Minimally Invasive Versus Open Liver Resections for Hepatocellular Carcinoma in Patients with Metabolic Syndrome

Objective: To compare minimally invasive (MILR) and open liver resections (OLR) for hepatocellular carcinoma (HCC) in patients with metabolic syndrome (MS). Summary background data: Liver resections for HCC on MS are associated with high perioperative morbidity and mortality. No data on the minimally invasive approach in this setting exist. Methods: A multicenter study involving 24 institutions was conducted. Propensity scores were calculated, and inverse probability weighting was used to weight comparisons. Short- and long-term outcomes were investigated. Results: 996 patients were included, 580 in OLR and 416 in MILR. After weighting, groups were well matched. Blood loss was similar between groups (OLR 275.9±3.1 vs. MILR 226±4.0, P=0.146). There were no significant differences in 90-day morbidity (38.9% vs. 31.9% OLRs and MILRs, P=0.08) and mortality (2.4% vs. 2.2% OLRs and MILRs, P=0.84). MILRs were associated with lower rates of major complications (9.3% vs. 15.3%, P=0.015), post hepatectomy liver failure (0.6% vs. 4.3%, P=0.008) and bile leaks (2.2% vs. 6.4%, P=0.003); ascites was significantly lower at postoperative day 1 (2.7% vs. 8.1%, P=0.002) and day 3 (3.1% vs. 11.4%, P<0.001); hospital stay was significantly shorter (5.8±1.9 vs. 7.5±1.7, P<0.001). There was no significant difference in overall survival and disease-free survival. Conclusions: MILR for HCC on MS is associated with equivalent perioperative and oncological outcomes to OLRs. Fewer major complications, post hepatectomy liver failures, ascites and bile leaks can be obtained, with shorter hospital stay. The combination of lower short-term severe morbidity and equivalent oncologic outcomes favor MILR for MS when feasible.