Laparoscopic Hepatectomy for Hepatocellular Carcinoma: The Opportunities, the Challenges, and the Limitations.

To the Editor: We read with great interest the recent publication of Yoon et al demonstrating the long-term outcomes of pure laparoscopic hepatectomy (LH) versus open hepatectomy (OH) for hepatocellular carcinoma (HCC) with background cirrhosis. Laparoscopic group demonstrated significantly shorter operation time and hospital stay as well as pain and warm ischemia time compared with open approach. The striking finding of the study, though, was that LH was not inferior compared with OH in terms of 2-year disease-free survival rate or 2-year overall survival. These findings should be accumulated into a rapidly growing body of data evaluating the role of LH in patients with HCC. LH has undergone widespread dissemination after the first international consensus conference in 2008, and specialized centers continue to report remarkable achievements. We think that the LH ‘‘success’’ is currently based on the concept: appropriate patient, with appropriate disease treated at the appropriate center. The selection of patients is of paramount importance. Almost all studies on the field demonstrate data from highly selected patients. The majority of patients are relatively young (around 60 y of age) without severe comorbidities, with very limited data for patients >70 years. Despite the fact that the authors demonstrated similar resection margins in both LH and OH groups, a recent meta-analysis demonstrated that LR results in significantly larger tumor margins compared to OR. This could be of paramount clinical interest during the preoperative plan, since patients with chronic liver disease and a marginal FLR cannot be easily offered a LH due to the risk of postoperative liver failure. Moreover, almost all studies evaluating the role of LH in patients with HCC, included patients with Child-Pugh score of A. In their study, Truant et al included patients with Child-Pugh B cirrhosis. Due to the small percentage of these patients (around 10% of total study population), no safe conclusions can be drawn about the safety and efficacy of LH in these patients. Thus, future studies should evaluate the role of LH in patients with HCC and Child-Pugh B liver disease. Another issue to highlight is that Yoon et al did not present the number and magnitude of hepatectomies (major/minor) in both groups. Moreover, there are no data about the number of anatomic and parenchymal sparing hepatectomies in both groups. It is well-established in the literature that major open abdominal operations are correlated with increased systematic inflammatory response that, in turn, is related with increased systematic and surgery-linked postoperative complications. This concept could fairly explain the difference in morbidity rates between the two approaches, that is marginally nonsignificant (P 1⁄4 0.053) but indicative of a tendency. Finally, it seems reasonable, when evaluating oncologic outcomes, to reserve final judgment until an analysis that accounts for the operative procedure and anatomic location of the tumor can be completed. The lack of randomization between the 2 groups reflects the inherent difficulty of each study to present with fidelity the real potential of LH in patients with HCC. Currently, we know that the number of cases suitable for laparoscopic approach only accounts for 20% to 30% of all cases and there is a learning curve effect in each center. A recent study demonstrated that to perform safely and efficiently the first major LH, a preparatory experience gained from 64 minor hepatectomies should take place. The latter reflects the need and value of operating in specialized high-volume centers that—a priori—could offer ‘‘exposure’’ needed to reach the learning curve. But once the center’s experience gets mature, it might become even more difficult to recruit patients in randomized trials. Due to many methodology and clinical queries, the final result of superiority of LH in patients with HCC, in patients with cirrhosis may not reflect the truth about the potential of this operation. The previous experience on laparoscopic/minimally invasive operations (laparoscopic cholecystectomy) offered a prisma through which the opportunities and challenges of this tool in liver surgery could be viewed. In less advanced and sophisticated operations the lack of high-quality randomized controlled trials did not affect the broad and unanimous clinical application of the procedure, due to its obvious clinical benefits and easy-toreach learning curves (many surgeons can replicate the same results). Unfortunately, the suggested generalization of LH will take longer time because it is a more complex procedure. Since the jury is still out about its surgical and oncological outcomes compared with OH, and not until the majority of the surgeons have acquired enough experience, it is still hard for LH to be considered as a standard practice. It is because the underlying meaning of standard practice means most surgeons can do this operation in an efficient, safe and standardized way. LH has gained ground the last years but the road is still long.