Author information
1Hepatobiliary Surgery Division, IRCCS San Raffaele Hospital, Milan, Italy.
2Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.
3Department of General Surgery, Sengkang General Hospital, Singapore, Singapore.
4Department of Digestive, HBP, and Liver Transplantation, Hôpital Pitié-Salpêtrière, Sorbonne Université, Paris, France.
5Hepatic Surgery Center and Hubei Key Laboratory of Hepato-Biliary-Pancreatic Diseases, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
6Department of Surgery, Fondazione Poliambulanza, Brescia, Italy.
7The Intervention Centre and Department of HPB Surgery, Oslo University Hospital, Institute of Clinical Medicine, University of Oslo, Oslo, Norway.
8Division of General Surgery, Department of Surgery, Far Eastern Memorial Hospital, New Taipei City, Taiwan.
9Department of HPB Surgery and Liver Transplantation, Beaujon Hospital, University Paris Cite, Clichy, France.
10Liver Surgery Unit, Department of Gastroenterology, University of Sao Paulo School of Medicine, Sao Paulo, Brazil.
11General Surgery Department, Azienda Ospedaliera Ospedali Riuniti Villa Sofia-Cervello, Palermo, Italy.
12General Surgery Department, F. Tappeiner Hospital, Merano, Italy.
13HPB Surgery and Liver Transplantation, Fondazione IRCCS Istituto Nazionale Tumori di Milano and University of Milan, Milan, Italy.
14Hepatopancreatobiliary Unit, Department of Surgery, Changi General Hospital, Singapore, Singapore.
15Digestive Health Institute, AdventHealth Tampa, Tampa, Florida, USA.
16Department of Abdominal and General Surgery, University Medical Center Maribor, Maribor, Slovenia.
17Department of General Surgery, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea.
18Division of Hepato-Biliary and Pancreatic Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
19Hepatobiliary Surgery and Liver Transplantation Unit, Biocruces Bizkaia Health Research Institute, Cruces University Hospital, University of the Basque Country, Bilbao, Spain.
20HPB Surgery and Transplantation Unit, United Hospital of Ancona, Department of Experimental and Clinical Medicine Polytechnic, University of Marche, Ancona, Italy.
21Hepatobiliary Surgery Unit, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Catholic University of the Sacred Heart, Rome, Italy.
22General and Hepatobiliary Surgery, Department of Surgery, Dentistry, Gynecology, and Pediatrics, University of Verona, GB Rossi Hospital, Verona, Italy.
23Department of Surgery, Chang Gung Memorial Hospital, Kaohsiung, Taiwan.
24Department of Hepatobiliary Surgery, Affiliated Jinhua Hospital, Zhejiang University School of Medicine, Jinhua, China.
25General and Digestive Surgery, Hospital Clinic, IDIBAPS, CIBERehd, University of Barcelona, Barcelona, Spain.
26General and Digestive Surgery, Hospital Universitario La Paz, IdiPAZ, CIBERehd, Madrid, Spain.
27Department of Hepato-Pancreato-Biliary Surgery, Moscow Clinical Scientific Center, Moscow, Russia.
28Department of Surgery, Okazaki Medical Center, Fujita Health University School of Medicine, Okazaki, Japan.
29HPB Surgery and Liver Transplant Unit, University of Modena and Reggio Emilia, Modena, Italy.
30Department of Digestive and Hepatobiliary and Pancreatic Surgery, AP-HP, Henri-Mondor Hospital, Creteil, France.
31Hepatobiliary Surgery Unit, Department of Medicine and Surgery, University of Parma, Parma, Italy.
32Division of General and Transplant Surgery, University of Pisa, Pisa, Italy.
33Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
34Division of Hepatopancreatobiliary Surgical Oncology, Department of Abdominal Oncology, National Cancer Center - IRCCS-G. Pascale, Naples, Italy.
35Unit of Hepato-Pancreatc-Biliary Surgery, "F. Miulli" General Regional Hospital, Acquaviva delle Fonti, Bari, Italy.
36Department for the Treatment and Study of Abdominal Diseases and Abdominal Transplantation, Istituto di Ricovero e Cura a Carattere Scientifico-Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione (IRCCS-ISMETT), University of Pittsburgh Medical Center Italy, Palermo, Italy.
37Department of General Surgery and Medical Surgical Specialties, University of Catania, Catania, Italy.
38The Liver Institute, Methodist Dallas Medical Center, Dallas, Texas, USA.
39Department of Surgery, University of Washington Medical Center, Seattle, WA, USA.
40HPB and Liver Transplant Unit, Department of General Surgery, Clinica Universidad de Navarra, Universidad de Navarra, Pamplona, Spain.
41Institute of Health Research of Navarra (IdisNA), Pamplona, Spain.
42Division of Hepatopancreatobiliary Surgery, Department of Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea.
43Department of General, Visceral and Transplantation Surgery, Clinic and University Hospital Virgen de la Arrixaca, IMIB-ARRIXACA, El Palmar, Murcia, Spain.
44Department of Liver Surgery and Transplantation, Liver Cancer Institute, Zhongshan Hospital, Fudan University, Shanghai, China.
45Department of Hepatopancreatobiliary and Liver Transplant Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.
46Department of Surgery, Campus Charité Mitte and Campus Virchow-Klinikum, Charité-Universitätsmedizin, Corporate Member of Freie Universität Berlin, and Berlin Institute of Health, Berlin, Germany.
47Department of Surgery, Pamela Youde Nethersole Eastern Hospital, Hong Kong SAR, China.
48Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, New Territories, Hong Kong SAR, China.
49Department of Digestive and Hepatobiliary/Pancreatic Surgery, Groeninge Hospital, Kortrijk, Belgium.
50Department of Surgery, Fukuyama City Hospital, Hiroshima, Japan.
51Hepatobiliary and Pancreatic Surgery Unit, Department of Surgery, Dr. Josep Trueta Hospital, IdIBGi, Girona, Spain.
52Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
53Department of General and Oncological Surgery, Mauriziano Hospital, Turin, Italy.
54Division of General Surgery and Liver Transplantation, S. Camillo Forlanini Hospital, Rome, Italy.
55Department of Hepatobiliary Surgery, Assistance Publique Hopitaux de Paris, Centre Hepato-Biliaire, Paul-Brousse Hospital, Villejuif, France.
56Department of General Surgery, Sir Run-Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China.
57Department of Digestive, Oncologic and Metabolic Surgery, Institute Mutualiste Montsouris, Universite Paris Descartes, Paris, France.
58Center for Advanced Treatment of Hepatobiliary and Pancreatic Diseases, Ageo Central General Hospital, Saitama, Japan.
59Department of Clinical Medicine and Surgery, Division of HPB, Minimally Invasive and Robotic Surgery, Federico II University Hospital Naples, Naples, Italy.
60Department of Surgery, Queen Mary Hospital, The University of Hong Kong, Hong Kong SAR, China.
61Department of Surgery, Fujita Health University School of Medicine, Aichi, Japan.
62Department of Surgery, Seoul National University Hospital Bundang, Seoul National University College of Medicine, Seoul, Korea.
63Department of Hepatopancreatobiliary Surgery, University Medical Center, University of Medicine and Pharmacy, Ho Chi Minh City, Vietnam.
64Faculty of Hepatopancreatobiliary Surgery, The First Medical Center of Chinese People's Liberation Army (PLA) General Hospital, Beijing, China.
65Department of Surgery, University Hospital Southampton, Southampton, UK.
66Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital and National Cancer Centre Singapore, Singapore, Singapore. bsgkp@hotmail.com.
67Surgery Academic Clinical Programme, Duke National University of Singapore Medical School, Singapore, Singapore. bsgkp@hotmail.com.
Abstract
Background: Minimally invasive liver resections (MILR) offer potential benefits such as reduced blood loss and morbidity compared with open liver resections. Several studies have suggested that the impact of cirrhosis differs according to the extent and complexity of resection. Our aim was to investigate the impact of cirrhosis on the difficulty and outcomes of MILR, focusing on major hepatectomies.
Methods: A total of 2534 patients undergoing minimally invasive major hepatectomies (MIMH) for primary malignancies across 58 centers worldwide were retrospectively reviewed. Propensity score (PSM) and coarsened exact matching (CEM) were used to compare patients with and without cirrhosis.
Results: A total of 1353 patients (53%) had no cirrhosis, 1065 (42%) had Child-Pugh A and 116 (4%) had Child-Pugh B cirrhosis. Matched comparison between non-cirrhotics vs Child-Pugh A cirrhosis demonstrated comparable blood loss. However, after PSM, postoperative morbidity and length of hospitalization was significantly greater in Child-Pugh A cirrhosis, but these were not statistically significant with CEM. Comparison between Child-Pugh A and Child-Pugh B cirrhosis demonstrated the latter had significantly higher transfusion rates and longer hospitalization after PSM, but not after CEM. Comparison of patients with cirrhosis of all grades with and without portal hypertension demonstrated no significant difference in all major perioperative outcomes after PSM and CEM.
Conclusions: The presence and severity of cirrhosis affected the difficulty and impacted the outcomes of MIMH, resulting in higher blood transfusion rates, increased postoperative morbidity, and longer hospitalization in patients with more advanced cirrhosis. As such, future difficulty scoring systems for MIMH should incorporate liver cirrhosis and its severity as variables.