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135Vol. 212, No. 1, January 2011 Letters

reat in recent years that laparoscopy might well offer littleore than additional cost.In addition to the problems extrapolating the Dagher

nd colleagues1 data to patients with HCC and cirrhosisn need of a major hepatectomy, there are also concernshat the study might have been susceptible to selectionias. As other investigators have noted,6 there are norospective randomized data comparing laparoscopicith open hepatectomy. Welsh and colleagues6 have ar-ued that criteria for laparoscopic hepatectomy oftenelects patients who need more straightforward opera-ions, with less risk of an involved margin and betterong-term survival compared with patients unfit for aaparoscopic approach. The criteria for a laparoscopicpproach set forth by Dagher and colleagues1 (compen-ated or no cirrhosis, low-grade esophageal varices andlatelet count �80 � 109/L, small tumors, no majorascular invasion, and American Society of Anesthesiol-gists score �3) seem somewhat nonspecific and unin-ormative about choice of operative approach becauseany of these criteria, except for tumor size, are used as

riteria for eligibility for liver resection among cirrhoticatients in general.In sum, Dagher and colleagues’ retrospective review of

ata from 3 institutions strongly suggest that laparoscopicepatectomy might be safe and effective for patients withCC and cirrhosis who are in need of a minor hepatec-

omy. Whether the findings from the current unrandom-zed series of laparoscopic hepatectomies are impacted byelection bias and whether these data can be extrapolated toatients with HCC and cirrhosis in need of a major hepa-ectomy remains largely unanswered. Additional studiesith a larger number of patients undergoing major hepa-

ectomy with HCC and cirrhosis will be needed beforeata-derived conclusions can be drawn concerning laparo-copic hepatectomy in this group of patients.

EFERENCES

. Dagher I, Belli G, Fantini C, et al. Laparoscopic hepatectomy forhepatocellular carcinoma: a European experience. J Am Coll Surg2010;211:16–23.

. Dagher I, Di Giuro G, Dubrez J, et al. Laparoscopic versus openright hepatectomy: a comparative study. Am J Surg 2009;198:173–177.

. Dagher I, O’Rourke N, Geller DA, et al. Laparoscopic majorhepatectomy: an evolution in standard of care. Ann Surg 2009;250:856–860.

. Tranchart H, Di Giuro G, Lainas P, et al. Laparoscopic resectionfor hepatocellular carcinoma: a matched-pair comparative study.Surg Endosc 2010;24:1170–1176.

. Gagandeep S, Selby R. Laparoscopic liver resections: extent ofresection defines length of stay. J Gastrointest Surg 2006;10:

1188; author reply 1188�1189. l

. Welsh FK, Tekkis PP, John TG, Rees M. Open liver resection forcolorectal metastases: better short- and long-term outcomes inpatients potentially suitable for laparoscopic liver resection. HPB(Oxford) 2010;12:188–194.

isclosure Information: Nothing to disclose.

eply

brahim Dagher, MD, PhD, Hadrien Tranchart, MD,ominique Franco, MD

lamart, France

e wish to thank Drs Khan, Pawlik, and Cunningham forheir interest in our work.1 We fully agree that major lapa-oscopic liver resection, especially in cirrhotic patients, is ahallenging procedure requiring additional studies and weave focused on this issue in many other publications.2-7

he aim of the current study1 was not to discuss majorepatectomies but to analyze our results of laparoscopicesections for hepatocellular carcinomas (HCCs).

Dr Khan and colleagues think that the number ofajor hepatectomies in the present series is small and

ot representative of resections for HCCs. However, theercentage of major hepatectomies in our series of lapa-oscopic hepatectomies for HCCs (9.8%) is similar tohe rate reported by teams performing open liver resec-ions for HCC,8 and is greater than previous large lapa-oscopic series.9,10 In fact, and independent of the lapa-oscopic or open approach, the type of liver resectionecommended in cirrhotic patients is a compromise be-ween parenchyma-sparing and an adequate tumor-freeargin. The concept of limited anatomical liver resec-

ion has been developed and is mostly applied in surgeryor HCCs, resulting in a small percentage of major hep-tectomies in all series. As a matter of fact, laparoscopy isery suitable for anatomical liver resections, includingajors, and we have discussed this debatable issue

lsewhere.6

Dr Khan and colleagues asked for the conversion rate forajor resections in cirrhosis. Sixteen patients had major

esections in this series, with 3 conversions (18.7%), a fig-re slightly higher than that in the large series of laparo-copic major liver resections6 (12.4%), which included aajority of noncirrhotic patients.We did not compare the mean operative time, blood

oss, and complications of major and minor hepatectomies.n all series of liver resections for tumors by a laparoscopic orpen approach, these figures are higher after major than after

imited liver resections. There is no reason to show it again.

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136 Letters J Am Coll Surg

Patient selection is paramount. We identified criteriaelated to the tumor (ie, size, position, vicinity to majoressels) that are specific to laparoscopy. The purpose of ourork was not to demonstrate that laparoscopy could besed in all patients, but that it was useful in selected pa-ients. Progress in laparoscopy will enable us to do morend more cases in the coming years, as it was in the past 5 years.o what extent laparoscopy will be used in treatment of HCCsannot yet be devised.Whatever place laparoscopy will have inesection of HCCs, it is our strong belief that selection criteriaelated to the underlying liver (compensated or not cirrhosis,ow-grade esophageal varices, platelet count �80 109/L) areot widened by the use of laparoscopy.In the absence of prospective randomized trials on laparo-

copic liver resection for HCC, the only available data arease-matched studies.11-13 These studies have answered ques-ions about the safety and postoperative course of laparoscopi-ally treated patients with HCC. To our knowledge, our se-ies1 is the largest retrospective study on laparoscopic liveresection for HCC, including 10% of major resections, whichs a high rate for this indication. Our study1 did not focus on

ajor liver resections but showed that they can be performeds well as limited liver resections for treatment of HCC, pro-ided that a careful selection of patients is made. We do notnow if it will be possible to design multicentric randomizedssays on the laparoscopic liver resection because of the limitedumber of patients, limited number of experienced teams,nd need for a large number of patients to demonstrate themall but indisputable benefit of this technique. As ever, newechniques bring controversies. Our role is to show by succes-ive clinical studies that laparoscopy is suitable for most liver

esections in most indications. D

EFERENCES

1. Dagher I, Giulio B, Fantini C, et al. Laparoscopic hepatectomyfor hepatocellular carcinoma: a European experience. J Am CollSurg 2010;211:16–23.

2. Dagher I, Caillard C, Proske JM, et al. Laparoscopic right hep-atectomy: original technique and results. J Am Coll Surg 2008;206:756–760.

3. Dagher I, Franco D. [Right hepatectomy by laparoscopic ap-proach]. J Chir (Paris) 2007;144:47–51.

4. Dagher I, Franco D. [Left hepatectomy: laparoscopic tech-nique]. J Chir (Paris) 2007;144:432–433.

5. Di Giuro G, Balzarotti R, Lainas P, et al. Laparoscopic left hep-atectomy with intraoperative biliary exploration for hepatoli-thiasis. J Gastrointest Surg 2009;13:1147–1148.

6. Dagher I, O’Rourke N, Geller DA, et al. Laparoscopic major hepatec-tomy: an evolution in standard of care. Ann Surg 2009;250:856–860.

7. Dagher I, Di Giuro G, Dubrez J, et al. Laparoscopicversusopenrighthepatectomy: a comparative study. Am J Surg 2009;198:173–177.

8. Hasegawa K, Kokudo N, Imamura H, et al. Prognostic impactof anatomic resection for hepatocellular carcinoma. Ann Surg2005;242:252–259.

9. Kaneko H, Tsuchiya M, Otsuka Y, et al. Laparoscopic hepatec-tomy for hepatocellular carcinoma in cirrhotic patients. J Hepa-tobiliary Pancreat Surg 2009;16:433–438.

0. Chen HY, Juan CC, Ker CG. Laparoscopic liver surgery for patientswith hepatocellular carcinoma. Ann Surg Oncol 2008;15:800–806.

1. Belli G, Limongelli P, Fantini C, et al. Laparoscopic and opentreatment of hepatocellular carcinoma in patients with cirrhosis.Br J Surg 2009;96:1041–1048.

2. Tranchart H, Di Giuro G, Lainas P, et al. Laparoscopic resectionfor hepatocellular carcinoma: a matched-pair comparativestudy. Surg Endosc 2010;24:1170–1176.

3. Laurent A, Cherqui D, Lesurtel M, et al. Laparoscopic liverresection for subcapsular hepatocellular carcinoma complicatingchronic liver disease. Arch Surg 2003;138:763–769.

isclosure Information: Nothing to disclose.