to the liver is resection. Hepatic and colorectal minimally invasive approaches have been practiced for more than 20 years; however, they have only more recently become more mainstream. Luo et al. 1 very appropriately asked the question if hepatic resection is safe, feasible, and effective in a minimally invasive manner. Their analysis included seven studies with a total of 624 patients, 39% of whom underwent a laparoscopic operation. The findings of this study are intriguing in that they found that a lower R1 resection was observed in the laparoscopic group, as was a lower rate of bleeding and transfusion. Overall, there was also a lower complication rate. This study complements the presently available data that demonstrate the potential safety of laparoscopic hepatectomy in experienced hands. As the authors noted, however, appropriate and careful patient selection remains essential, and further study is needed to adequately define these criteria.
Jung et al., 2 in their article, have recognized the benefits and general adoption of laparoscopic hepatic resection, by experienced surgeons, and investigated the outcomes of synchronous laparoscopic colorectal and hepatic resection, compared with an open approach, in Stage IV colorectal cancer. The authors reported 24 cases of simultaneous laparoscopic hepatic resections and laparoscopic colorectal resections in this case-matched study. They found that the operative time in laparoscopic resections was longer by approximately 46 minutes; however, the hospital stay was shorter by 2.5 days. With a small study size, an in-depth comparison of complications between the two groups is difficult. In the short term, however, benefits were observed. Although this article demonstrates the potential benefits of synchronous minimally invasive resection, further long-term follow-up will be necessary to establish any survival advantage or disadvantage.
Laparoscopic hepatic surgery is not only being used for metastatic disease, but also for primary liver tumors, as demonstrated by the work of Herman et al. 3 This group retrospectively evaluated the short- and mid-term results of laparoscopic resection of hepatocellular carcinoma (HCC) in 30 patients over a 6-year period. The patients undergoing laparoscopic surgery in this cohort were very highly selected—those with preserved liver function and small (<5-cm) tumors. The authors observed conversion to an open technique in 13% of patients and had survival and recurrence rates similar to what has been reported elsewhere in the literature. As this modality for the resection of HCC continues to mature, the development and refinement of specific patient selection criteria will be critical to ensuring a safe and effective approach. Despite the controversies regarding liver transplantation versus resection for the treatment of HCC, Herman et al. 3 made an effort to define these very criteria in this article.
The pervasiveness of laparoscopic surgery has made operating on patients with various comorbidities routine. Inbar et al. 4 sought to retrospectively explore changes in glomerular filtration rate (GFR) in patients with chronic kidney disease undergoing open and laparoscopic surgery. They reviewed 90 consecutive patients with an impaired GFR (<60 mL/minute). Forty-seven patients underwent a laparoscopic approach, whereas 43 patients had an open operation. Changes in postoperative renal function were found to be similar in both groups. After multivariate analysis, the only risk factor for a significant decrease in GFR was the development of postoperative complications.
Finally, an innovative article by Hiroshima et al. 5 examined the use of fluorescence-guided surgery to define the extent of resection of colonic tumors. Their approach utilized an anti–carcinoembryonic antigen antibody conjugated to a fluorescent protein to localize a human patient tumor that had been orthotopically implanted in mice. The authors were able to demonstrate the ability to obtain free margins after resection, as well as an absence of tumor cells in the surgical resection bed, done on the basis of antibody localization. As indicated by these authors, the potential applications of this work are fascinating, and the further development of “fluorescence colonoscopy” or “fluorescence-guided surgery” may have significant future clinical impact by improving tumor detection and localization.
As laparoscopic or robotic techniques continue to advance and these modalities are utilized to develop new methods of performing surgery, their impact on patient safety and outcomes will always be questioned. These questions, which prompt novel research, not only serve the purpose of maintaining the highest quality and standards of patient care, but also serve to enhance and cultivate these very technologies. These select articles, and this issue of the Journal, serve as perfect examples of this relationship.