Division of Surgical Oncology, Department of Surgery, University of Tennessee Health Science Center, Memphis, TN, USA.
Ann Surg Oncol. 2019 Jan;26(1):282-289. doi: 10.1245/s10434-018-7073-6. Epub 2018 Nov 19.
Laparoscopic liver resection (LLR) is increasingly utilized for patients with hepatocellular carcinoma (HCC). However, long-term outcomes for patients requiring conversion to an open procedure during LLR have not been examined.
Patients undergoing attempted LLR for HCC were identified within the National Cancer Database. Patients undergoing successful LLR were compared with those who required unplanned conversion with regard to perioperative outcomes and overall survival (OS). Those experiencing conversion were further compared with patients who underwent planned open resection after propensity score matching.
Unplanned conversion occurred in 228 (18.0%) of 1270 patients undergoing LLR. Compared with successful LLR, conversion was associated with greater length of stay (6 vs. 4 days, p < 0.001), higher readmission rates (7.8% vs. 2.6%, p = 0.001), and reduced OS (55.1 vs. 67.6 months, p = 0.074). Unplanned conversion during major hepatectomy was associated with significantly worse OS (median 35.7 months) compared with successful major and minor LLR (median not reached and 67.6 months, respectively, p = 0.004). Compared with planned open resection, similar results were noted as conversion during major LLR was associated with worse OS (median 27.3 months) compared with open major hepatectomy (median not reached; p = 0.002). Unplanned conversion was independently associated with increased mortality (hazard ratio 1.38) after adjustment in a multivariable model. Tumor size was the strongest predictor of conversion on logistic regression analysis.
Unplanned conversion during LLR for HCC is associated with inferior OS. This difference is most pronounced for major hepatectomy. LLR should be considered cautiously in patients with larger, more advanced tumors likely to require major resection.
腹腔镜肝切除术（LLR）越来越多地用于治疗肝细胞癌（HCC）患者。然而，对于在 LLR 过程中需要转为开放手术的患者，尚未对其长期结果进行研究。
在国家癌症数据库中确定了接受 HCC 尝试 LLR 的患者。将成功进行 LLR 的患者与那些需要非计划性转为开放手术的患者在围手术期结果和总生存期（OS）方面进行比较。对那些需要转为开放手术的患者进一步与接受计划开放切除的患者进行倾向评分匹配比较。
228 例（18.0%）接受 LLR 的患者发生了非计划性转为开放手术。与成功的 LLR 相比，转为开放手术与更长的住院时间（6 天 vs. 4 天，p<0.001）、更高的再入院率（7.8% vs. 2.6%，p=0.001）和降低的 OS（55.1 个月 vs. 67.6 个月，p=0.074）相关。在主要肝切除术中发生非计划性转为开放手术与显著更差的 OS 相关（中位 35.7 个月），与成功的主要和次要 LLR 相比（分别为中位未达到和 67.6 个月，p=0.004）。与计划开放切除相比，同样观察到相似的结果，因为在主要 LLR 中发生的转为开放手术与开放的主要肝切除术相比，OS 更差（中位未达到；p=0.002）。在多变量模型中进行调整后，非计划性转为开放手术与死亡率增加独立相关（危险比 1.38）。在逻辑回归分析中，肿瘤大小是转为开放手术的最强预测因素。
在 HCC 的 LLR 中发生非计划性转为开放手术与较差的 OS 相关。对于主要肝切除术，这种差异最为明显。对于预计需要进行主要切除的较大、较晚期肿瘤的患者，应谨慎考虑 LLR。
