Long-term Outcomes Of Liver Resection Research Articles

Recurrence and tumor-related death after resection of hepatocellular carcinoma in patients with metabolic syndrome

Background and aimsMetabolic syndrome (MS) is a growing epidemic and a risk factor for the development of hepatocellular carcinoma (HCC). This study aims to investigate the long-term outcomes of liver resection (LR) for HCC in patients with MS. Rates, timing, patterns, and treatment of recurrences were investigated, and cancer-specific survivals were assessed. MethodsBetween 2001 and 2021, data from 24 centers were collected. Overall survival (OS), recurrence-free survival (RFS), and cancer-specific survival were analyzed as well as recurrence patterns and treatment. The analysis was conducted using a competing-risk framework. The trajectory of the risk of recurrence over time was applied to a competing risk analysis. For post-recurrence survival, death due to tumor progression was the primary endpoint whereas deaths with recurrence due to other causes were considered as competing events. Results813 patients were included. Median OS was 81.4 months (28.1-157.0), and recurrence occurred in 48.3% of patients with a median RFS of 39.8 months (15.7-174.7). Cause-specific hazard of recurrence showed a first peak 6 months (0.027), and a second peak 24 months (0.021) after surgery. The later the recurrence, the higher the chance of receiving curative intent approaches (p=0.001). Size >5cm, multiple tumors, microvascular invasion, and cirrhosis were independent predictors of recurrence showing a cause-specific hazard over time. RFS was associated with death for recurrence (HR 0.985, 95%CI: 0.977, 0.995; p=0.002). ConclusionsPatients with MS undergoing LR for HCC have good long-term survival. Recurrence occurs in 48% of patients with a double peak incidence and time-specific hazards depending on tumor-related factors and underlying disease. The timing of recurrence significantly impacts survival. Surveillance after resection should be adjusted over time depending on risk factors.

Impact of tumor size on the outcomes of hepatic resection for hepatocellular carcinoma: a retrospective study

BackgroundTo evaluate the impact of tumor size on the perioperative and long-term outcomes of liver resection for hepatocellular carcinoma (HCC).MethodsWe reviewed the patients’ data who underwent liver resection for HCC between November 2009 and 2019. Patients were divided into 3 groups according to the tumor size. Group I: HCC < 5 cm, Group II: HCC between 5 to 10 cm, and Group III: HCC ≥ 10 cm in size.ResultsThree hundred fifteen patients were included in the current study. Lower platelets count was noted Groups I and II. Higher serum alpha-feto protein was noted in Group III. Higher incidence of multiple tumors, macroscopic portal vein invasion, nearby organ invasion and presence of porta-hepatis lymph nodes were found in Group III. More major liver resections were performed in Group III. Longer operation time, more blood loss and more transfusion requirements were found in Group III. Longer hospital stay and more postoperative morbidities were noted in Group III, especially posthepatectomy liver failure, and respiratory complications.The median follow-up duration was 17 months (7–110 months). Mortality occurred in 100 patients (31.7%) and recurrence occurred in 147 patients (46.7%). There were no significant differences between the groups regarding recurrence free survival (Log Rank, p = 0.089) but not for overall survival (Log Rank, p = 0.001).ConclusionHCC size is not a contraindication for liver resection. With proper selection, safe techniques and standardized care, adequate outcomes could be achieved.

Long-term outcomes of liver resection for multiple hepatocellular carcinomas: Single-institution experience with 187 patients.

Backgrounds/AimsSurgical resection for the treatment of multiple hepatocellular carcinomas (HCCs) is controversial. This study aimed to evaluate the clinical and oncological outcomes after liver resection in patients with multiple HCCs.MethodsClinicopathological and survival data of 187 patients who underwent curative resection for multiple HCCs between June 2004 and December 2016 at Asan Medical Center, Seoul, South Korea were retrospectively reviewed. The prognostic factors for recurrence and survival were identified using univariate and multivariate analyses.ResultsOf the 187 patients, 153 (81.8%) had two nodules, 23 (12.3%) had three nodules, and 11 (5.9%) had more than three nodules. Multiple tumors were located in the ipsilateral lobe in 163 (87.2%) patients. Anatomical resection, non-anatomical resection, and both types of resections were performed in 81.3%, 8.0%, and 10.7% patients, respectively. Recurrence occurred in 133 (71.1%) patients, and the mean time to recurrence after surgery was 34.2 months. Independent risk factors for tumor recurrence in multivariate analyses were indocyanine green retention rate at 15 min ≥15%, preoperative alpha-fetoprotein level ≥400 ng/ml, and total tumor diameter ≥6 cm. The 1-, 3-, 5-, and 10-year disease-free survival rates were 94.1%, 81.7%, 69.7%, and 39.4%, respectively, and the 1-, 3-, 5-, and 10-year survival rates were 93.5%, 74.2%, 64.9%, and 38.8%, respectively.ConclusionsOur experience shows that liver resection can be considered a first-line treatment option for selected patients with multiple HCCs who have well-preserved liver function.

Short- and Long-Term Outcomes of Liver Resection for Intrahepatic Cholangiocarcinoma Associated with the Metabolic Syndrome.

While the metabolic syndrome (MS) is being recognized as an important risk factor for intrahepatic cholangiocarcinoma (ICC), the outcomes of liver resection in this context remain poorly described. This study aims to report the short- and long-term results of hepatectomy for patients with MS as risk factor for the development of ICC (MS+). All patients undergoing hepatectomy for ICC between 2000 and 2016 at a single center were retrospectively analyzed. The perioperative outcomes of MS+ and ICCpatients without MS (MS-) were compared. Among 115 resected ICC patients, 40 (34.8%) were MS+ and 75 (65.2%) were MS-. MS+ exhibited an increased Charlson comorbidity index (5 ± 2 vs. 2 ± 2, p < 0.001) than MS- patients. While operative characteristics did not differ significantly between the 2 groups, MS+ experienced higher rate of major complications (62.5 vs. 29.3%, p = 0.001). On multivariate analysis, MS+ was an independent risk factor of major complication (HR 2.86, 95% CI 1.07-7.60, p = 0.036) and major cardiorespiratory complication (HR 4.35, 95% CI 1.50-12.62, p = 0.007). Pathological analysis revealed that MS+ displayed higher rates of non-alcoholic fatty liver disease (60.0 vs. 31.1%, p = 0.003) and non-alcoholic steatohepatitis (25 vs. 5.4%, p = 0.005). MS+ was independently associated with decreased risk of recurrence (HR 0.47, 95% CI 0.26-0.85, p = 0.001). MS+ accounts for 35% of resected ICC patients. The existence of significant cardiovascular comorbidities increases postoperative morbidity and requires specific management.

Short-term and long-term outcomes of liver resection for HCC patients with portal vein tumor thrombus

BackgroundPortal vein tumor thrombosis (PVTT) in hepatocellular carcinoma (HCC) is a sign of advanced stage disease, which is associated with poor prognosis. Liver resection (LR) may provide better prognosis in selected patients. In the present study, we aimed to assess information from HCC patients with PVTT who died within 3 months or 2 years after LR in order to identify preoperative factors correlated to short-term or long-term survival, by which inappropriate selection of patients for LR might be avoided in the future.MethodsA retrospective cohort study consisting of 487 consecutive cases of HCC patients with PVTT was performed from 2008 to 2010 at Eastern Hepatobiliary Surgery Hospital. Medical records, including laboratory values, imaging results and treatment information, were obtained from participants. Study endpoints were survival at 3 months and 2 years post-hepatectomy. Logistic regression analysis was utilized to determine the significant pre-operative factors influencing short-term or long-term survival.ResultsIn multivariable analysis, α-fetoprotein, total bilirubin and radiologic ascites were significantly associated with short-term survival, while α-fetoprotein level, clinical significant portal hypertension, extent of PVTT and tumor differentiation were factors significantly associated with long-term survival.ConclusionsThe independent risk factors of poor short-term survival were the liver function-associated, such as factors radiologic ascites and total bilirubin, while tumor differentiation indicating the tumor biology was associated with longer-term survival. In addition, α-fetoprotein was a risk factor associated with both short-term and longer-term survivals.

Systematic Review and Meta-Analysis of Liver Resection for Colorectal Metastases in Elderly Patients

Background: This systematic review and meta-analysis evaluated the short- and long-term outcomes of liver resection for colorectal liver metastases (CRLM) in elderly patients. Methods: A PubMed, EMBASE, and Cochrane Library search was performed from January 1995 to April 2017, for studies comparing both short- and long-term outcomes in younger and elderly patients undergoing liver resection for CRLM. Results: Eleven studies comparing patients aged <70 years with patients aged >70 years and 4 studies comparing patients aged <75 years with patients aged >75 years were included. Postoperative morbidity was similar in patients aged >70 years (27 vs. 30%; p = 0.35) but higher in patients aged >75 years (21 vs. 32%; p = 0.001). Postoperative mortality was higher in both patients aged >70 years (2 vs. 4%; p = 0.01) and in patients aged >75 years (1 vs. 6%; p = 0.02). Mean 5-year overall survival was lower in patients aged >70 years (40 vs. 32%; p < 0.001) but equal in patients aged >75 years (42 vs. 32%; p = 0.06). Conclusion: Although postoperative morbidity and mortality were increased with higher age, liver resection for CRLM seems justified in selected elderly patients.

Perioperative and long-term outcomes of liver resection for hepatitis B virus-related hepatocellular carcinoma without versus with hepatic inflow occlusion: study protocol for a prospective randomized controlled trial.

BackgroundThe high prevalence of hepatitis B virus (HBV) imposes a huge burden of hepatocellular carcinoma (HCC) in Asia. Surgical resection remains an important therapeutic strategy for HCC. Hepatic inflow occlusion, known as the Pringle maneuver, is the most commonly used method of reducing blood loss during liver parenchymal transection. A major issue with this maneuver is ischemia-reperfusion injury to the remnant liver, and the hemodynamic disturbance it induces in the tumor-bearing liver raises an oncological concern. Given the technical advances in living donor liver transplantation, vascular occlusion in liver resection can be avoided in experienced hands. The aim of this study is to compare the perioperative and long-term outcomes of liver resection for HBV-related HCC without versus with hepatic inflow occlusion.Methods/designThis study will include eligible patients with HBV-related HCC elected for liver resection. Fifty-seven patients will be enrolled in each randomization arm to detect a 20 % difference in the serum level of total bilirubin on postoperative day 5 (80 % power and α = 0.05). The secondary endpoints include procedural parameters, perioperative liver function and inflammatory response, postoperative morbidity and mortality, and long-term outcomes. Patients will be followed for up to 5 years. Data will be statistically analyzed on an intention-to-treat basis.DiscussionThis prospective randomized controlled trial is designed to compare the perioperative and long-term outcomes of liver resection for HBV-related HCC without versus with vascular occlusion. The clinical implications of these outcomes may change current surgical practice and fill the oncological gaps therein.Trial registrationClinicaltrials.gov identifier NCT02563158. Registered on 28 September 2015.Electronic supplementary materialThe online version of this article (doi:10.1186/s13063-016-1621-9) contains supplementary material, which is available to authorized users.

Surgical Management of Renal Cell Cancer Liver Metastases.

There is an increasing trend toward performing liver resections in the setting of metastatic disease. Renal cell cancer liver metastases are associated with poor survival. The indications for and the short- and long-term outcomes of liver resection for renal cell cancer liver metastases remain not well defined. A focused, structured literature review on PubMed, EMBASE, and Google Scholar was performed to identify primary research articles, on short- and long-term outcomes and prognostic factors of patients undergoing liver resection for renal cell cancer liver metastases. Only studies with a sample size equal or larger than 10 patients were included. A total of 10 studies met inclusion criteria. Median overall survival ranged between 16 and 142 months. Major morbidity was rare while 30-day postoperative mortality was less than 5%. A disease-free interval of more than 2 years from nephrectomy to evidence of liver metastases and a radical, microscopically negative surgical resection (R0) were the most consistent prognostic factors that, in turn, could be used as potential selection criteria to identify patients who can benefit the most from liver-directed surgery. Liver surgery for renal cell cancer liver metastases can be performed with low mortality, acceptable morbidity, and promising survival benefit in carefully selected patients. Studies that can assess the impact of modern, targeted regimens in the preoperative setting and liver-directed surgery and in turn shape new selection criteria are warranted.

Morbidity of hepatic resection for intermediate and advanced hepatocellular carcinoma.

According to current treatment guidelines, surgical resection of hepatocellular carcinoma (HCC) is mostly restricted to a limited subgroup of patients. Due to improved surgical techniques and perioperative management, liver resections may also be performed more extendedly and also in cirrhotic livers with clinical signs of portal hypertension in selected patients. In this study, the clinical and long-term outcomes of liver resection in HCC patients with or without liver cirrhosis were evaluated. One hundred fifty-eight patients undergoing liver resection for primary HCC at our institution were identified. Logistic and Cox regression analyses were used to identify prognostic parameters for postoperative complications and survival. In our cohort of patients, there was no association between clinical parameters or extent of surgical resection and postoperative morbidity. Only Barcelona Clinic Liver Cancer (BCLC) stage C patients were at significantly higher risk for major complications (OR 5.27, P = 0.009). Risk factors influencing long-term survival were patient age (HR 1.026, P = 0.027) and BCLC stage C (HR 3.47, P = 0.002). Compared to patients without liver cirrhosis, BCLC stage A and B patients undergoing resection were at similar risk for the development of severe complications and long-term mortality. Liver resection as potentially curative therapy can be performed in selected patients in BCLC stage B, as well as in patients with clinical signs of portal hypertension. The resection of HCC-classified BCLC stage C is feasible but associated with significant morbidity and mortality.

Implication of Microscopic and Macroscopic Vascular Invasion for Liver Resection in Patients with Hepatocellular Carcinoma

Background and Aim: Long-term data after liver resection for hepatocellular carcinoma (HCC) with vascular invasion are rare for non-Asian patients. The aim of the present study was to analyze the long-term outcome of liver resection for HCC with vascular invasion and to compare the results of subgroups with micro- and macrovascular invasion. Methods: From January 2000 to September 2010, 288 patients without extrahepatic metastases underwent liver resection for HCC. In 107 out of 288 patients (37%), vascular invasion was found in the final pathological analysis. The long-term outcome as well as the perioperative course of these patients was analyzed using a prospective database. Results: The 1-, 3- and 5-year cumulative survival rate of HCC patients with vascular invasion was 64.3, 41.4 and 23.9%, respectively. The median survival was 19 months. In the multivariate analysis, the overall survival was not influenced by the type of vascular invasion (micro- vs. macrovascular invasion), however overall survival was significantly impaired in case of lymphatic vessel invasion, intraoperative blood transfusions, need of fresh frozen plasma application, prolonged ICU stay and elevated preoperative bilirubin levels. Conclusions: Acceptable survival rates can be achieved in selected patients with macrovascular invasion after surgical resection, which is not markedly different from those with microvascular invasion. In view of an otherwise poor prognosis, liver resection seems to be justified for selected HCC patients with macrovascular invasion, although this stands in contrast with the BCLC recommendations. However, it is in accordance for example with the guidelines of the Asia-Pacific Association for the Study of the Liver.

A Worldwide Survey of the Current Daily Practice in Liver Surgery

Background: Liver resection remains the mainstay of curative treatment for liver malignancies. A variety of preoperative assessments and surgical techniques have improved the short- and long-term outcomes of liver resection in patients with liver tumors. Recently, laparoscopic hepatectomies have been increasingly performed. The aim of the present study is to survey the current practice of liver surgery in high-volume centers in the world. Methods: A questionnaire on the preoperative assessment for liver surgery, open hepatectomy, and laparoscopic hepatectomy was sent to 94 liver centers in the world. Results: Forty-two centers (45%) responded to this survey (29 Asian, 9 European, and 4 North American centers). All but one of the centers evaluated the future liver remnant (FLR) volume, and 95% of them performed preoperative portal vein embolization to increase the FLR volume. In half of the centers, the required FLR volume was over 30% in patients with normal liver and 50% in patients with cirrhotic liver. To reduce the intraoperative blood loss, half of the centers routinely used Pringle’s maneuver, and 85% restricted the intraoperative fluid infusion to reduce the central venous pressure. More than 10 laparoscopic hepatectomies were performed per year in 62% of the centers, and more than 30 were performed in 26%, respectively. Laparoscopic major hepatectomies were performed in 24%. Two-thirds answered that the laparoscopic approach would be feasible in donor hepatectomy. Conclusion: The evaluation of FLR volume in patients with normal or cirrhotic liver and the usage of preoperative portal vein embolization have become essential practice in more than 90% of the centers. Reduced blood loss has been achieved using Pringle’s maneuver, restriction of fluid infusion, and a variety of surgical devises. The laparoscopic approach is increasingly extended to major hepatectomy or donor hepatectomy.

Evolution of Long-Term Outcome of Liver Resection for Colorectal Metastases: Analysis of Actual 5-Year Survival Rates over Two Decades

Liver resection (LR) is the only potentially curative treatment of colorectal liver metastases (CRLM). Its outcome over the past 2 decades was studied using actual 5-year survival rates. Data of 393 consecutive patients who underwent LR for CRLM at Mauriziano Umberto I (Turin) until June 2005 were analyzed. Excluding R2 resections (n = 4) or incomplete 5-year follow-up (n = 13), 376 patients were divided according to LR date into groups A (before 1995: 90 patients), B (1995-2000: 94 patients), C (2001-2005: 192). Group C presented increased multiple and bilobar metastases compared with combined group A and B (C vs AB: 54.7% vs 40.2%, P = 0.005; 28.1% vs 19.0%, P = 0.038, respectively), decreased metastases diameter (C vs AB: 32 vs 40 mm, P = 0.0001). The 5-year overall survival, calculated excluding 4 operative mortalities (group AB), increased over the years (A, 20.5%; B, 32.6%; C, 46.4%; P < 0.0001). Early recurrences (1 year) were not decreased, extrahepatic recurrences even increased (C vs AB: 17.2% vs 8.6%, P = 0.015). Recurrence-free 5-year survival improved (C vs AB: 23.4% vs 13.9%, P = 0.019) linked to decreased liver recurrences (C vs AB: 26.8% vs 37.4%, P = 0.023). Resection rate (59% overall for liver recurrence) increased along with 5-year survival after recurrence (A, 4.0%; B, 14.2%; C, 21.4%; P < 0.0001). Survival improvement was confirmed for multiple (P = 0.003) and synchronous metastases (P = 0.008), N+ tumors (P = 0.005), and in patients without chemotherapy (P = 0.001). Long-term outcome of LR for CRLM improved over 20 years, even in patients with negative prognostic factors, linked to hepatic recurrences reduction and increased survival after recurrence.

Prognostic factors in the surgical treatment of caudate lobe hepatocellular carcinoma

To evaluate the short- and long-term outcomes of liver resection for caudate lobe hepatocellular carcinoma (HCC). We retrospectively analyzed 114 consecutive patients with HCC, originating from the caudate lobe, who underwent resection between January 2001 and January 2007. Univariate and multivariate analyses were performed on several clinicopathologic variables to determine the factors affecting long-term outcome and intrahepatic recurrence. Overall mortality and morbidity were 0% and 18%, respectively. After a median follow-up of 31 mo (interquartile range, 11-66 mo), tumor recurrence had occurred in 76 patients (66.7%). The 1-, 3-, and 5-year disease-free survival rates were 65.7%, 38.1%, and 18.4%, respectively. The 1-, 3-, and 5-year overall survival rates were 76.1%, 54.7%, and 31.8%, respectively. Univariate analysis showed that subsegmental location of the tumor (45.7% vs 16.2%, P = 0.01), liver cirrhosis (12.3% vs 47.9%, P = 0.03), surgical margin (18.5% vs 54.6%, P = 0.04), vascular invasion (37.9% vs 23.2%, P = 0.04) and extended caudate resection (42.1% vs 15.4%, P = 0.04) were related to poorer long-term survival. Multivariate analysis showed that only subsegmental location of the tumor, liver cirrhosis and surgical margin were significant independent prognostic factors. Hepatectomy was an effective treatment for HCC in the caudate lobe. The subsegmental location of the tumor, liver cirrhosis and surgical margin affected long-term survival.

Perioperative Factors Affecting Long-Term Outcomes of 473 Consecutive Patients Undergoing Hepatectomy for Hepatocellular Carcinoma

The aim of this study was to evaluate the long-term outcomes of liver resection for hepatocellular carcinoma (HCC). Between January 1993 and December 2002, a total of 473 patients underwent hepatectomy for HCC at a medical center in Taiwan. Clinicopathological and surgical characteristics were studied to identify prognostic factors influencing survival. There were 379 men (80.1%) with mean +/- standard deviation age of 53.1 +/- 13.1 years. The etiology of HCC was hepatitis B (n = 277), hepatitis C (n = 90), coinfection with hepatitis B and C (n = 47), and non-B or C hepatitis (n = 50). The blood loss was 282.3 +/- 370.5 ml, and 411 patients (86.9%) did not require perioperative blood transfusion. On univariate analysis, the statistically significant independent factors for disease-free survival were alfa-fetoprotein (AFP) levels of >400 ng/ml, indocyanine green retention of >10%, Pringle maneuver, blood transfusion, tumor diameter >5 cm, bilateral tumors, microvascular invasion, adjacent tissue invasion, daughter nodules and cirrhotic liver. The univariate factors influencing overall survival were similar to those influencing disease-free survival except for AFP. Independent factors that statistically significantly affected overall survival on multivariate analysis included Pringle maneuver, blood transfusion, tumor diameter >3 cm, microvascular invasion, daughter nodules, and liver cirrhosis. The 1-, 5-, and 10-year disease-free survival were 75.3, 43.3, and 22.3%, respectively. The 1-, 5-, and 10-year overall survival were 86.7, 55, and 33.7%, respectively. AFP, indocyanine green retention of >10%, blood transfusion, Pringle maneuver, tumor diameter of >3 cm, bilateral tumors, microvascular invasion, adjacent tissue invasion, daughter nodules, and liver cirrhosis influence survival.

Long-Term Outcome of Liver Resection and Transplantation for Caroli Disease and Syndrome

To assess the preoperative disease characteristics as well as the rate of postoperative complications, patient survival, and course of symptoms after liver resection or orthotopic liver transplantation (OLT) for Caroli disease (CD) or syndrome (CS). The clinical course of monolobar or diffuse CD or CS is often characterized by multiple conservative treatment attempts and interventions with recurrent episodes of cholangitis and a serious reduction in quality of life. The role and effectiveness of surgical treatment is still not well defined. Between June 1989 and December 2002, we treated 44 consecutive patients with CD or CS who had failure of conservative treatment before and were referred for surgical intervention. Demographic and clinical data, operative procedures and related morbidity, course of symptoms, and long-term follow-up were reviewed. Four patients with palliative resection for cholangiocarcinoma and incidental diagnosis of CD were excluded from the analysis. Twenty-two women and 18 men had a median period of 26.5 months from onset of symptoms to surgical therapy. Their median age at therapy was 49 years and 80% of the patients had monolobar disease with a left-right ratio of 2.6 to 1. Thirty-three (82.5%) patients underwent liver resection, while 4 (10%) patients received OLT for diffuse disease. Biliodigestive anastomosis alone was performed in 3 (7.5%) patients with contraindications to OLT. Patients (37.5%) had minor postoperative complications, which were treated conservatively, while 2 (5%) transplanted patients had a reoperation due to intraperitoneal bleeding. After a median follow-up of 86.5 months, we observed a favorable patient and graft survival. Three deaths during follow-up were not related to treatment or disease complications. Follow-up of disease-related symptoms, biliary complications, and antibiotic treatment revealed a significant improvement. Our data show that liver resection for monolobar CD or CS and OLT for diffuse manifestations can achieve excellent long-term patient survival with marked symptom relief. Because of life-threatening long-term complications such as biliary sepsis and development of cholangiocarcinoma, timely indication for surgical treatment is crucial.

Portal Hypertension: Contraindication to Liver Surgery?

In recent decades liver resection has become a safe procedure, mainly because of better patient selection. Despite this progress, however, outcomes of hepatectomy in cirrhotic patients with portal hypertension are still uncertain. The aim of this study was to elucidate early and long-term outcomes of liver resection in these patients. Between 1985 and 2003, a total of 245 cirrhotic patients underwent hepatectomy for HCC. Altogether, 217 patients were eligible for this analysis and were divided into two groups according to the presence of portal hypertension at the time of surgery: 99 patients with portal hypertension and 118 without it. Patients with portal hypertension had worse preoperative liver function (Child-Pugh A class patients: 66.7% vs. 94.9%; P<0.0001). No differences were encountered in terms of intraoperative and pathology data. Operative mortality was similar (11.1% vs. 5.1%; P=0.100), but patients with portal hypertension had higher morbidity (43.4% vs. 30.5%; P=0.049) and received a higher rate of blood and plasma transfusions (51.5% vs. 32.2%, P=0.004; 77.8% vs. 57.6%, P=0.0017). Considering only Child-Pugh A patients, short-term results were similar in the two groups in terms of mortality, morbidity, and transfusion rates. The 5-year survival rate was significantly higher in patients without portal hypertension (39.8% vs. 28.9%; P=0.020), although when considering only Child-Pugh A patients no difference of survival was encountered. Multivariate analysis identified Child-Pugh classification, tumor diameter, and vascular invasion as independent predicting factors for survival. Portal hypertension should not be considered an absolute contraindication to hepatectomy in cirrhotic patients. Child-Pugh A patients with portal hypertension have short- and long-term results similar to patients with normal portal pressure.

Spontaneous Rupture of Hepatocellular Carcinoma

To review the management of spontaneous ruptured hepatocellular carcinoma in the acute phase, the definitive treatment after hemostasis, and the prognosis. A MEDLINE search was undertaken to identify articles in English from 1970 to 2004 using the key words "hepatocellular carcinoma," "spontaneous rupture," "therapeutic embolization," and "laparoscopy." Additional articles were identified by a manual search of the references from the key articles. There were no exclusion criteria for published information on the topics. All studies that contained material applicable to the topic were considered. In the acute phase, transarterial embolization for hemostasis has a high success rate (53%-100%). It has a lower 30-day mortality rate than open surgical methods (0%-37% vs 28%-75%). For the definitive treatment, staged liver resection has a higher resection rate (21%-56% vs 13%-31%) and a lower in-hospital mortality rate (0%-9% vs 17%-100%) than 1-stage emergency liver resection. Staged liver resection has a good survival rate (1-year survival, 54.2%-100%; 3-year survival, 21.2%-48%; 5-year survival, 15%-21.2%). Transarterial embolization is effective in controlling bleeding from ruptured hepatocellular carcinoma in the acute phase. The serum bilirubin level, shock on hospital admission, and prerupture disease state are important prognostic factors to predict survival in the acute phase. For definitive treatment, staged liver resection after attaining hemostasis is better than 1-stage emergency liver resection. Laparoscopy and laparoscopic ultrasonography may decrease unnecessary exploratory laparotomy, thus increasing the resection rate of previously ruptured hepatocellular carcinoma. Prolonged survival can be achieved in select patients with definitive treatment. It is still uncertain whether the long-term outcome of liver resection is the same for hepatocellular carcinoma with and without rupture when patients with the same tumor stage and liver functional state are compared.

Percutaneous Portal Vein Embolization Increases the Feasibility and Safety of Major Liver Resection for Hepatocellular Carcinoma in Injured Liver

To assess the influence of preoperative portal vein embolization (PVE) on the long-term outcome of liver resection for hepatocellular carcinoma (HCC) in injured liver. On an healthy liver, PVE of the liver to be resected induces hypertrophy of the remnant liver and increases the safety of hepatectomy. On injured liver, this effect is still debated. During the study period, 10 patients underwent preoperative PVE and 19 patients did not before resection of three or more liver segments for HCC in injured liver (cirrhosis or fibrosis). PVE was performed when the estimated rate of remnant functional liver parenchyma (ERRFLP) assessed by computed tomographic scan volumetry was less than 40%. In all patients, PVE was feasible. There were no deaths or complications. The ERRFLP after PVE was significantly increased compared with the pre-PVE value. Liver resection was performed after PVE in 9 of 10 patients, with surgical death and complication rates of 0% and 45%, respectively. PVE increased the number of resections of three or more segments by 47% (9/19). Overall actuarial survival rates with or without previous PVE (89%, 67%, and 44% vs. 80%, 53%, and 53% at 1, 3 and 5 years, respectively) and disease-free actuarial survival rates (86%, 64%, and 21% vs. 55%, 17%, and 17% at 1, 3, and 5 years respectively) after hepatectomy were comparable. With the use of PVE, more patients with previously unresectable HCC in injured liver can benefit from resection. Long-term survival rates are comparable to those after resection without PVE.

Resection of nonresectable liver metastases from colorectal cancer after percutaneous portal vein embolization.

To assess the influence of preoperative portal vein embolization (PVE) on the long-term outcome of liver resection for colorectal metastases. Preoperative PVE of the liver induces hypertrophy of the remnant liver and increases the safety of hepatectomy. Thirty patients underwent preoperative PVE and 88 patients did not before resection of four or more liver segments. PVE was performed when the estimated rate of remnant functional liver parenchyma (ERRFLP) assessed by CT scan volumetry was less than 40%. PVE was feasible in all patients. There were no deaths. The complication rate was 3%. The post-PVE ERRFLP was significantly increased compared with the pre-PVE value. Liver resection was performed after PVE in 19 patients (63%), with surgical death and complication rates of 4% and 7% respectively. PVE increased the number of resections of more than four segments by 19% (17/88). Actuarial survival rates after hepatectomy with or without previous PVE were comparable: 81%, 67%, and 40% versus 88%, 61%, and 38% at 1, 3, and 5 years respectively. PVE allows more patients with previously unresectable liver tumors to benefit from resection. Long-term survival is comparable to that after resection without PVE.