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Editor's note
Primary liver cancer (PLC) is one of the most common cancers worldwide and a common cause of cancer death, with hepatocellular carcinoma (HCC) accounting for about 85% of all primary liver cancers. Despite advances in medical technology, curative surgical resection of primary tumors remains a key component of HCC treatment. Robotic hepatectomy (RLR) is a relatively new technology that combines the advantages of traditional surgery with the precision and flexibility of robotic surgical systems, but it is still unclear whether RLR is superior to traditional surgery in clinical practice.
Recently, Professor Zhu Zhenyu's team from the Fifth Medical Center of the PLA General Hospital published a retrospective cohort study in the journal Hepatology Intertional, evaluating the potential impact of RLR on the long-term prognosis of HCC patients, and at the same time evaluating the learning curve of the technology for HCC treatment.
Background:
Recent high-quality retrospective and prospective studies have confirmed the safety and efficacy of RLR in terms of short- and long-term prognosis, demonstrating its superiority over open hepatectomy (OLR). With regard to the comparison of RLR with laparoscopic hepatectomy (LLR), the existing high-quality retrospective studies have focused on short-term prognosis, and there is a serious lack of evidence for long-term prognosis.
Research Methods:
The study included patients who received RLR and LLR treatment for resected HCC between July 2016 and July 2021. The investigators used propensity score matching (PSM) to match patients in the RLR group and LLR group in a 1:3 ratio, comprehensively collected and analyzed the efficacy and safety data of the patients, and evaluated the learning curve of RLR.
Findings:
Over a five-year period, a total of 529 patients were enrolled, including 107 in the RLR group (85 males and 22 females) and 422 in the OLR group (348 males and 74 females). In the initial analysis, the investigators observed a significant reduction in ASA scores in patients who received RLR (P=0.03). In addition, there was a significant difference in IWATE standard difficulty between the RLR group and the OLR group before PSM (P=0.04). Compared with the LLR group, the ECOG PS score was also significantly lower in the RLR group (P=0.01). The CPT status of the RLR group was significantly higher than that of the LLR group (P=0.01).
After PSM, a total of 341 patients were enrolled, including 97 in the RLR group and 244 in the LLR group. The operation time in the RLR group was significantly longer [median (IQR), 210 (152.0~298.0) min vs. 183.5 (132.3~263.5) min; P=0.04], there was no significant difference in the prognosis between other perioperative and postoperative short-term patients.
Overall survival (OS) was similar between the two groups (P=0.43), but recurrence-free survival (RFS) was longer in the RLR group (median 65 months vs. 56 months, P=0.006). The estimated 5-year OS was 74.8% (95%CI: 65.4%~85.6%) and 80.7% (95%CI: 74.0%~88.1%) in the RLR and LLR groups, respectively. The estimated 5-year RFS in the RLR and LLR groups were 58.6% (95%CI: 48.6%~70.6%) and 38.3% (95% CI: 26.4%~55.9%), respectively. In multivariate Cox regression analysis, RLR (HR: 0.586, 95% CI: 0.393~0.874, P=0.008) became an independent predictor of recurrence rate reduction and RFS improvement.
Figure 1. a: Kaplan-Meier curve of overall survival (OS) after PSM; b: Kaplan-Meier curve of recurrence-free survival (RFS) after PSM
(Image from the literature)
The surgical learning curve showed that after approximately the 11th operation, the learning curve of RLR tended to stabilize and enter the proficiency stage.
Figure 2. The learning curve for robotic hepatectomy
(Image from the literature)
Conclusions of the study
The results of this study confirm the feasibility and safety of RLR as a surgical treatment for HCC. RFS improved in HCC patients after RLR, while OS was comparable to LLR. This study highlights the oncological feasibility of RLR for the treatment of HCC and lays the groundwork for future randomized controlled trials.
参考文献：Li,H.,Meng,L.,Yu,S.et al. Efficacy and safety of robotic versus laparoscopic liver resection for hepatocellular carcinoma: a propensity score-matched retrospective cohort study. Hepatol Int(2024). https://doi.org/10.1007/s12072-024-10658-6
Source: Editorial Board of International Liver Disease