The Efficacy And Safety Of Anterior Approach Versus Conventional Approach Liver Resection For Large Liver Cancer: A Systematic Review And Meta-Analysis

Background:To assess the safety and superiority of anterior approach(AA), a meta-analysis was undertaken to compare AA and conventional approach(CA) for major hepatectomy with regard to surgical and oncologic outcomes.Methods:A systematic literature search(Pub Med, EMBASE, Cochrane Library, Web of Knowledge, China National Knowledge Infrastructure, Chinese Medical Current Contents and Wanfang database) was performed to identity relevant articles up to December 2013. Comparative studies, including randomized controlled trials(RCTs) and non-randomized controlled trials(NRCTs), reporting the outcomes of both AA and CA for liver resection were included in this meta-analysis. Additional studies were identified by a manual search of all the references of all retrieved articles. All eligible literatures were included according to the inclusion and exclusion criteria. Quality assessment was made based on the Cochrane Collaboration’s risk of bias tool or Newcastle-Ottawa Scale, which was recommended in Cochrane Handbook for Systematic Reviews of Interventions. We collected the first author, year of publication, study population characteristics, study design and outco mes of each study. The evaluated endpoints were intraoperative outcomes, postoperative outcomes and oncological outcomes. Each result was extracted and filled in specialized electronic forms(Excels, Microsoft Office 2010). Two independent reviewers performed quality assessment and data attraction respectively. Disagreement in study inclusion and quality assessment between the two researchers was resolved by discussion and consensus. If this procedure failed, a third reviewer was adjudicated. Data were analyzed using Review Manager Software, version 5.1.Results:Thirteen eligible studies including 1287 patients were included. Pooled analysis showed that, compared with CA, AA hepatectomy significantly reduced intraoperative blood loss(MD-349.39; 95% CI-636.9--61.81; p=0.02), the requirement of blood transfusions(OR 0.41; 95% CI 0.24-0.72; p=0.002), operative time(MD-40.81, 95% CI-57.81--23.80; p<0.00001), mortality(OR 0.32; 95% CI 0.16-0.62; p=0.0009) and hospital stay(MD-4.52; 95% CI-8.36--0.69; p=0.02); AA also had lower postoperative recurrence rate(OR 0.45; 95% CI 0.29-0.69; p=0.0003) and higher 1- and 3-year overall disease survival rate(OR 2.72; 95% CI 1.59-4.66; p=0.0003; OR 4.47; 95% CI 2.61-7.63; p<0.00001).Conclusion:Based on current evidence, AA hepatectomy could improves surgical outcomes, including reducing the intraoperative blood loss decreasing the blood transfusion rate, decreasing operative time, reducing the hospital mortality and postoperative complication morbility, and shortening hospital stays comparing to CA hepatectomy. With regard to long-term and oncologic outcomes, AA hepatectomy could decrease the recurrence rate of hepatocellular carcinoma(HCC), and achieve better 1– year and 3-year overall survivals(OS) for HCC patients. However, further large-sized, well-designed and multicentric randomized controlled trials are still required before strong recommendations can be made.