TOPIC Can we expand the indications for laparoscopic liver resection? A systematic review and meta-analysis of laparoscopic liver resection for patients with hepatocellular carcinoma and chronic liver disease Zenichi Morise · Ruben Ciria · Daniel Cherqui · Kuo-Hsin Chen · Giulio Belli · Go Wakabayashi © 2015 Japanese Society of Hepato-Biliary-Pancreatic Surgery Abstract Liver resection (LR) for patients with hepatocellu- lar carcinoma (HCC) and chronic liver disease (CLD) poses a high risk of serious postoperative complications and multicentric metachronous lesions requiring repeated treat- ment. The efficacy of laparoscopic LR (LLR) for such patients has yet to be established. The objective of this study is to test the outcomes of LLR for HCC with the aim of con- sidering potential expansion of the indications for LLR. We performed a systematic review of the pertinent English- language literature. Our search yielded four meta-analyses and 23 comparative studies of LLR for HCC. On the basis of the findings from these studies and our newly conducted meta-analysis, the possibility for expanding the indications for LLR to HCC was examined. The studies show that LLR (vs open) for HCC generally yields better short-term out- comes without compromising long-term outcomes, and that incidences of postoperative ascites and liver failure are decreased with LLR. Several studies show the benefits of LLR for patients with severe CLD and for repeat surgery. Re- ductions of postoperative ascites and liver failure are among the advantages of LLR. These characteristics of LLR may allow us to expand the indications of LLR to HCC with CLD. Keywords Chronic liver disease · Hepatocellular carcinoma · Laparoscopic liver resection · Repeat hepatectomy Introduction Hepatocellular carcinoma (HCC) is the fifth most common primary cancer and the third most common cause of cancer- related deaths worldwide [1, 2]. The treatment options for HCC include liver resection (LR) [3], liver transplantation (LT) [4], transarterial chemoembolization (TACE), and local ablation therapy [5]. LR and LT provide the best hope for cure [6–8]. However, most patients with HCC have underlying chronic liver disease (CLD) and are thus at high risk for devel- opment of worrisome postoperative complications and metachronous multicentric recurrent lesions. When consider- ing the options for treatment of HCC in patients with CLD, the degree of invasive surgical stress, especially affecting the diseased liver, should be considered in addition to the oncological therapeutic effects. Patients with liver cirrhosis (LC) have various (overt and preliminary [9]) symptoms and a high risk of morbidity and even mortality following anesthe- sia and surgery [10, 11]. Even limited LR for severe cirrhotic patients often leads to refractory ascites, which can itself be- come fatal [12, 13]. Currently, LR, LT, local ablation therapy, or TACE is se- lected for HCC patients with CLD, depending on the tumor Z. Morise (✉) Department of Surgery, Fujita Health University School of Medicine, Banbuntane Houtokukai Hospital, 3-6-10 Otobashi, Nakagawa-ku, Nagoya, Aichi 454-8509, Japan e-mail: zmorise@aol.com R. Ciria Department of Surgery, Iwate Medical University School of Medicine, Iwate, Japan; Unit of Hepatobiliary Surgery and Liver Transplantation, University Hospital Reina Sofía, IMIBIC, Cordoba, Spain D. Cherqui Hepatobiliary Center, Paul Brousse Hospital, Villejuif, France K.-H. Chen Division of General Surgery, Department of Surgery, Far-Eastern Memorial Hospital, Taipei, Taiwan G. Belli Department of General and HPB Surgery, Loreto Nuovo Hospital, Napoli, Italy G. Wakabayashi Department of Surgery, Iwate Medical University School of Medicine, Iwate, Japan J Hepatobiliary Pancreat Sci (2015) ••:••–•• DOI: 10.1002/jhbp.215