Minimally invasive versus open hepatectomy for the resection of colorectal liver metastases: A systematic review and meta-analysis


Ahmad Ozair, Faculty of Medicine, King George's Medical University, Uttar Pradesh, Lucknow, India.
Amelia Collings, Department of Surgery, Indiana University, Indianapolis, IN, USA.Follow
Alexandra M. Adams, Department of Surgery, Brooke Army Medical Centre, Fort Sam Houston, San Antonio, TX, USA.Follow
Rebecca Dirks, Department of Surgery, Indiana University, Indianapolis, IN, USA.
Bradley S. Kushner, Department of Surgery, Washington University School of Medicine in St. Louis, St. Louis, MO, USA.
Iswanto Sucandy, Digestive Health Institute, AdventHealth Tampa, Tampa, FL, USA.
David Morrell, Department of Surgery, Penn State Health Milton S. Hershey Medical Center, Hershey, PA, USA.
Ahmed M. Abou-Setta, Department of Community Health Sciences, Rady Faculty of Health Sciences, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada.Follow
Timothy Vreeland, Department of Surgery, Brooke Army Medical Centre, Fort Sam Houston, San Antonio, TX, USA.
Jake Whiteside, Department of Surgery, Indiana University, Indianapolis, IN, USA.
Jordan M. Cloyd, Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA.
Mohammed T. Ansari, School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada.Follow
Sean P. Cleary, Division of Hepatobiliary and Pancreas Surgery, Department of Surgery, Mayo Clinic, Rochester, MN, USA.
Eugene Ceppa, Department of Surgery, Indiana University, Indianapolis, IN, USA.Follow
William Richardson, Section of General Surgery, Oschner Clinic, New Orleans, LA, USA.
Adnan Alseidi, Department of Surgery, University of California San Francisco, San Francisco, CA, USA.
Ziad Awad, Department of Surgery, University of Florida College of Medicine-Jacksonville, Jacksonville, FL, USA.
Subhashini Ayloo, Department of Surgery, Warren Alpert Medical School, Brown University, Providence, RI, USA.Follow
Joseph F. Buell, Division of Surgery, Mission Healthcare System, HCA Healthcare, Asheville, NC, USA.Follow
Georgios Orthopoulos, Department of Surgery, University of Massachusetts Chan Medical School-Baystate, Springfield, MA, USA.
Samer Sbayi, Department of Surgery, Renaissance School of Medicine, Stony Brook University, New York, NY, USA.
Go Wakabayashi, Center for Advanced Treatment of Hepatobiliary and Pancreatic Diseases, Department of Surgery, Ageo Central General Hospital, Ageo City, Japan.
Bethany J. Slater, Advocate Aurora HealthFollow
Aurora Pryor, Department of Surgery, Stony Brook University, Stony Brook, NY, USA.
D Rohan Jeyarajah, Department of Surgery, TCU School of Medicine, and Methodist Richardson Medical Center, 2805 East President George Bush Highway, Fort Worth, TX, USA.


Background: While surgical resection has a demonstrated utility for patients with colorectal liver metastases (CRLM), it is unclear whether minimally invasive surgery (MIS) or an open approach should be used. This review sought to assess the efficacy and safety of MIS versus open hepatectomy for isolated, resectable CRLM when performed separately from (Key Question (KQ) 1) or simultaneously with (KQ2) the resection of the primary tumor.

Methods: PubMed, Embase, Google Scholar, Cochrane CENTRAL, International Clinical Trials Registry Platform (ICTRP), and databases were searched to identify both randomized controlled trials (RCTs) and non-randomized comparative studies published during January 2000-September 2020. Two independent reviewers screened literature for eligibility, extracted data from included studies, and assessed internal validity using the Cochrane Risk of Bias 2.0 Tool and the Newcastle-Ottawa Scale. A random-effects meta-analysis was performed using risk ratios (RR) and mean differences (MD).

Results: From 2304 publications, 35 studies were included for meta-analysis. For staged resections, three RCTs and 20 observational studies were included. Data from RCTs indicated MIS having similar disease-free survival (DFS) at 1-year (RR 1.03, 95%CI 0.70-1.50), overall survival (OS) at 5-years (RR 1.04, 95%CI 0.84-1.28), fewer complications of Clavien-Dindo Grade III (RR 0.62, 95%CI 0.38-1.00), and shorter hospital length of stay (LOS) (MD -6.6 days, 95%CI -10.2, -3.0). For simultaneous resections, 12 observational studies were included. There was no evidence of a difference between MIS and the open group for DFS-1-year, OS-5-year, complications, R0 resections, blood transfusions, along with lower blood loss (MD -177.35 mL, 95%CI -273.17, -81.53) and shorter LOS (MD -3.0 days, 95%CI -3.82, -2.17).

Conclusions: Current evidence regarding the optimal approach for CRLM resection demonstrates similar oncologic outcomes between MIS and open techniques, however MIS hepatectomy had a shorter LOS, lower blood loss and complication rate, for both staged and simultaneous resections.



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