title: Technology-assisted versus clamp-crush liver resection: a systematic review and meta-analysis.
abstract: OBJECTIVE
  To review the published evidence on technology-assisted liver resection regarding operative time, intraoperative bleeding, mortality, hospital stay, postoperative bile leak, and other outcomes.
  
  
  METHODS
  A systematic review of clinical studies comparing liver resection using vessel sealing systems (VSSs-LigaSure), Cavitron Ultrasonic Surgical Aspirator (CUSA), or radiofrequency dissecting sealer (RFDS) with the conventional clamp-crushing technique (CC) was performed. Data for each modality were synthesized and individually compared with CC with the methodology of meta-analysis.
  
  
  RESULTS
  In all, 8 randomized controlled trials (RCTs) and 7 nonrandomized studies evaluating 1539 patients were included. Compared with CC, the VSS group (3 RCTs and 3 nonrandomized studies) had significantly lower blood loss by a mean of 109 mL (weighted mean difference [WMD] = -109; 95% confidence interval [CI] = -192, -26; data on 494 patients), lower risk for postoperative bile leak by 63% (odds ratio [OR] = 0.37; CI = 0.17, 0.78; 559 patients), and shorter total hospital stay by 2 days (WMD = -2.04; CI = -3.08, -1; 340 patients); no difference was noted for liver parenchyma transection time and mortality. No difference was noted between CUSA (4 RCTs and 1 nonrandomized study) or RFDS (3 RCTs and 3 nonrandomized studies) versus CC for any of the studied outcomes.
  
  
  CONCLUSIONS
  Of the 3 modalities used in liver resection (VSS, CUSA, and RFDS), only VSS appeared to offer significant benefit over standard CC. However, the generalization of our findings is limited by the scarcity and clinical heterogeneity of the published studies. Large, well-designed and implemented RCTs are warranted to further investigate the usefulness of novel modalities used in liver resection.
authors.affiliation: Alfa Institute of Biomedical Sciences (AIBS), Athens, Greece. v.alexiou@aibs.gr
authors.forename: Vangelis G
authors.initials: VG
authors.lastname: Alexiou
authors.forename: Thomas
authors.initials: T
authors.lastname: Tsitsias
authors.forename: Michael N
authors.initials: MN
authors.lastname: Mavros
authors.forename: Gavin S
authors.initials: GS
authors.lastname: Robertson
authors.forename: Timothy M
authors.initials: TM
authors.lastname: Pawlik
mesh_terms: D004598:Electrosurgery; D006498:Hepatectomy / Q000009:adverse effects / Q000295:instrumentation* / Q000379:methods*; D006801:Humans; D007902:Length of Stay; D008099:Liver / Q000601:surgery; D011183:Postoperative Complications; D016896:Treatment Outcome