Short- and medium-term impacts of unplanned intraoperative conversion during laparoscopic liver resection for hepatocellular carcinoma patients: a propensity score-matched study.

Background & aims: Although laparoscopic liver resection (LLR) has been widely accepted and considered a safe alternative to open liver resection in patients with hepatocellular carcinoma (HCC), it is still inevitable that some patients will encounter difficulties during LLR and need to be converted to open liver resection (OLR). It is currently uncertain whether unplanned intraoperative conversion to open liver resection (UCOLR) during LLR in HCC patients has a negative impact on patient prognosis, and there are still no comparative studies between HCC patients who underwent successful LLR and those who underwent UCOLR. Therefore, the aim of this study was to compare the short- and medium-term outcomes of LLR and UCOLR for HCC between two matched groups.

Methods: We retrospectively studied patients with HCC who underwent LLR or UCOLR between November 2016 and November 2022 at West China Hospital, Sichuan University. After 1:4 propensity score matching (PSM) was performed to reduce selection bias, the short-term and medium-term oncological outcomes of LLR and UCOLR were compared.

Results: Out of 846 patients included in this study (806 in the LLR group and 40 in the UCOLR group), 150 patients in the LLR group and 40 patients in the UCOLR group were selected for further comparison after 1:4 PSM. Compared to those who underwent successful LLR, patients who experienced UCOLR during LLR had significantly more intraoperative bleeding (500 ml vs. 200 ml, p < 0.001), required more blood transfusions (p < 0.001), had higher transfusion rates (47.5% vs. 6.0%, p < 0.001), and experienced longer operative times (244 min vs. 210 min, p = 0.042). Additionally, the overall complication rate was significantly greater in the UCOLR group than in the LLR group (45.0% vs. 20.7%, p = 0.002). Further analysis revealed that patients in the UCOLR group had a significantly greater risk of pulmonary infections (37.5% vs. 15.3%, p = 0.002), pleural effusion (27.5% vs. 7.3%, p < 0.001), anemia (22.5% vs. 4.7%, p < 0.001), and bile leakage (10.0% vs. 2.0%, p = 0.017). Moreover, those who experienced conversion to UCOLR reported significantly more postoperative pain (62.5% vs. 7.3%, p < 0.001) and longer hospital stays (6 days vs. 5 days, p = 0.005). In terms of quality of life (QOL) assessment, the LLR group showed a trend toward better general health at 1 and 3 months after surgery. However, no significant differences were detected between the LLR and UCOLR groups in terms of 3-year disease-free survival (76.4% for LLR vs. 63.5% for UCOLR, p = 0.075) or overall survival (82.2% for LLR vs. 71.7% for UCOLR, p = 0.124).

Conclusion: Compared to patients who underwent successful LLR, patients in the UCOLR group experienced worse short-term outcomes, although medium-term survival outcomes at 3 years were comparable. Additionally, segment 7 or 8 lesions with high AFP have a greater chance of conversion and an increased rate of recurrence after unplanned conversion. We should be cautious while selecting patient for laparoscopic liver resection.