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Why do we need guidelines in laparoscopic liver surgery?
HPB
http://dx.doi.org/10.1016/j.hpb.2017.01.003
LEADING ARTICLE
Why do we need guidelines in laparoscopic liver surgery? Mohammad Abu Hilal University Hospital Southampton NHS Foundation Trust, Southampton, UK
Correspondence Mohammad Abu Hilal, University Hospital Southampton NHS Foundation Trust, E level, Tremona Road, Southampton, SO166YD, United Kingdom. E-mail: [email protected]
The enormous variety of laparoscopic liver resections currently being performed is a truly remarkable feat, especially when one considers that the first reported resection occurred only six years after the first laparoscopic cholecystectomy.1 Following this first liver resection, it took some time for the laparoscopic approach to gain popularity within the hepatobiliary surgical community. Initially, doubts were voiced as to the technical feasibility and safety of laparoscopy and this limited its initial dissemination. However, thanks to the efforts of dedicated pioneers, laparoscopic liver surgery (LLS) has undergone a progressive expansion since the late 1990’s. In the early stages of its development, LLS was only performed in the anterior segments of the liver, for primarily benign disease, in a carefully selected cohort. In 1996, Azagra and Kaneko reported the first series of anatomical resections performed laparoscopically.2,3 This set the precedent that left lateral sectionectomies be considered as the first standardised procedure in LLS. In the following years, LLS was performed for both colorectal liver metastases and hepatocellular carcinoma producing similar short-term oncological outcomes to those observed with open surgery.4 With the on-going expansion of LLS, the first consensus conference was held in Louisville in 2008.5 During the conference the available evidence was scrutinized by an eminent group of international hepatobiliary surgeons. It was concluded that solitary lesions of less than 5 cm in diameter, located in liver segments 2 to 6 were ideal for the laparoscopic approach, and further to this it was suggested that the laparoscopic approach be considered as standard practice for left lateral sectionectomies. However, the consensus also highlighted a lack of long-term oncological data and consistent evidence on the feasibility and safety of more technically demanding resections. The enthusiasm generated by this consensus meeting sparked international interest and served to further drive advancements. An exponential uptake of LLS was seen across the continents of America, Europe and Asia and was paralleled by an increase in available evidence. Resections have increased in complexity with
HPB 2017, 19, 287–288
the feasibility and safety of major hepatectomies as well as resections of the postero-superior segments being demonstrated in some advanced centres.6 As time has passed, evidence regarding the long-term oncological outcomes for malignant diseases has been published and this appears to have dispelled concerns of inferior oncological efficiency.7 This rapid and widespread diffusion of LLS mandated a reappraisal of its standing, and a second expert consensus conference was hosted in Morioka in 2014.8 Forty-three respected hepatobiliary surgeons convened for a three-day meeting to draw recommendations on LLS with particular consideration given to technical issues, disease-specific indications, surgical outcomes and cost-effectiveness. An integral component of these consensus meetings was the comparison of the laparoscopic and the traditional open approach to liver resection. Whilst all new advances must be compared to the current gold standard in any development, the emphasis given to this comparison may have been too great. It was clear that while LLS would continue to develop, open resections would still remain as a central pillar of liver surgery for decades to comes. Whilst the laparoscopic approach must continue to demonstrate a lack of inferiority to its open counter-part, the focus must now be to direct future developments exploring and testing the limits of its expansion within a clear, standardised and evidence-based pathway with patient safety being of paramount importance. In the last decade, clinical practice guidelines have been developed in various surgical fields to provide “systematically developed statements to assist practitioners and patient decisions about appropriate health care for specific clinical circumstances”.9,10 These guidelines are based upon focused research questions that are relevant to the topic and require a systematic review of current evidence to offer guidance in the appropriateness of care, to act as a rational base for referral, to reduce inappropriate variations of practise and to highlight shortcoming in existing evidence. A set of such guidelines is obligatory with the on-going development of LLS, and necessary for
© 2017 Published by Elsevier Ltd on behalf of International Hepato-Pancreato-Biliary Association Inc.
HPB
288
both tertiary-referral hepatobiliary centres already practising laparoscopic liver resections and for those surgical units wishing to explore the field. Clear guidelines will enable the expansion and adoption of LLS in a systematic, progressive step-wise manner taking into account locally available expertise and resources, thus providing reassurance to both surgeons and patients that safety and good clinical outcomes remain of the highest importance. These will facilitate decision-making in daily clinical practice for surgeons and provide reassurance on the appropriateness of their activity. In addition, healthcare systems may also benefit from a consistently delivered standard of care at a local and national level. Finally, guidelines can highlight the standard of care should there be any medico-legal contention.9,10 With these issues in mind, the first European Guidelines Meeting for Laparoscopic Liver Surgery (EGMLLS) will be held in Southampton (UK) in February 2017 and will finalise and disclose the results of a year-long project undertaken by an international panel of experts in the field. The development of these guidelines began with a meticulous literature review of all current and previous evidence with the specific intent of ascertaining the level of evidence available on the given topic. These data have been considered by leading surgeons who have been tasked with the development of concise, simple evidence-based recommendations following reiterative collective discussion. The guidelines produced will represent a comprehensive guide for all aspects of LLS covering indications, patient selection, feasibility and efficiency, surgical techniques and pathways for the future expansion. In an era of increasing complexity of medical care and the progressive acceptance of minimally-invasive approaches to surgical procedures, robust guidelines are required for the safe expansion of LLS. It is very much anticipated that the
HPB 2017, 19, 287–288
recommendations that have been produced for the consideration of the expert EGMLLS panel will serve as a template for future development and safe practice. References 1. Reich H, McGlynn F, DeCaprio J, Budin R. (1991) Laparoscopic excision of benign liver lesions. Obstet Gynecol 78:956–958. 2. Azagra JS, Goergen M, Gilbart E, Jacobs D. (1996) Laparoscopic anatomical (hepatic) left lateral segmentectomy-technical aspects. Surg Endosc 10:758–761. 3. Kaneko H, Takagi S, Shiba T. (1996) Laparoscopic partial hepatectomy and left lateral segmentectomy: technique and results of a clinical series. Surgery 120:468–475. 4. Abu Hilal M, Underwood T, Zuccaro M, Primrose J, Pearce N. (2010) Short- and medium-term results of totally laparoscopic resection for colorectal liver metastases. Br J Surg 97:927–933. 5. Buell JF, Cherqui D, Geller DA, O’Rourke N, Iannitti D, Dagher I et al. (2009) The international position on laparoscopic liver surgery: the Louisville Statement, 2008. Ann Surg 250:825–830. 6. Di Fabio F, Samim M, Di Gioia P, Godeseth R, Pearce NW, Abu Hilal M. (2014) Laparoscopic major hepatectomies: clinical outcomes and classification. World J Surg 38:3169–3174. 7. Cipriani F, Rawashdeh M, Stanton L, Armstrong T, Takhar A, Pearce NW et al. (2016) Propensity score-based analysis of outcomes of laparoscopic versus open liver resection for colorectal metastases. Br J Surg 103:1504–1512. 8. Wakabayashi G, Cherqui D, Geller DA, Buell JF, Kaneko H, Han HS et al. (2015) Recommendations for laparoscopic liver resection: a report from the second international consensus conference held in Morioka. Ann Surg 261:619–629. 9. Woolf SH, Grol R, Hutchinson A, Eccles M, Grimshaw J. (1999) Clinical guidelines: potential benefits, limitations, and harms of clinical guidelines. BMJ 20:527–530. 10. Shekelle PG, Woolf SH, Eccles M, Grimshaw J. (1999) Clinical guidelines: developing guidelines. BMJ 27:593–596.
© 2017 Published by Elsevier Ltd on behalf of International Hepato-Pancreato-Biliary Association Inc.
http://dx.doi.org/10.1016/j.hpb.2017.01.003
LEADING ARTICLE
Why do we need guidelines in laparoscopic liver surgery? Mohammad Abu Hilal University Hospital Southampton NHS Foundation Trust, Southampton, UK
Correspondence Mohammad Abu Hilal, University Hospital Southampton NHS Foundation Trust, E level, Tremona Road, Southampton, SO166YD, United Kingdom. E-mail: [email protected]
The enormous variety of laparoscopic liver resections currently being performed is a truly remarkable feat, especially when one considers that the first reported resection occurred only six years after the first laparoscopic cholecystectomy.1 Following this first liver resection, it took some time for the laparoscopic approach to gain popularity within the hepatobiliary surgical community. Initially, doubts were voiced as to the technical feasibility and safety of laparoscopy and this limited its initial dissemination. However, thanks to the efforts of dedicated pioneers, laparoscopic liver surgery (LLS) has undergone a progressive expansion since the late 1990’s. In the early stages of its development, LLS was only performed in the anterior segments of the liver, for primarily benign disease, in a carefully selected cohort. In 1996, Azagra and Kaneko reported the first series of anatomical resections performed laparoscopically.2,3 This set the precedent that left lateral sectionectomies be considered as the first standardised procedure in LLS. In the following years, LLS was performed for both colorectal liver metastases and hepatocellular carcinoma producing similar short-term oncological outcomes to those observed with open surgery.4 With the on-going expansion of LLS, the first consensus conference was held in Louisville in 2008.5 During the conference the available evidence was scrutinized by an eminent group of international hepatobiliary surgeons. It was concluded that solitary lesions of less than 5 cm in diameter, located in liver segments 2 to 6 were ideal for the laparoscopic approach, and further to this it was suggested that the laparoscopic approach be considered as standard practice for left lateral sectionectomies. However, the consensus also highlighted a lack of long-term oncological data and consistent evidence on the feasibility and safety of more technically demanding resections. The enthusiasm generated by this consensus meeting sparked international interest and served to further drive advancements. An exponential uptake of LLS was seen across the continents of America, Europe and Asia and was paralleled by an increase in available evidence. Resections have increased in complexity with
HPB 2017, 19, 287–288
the feasibility and safety of major hepatectomies as well as resections of the postero-superior segments being demonstrated in some advanced centres.6 As time has passed, evidence regarding the long-term oncological outcomes for malignant diseases has been published and this appears to have dispelled concerns of inferior oncological efficiency.7 This rapid and widespread diffusion of LLS mandated a reappraisal of its standing, and a second expert consensus conference was hosted in Morioka in 2014.8 Forty-three respected hepatobiliary surgeons convened for a three-day meeting to draw recommendations on LLS with particular consideration given to technical issues, disease-specific indications, surgical outcomes and cost-effectiveness. An integral component of these consensus meetings was the comparison of the laparoscopic and the traditional open approach to liver resection. Whilst all new advances must be compared to the current gold standard in any development, the emphasis given to this comparison may have been too great. It was clear that while LLS would continue to develop, open resections would still remain as a central pillar of liver surgery for decades to comes. Whilst the laparoscopic approach must continue to demonstrate a lack of inferiority to its open counter-part, the focus must now be to direct future developments exploring and testing the limits of its expansion within a clear, standardised and evidence-based pathway with patient safety being of paramount importance. In the last decade, clinical practice guidelines have been developed in various surgical fields to provide “systematically developed statements to assist practitioners and patient decisions about appropriate health care for specific clinical circumstances”.9,10 These guidelines are based upon focused research questions that are relevant to the topic and require a systematic review of current evidence to offer guidance in the appropriateness of care, to act as a rational base for referral, to reduce inappropriate variations of practise and to highlight shortcoming in existing evidence. A set of such guidelines is obligatory with the on-going development of LLS, and necessary for
© 2017 Published by Elsevier Ltd on behalf of International Hepato-Pancreato-Biliary Association Inc.
HPB
288
both tertiary-referral hepatobiliary centres already practising laparoscopic liver resections and for those surgical units wishing to explore the field. Clear guidelines will enable the expansion and adoption of LLS in a systematic, progressive step-wise manner taking into account locally available expertise and resources, thus providing reassurance to both surgeons and patients that safety and good clinical outcomes remain of the highest importance. These will facilitate decision-making in daily clinical practice for surgeons and provide reassurance on the appropriateness of their activity. In addition, healthcare systems may also benefit from a consistently delivered standard of care at a local and national level. Finally, guidelines can highlight the standard of care should there be any medico-legal contention.9,10 With these issues in mind, the first European Guidelines Meeting for Laparoscopic Liver Surgery (EGMLLS) will be held in Southampton (UK) in February 2017 and will finalise and disclose the results of a year-long project undertaken by an international panel of experts in the field. The development of these guidelines began with a meticulous literature review of all current and previous evidence with the specific intent of ascertaining the level of evidence available on the given topic. These data have been considered by leading surgeons who have been tasked with the development of concise, simple evidence-based recommendations following reiterative collective discussion. The guidelines produced will represent a comprehensive guide for all aspects of LLS covering indications, patient selection, feasibility and efficiency, surgical techniques and pathways for the future expansion. In an era of increasing complexity of medical care and the progressive acceptance of minimally-invasive approaches to surgical procedures, robust guidelines are required for the safe expansion of LLS. It is very much anticipated that the
HPB 2017, 19, 287–288
recommendations that have been produced for the consideration of the expert EGMLLS panel will serve as a template for future development and safe practice. References 1. Reich H, McGlynn F, DeCaprio J, Budin R. (1991) Laparoscopic excision of benign liver lesions. Obstet Gynecol 78:956–958. 2. Azagra JS, Goergen M, Gilbart E, Jacobs D. (1996) Laparoscopic anatomical (hepatic) left lateral segmentectomy-technical aspects. Surg Endosc 10:758–761. 3. Kaneko H, Takagi S, Shiba T. (1996) Laparoscopic partial hepatectomy and left lateral segmentectomy: technique and results of a clinical series. Surgery 120:468–475. 4. Abu Hilal M, Underwood T, Zuccaro M, Primrose J, Pearce N. (2010) Short- and medium-term results of totally laparoscopic resection for colorectal liver metastases. Br J Surg 97:927–933. 5. Buell JF, Cherqui D, Geller DA, O’Rourke N, Iannitti D, Dagher I et al. (2009) The international position on laparoscopic liver surgery: the Louisville Statement, 2008. Ann Surg 250:825–830. 6. Di Fabio F, Samim M, Di Gioia P, Godeseth R, Pearce NW, Abu Hilal M. (2014) Laparoscopic major hepatectomies: clinical outcomes and classification. World J Surg 38:3169–3174. 7. Cipriani F, Rawashdeh M, Stanton L, Armstrong T, Takhar A, Pearce NW et al. (2016) Propensity score-based analysis of outcomes of laparoscopic versus open liver resection for colorectal metastases. Br J Surg 103:1504–1512. 8. Wakabayashi G, Cherqui D, Geller DA, Buell JF, Kaneko H, Han HS et al. (2015) Recommendations for laparoscopic liver resection: a report from the second international consensus conference held in Morioka. Ann Surg 261:619–629. 9. Woolf SH, Grol R, Hutchinson A, Eccles M, Grimshaw J. (1999) Clinical guidelines: potential benefits, limitations, and harms of clinical guidelines. BMJ 20:527–530. 10. Shekelle PG, Woolf SH, Eccles M, Grimshaw J. (1999) Clinical guidelines: developing guidelines. BMJ 27:593–596.
© 2017 Published by Elsevier Ltd on behalf of International Hepato-Pancreato-Biliary Association Inc.