Difficult procedures, better outcomes
Editorial

Difficult procedures, better outcomes

Davit L. Aghayan1,2,3^, Airazat M. Kazaryan1,2,3,4,5,6,7^, Åsmund Avdem Fretland1,3,8^, Bjørn Edwin1,3,8^

1The Intervention Centre, Oslo University Hospital-Rikshospitalet, Oslo, Norway; 2Department of Surgery N1, Yerevan State Medical University after M. Heratsi, Yerevan, Armenia; 3Institute of Clinical Medicine, Medical Faculty, University of Oslo, Oslo, Norway; 4Department of Gastrointestinal and Pediatric Surgery, Oslo University Hospital-Ullevål, Oslo, Norway; 5Department of Surgery, Østfold Hospital Trust, Grålum, Norway; 6Department of Faculty Surgery N 2, I.M. Sechenov First Moscow State Medical University, Moscow, Russia; 7Department of Surgery, Fonna Hospital Trust, Odda, Norway; 8Department of HPB Surgery, Oslo University Hospital-Rikshospitalet, Oslo, Norway

^ORCID: Davit L. Aghayan, 0000-0001-7051-3512; Airazat M. Kazaryan, 0000-0001-9960-0820; Åsmund Avdem Fretland, 0000-0002-0945-5189; Bjørn Edwin, 0000-0002-3137-6225.

Correspondence to: Davit L. Aghayan, MD, PhD. The Intervention Centre, Oslo University Hospital-Rikshospitalet, P.O. Box 4950 Nydalen, N-0424 Oslo, Norway; Department of Surgery N1, Yerevan State Medical University after M. Heratsi, Yerevan, Armenia; Institute of Clinical Medicine, Medical Faculty, University of Oslo, Oslo, Norway. Email: dr.aghayan@gmail.com.

Comment on: Ratti F, Cipriani F, Fiorentini G, et al. Have we really understood when the efforts of laparoscopic liver resection are justified?-a complexity-based appraisal of the differential benefit. Hepatobiliary Surg Nutr 2022;11:363-74.

Keywords: Liver resection; laparoscopic liver surgery; minimally invasive liver surgery; complex procedures

Submitted Jun 21, 2023. Accepted for publication Jul 02, 2023. Published online Jul 11, 2023.

doi: 10.21037/hbsn-23-302

Despite the initial skepticism and challenges, minimally invasive liver surgery especially laparoscopic liver resections (LLR), has become a first-choice surgical treatment for various liver tumors in many specialized centers worldwide (1-3). It is a safe alternative to open surgery thanks to advantages such as reduced blood loss and complication rates, shorter hospital stay, and better quality of life (4-7). However, laparoscopy requires relatively long learning, and complex procedures are limited to high-volume expert centers (8).

We read with great interest a recently published article by Ratti and coauthors, where they assessed the differential benefit of LLR over open surgery according to technical complexity (9). The study is based on a single high-volume expert center’s experience from San Raffaele Hospital in Milan, Italy (one of the pioneer centers in LLR). It includes data on 2,971 (1,939 open and 1,032 LLRs) procedures performed between 2004 and 2019. The whole study population (both open and LLR) was stratified into three groups (low-, intermediate-, and high-difficulty) according to the technical complexity, which was determined using the Difficulty Scoring System developed for LLR by Ban and coauthors in 2014 (10). After that, propensity score matching was applied to compare open and LLR in each group, and it showed that laparoscopy was associated with significantly less blood loss, lower postoperative transfusion rate, lower postoperative complication rate, and shorter hospital stay in all three levels of technical difficulty.

Besides, the authors calculated the differential benefit of one technique over the other in the individual difficulty group and used intraoperative blood loss and postoperative 90-day morbidity as outcome indicators. Remarkably, it showed that LLR provided a greater advantage in terms of both blood loss and morbidity in high-difficulty procedures than in low- and intermediate-difficulty procedures.

As early adopters of LLR (from 1998), we support the findings provided by Ratti and coauthors; however, the readers should interpret these results cautiously. These results originate in a high-volume expert center with extensive experience in both laparoscopic and open liver surgery, an ideal situation for testing both techniques and cannot be applied in centers with less expertise. The surgeon’s experience/learning curve as a variable included in the analyses might have helped to explain the advantages of LLR in high-difficulty procedures. Before starting with complex procedures, the surgeon must already have mastered low and intermediate-difficulty resections, which we believe is one of the possible explanations. A multicenter study comparing the practice and outcome of LLR between high-volume expert and nationwide low-to-medium volume centers reported significantly better perioperative outcomes in high-volume centers for the total cohort and in three levels of complexity when stratifying patients by the difficulty of procedures, and the difference was more pronounced for high-risk, complex procedures (8).

There are limitations also highlighted by the authors. The Ban Difficulty Scoring System was applied to stratify both open and laparoscopic procedures by complexity; however, one should be aware that this scoring system was developed for pure laparoscopic liver resections, and its employment in open liver resections implies some limitations. The authors justify this approach by normalizing the bias related to patient and tumor background via difficulty grouping, propensity score matching, and bootstrapping, although 3 (tumor location, extent of liver resection, tumor size) out of 5 parameters of the scoring system were also used in the propensity score matching. This, we believe, might increase the risk of excluding a number of important patients from the open surgery groups.

Despite the limitations above and the biases raised by the authors, the current study provides substantial evidence on LLRs and supports the further spread and implementation of this patient-friendly procedure.

Acknowledgments

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Hepatobiliary Surgery and Nutrition. The article did not undergo external peer review.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://hbsn.amegroups.com/article/view/10.21037/hbsn-23-302/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

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  2. Aghayan DL, Kazaryan AM, Fretland ÅA, et al. Evolution of laparoscopic liver surgery: 20-year experience of a Norwegian high-volume referral center. Surg Endosc 2022;36:2818-26. [Crossref] [PubMed]
  3. Goh BKP, Han HS, Chen KH, et al. Defining Global Benchmarks for Laparoscopic Liver Resections: An International Multicenter Study. Ann Surg 2023;277:e839-48. [Crossref] [PubMed]
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  6. Robles-Campos R, Lopez-Lopez V, Brusadin R, et al. Open versus minimally invasive liver surgery for colorectal liver metastases (LapOpHuva): a prospective randomized controlled trial. Surg Endosc 2019;33:3926-36. [Crossref] [PubMed]
  7. Fretland ÅA, Dagenborg VJ, Waaler Bjørnelv GM, et al. Quality of life from a randomized trial of laparoscopic or open liver resection for colorectal liver metastases. Br J Surg 2019;106:1372-80. [Crossref] [PubMed]
  8. Görgec B, Fichtinger RS, Ratti F, et al. Comparing practice and outcome of laparoscopic liver resection between high-volume expert centres and nationwide low-to-medium volume centres. Br J Surg 2021;108:983-90. [Crossref] [PubMed]
  9. Ratti F, Cipriani F, Fiorentini G, et al. Have we really understood when the efforts of laparoscopic liver resection are justified?-a complexity-based appraisal of the differential benefit. Hepatobiliary Surg Nutr 2022;11:363-74. [Crossref] [PubMed]
  10. Ban D, Tanabe M, Ito H, et al. A novel difficulty scoring system for laparoscopic liver resection. J Hepatobiliary Pancreat Sci 2014;21:745-53. [Crossref] [PubMed]
Cite this article as: Aghayan DL, Kazaryan AM, Fretland ÅA, Edwin B. Difficult procedures, better outcomes. Hepatobiliary Surg Nutr 2023;12(4):634-636. doi: 10.21037/hbsn-23-302

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