Systematic review of laparoscopic versus open surgery in the treatment of non-parasitic liver cysts

We conducted a systematic review of the literature on the electronic databases Medline, Embase, Ovid and Cochrane to identify studies from 1990 to 2011 regarding the surgical management of non-parasitic liver cysts treated with laparoscopy (LT) and/or laparotomy (OT) to identify short-term and long-term outcomes of the relative treatments. Two reviewers independently extracted data regarding the following parameters: first author, year of publication, type of journal, study design, number of patients operated on, male/female ratio, mean age, mean size of the cysts treated, laparoscopic conversion rate, morbidity, mortality and recurrence in both groups (LT and OT). A qualitative analysis was carried out using the Pearson Chi square test and the Fischer’s exact test where necessary. The data analysis was conducted by dividing the sample into three periods in relation to the development of laparoscopic surgery: period 1 (P1), 1990–1995 “pioneering” period of laparoscopy; period 2 (P2), 1996–2000 period of the “development of laparoscopy”; period 3 (P3), 2001–2011 period of “diffusion of laparoscopy.” Thirty studies involving 948 patients comparing LT with OT were included in the final pooled analysis. Twenty-two studies were retrospective (73.3 %) and only 8 (26.7 %) were prospective. The number of publications increased during the three periods analysed. The correlation between the type of journal and the year of publication showed an increase (p = 0.048) in journals dedicated to LT during the three periods. In P1, the preferred approach was open surgery (66.3 %) with only 11 cases treated with LT. The conversion rate was 18.1 %. The overall complication rate was 33.3 % with a substantial equivalence between the two approaches (27.2 % for laparoscopic surgery and 36.6 % for laparotomic). The overall recurrence rate was 18.1 % with 36.3 % in the laparoscopic group and 9.2 % in the laparotomic group. In P2, the preferred approach was laparoscopic (56.7 %). The conversion rate was 2.3 %. The overall complication rate was 5.8 % but with some differences between the two approaches (10.3 % for the laparoscopic approach and 0 % for open surgery). The overall recurrence rate was 14.4 % with 17.4 % in the laparoscopic group and 10.4 % in the laparotomic group. In P3, the preferred approach was laparoscopic (69.9 %). The overall recurrence rate was 11.1 %; it was 6.1 % for the laparoscopic approach while it was 11.5 % for laparotomic. In all three periods analysed, the laparoscopic approach showed a statistically significant reduction in operative time (p = 0.009) and hospital stay (p = 0.001) and a significant (p < 0.05) reduction rate in symptomatic recurrences in patients with polycystic liver disease (25 %) as compared with simple liver cysts (7.5 %). The current data in the literature show that the laparoscopic approach may be the treatment of choice in patients with symptomatic non-parasitic cysts of the liver, providing the short-term advantages of minimally invasive surgery. Recurrence rates were acceptable and comparable to those of conventional surgery. Long-term outcomes should be verified by additional randomised controlled trials and long-term follow-ups.