Laparoscopic vs Open Hepatectomies
Original Investigation Research
Invited Commentary
A Comparison of Laparoscopic vs Open Hepatectomy Good Try, but We Still Have Selection Bias Thomas R. Biehl, MD
I commend Franken et al1 for an outstanding attempt to eliminate selection bias from this retrospective case series comparing laparoscopic with open hepatectomy for the management of mostly malignant disease of the liver. The auRelated article page 941 thors performed 52 laparoscopic hepatic resections during a period of approximately 10 years. They then tried to find comparable open liver resections with similar diagnoses and similar complexity during the same period. An investigator blinded to outcomes of the operations was chosen to match the cases. These 2 groups were thus matched and compared for outcomes. This novel approach seeks to eliminate the problem of selection bias that we see in any retrospective study. If you examine the 2 cohorts, they seem to be well matched. The patients were the same with respect to age, sex, extent of liver resection, degree of cirrhosis, dates of operation, and technique of resection, almost as if they had been prospectively randomized. On more careful review, however, differences are notable. Although the match with regard to extent of resection was close, absence of laparoscopic hepatic resections of segments 1 and 4 was distinct. In my opinion, these resections tend to be more complex. Similar open resections were not eliminated; they were just not studied. I believe this reveals that patients were chosen for a laparoscopic resection based on the ARTICLE INFORMATION Author Affiliation: Department of Surgery, Virginia Mason Medical Center, Seattle, Washington. Corresponding Author: Thomas R. Biehl, MD, Department of Surgery, Virginia Mason Medical Center, 1100 Ninth Ave, C6-SUR, Seattle, WA 98101 ([email protected]).
expectation of the surgeon that the outcome was going to be “good.” Why else would an experienced surgeon choose an operation? In fact, these experienced surgeons did just that. The outcomes are outstanding. Operative time, blood loss, complication and mortality rates, length of stay, and readmission rate are commendable, even benchmark numbers for any liver resection series (laparoscopic or open). We all do this every day. It is the mark of a good surgeon, not only technically, but judgmentally. In fact, most would argue that good preoperative judgment is the key to good outcomes despite technical expertise, but preoperative judgment cannot really be accounted for in this retrospective study. However, please do not misinterpret my point. The outcomes reported in this study are excellent. They clearly show that major hepatic resections can be safely performed laparoscopically. Patients may have less blood loss and shorter length of stay without more readmissions, morbidity, and mortality. As stated in the title, the short-term outcomes clearly are good. In any cancer series, however, the real proof is in long-term outcomes, and I am hopeful that long-term results will be reported later. Perhaps these results will be as good as or even better than those of open hepatectomy. If these long-term outcomes are improved, the improvement will be not only because the procedures are laparoscopic but also because they are performed well, by a good surgeon who knows when to operate, when not to, and how to do so.
Published Online: July 30, 2014. doi:10.1001/jamasurg.2014.1032. Conflict of Interest Disclosures: None reported.
laparoscopic vs open hepatectomy [published online July 30, 2014]. JAMA Surg. doi:10.1001 /jamasurg.2014.1023.
REFERENCE 1. Franken C, Lau B, Putchakayala K, DiFronzo LA. Comparison of short-term outcomes in
jamasurgery.com
JAMA Surgery September 2014 Volume 149, Number 9
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archsurg.jamanetwork.com/ by a University of Georgia User on 05/26/2015
947
Original Investigation Research
Invited Commentary
A Comparison of Laparoscopic vs Open Hepatectomy Good Try, but We Still Have Selection Bias Thomas R. Biehl, MD
I commend Franken et al1 for an outstanding attempt to eliminate selection bias from this retrospective case series comparing laparoscopic with open hepatectomy for the management of mostly malignant disease of the liver. The auRelated article page 941 thors performed 52 laparoscopic hepatic resections during a period of approximately 10 years. They then tried to find comparable open liver resections with similar diagnoses and similar complexity during the same period. An investigator blinded to outcomes of the operations was chosen to match the cases. These 2 groups were thus matched and compared for outcomes. This novel approach seeks to eliminate the problem of selection bias that we see in any retrospective study. If you examine the 2 cohorts, they seem to be well matched. The patients were the same with respect to age, sex, extent of liver resection, degree of cirrhosis, dates of operation, and technique of resection, almost as if they had been prospectively randomized. On more careful review, however, differences are notable. Although the match with regard to extent of resection was close, absence of laparoscopic hepatic resections of segments 1 and 4 was distinct. In my opinion, these resections tend to be more complex. Similar open resections were not eliminated; they were just not studied. I believe this reveals that patients were chosen for a laparoscopic resection based on the ARTICLE INFORMATION Author Affiliation: Department of Surgery, Virginia Mason Medical Center, Seattle, Washington. Corresponding Author: Thomas R. Biehl, MD, Department of Surgery, Virginia Mason Medical Center, 1100 Ninth Ave, C6-SUR, Seattle, WA 98101 ([email protected]).
expectation of the surgeon that the outcome was going to be “good.” Why else would an experienced surgeon choose an operation? In fact, these experienced surgeons did just that. The outcomes are outstanding. Operative time, blood loss, complication and mortality rates, length of stay, and readmission rate are commendable, even benchmark numbers for any liver resection series (laparoscopic or open). We all do this every day. It is the mark of a good surgeon, not only technically, but judgmentally. In fact, most would argue that good preoperative judgment is the key to good outcomes despite technical expertise, but preoperative judgment cannot really be accounted for in this retrospective study. However, please do not misinterpret my point. The outcomes reported in this study are excellent. They clearly show that major hepatic resections can be safely performed laparoscopically. Patients may have less blood loss and shorter length of stay without more readmissions, morbidity, and mortality. As stated in the title, the short-term outcomes clearly are good. In any cancer series, however, the real proof is in long-term outcomes, and I am hopeful that long-term results will be reported later. Perhaps these results will be as good as or even better than those of open hepatectomy. If these long-term outcomes are improved, the improvement will be not only because the procedures are laparoscopic but also because they are performed well, by a good surgeon who knows when to operate, when not to, and how to do so.
Published Online: July 30, 2014. doi:10.1001/jamasurg.2014.1032. Conflict of Interest Disclosures: None reported.
laparoscopic vs open hepatectomy [published online July 30, 2014]. JAMA Surg. doi:10.1001 /jamasurg.2014.1023.
REFERENCE 1. Franken C, Lau B, Putchakayala K, DiFronzo LA. Comparison of short-term outcomes in
jamasurgery.com
JAMA Surgery September 2014 Volume 149, Number 9
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archsurg.jamanetwork.com/ by a University of Georgia User on 05/26/2015
947
