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RFA of HCC, and 5 by WR. Two patients were subjected to repeat hepatectomies in the treatment of primary or secondary
a third repeat procedure consisting of laparoscopic WR of tumors of the liver. [1-5] At present, studies on laparoscopic
segment II and VI, respectively, for a second recurrence of hepatic re-interventions are limited. Technical difficulties
liver metastases. of both repeat hepatectomy and laparoscopic approach
have slowed the spread of laparoscopic re-interventions on
The laparoscopic procedure was successfully completed in the liver. Few papers are available on this procedure, and
23 cases (95.9%). Adhesions were graded by the staff surgeons investigations are biased due to the retrospective nature
using the scale presented in Table 3, similar to that used in a of these studies, and to the time differences between the
multi-center study on adhesion prevention. Grades 3 and 4 series of open and laparoscopic interventions [Table 4]. [6,15-22]
[10]
adhesions were present in 5 patients (71.4%) in Group 1 and
2 patients (11.7%) in the Group 2. Tsuchiya et al. reported a cohort of 14 patients affected by
[20]
HCC, who underwent laparoscopic repeat resection after a
Of the 24 patients, one underwent conversion to laparotomy primary procedure (laparoscopic hepatectomy, RFA, resection
in Group 1, not because of adhesions but due to inadequate of extrahepatic metastasis, or diagnostic assessment).
control of the resection margin for a HCC located in They demonstrated that 2-year survival in patients with
segment IV. One patient, receiving a laparoscopic RFA of intrahepatic recurrence (100%) is significantly higher than in
a HCC of 28 mm in VII segment after primary intervention those with the extrahepatic recurrence (42.9%).
of segmentectomy associated with laparoscopic RFA, was
subjected to intestinal resection associated with ileostomy Indeed, the surgical strategy can be changed, and survival
to treat peritonitis from intestinal perforation that occurred
during laparoscopic RFA. can be impaired because of the presence of concomitant
peritoneal recurrence or because of extensive peritoneal
The mean operative time for re-intervention was significantly adhesiolysis. Biopsies of suspicious lesions are mandatory
longer for Group 1 (220.14 ± 80.06 min) than for to identify carcinomatous foci in dense adhesions to treat
Group 2 (150 ± 56.18 min; P = 0.001), whereas the mean the extrahepatic recurrence if possible, or to abstain from a
blood loss was comparable in both groups: 297 ± 134 mL surgical procedure.
in Group 1 and 272.2 ± 120 mL in Group 2 (P > 0.05).
[18]
The mean hospital stay was 6.4 ± 2.5 days in Group 1 and Shafaee et al. analyzed the experience of laparoscopic repeat
5.2 ± 3 days in Group 2 (P > 0.05). The resection margins liver resection of three institutions recruiting 76 patients (61
were disease-free in all the patients. with liver metastasis, 3 with HCC, and 12 with benign lesions)
divided into two groups according to the first surgical
The overall post-operative morbidity and mortality rates were approach. Peri-operative outcomes (in terms of estimated
29.1% (7/24) and 0%, respectively. According to Dindo-Clavien blood loss and intra-operative transfusions) were better in
classification, overall morbidity varied between Grades I patients with previous LRs than in patient with previous
[11]
and IIIa. Morbidity rate was 29.4% in Group 1 and 28.5% in ORs. Furthermore, long-term outcomes in terms of hepatic
Group 2. In Group 1, 2 patients had atelectasis treated by recurrence and the need for laparoscopic re-interventions
physical therapy (Clavien’s Grade II), 2 had pneumonia treated were compared with those of open repeat resection in other
by antibiotics (Clavien’s Grade II) and 1 had bleeding from studies, [1-5] and similar outcomes were observed.
one trocar site treated by compression (Clavien’s Grade II). In
Group 2, 1 patient presented post-operatively with moderate Table 4: Retrospective studies about laparoscopic repeat
ascites, 1 with atelectasis (Clavien’s Grade I) and 1 presented surgery of the liver
with intestinal perforation that occurred during a laparoscopic Year Author Number Tumor
RFA, requiring a re-intervention (Clavien’s Grade IIIa). 2009 Belli et al. [6] 12 cases HCC
2009 Liang et al. [15] 1 case HCC
Long-term outcomes in terms of hepatic recurrence have not 2010 Cheung et al. [16] 1 case HCC
yet been evaluated. 2011 Hu et al. [17] 6 cases HCC
[18]
2011 Shafaee et al. (tri-institutional) 76 cases HCC + metastasis
2011 Nakahira et al. [19] 15 cases HCC + metastasis
DISCUSSION
2012 Tsuchiya et al. [20] 16 cases HCC
2013 Kanazawa et al. [21] 40 cases HCC
Recurrence rate for liver malignancy is estimated at 2014 Shelat et al. [22] 19 cases HCC + metastasis
77-100% for HCC [12,13] and 60% for metastasis from colorectal 2015 Cioffi et al. (this series) 24 cases HCC + metastasis
carcinoma. Nevertheless, current data report efficacy of HCC: hepatocellular carcinoma
[14]
Hepatoma Research | Volume 1 | Issue 1 | April 15, 2015 33