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GLOBAL VALUE DOSSIER FOR MINIMALLY INVASIVE SURGERY (MIS)
LIVER RESECTION
Global Value Dossier: Liver Resection 2
Prepared by: Jayne Smith-Palmer and Richard Pollock
Ossian Health Economics and Communications, Bäumleingasse 20, 4051 Basel, Switzerland
Phone: +41 61 271 6214
E-mail: [email protected]
Version No. 2.1
Date: March 29, 2016
Global Value Dossier: Liver Resection 3
Contents
1. Liver resection .................................................................................................................... 4
1.1. Overview of procedure .............................................................................................. 4
1.2. Clinical and economic outcomes with laparoscopic versus open liver resection .... 7
1.1.1. Clinical and economic evidence tables ............................................................ 13
1.3. References ............................................................................................................... 24
List of Tables
Table 1-1 Summary of meta-analyses comparing laparoscopic versus open liver resection .............................................................................................................................. 14
Table 1-2 Summary of key clinical studies comparing laparoscopic versus open liver resection............................................................................................................... 15
Table 1-3 Summary of key studies comparing economic outcomes of laparoscopic versus open liver resection .............................................................................................. 22
List of Figures
Figure 1-1 Port placement for 4 laparoscopic liver resection operations: 1) S6 partial hepatectomy, 2) lateral segmentectomy, 3) S4 partial hepatectomy, and 4) S5 partial hepatectomy ........................................................................................... 4
Figure 1-2 Port and cart placement for robotic right hepatectomy. A Port placement: 1) optical port, 2) 8mm trocar for right operating arm, 3) 8mm trocar for left operating arm, and 4) 8mm trocar for fourth robotic arm. A indicates assistant port. B Robotic cart placement .......................................................................... 5
Figure 1-3 Temporal trends in laparoscopic liver resection for benign liver tumors stratified by patients and hospital ..................................................................... 5
Figure 1-4 Length of stay for laparoscopic versus open liver resection ............................ 9
Figure 1-5 Operating time for laparoscopic versus open liver resection ......................... 10
Figure 1-6 Blood loss for laparoscopic versus open liver resection ................................. 11
Figure 1-7 Rates of surgical site infection for laparoscopic versus open liver resection . 12
Figure 1-8 Total hospital costs for laparoscopic versus open liver resection in US-based studies .............................................................................................................. 13
Global Value Dossier: Liver Resection 4
1. Liver resection
1.1. Overview of procedure
Liver resection or hepatectomy is the surgical removal of all or part of the liver, referred to as full or partial hepatectomy, respectively. The procedure is widely performed for the treatment of various liver diseases, such as malignant tumors, benign tumors, calculi in the intrahepatic ducts, hydatid disease, and abscesses.1 The most common indication for laparoscopic liver resection is a solitary liver metastasis from a colorectal cancer, but it may also be used for hepatocellular carcinoma (HCC) and for benign liver tumours or cysts.2 Despite technical advances, liver resection is still burdened by relatively high rates of post-operative morbidity (4.09%−47.7%) and mortality (0.24%−9.7%).1 Common post-hepatectomy complications include fever, hemorrhage, bile leakage, liver failure, pleural effusion, and subphrenic infection.1
Laparoscopic hepatectomy can be achieved with a variety of different port placements, facilitating multiple resections with minimal adhesions in patients with recurrent disease (Figure 1-1).3 Typical port and cart placement for robotic hepatectomy is illustrated in Figure 1-2.4
Figure 1-1 Port placement for 4 laparoscopic liver resection operations: 1) S6 partial hepatectomy, 2) lateral segmentectomy, 3) S4 partial hepatectomy, and 4) S5 partial hepatectomy
Global Value Dossier: Liver Resection 5
Figure 1-2 Port and cart placement for robotic right hepatectomy. A Port placement: 1) optical port, 2) 8mm trocar for right operating arm, 3) 8mm trocar for left operating arm, and 4) 8mm trocar for fourth robotic arm. A indicates assistant port. B Robotic cart placement
The proportion of liver resections conducted laparoscopically has been increasing steadily from 2000-2011, with 6.2% of all benign tumor resection procedures conducted laparoscopically in patients aged under 65 years in the United States between 2008-2011 according to data from the Nationwide Inpatient Sample database (Figure 1-3).5
Figure 1-3 Temporal trends in laparoscopic liver resection for benign liver tumors stratified by patients and hospital
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Guidelines on laparoscopic liver resection
2005 United Kingdom National Institute for Health and Care Excellence interventional procedure guidance on laparoscopic liver resection
Evidence on the safety and efficacy of laparoscopic liver resection is adequate to support the use of the procedure
o In five studies (n=217) that compared laparoscopic liver resection with open resection in patients with malignant tumors, there were no statistically significant differences in the extent of the resection margins
o Four of six non-randomized comparative studies reported that the post-operative hospital stay was significantly shorter after laparoscopic liver resection (mean stay ranged from 4 to 15 days) than after open liver resection (mean stay ranged from 8 to 22 days)
Patient selection for laparoscopic liver resection should be carried out by a multidisciplinary team. Surgeons undertaking laparoscopic liver resection should have specialist training and expertise both in laparoscopic techniques and in the specific issues relating to liver surgery
2015 Recommendations for laparoscopic liver resection: a report from the second international consensus conference held in Morioka, Japan6
Minor laparoscopic liver resection is confirmed to be a standard practice in surgery but is still in an assessment phase (IDEAL 3) as it is adopted by an increasing proportion of surgeons. Judged as a whole, available literature studies indicated that some outcomes such as certain post-operative complications and length of stay were superior to open procedures and no outcomes were inferior. Unfortunately, the quality of studies is generally designated as low. Thus, additional higher quality studies are suggested to define its role and benefits in relation to open surgery
Major laparoscopic liver resection is an innovative procedure. It is still in an exploration or learning phase (IDEAL 2b) and has incompletely defined risks. It should continue to be introduced cautiously. Judged as a whole, available literature studies indicated that length of stay is superior to open procedures and other outcomes were not inferior. Blood loss is also reported to be less but questions remain regarding the methodology used. Again, the quality of studies is generally designated as low. Therefore, there are strong recommendations for additional higher quality studies including registries to define its role and benefits in relation to open surgery
Global Value Dossier: Liver Resection 7
1.2. Clinical and economic outcomes with laparoscopic versus open liver resection
Key findings
Clinical outcomes
Length of stay: Length of stay was shorter with laparoscopic liver resection than open resection in all studies assessed11,12,13,14,15,16,17,19,20,21,22,23,24,25,26,27 and significantly lower in the majority of studies11,13,14,15,16,17,19,20,21,22,23,26,27 only three studies showed a non-significant difference12,24,25
Operating time: Differences in operating time varied across the included studies, with a majority of studies reporting a non-significant difference in operative time12,13,14,15,19,21,23,24,26,27
Mortality: The Parks et al. meta-analysis reported lower rates of mortality with laparoscopic liver resection relative to open liver resection9
Complications: Where studies assessed operative and post-operative complications, data consistently favored laparoscopic liver resection over open resection11,22,25,26
Blood loss: Of the studies that reported blood loss, the majority of studies also reported a significant reduction with laparoscopic surgery11,12,16,18,19,21,22,23
Blood transfusion: Three studies reported a significantly lower proportion of patients requiring blood transfusion with laparoscopic versus open liver resection,11,19,25 however, several others reported no significant difference14,15,17,21,26
Economic outcomes
Total hospital costs: Overall, laparoscopic liver resection was associated with higher operative costs15,17,19 but with lower post-operative costs relative to open liver resection19,28
o United States: In two US-based studies laparoscopic liver resection was associated with lower overall costs than open liver resection; however, this did not achieve statistical significance,16,29 in a third US study laparoscopic liver resection was also associated with lower costs for on-course procedures, but not for procedures with deviations from procedure11
o Japan: In Japan, total hospital costs were higher, but not significantly so with laparoscopic liver resection than with open liver resection13
Savings due to clinical benefits: A systematic review of cost studies showed that lower overall costs with laparoscopic liver resection were driven by lower ward stay costs and lower high dependency unit costs, which in turn are likely attributable to a shorter length of stay and lower complication rate with laparoscopic liver resection
Other findings
Learning curve: A learning curve is evident with laparoscopic liver resection with operating time and blood loss decreasing as surgeon experience increased7
Time to mobilization: Time to first mobilization was significantly shorter for laparoscopic liver resection than for open liver resection20
Global Value Dossier: Liver Resection 8
Conversion: For laparoscopic liver resection significant risk factors for conversion to open surgery include resection of the postero-superior segments and major (compared with minor) resection8
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Figure 1-4 Length of stay for laparoscopic versus open liver resection
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Global Value Dossier: Liver Resection 10
Figure 1-5 Operating time for laparoscopic versus open liver resection
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Global Value Dossier: Liver Resection 11
Figure 1-6 Blood loss for laparoscopic versus open liver resection
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Global Value Dossier: Liver Resection 12
Figure 1-7 Rates of surgical site infection for laparoscopic versus open liver resection
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Global Value Dossier: Liver Resection 13
Figure 1-8 Total hospital costs for laparoscopic versus open liver resection in US-based studies
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1.1.1. Clinical and economic evidence tables
A summary of clinical evidence on laparoscopic versus open pancreatectomy from published meta-analyses and published studies is shown in Table 1-1 and Table 1-2, respectively. A summary of economic evidence from published cost studies is shown in Table 1-3.
In the following tables outcomes where p<0.05 are underlined.
Global Value Dossier: Liver Resection 14
Table 1-1 Summary of meta-analyses comparing laparoscopic versus open liver resection
Authors Details Procedures Outcome Outcome P value
Parks et al. 20139 Random effects meta-analysis of 15 studies (N=1,002, 556 open hepatectomy, 446 laparoscopic hepatectomy)
Laparoscopic versus open liver resection for solid tumors (in studies reporting 1-, 3- or 5-year overall survival for patients with malignancies)
Peri-operative Operative time, hours Blood loss, mL Oncological margins Post-operative Length of hospital stay Post-operative mortality Survival All-cancers, risk of death, 1-year All-cancers, risk of death, 3-year All-cancers, risk of death, 5-year HCC, risk of death, 1-year HCC, risk of death, 3-year HCC, risk of death, 5-year CRM, risk of death, 1-year CRM, risk of death, 3-year
−5.82 (−7.59, 19.23)a −104 (0.7, 207)a
Analysis not possible 15 studies favoring laparoscopy 0.7% laparoscopy; 1.5% open 0.71 (0.42, 1.20)b 0.76 (0.56, 1.03)b 0.80 (0.59, 1.10)b 0.78 (0.43, 1.42)b 0.95 (0.64, 1.39)b 0.81 (0.57, -1.15 b 0.55 (0.17, 1.80)b 0.49 (0.25, 0.95)b
0.395 0.048 N/A Significant NR 0.202 0.076 0.173 0.422 0.778 0.239 0.325 0.036
Rao et al. 201210 Random effects meta-analysis of 10 studies (N=700)
Laparoscopic (296/700) versus open (404/700) hepatic resections for malignant lesions
Peri-operative Operative time Operative blood loss, mL Transfusions Use of portal triad clamping Post-operative Time to first oral intake, days Length of hospital stay, days Overall complication rate
NR −163 (-262, 73)a
0.35 (0.20, 0.60)b
0.08 (0.01, 0.46)b −1.3 (−2.2, −0.4)a
−4.3 (−6.3, −2.2)a
0.4 (0.3, 0.7)b
0.71 <0.001 <0.001 0.005 0.007 <0.001 0.002
CRM, colorectal metastases; HCC, hepatocellular carcinoma; NR, not reported. a Weighted mean difference, negative values indicate a reduced value with laparoscopic liver resection b Odds ratios are reported as OR (95% confidence interval). Values less than 1 favor laparoscopic liver resection
Global Value Dossier: Liver Resection 15
Table 1-2 Summary of key clinical studies comparing laparoscopic versus open liver resection Study Setting Study details Procedure (year
performed) Summary of clinical findings Endpoint Open Laparoscopic P value
Cannon et al. 201311
United States
Retrospective review of 98 consecutive patients at a single institution from 2007 through 2011 undergoing first-time hepatic resection
Open versus laparoscopic hepatic resection (2007−2011)
Overall population (N=98) Peri-operative On course operations, % Mean (SD) blood loss, mL Transfusion required, % Patients experiencing complications, % Post-operative Mean (SD) LoS, days Right hepatectomy subgroup (n=45) Peri-operative On course operations,% Mean (SD) blood loss, mL Transfusion required, % Patients experiencing complications, % Post-operative Mean (SD) LoS, days
27 484 (427) 29 42 6.4 (2.6) 32 527 (503) 36.4 27.3 5.9 (2.0)
74 194 (183) 7.0 23 4.2 (5.3) 65 248 (220) 8.7 34.8 4.0 (1.8)
<0.001 <0.001 0.003 0.048 0.009 NR 0.024 0.035 0.587 0.002
Iwahashi et al. 201312
Japan Database analysis of 21 laparoscopic resection colorectal liver metastasis patients matched with 21 consecutive open resection patients matched by tumor size
Open versus laparoscopic liver resection (2007−2012)
Peri-operative Mean (SD) operative time, minutes Mean (SD) blood loss, mL Post-operative Patients experiencing complications, n Mean LoS, days 1 year overall survival, % 3 year overall survival, % 5 year overall survival, % 1 year disease-free survival, % 3 year disease-free survival, % 5 year disease-free survival, %
369 (31) 326 (50) 5 27.0 89 89 51 64 33 25
377 (29) 198 (39) 2 18.3 100 84 42 57 14 14
ns <0.05 0.21 0.14 ns ns ns ns ns ns
Kawaguchi et al. 201513
Japan Retrospective analysis of 65 patients undergoing laparoscopic (n=17) or open (n=48)
Open versus laparoscopic liver resection (2012−2013)
Peri-operative Median (range) operative time, minutes Median (range) blood loss, mL Inflow occlusion, % Median (range) time of occlusion, minutes
258 (123, 490) 541 (0, 1716) 60 120 (50, 194)
369 (165, 602) 150 (0, 675) 88 57 (17, 151)
0.11 0.07 0.16 0.03
Global Value Dossier: Liver Resection 16
Table 1-2 Summary of key clinical studies comparing laparoscopic versus open liver resection Study Setting Study details Procedure (year
performed) Summary of clinical findings Endpoint Open Laparoscopic P value
hepatectomy performed by a single surgeon
Post-operative Median (range) postoperative LoS, days Median (range) total LoS, days Median (range) AST POD 1, U/L Median (range) AST POD 3, U/L Median (range) bilirubin POD 1, mg/dL Median (range) bilirubin POD 3, mg/dL Median (range) INR POD 1 Median (range) INR POD 3 Median (range) tube drainage POD 1, mL Median (range) tube drainage POD 3, mL
9 (5, 12) 12 (9, 15) 186 (68, 386) 65 (29, 169) 1 (0.5, 1.49) 0.8 (0.4, 1.2) 1.19 (1.04, 1.49) 1.16 (1.01, 1.29) 150 (2, 400) 85 (0, 300)
5 (4, 6) 8 (7, 13) 310 (147, 1424) 115 (50, 413) 0.9 (0.5, 1.6) 0.9 (0.5, 1.5) 1.14 (1.01, 1.46) 1.13 (1.00, 1.80) 30 (10, 90) 10 (0, 190)
<0.01 <0.01 0.01 0.18 0.79 0.10 0.62 0.67 <0.01 0.04
Kim et al. 201314
Korea Retrospective, propensity-score matched analysis of 58 patients undergoing laparoscopic (n=29) versus open (n=29) liver resection at Seoul National University Hospital
Open versus laparoscopic liver resection (2000−2012)
Peri-operative Mean (SD) operative time, minutes Mean (SD) clamping time, minutes Mean (SD) estimated blood loss, mL Transfusions, % Post-operative ICU stay, % Mean (SD) ICU LoS, days Mean (SD) hospital stay, days Overall complication rate, % Wound infection, % Bile leakage, % Postoperative ascites, % Oncologic and long-term outcomes Overall recurrence rate, % Time to recurrence, months (range) Overall mortality, % Mean (SD) overall survival, months Mean (SD) disease-free survival, months 5-year survival, %
203 (51) 4.7 (9.2) 261 (301) 0.0 17.2 0.4 (1.0) 13.4 (7.4) 38 6.9 6.9 0.0 55 32.57 (26.29) 20.7 59.5 (35.4) 39.8 (32.7) 88
210 (82) 5.9 (14.6) 484 (820) 3.4 17.2 0.5 (1.1) 7.7 (2.9) 13.8 6.9 6.9 17.2 38 15.43 (5.44) 6.9 47.9 (29.9) 33.4 (29.1) 92
0.681 0.790 0.065 0.317 1.000 0.952 0.001 0.118 1.000 1.000 0.025 0.839 0.120 0.219 0.168 0.361 NR
López-Ben et al. 201415
Spain Retrospective 2:1 control case-matched study of
Open versus laparoscopic liver
Peri-operative Median blood loss, mL (range) Median operative time, minutes (range)
475 (20, 2,000) 200 (70, 450)
401 (18, 2,192) 295 (120, 600)
0.89 0.0001
Global Value Dossier: Liver Resection 17
Table 1-2 Summary of key clinical studies comparing laparoscopic versus open liver resection Study Setting Study details Procedure (year
performed) Summary of clinical findings Endpoint Open Laparoscopic P value
consecutive laparoscopic (n=50) hepatectomies versus open (n=100) hepatectomies
resection (2005−2012)
Conversions, % Post-operative Overall morbidity, % Biliary fistula, % Hemoperitoneum, % Surgical site infection, % Intraabdominal abscess, % Ascites, % Transfusions, % Reoperation, % Mortality, % Median (range) hospital stay, days Readmissions, %
N/A 36 3 4 18 12 4 20 3 1 7 (3, 44) 7
12 36 0 8 2 2 8 16 2 2 4 (1, 60) 0
N/A 1.00 0.29 0.25 0.007 0.033 0.44 0.94 0.59 0.65 0.0001 0.09
Medbery et al. 201416
United States
Retrospective record review of elective laparoscopic (n=48) and open (n=57) hepatectomy for both benign and malignant conditions at Emory University Hospital
Open versus laparoscopic liver resection (2008−2012)
Peri-operative Mean (SD) case time, minutes Mean (SD) operative room time, minutes Mean (SD) estimated blood loss, mL Portal triad clamping, % Crystalloid IV fluid requirement, mL (SD) Red blood cell units transfused, units Arterial line monitoring, % Central venous line monitoring, % Post-operative ICU admissions, % Mean (SD) ICU days, days Post-operative complications, % Median (range) hospital LoS, days 30-day emergency room visit, % 30-day readmissions, % 30-day mortality, %
222 (81) 285 (85) 737 (947) 49.1 2,607 (1,161) 0.60 70 40.4 54 2.6 (3.1) 44 7 (4, 35) 12.3 7.0 3.5
174 (29) 233 (32) 281 (306) 8.3 1,906 (796) 0.13 21 6.3 17 2.0 (2.2) 27 5 (3, 31) 16.7 14.6 4.2
<0.001 <0.001 0.002 <0.001 0.01 0.14 <0.001 <0.001 <0.001 0.64 0.075 <0.001 0.52 0.34 1.00
Shin et al. 201517
Korea Retrospective review of 195 patients with IHD stones undergoing
Open versus laparoscopic liver resection, including hemihepatectomy
Peri-operative Mean (SD) operation time, minutes Mean (SD) estimated blood loss, mL Intraoperative transfusion, %
210 (52) 378(433) 7.4
174(57) 263 (166) 7.5
0.002 0.150 0.987
Global Value Dossier: Liver Resection 18
Table 1-2 Summary of key clinical studies comparing laparoscopic versus open liver resection Study Setting Study details Procedure (year
performed) Summary of clinical findings Endpoint Open Laparoscopic P value
left-sided laparoscopic hepatectomy (n=40) or open hepatectomy (n=155)
and left lateral sectionectomy (2002−2013)
Post-operative Mean (SD) hospital stay, days Complications, % Wound problems, % Intraabdominal fluid collection, % Biliary fistula, % T-tube tractitis, % Initial residual stone, % Final residual stone, % Recurrent stone, %
14.3 (5.5) 40.7 18.5 14.8 3.7 3.7 24.1 5.6 5.6
7.9 (2.6) 17.5 5 12.5 0 0 12.5 0 2.5
<0.001 0.015 0.052 0.748 0.219 0.219 0.159 0.130 0.468
Slakey et al. 201318
United States
Retrospective chart review (N=62) in patients undergoing laparoscopic (n=45) versus open (n=17) resection of hepatic lesions
Open versus laparoscopic liver resection (year not reported)
Peri-operative Mean (range) blood loss, mL Post-operative Cases with complications, % Mortality at 30 days, % Mortality at 12 months, % IV pain medications >5 days, % ICU stay >5 days, % Hospital stay >10 days, % Postoperative ileus >4 days, %
988 (10, 5,000) 53 6 18 29 29 35 18
95 (0, 350) 16 0 0 11 7 7 2
0.0001 0.007 0.86 0.06 0.17 0.05 0.01 0.10
Slim et al. 201219
Italy Retrospective 1:1 control case-matched study of laparoscopic (n=46) versus open (n=46) hepatectomy at the Niguarda Ca’ Granda Hospital, Milan
Open (2006−2008) versus laparoscopic (2008−2011) liver resection
Peri-operative Mean (range) blood loss, mL Transfusions, % Operative time (range), minutes Post-operative Hospital stay, days (range) Mild liver failure, % Moderate–severe liver failure, % Biliary leakage, % Abdominal collection/abscesses, % Septic shock, % Pneumonia, % Pleural effusion, % Intra-abdominal bleeding, %
200 (50, 2,000) 17.4 170 (85, 315) 8 (5, 54) 6.5 6.5 6.5 6.5 6.5 4.3 10.9 4.3
100 (10, 800) 4.3 155 (45, 400) 5 (3, 22) 4.6 − − 2.2 − − 7.0 −
0.048 0.040 0.098 <0.001 NR NR NR NR NR NR NR NR
Global Value Dossier: Liver Resection 19
Table 1-2 Summary of key clinical studies comparing laparoscopic versus open liver resection Study Setting Study details Procedure (year
performed) Summary of clinical findings Endpoint Open Laparoscopic P value
Abdominal chronic pain, % Subclavian vein thrombosis, %
2.2 2.2
− −
NR NR
Wang et al. 201520
China Retrospective matched analysis of 30 elderly (≥70 years) patients undergoing laparoscopic resection for malignant carcinoma versus 1:2 open resection controls at the Chinese PLA General Hospital
Open versus laparoscopic liver resection (2008−2014)
Post-operative Patients with ICU stay, % ICU LoS, days (range) First pure liquid diet, days (range) First mobilization out of bed, days (range) Hospital LoS, days (range) Post-operative complications, % Pleural effusion Wound infection Chest infection Bile leak Ascites
38.3 0 (0, 3.9) 1.6 (0.6,6.6) 2.8 (0.6, 9.9) 10 (7, 22) 16.7 3.3 3.3 1.67 1.67 3.3
11.5 0 (0, 1.1) 1.0 (0.4, 3.7) 1.7 (0.6, 3.8) 5 (3, 16) 10.0 3.3 3.3 0 3.3 0
0.006 0.004 0.017 <0.001 <0.001 0.532
Xiao et al. 201521
China Retrospective evaluation for hepatocellular carcinoma by laparoscopy (n=41) or open surgery (n=86) at Southwest Hospital, Third Military Medical University, China
Open versus laparoscopic liver resection (2010−2012)
Peri-operative Mean (SD) operative time, minutes Mean (SD) blood loss, mL Transfusions, % Post-operative Mean (SD) post-operative stay, days
235 (66) 450 (345) 14 14.5 (6.0)
242 (74) 272 (171) 7 9.4 (2.7)
0.589 0.001 0.430 0.000
Luo et al. 201522
China Retrospective matched case-control study, n=53 laparoscopic, n=53 open
Open versus laparoscopic hepatectomy for hepatocellular carcinoma (2008–2015)
Peri-operative Median (range) operating time, minutes Median (range) blood loss, mL Post-operative Median (range) LoS, days Overall complications, %
150 (120, 280) 290 (190, 450) 12 (8, 35) 36
180 (150, 380) 210 (190, 450) 10 (7, 25) 30
0.025 0.012 0.015 0.536
Zhang et al. 201523
China Single center retrospective cohort study, n=30
Open versus laparoscopic left segmentectomy (2009–2013)
Peri-operative Mean (SD) operating time, minutes Mean (SD) blood loss, mL Mean resection margins, mm
150 (37) 328 (37) 21.5
120 (30) 200 (22) 20
ns <0.05 ns
Global Value Dossier: Liver Resection 20
Table 1-2 Summary of key clinical studies comparing laparoscopic versus open liver resection Study Setting Study details Procedure (year
performed) Summary of clinical findings Endpoint Open Laparoscopic P value
laparoscopic, n=20 open
Post-operative Mean (SD) LoS, days
8 (1)
5 (1)
<0.05
Siniscalchi et al. 201424
Italy Retrospective single center analysis, n=23 laparoscopic, n=133 open
Open versus laparoscopic minor hepatic resection for hepatocellular carcinoma (2005–2010)
Peri-operative Mean (SD) operating time, minutes Post-operative Mean (SD) LoS, days Ascites, % Jaundice, % Liver failure, %
165 (80) 14.4 (21.8) 26 23 6.8
175 (91) 7.6 (5.5) 13 44 0
0.588 0.339 0.288 0.067 0.357
Kim et al. 201425
Korea Retrospective single center analysis, n=70 laparoscopic, n=76 open (propensity matched)
Laparoscopic versus open liver resection for hepatocellular carcinoma (2004–2012)
Peri-operative Mean (SD) operating time, minutes Transfusion, % Post-operative Complication, % Wound infection, % Mean (SD) LoS, days Mean (SD) resection margin, cm
282 (80) 41 14.5 0 17.1 (15.9) 0.80 (0.82)
216 (122) 24 7.1 5.3 12.0 (23.0) 1.07 (1.37)
0.001 0.001 0.450 NR 0.440 0.147
Ai et al. 201326 China Retrospective single center analysis, n=97 laparoscopic, n=178 open
Open versus laparoscopic liver resection for hepatocellular carcinoma with tumor size 5–10 cm (2007–2011)
Peri-operative Mean (SD) operating time, minutes Mean (SD) blood loss, mL Blood transfusion, % Resection margin, cm Post-operative Mean (SD) LoS, days Complications, % Clavien I Clavien II Clavien III Wound infection, % Ascites, % Bile leakage, %
225 (112) 454 (365) 2.8 1.36 (0.62) 13.5 (3.8) 10.1 14.0 3.9 2.8 2.2 2.8
245 (105) 460 (426) 4.6 1.53 (0.59) 8.2 (3.6) 3.1 7.2 0 1.0 0 0
0.469 0.913 0.480 0.818 0.028 0.000 0.003 0.002 0.010 0.003 0.001
Hu et al. 201127 China Retrospective single center analysis,
Laparoscopic vs open liver lobectomy
Peri-operative Mean (SD) operating time, minutes Mean (SD) blood loss, mL
170 (32) 480 (46)
180 (45) 520 (30)
ns ns
Global Value Dossier: Liver Resection 21
Table 1-2 Summary of key clinical studies comparing laparoscopic versus open liver resection Study Setting Study details Procedure (year
performed) Summary of clinical findings Endpoint Open Laparoscopic P value
n=30 laparoscopic, n=30 open
(segmentectomy) for hepatocellular carcinoma (2006–2011)
Post-operative Mean (SD) time to ambulation, days Mean (SD) time to oral intake, days Mean (SD) LoS, days Complications, % Wound infection, % Bile leakage, %
5.7 (3.2) 5.5 (1.6) 20 (3.2) 10 3.3 0
2.3 (2.5) 2.2 (1.4) 13 (2.1) 13.3 0 10
<0.01 <0.05 <0.01 ns NR NR
AST, aspartate aminotransferase; ICU, intensive care unit; INR, international normalized ratio; LoS, length of stay; N/A not applicable; NR, not reported; POD postoperative day; SD, standard deviation
Global Value Dossier: Liver Resection 22
Table 1-3 Summary of key studies comparing economic outcomes of laparoscopic versus open liver resection Study Setting Study details Procedures Currency
(Cost year) Cost Outcome Open Laparoscopic P value
Cannon et al. 201311
United States
Retrospective review of 98 consecutive patients at a single institution from 2007 through 2011 undergoing first-time hepatic resection
Open versus laparoscopic hepatic resection
USD (cost year not specified)
Median total hospital charges On course Minor deviation Moderate deviation Major deviation Median operative changes On course Minor deviation Moderate deviation Major deviation
54,704 60,665 80,734 138,606 31,400 32,949 36,845 45,429
49,994 63,878 93,979 NA 34,019 32,974 49,639 NA
0.402 0.544 0.208 NA 0.131 0.828 0.112 NA
Kawaguchi et al. 201513
Japan Retrospective analysis of laparoscopic (n=17) or open (n=48) hepatectomy performed by a single surgeon
Open versus laparoscopic liver resection (2012−2013)
JPY (2013) Mean (SD) operation charge Mean (SD) surgical costs Total (SD) treatment charge Mean (SD) charge per day Rough (SD) balance Rough (SD) balance per day
396,256 (51,022) 105,440 (36,529) 1,185,839 (209,570) 101,551 (13,439) 1,080,399 (195,243) 92,639 (13,336)
530,280 (76,780) 130,686 (59,613) 1,204,614 (117,364) 138,805 (21,669) 1,073,928 (110,879) 123,373 (17,032)
<0.01 0.43 >0.99 <0.01 0.87 <0.01
Limongelli et al. 201428
Multiple Systematic review of costs associated with laparoscopic versus open liver resection
Open versus laparoscopic liver resection (9 studies)
USD (converted from various currencies)
Ward stay costs High-dependency unit costs Equipment costs Theater costs Total costs
5,291 5,857 2,207 11,406 23,419
2,972 1,829 3,545 14,538 19,269
NR NR NR NR NR
Global Value Dossier: Liver Resection 23
Table 1-3 Summary of key studies comparing economic outcomes of laparoscopic versus open liver resection Study Setting Study details Procedures Currency
(Cost year) Cost Outcome Open Laparoscopic P value
Medbery et al. 201416
United States
Retrospective record review of elective laparoscopic (n=48) and open (n=57) hepatectomy for both benign and malignant conditions at Emory University Hospital
Open versus laparoscopic liver resection (2008−2012)
USD Total operative Operating room Anesthesia Total postoperative PACU Floor ICU Radiology Pathology Laboratory tests Pharmacy Miscellaneous Total overall
10,411 (2,436) 8,708 (2,185) 1,702 (551) 16,341 (14,050) 673 (417) 6,049 (4,421) 2,844 (5,226) 1,165 (2,107) 344 (249) 1,555 (1,691) 2,260 (3,100) 1,450 (2,375) 26,751 (14,574)
16,605 (3,649) 15,287 (3,512) 1,318 (237) 9,075 (6,464) 574 (325) 4,522 (1,936) 1,052 (3,195) 223 (324) 237 (320) 798 (1,279) 1,208 (1,077) 461 (1,039) 25,679 (8,602)
<0.0001 <0.0001 <0.0001 0.001 0.18 0.029 0.041 0.003 0.058 0.012 0.027 0.009 0.65
Vanounou et al. 201029
United States
Deviation-based cost modeling analysis based on n=44 laparoscopic and n=29 open liver resections
Open versus laparoscopic liver resection (2002–2008)
USD (year not states)
Weighted median total hospital costs, all patients Median cost, on course Median cost minor deviation Median cost moderate deviation Median cost major deviation
18,043 17,290 16,201 19,891 24,425
15,104 13,962 14,441 18,648 33,703
NR 0.03 0.31 0.58 0.22
EUR, Euros; JPY, Japanese Yen; SD, standard deviation; SE, standard error; USD, United States dollars
24 Global Value Dossier: Liver Resection 24
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