Major Hepatectomy For Hepatocellular Carcinoma Research Articles

Volume–Outcome Associations after Major Hepatectomy for Hepatocellular Carcinoma: a Nationwide Taiwan Study

ObjectiveThe objective of this study was to explore volume–outcome associations after major hepatectomy for hepatocellular carcinoma (HCC). MethodsThis population-based cohort study retrospectively analyzed 23,107 major hepatectomies for HCC patients from 1998 to 2009. Relationships between hospital/surgeon volume and patient outcome were analyzed by propensity score matching (PSM). Five-year overall survival (OS) was estimated by Kaplan–Meier method, and differences were compared by log-rank test. ResultsThe mean length of stay (LOS) after major hepatectomy was 18.1 days, and the mean hospital cost was US$5,088.2. After PSM, the mean OS in high- and low-volume hospitals was 71.1 months (standard deviation (SD) 0.7 months) and 68.6 months (SD 0.6 months), respectively; the mean OS in high- and low-volume surgeons was 78.5 months (SD 0.7 months) and 66.9 months (SD 0.7 months), respectively. The PSM analysis showed that treatment by high-volume hospitals and treatment by high-volume surgeons were both associated with significantly shorter LOS, lower hospital cost, and longer survival compared to their low-volume counterparts (P < 0.001). ConclusionsThe results of this nationwide study support the regionalization of HCC treatment by hospital volume and by surgeon volume. High surgeon volume revealed both short- and long-term benefits. The applicability of PSM in volume–outcome analysis may also be confirmed.

A survival benefit of major hepatectomy for hepatocellular carcinoma identified by preoperative [18F] fluorodeoxyglucose positron emission tomography in patients with well-preserved hepatic function

Hepatic resection can cure hepatocellular carcinoma (HCC). However, the optimal extent of resection remains controversial. Major hepatectomy could minimize a tumor recurrence, but it is harmful due to decreased hepatic functional reserve. [18F] fluorodeoxyglucose positron emission tomography (FDG-PET) scans are known as their reflection tumor differentiation and biological activity in HCC. To evaluate a benefit of major hepatectomy for HCC, we performed this retrospective analysis in patients with well-preserved hepatic function, and further analyzed in the subset identified by preoperative FDG-PET. We reviewed the medical records of 189 patients with HCC who underwent curative resection between August 2004 and December 2010 at two institutes. All patients underwent anatomical resection, either by major or minor hepatectomy. Median overall survival did not differ significantly between the major and minor hepatectomy groups (29.4 versus 26.3 months, p = 0.269). However, the major hepatectomy group had a better recurrence-free survival (24.5 versus 19.9 months, p = 0.004). On multivariate analysis, the presence of intrahepatic metastasis independently predicted overall survival (p = 0.009), but other examined variables did not. Overall survival and recurrence-free survival were significantly better following major hepatectomy rather than minor hepatectomy in patients whose preoperative FDG-PET indicated that the maximum standardized uptake value of the tumor (SUVtumor) was ≥4 and the tumor-to-nontumor SUV ratio (TNR) was ≥1.5. Our findings suggest that preoperative FDG-PET may be useful in identifying patients with favorable hepatic reserve who are most likely to benefit from major rather than minor hepatectomy.

810 Improved Long-Term Survival After Major Resection for Hepatocellular Carcinoma: A Multicenter Analysis Based on a New Definition of Major Hepatectomy

Background Advances in the surgical management of hepatocellular carcinoma (HCC) have expanded the indications for curative hepatectomy, including more extensive liver resections. The purpose of this study was to examine long-term survival trends for patients treated with major hepatectomy for HCC.

A New Prediction Model of Postoperative Complications after Major Hepatectomy for Hepatocellular Carcinoma

Background/Aims: Serum hyaluronic acid (HA) concentrations reflect the degree of hepatic dysfunction and may have potential for predicting postoperative complications in a major hepatectomy for hepatocellular carcinoma (HCC). Methods: Serum HA concentrations and other conventional liver function tests were measured prior to major hepatectomies in 52 patients. Independent predictors for postoperative complications were analyzed and the discriminant equation was established and validated. Results: Postoperative complications occurred in 17 patients. Serum HA concentrations and the estimated remnant liver volume ratio (remnantVol%) were recognized as independent predictors for postoperative complications (OR 1.03, 0.85; CI 95% 1.01–1.06, 0.76–0.95; p = 0.006, 0.006; respectively) and produced the discriminant equation: logit = 4.15 + 0.03 × (HA) –0.16 × (remnantVol%). The value of the area under the curve of a receiver operating characteristic analysis was 0.92. If the cut-off of the logit value was set to 0, then the predictive accuracy was 0.88. The validation accuracy performed by a leave-one-out cross-validation method was 0.83. Conclusions: The constructed discriminant equation model consisting of the preoperative serum HA concentrations and estimated remnantVol% could be useful for predicting postoperative complications in a major hepatectomy for HCC.

Strategies for Resection Using Portal Vein Embolization: Hepatocellular Carcinoma and Hilar Cholangiocarcinoma

Preoperative portal vein embolization (PVE) is increasingly used to optimize the volume and function of the future liver remnant (FLR) and to reduce the risk for complications of major hepatectomy for hepatocellular carcinoma (HCC) or hilar cholangiocarcinoma (CCA). In patients with HCC who are candidates for extended hepatectomy and in patients with HCC and well-compensated cirrhosis who are being considered for major hepatectomy, FLR volumetry is routinely performed, and PVE is employed in selected cases to optimize the volume and function of the FLR prior to surgery. Similarly, in patients with hilar CCA who are candidates for extended hepatectomy, careful preoperative preparation using biliary drainage, FLR volumetry, and PVE optimizes the volume and function of the FLR prior to surgery. Appropriate use of PVE has led to improved postoperative outcomes after major hepatectomy for these diseases and oncological outcomes similar to those in patients who undergo resection without PVE. Specific indications for PVE are being clarified. FLR volumetry is necessary for proper selection of patients for PVE. Analysis of the degree of hypertrophy of the FLR after PVE (a dynamic test of liver regeneration) complements analysis of the pre-PVE FLR volume (a static test). Together, FLR degree of hypertrophy and FLR volume are the best predictors of outcome after major hepatectomy in an individual patient, regardless of the degree of underlying liver disease. This article synthesizes the literature on the approach to patients with HCC and CCA who are candidates for major hepatectomy. The rationale and indications for FLR volumetry and PVE and outcomes following PVE and major hepatectomy for HCC and CCA are discussed.

Validation of POSSUM scoring systems for audit of major hepatectomy.

The aim of the study was to validate the use of Physiological and Operative Severity Score in the enUmeration of Mortality and morbidity (POSSUM) and Portsmouth (P) POSSUM scoring systems to predict postoperative mortality in a group of Chinese patients who had a major hepatectomy for hepatocellular carcinoma. A retrospective analysis was performed on data collected prospectively over a 6-year interval from January 1997 to December 2002. The mortality risks were calculated using both the POSSUM and the P-POSSUM equations. Two hundred and fifty-nine patients underwent major hepatectomy; there were 17 (6.6 per cent) postoperative deaths. Of 32 preoperative and intraoperative variables studied, age, smoking habit, serum creatinine concentration, American Society of Anesthesiologists grade, and physiological and operative severity scores were found to be significant factors predicting mortality. On multivariate analysis only the physiological and operative severity scores were independent variables. The POSSUM system overpredicted mortality risk (14.2 per cent) and there was a significant lack of fit in these patients (chi(2) = 14.1, 3 d.f., P = 0.003). The mortality rate predicted by P-POSSUM was 4.2 per cent and showed no significant lack of fit (chi(2) = 7.6, 3 d.f., P = 0.055), indicating that it predicted outcome effectively. A new logistic equation was derived from the present patient data set that requires testing prospectively. P-POSSUM significantly predicted outcome in Chinese patients who had major hepatectomy for hepatocellular carcinoma. A modified disease-specific equation requires further testing.

Use of the Endo-GIA Vascular Stapler for Hepatic Resection

The aim of this study was to analyse the outcome of hepatectomy using the Endo-GIA vascular stapler and to derive a strategy to avoid complications from its use. From October 1998 to December 2001, 156 patients underwent major hepatectomy for hepatocellular carcinoma. There were 124 men and 32 women, with a median age of 52.5 years. The Endo-GIA vascular stapler was used for division of the hepatic vein and hepatic duct. Intra- and postoperative clinical data were evaluated. The overall morbidity and mortality rates were 32.1% and 8.3%, respectively. Seventy-six percent of patients did not require blood transfusion. The median blood loss volume was 1 L. There were no complications related to the use of the Endo-GIA vascular stapler in dividing the hepatic veins. One patient (0.6%) had a complication from the use of the stapler for right hepatic duct transection and recovered uneventfully after hepaticojejunostomy. Intraoperative cholangiography was performed in subsequent patients undergoing right trisegmentectomy to avoid biliary complications. The Endo-GIA vascular stapler is a safe and useful tool to divide the hepatic vein, but surgeons should exercise particular caution to avoid complications when it is used for hepatic duct division.

Value of live donor liver transplantation experience in major hepatectomy for hepatocellular carcinoma.

Live donor liver transplantation (LDLT) mandates conversance in liver anatomy and major hepatectomy. Hepatocellular carcinoma is most reliably treated by hepatectomy. The outcomes of major hepatectomy for hepatocellular carcinoma are influenced by the surgeon's LDLT experience. We collected prospective cohort study data on patient and disease characteristics. Tertiary referral center. A retrospective study was performed on 250 patients who underwent major hepatectomy for hepatocellular carcinoma from January 16, 1996, through December 28, 2001. Overall and disease-free survival and outcomes including blood loss, blood transfusion, and complications. The 3 liver transplantation surgeons (LTSs) performed 102 major hepatectomies; the 4 hepatobiliary and pancreatic surgeons (HBPSs), 148 major hepatectomies. Patients in both groups had similar baseline characteristics. The mean +/- SD blood loss in the LTS and HBPS groups was 1.36 +/- 1.37 and 2.21 +/- 2.40 L, respectively (P<.001). The mean +/- SD blood transfusion in the LTS and HBPS groups was 0.27 +/- 0.82 and 0.51 +/- 0.94 L, respectively (P =.001). Fewer patients in the LTS group required blood transfusion (17/102 [16.7%]; HBPS group, 57/148 [38.5%]; P<.001). We found no difference in overall and disease-free survival between the groups. The median overall survival was 55.8 months for the nontransfused group, and 34.3 months for the transfused group (P =.06). Median disease-free survival was 16.1 months for the nontransfused group compared with 12.4 months for the transfused group (P =.25). Cox regression multivariate analysis showed that transfusion, cirrhosis, and venous invasion worsened overall survival. Venous invasion, cirrhosis, and tumor size adversely affected disease-free survival. The LTS group lost less blood and required less blood transfusions than the HBPS group. Blood transfusion worsened overall survival. The significantly lower blood transfusion requirement of the LTS group contributes to a potential advantage in their overall survival.

Minimal invasive hepatectomy (MIH) using a microwave coagulator for cirrhotic patient with small hepatocellular carcinoma

Surgical resection is the optimal treatment for hepatocellular carcinoma (HCC), however, in patients with liver cirrhosis, major hepatectomy is dangerous because of impaired liver function. We performed partial resection of the liver using microwave tissue coagulator (minimal invasive hepatectomy : MIH) in 14 cirrhotic patients with HCC smaller than 3 cm in diameter. Among 14 patients, 10 patients had hepatectomy with thoraco-abdominal approach. The blood loss during operation was 247 ± 95 ml, and only one patient had allogenic blood transfusion. We had not experienced postoperative major complications, and mean postoperative hospital stay was 18.5 ± 7.4 days. The serum interleukin-6 level at 1st postoperative day was 176 ± 48 pg/ml, which was significantly (p<0.05) lower than that in patients with major hepatectomy for HCC. Thus the partial resection of the liver using a microwave coagulator is considered to be less invasive, safe and useful method for cirrhotic patient with small HCC.

Major hepatectomy for hepatocellular carcinoma in patients with an unsatisfactory indocyanine green clearance test.

Liver failure is the commonest cause of postoperative death in patients with hepatocellular carcinoma (HCC). With the improvement in operative technique and perioperative care, the limit of hepatic functional reserve may be lowered. The aim of this study was to evaluate the postoperative morbidity, mortality and survival rates in patients with an indocyanine green (ICG) retention value higher than 14 per cent, after major hepatectomy for HCC. From January 1994 to December 1997, 117 patients underwent major hepatectomy for HCC; 92 patients had preoperative ICG retention at 15 min lower than 14 per cent (median 8.3 (range 1.6-13.8) per cent), while 25 patients had ICG retention greater than 14 per cent (17.4 (range 14.3-35.3) per cent). Data were collected prospectively and analysed retrospectively. The two groups of patients were similar in terms of age, sex ratio, preoperative platelet count, liver biochemistry, Child-Pugh status and operative procedures performed, but the prothrombin time was significantly longer in the high ICG group. The operative blood loss (1.5 litres), the amount of blood transfused and the number of patients requiring blood transfusion were similar. The postoperative complication rate (41 versus 40 per cent), duration of hospital stay (12 versus 13 days), hospital mortality rate (1 versus 4 per cent) and median survival time (47 versus 45 months) were not significantly different. With meticulous surgical technique to decrease intraoperative blood loss and good perioperative care, selected patients with limited hepatic functional reserve can achieve a good immediate postoperative result and a survival rate similar to that of patients with good hepatic functional reserve.

ICG clearance in assessing cirrhotic patients with hepatocellular carcinoma for major hepatic resection.

Objective: To deWne the safety of major hepatectomy for hepatocellular carcinoma (HCC) associated with cirrhosis and the selection criteria for surgery in terms of hospital mortality. Design: Major hepatectomy for HCC in the presence of cirrhosis is considered to be contraindicated by many surgeons because the reported mortality rate is high (26% to 50%). Previous workers recommended that only selected patients with Child's A status or indocyanine green (ICG) retention at 15 minutes of less than 10% undergo major hepatectomy. A survery was made, therefore, of our patients with HCC and cirrhosis undergoing major hepatectomy between 1989 and 1994. Setting: A tertiary referral center. Patients: The preoperative, intraoperative, and post-operative data of 54 patients with cirrhosis who had major hepatectomy were compared with those of 25 patients with underlying chronic active hepatitis and 22 patients with normal livers undergoing major hepatectomy for HCC. The data had been prospectively collected. Intervention: Major hepatectomy, defined as resection of two or more liver segments by Goldsmith and Woodburn nomenclature, was performed on all the patients. Main Outcome Measure: Hospital mortality, which was defined as death within the same hospital admission for the hepatectomy. Results: Preoperative liver function in patients with cirrhosis was worse than in those with normal livers. The intraoperative blood loss was also higher (P=.01), but for patients with cirrhosis, chronic active hepatitis, and normal livers, the hospital mortality rates (13%, 16%, and 14%, respectively) were similar. The hospital mortality rate for patients with cirrhosis in the last 2 years of the study was only 5%. Patients with cirrhosis could tolerate up to 10 L of blood loss and survive the major hepatectomy. By discriminant analysis, an ICG retention of 14% at 15 minutes was cutoff level that could maximally separate the patients with cirrhosis with and without mortality. Conclusion: Major hepatectomy for HCC in the presence of cirrhosis is associated with a mortality rate that is not different from the rate for patients with normal livers. An ICG retention of 14% at 15 minutes would serve as a better selection criterion than the 10% previously used.

Is There a Role for Perioperative Nutritional Support in Liver Resection?

Background: Resection of hepatocellular carcinoma is associated with high rates of morbidity and mortality. Since intensive nutritional support can reduce the catabolic response and improve protein synthesis and liver regeneration, we performed a prospective study to investigate whether perioperative nutritional support could improve outcome in patients undergoing hepatectomy for hepatocellular carcinoma. Methods: We studied 124 patients undergoing resection of hepatocellular carcinoma. Sixty-four patients (39 with cirrhosis, 18 with chronic active hepatitis, and 7 with no associated liver disease) were randomly assigned to receive perioperative intravenous nutritional support in addition to their oral diet, and 60 patients (33 with cirrhosis, 12 with chronic active hepatitis, and 15 with no associated liver disease) were randomly assigned to a control group. The perioperative nutritional therapy consisted of a solution enriched with 35 percent branched chain amino acids, dextrose, and lipid emulsion (50 percent medium-chain trigylcerides) given intravenously for 14 days perioperatively). Results: There was a reduction in the overall postoperative morbidity rate in the perioperative-nutrition group as compared with the control group (34 percent vs. 55 percent; relative risk, 0.66; 95 percent confidence interval, 0.45 to 0.96), predominantly because of fewer septic complications (17 percent vs. 37 percent; relative risk, 0.57; 95 percent confidence interval, 0.34 to 0.96). There were also a reduction in the requirement for diuretic agents to control ascites (25 percent vs. 50 percent; relative risk, 0.57; 95 percent confidence interval, 0.37 to 0.87), less weight loss after hepatectomy (median loss, 0 kg vs. 1.4 kg; P=0.01), and less deterioration of liver function as measured by the change in the rate of clearance of indocyanine green (–2.8 percent vs. –4.8 percent at 20 minutes, P=0.05). These benefits were seen predominantly in the patients with underlying cirrhosis who underwent major hepatechtomy. There were five deaths during hospitalization in the perioperativenutrition group, and nine in the control group (P not significant). Conclusions: Perioperative nutritional support can reduce complications after major hepatectomy for hepatocellular carcinoma associated with cirrhosis.

Hospital Mortality of Major Hepatectomy for Hepatocellular Carcinoma Associated With Cirrhosis

To define the safety of major hepatectomy for hepatocellular carcinoma (HCC) associated with cirrhosis and the selection criteria for surgery in terms of hospital mortality. Major hepatectomy for HCC in the presence of cirrhosis is considered to be contraindicated by many surgeons because the reported mortality rate is high (26% to 50%). Previous workers recommended that only selected patients with Child's A status or indocyanine green (ICG) retention at 15 minutes of less than 10% undergo major hepatectomy. A survey was made, therefore, of our patients with HCC and cirrhosis undergoing major hepatectomy between 1989 and 1994. A tertiary referral center. The preoperative, intraoperative, and postoperative data of 54 patients with cirrhosis who had major hepatectomy were compared with those of 25 patients with underlying chronic active hepatitis and 22 patients with normal livers undergoing major hepatectomy for HCC. The data had been prospectively collected. Major hepatectomy, defined as resection of two or more liver segments by Goldsmith and Woodburn nomenclature, was performed on all the patients. Hospital mortality, which was defined as death within the same hospital admission for the hepatectomy. Preoperative liver function in patients with cirrhosis was worse than in those with normal livers. The intraoperative blood loss was also higher (P = .01), but for patients with cirrhosis, chronic active hepatitis, and normal livers, the hospital mortality rates (13%, 16%, and 14%, respectively) were similar. The hospital mortality rate for patients with cirrhosis in the last 2 years of the study was only 5%. Patients with cirrhosis could tolerate up to 10 L of blood loss and survive the major hepatectomy. By discriminant analysis, an ICG retention of 14% at 15 minutes was the cutoff level that could maximally separate the patients with cirrhosis with and without mortality. Major hepatectomy for HCC in the presence of cirrhosis is associated with a mortality rate that is not different from the rate for patients with normal livers. An ICG retention of 14% at 15 minutes would serve as a better selection criterion than the 10% previously used.