Partial Hepatectomy In Patients Research Articles

Thermal Ablation Compared to Partial Hepatectomy for Recurrent Colorectal Liver Metastases: An Amsterdam Colorectal Liver Met Registry (AmCORE) Based Study

Background: Between 64 and 85% of patients with colorectal liver metastases (CRLM) develop distant intrahepatic recurrence after curative intent local treatment. The current standard of care for new CRLM is repeat local treatment, comprising partial hepatectomy and thermal ablation. Although relatively safe and feasible, repeat partial hepatectomy can be challenging due to adhesions and due to the reduced liver volume after surgery. This AmCORE based study assessed safety, efficacy and survival outcomes of repeat thermal ablation as compared to repeat partial hepatectomy in patients with recurrent CRLM.

Predictors of Post-operative Liver Decompensation Events Following Resection in Patients with Cirrhosis and Hepatocellular Carcinoma: A Population-based Study

Background: Appropriate patient selection for liver resection in hepatocellular carcinoma (HCC) is critical to mitigate major liver-related post-operative complications. Currently, no standard prognostic tool exists to predict the risk of POLDEs following partial hepatectomy in patients with cirrhosis and hepatocellular carcinoma. The objective of this study was to identify independent pre-operative predictors of post-operative liver decompensation events (POLDEs), for future development of prognostic tools to improve surgical decision-making. Method: This was a population-based, retrospective cohort study of patients with cirrhosis and incident HCC between 2007-2017, identified using administrative health data from Ontario, Canada. The occurrence of a POLDE or death within 2 years from surgery was described. Multivariable Cox regression identified independent predictors of POLDE-free survival, as well as cause-specific hazards for POLDEs and death. Results: Among 611 patients with cirrhosis and HCC who underwent liver resection, 160 (26.2%) experienced at least 1 POLDE and 189 (30.9%) died within 2 years of surgery. Presence of diabetes, hepatitis B cirrhosis etiology, major liver resection, and previous non-malignant decompensation were independent predictors of POLDE-free survival. Except extent of resection, the same risk factors were associated with POLDEs in cause-specific analysis. In contrast, only age and history of previous non-malignant decompensation were independent predictors of mortality. Conclusions: Among patients with cirrhosis undergoing resection for HCC, patient and disease-related factors are associated with POLDEs and POLDE-free survival. These factors can be used to both inform clinical practice and for the development of pre-operative prognostic tools, which may lead to improved outcomes in this population.

Impact of concurrent splenectomy and esophagogastric devascularization on surgical outcomes of partial hepatectomy for hepatocellular carcinoma in patients with clinically significant portal hypertension: A multicenter propensity score matching analysis

PurposePortal hypertension due to cirrhosis is common among patients with hepatocellular carcinoma (HCC). This study aimed to compare the outcomes of partial hepatectomy in patients with HCC and clinically significant portal hypertension (CSPH) with or without concurrent splenectomy and esophagogastric devascularization (CSED). Patients and methodsFrom a multicenter database, patients with HCC and CSPH who underwent curative-intent hepatectomy were identified. Postoperative morbidity and mortality, and long-term overall survival (OS) were compared in patients with and without CSED before and after propensity score matching (PSM). ResultsOf the 358 enrolled patients, 86 patients underwent CSED. Before PSM, the postoperative 30-day morbidity and mortality rates were comparable between the CSED and non-CSED group (both P > 0.05). Using PSM, 81 pairs of patients were created. In the PSM cohort, the 5-year OS rate of the CSED group were significantly better than the non-CSED group (52.9% vs. 36.5%, P= 0.046). The former group had a significantly lower rate of variceal bleeding on follow-up (7.4% vs. 21.7%, P= 0.014). On multivariate analysis, CSED was associated with significantly better OS (HR: 0.39, P < 0.001). ConclusionHepatectomy and CSED can safely be performed in selected patients with HCC and CSPH, which could improve postoperative prognosis by preventing variceal bleeding, and prolonging long-term survival.

Predictors of Postoperative Liver Decompensation Events After Resection in Patients with Cirrhosis and Hepatocellular Carcinoma: A Population-Based Study.

Appropriate patient selection for liver resection in hepatocellular carcinoma (HCC) is critical to mitigation of major liver-related postoperative complications. Currently, no standard prognostic tool exists to predict the risk of postoperative liver decompensation events (POLDEs) after partial hepatectomy for patients with cirrhosis and HCC. This study aimed to identify independent preoperative predictors of POLDEs for future development of prognostic tools to improve surgical decision-making. This population-based, retrospective cohort study investigated patients with cirrhosis and incident HCC between 2007 and 2017, identified using administrative health data from Ontario, Canada. The occurrence of a POLDE or death within 2 years after surgery was described. Multivariable Cox regression identified independent predictors of POLDE-free survival, as well as cause-specific hazards for POLDEs and death. Among 611 patients with cirrhosis and HCC who underwent liver resection, 160 (26.2%) experienced at least one POLDE, and 189 (30.9%) died within 2 years after surgery. Diabetes, cirrhosis etiology, major liver resection, and previous non-malignant decompensation were independent predictors of POLDE-free survival. Except for extent of resection, the same risk factors were associated with POLDEs in the cause-specific analysis. In contrast, only age and history of previous non-malignant decompensation were independent predictors of mortality. Among patients with cirrhosis undergoing resection for HCC, patient and disease-related factors are associated with POLDEs and POLDE-free survival. These factors can be used both to inform clinical practice and to advance the development of preoperative prognostic tools, which may lead to improved outcomes for this population.

Thermal Ablation Compared to Partial Hepatectomy for Recurrent Colorectal Liver Metastases: An Amsterdam Colorectal Liver Met Registry (AmCORE) Based Study.

Simple SummaryBetween 64 and 85% of patients with colorectal liver metastases (CRLM) develop distant intrahepatic recurrence after curative intent local treatment. The current standard of care for new CRLM is repeat local treatment, comprising partial hepatectomy and thermal ablation. Although relatively safe and feasible, repeat partial hepatectomy can be challenging due to adhesions and due to the reduced liver volume after surgery. This AmCORE based study assessed safety, efficacy and survival outcomes of repeat thermal ablation as compared to repeat partial hepatectomy in patients with recurrent CRLM. Repeat partial hepatectomy was not different from repeat thermal ablation with regard to survival, distant- and local recurrence rates and complications, whereas length of hospital stay favored repeat thermal ablation. Thermal ablation should be considered a valid and potentially less invasive alternative in the treatment of recurrent new CRLM, while the eagerly awaited results of the COLLISION trial (NCT03088150) should provide definitive answers regarding surgery versus thermal ablation for CRLM.The aim of this study was to assess safety, efficacy and survival outcomes of repeat thermal ablation as compared to repeat partial hepatectomy in patients with recurrent colorectal liver metastases (CRLM). This Amsterdam Colorectal Liver Met Registry (AmCORE) based study of two cohorts, repeat thermal ablation versus repeat partial hepatectomy, analyzed 136 patients (100 thermal ablation, 36 partial hepatectomy) and 224 tumors (170 thermal ablation, 54 partial hepatectomy) with recurrent CRLM from May 2002 to December 2020. The primary and secondary endpoints were overall survival (OS), distant progression-free survival (DPFS) and local tumor progression-free survival (LTPFS), estimated using the Kaplan–Meier method, and complications, analyzed using the chi-square test. Multivariable analyses based on Cox proportional hazards model were used to account for potential confounders. In addition, subgroup analyses according to patient, initial and repeat local treatment characteristics were performed. In the crude overall comparison, OS of patients treated with repeat partial hepatectomy was not statistically different from repeat thermal ablation (p = 0.927). Further quantification of OS, after accounting for potential confounders, demonstrated concordant results for repeat local treatment (hazard ratio (HR), 0.986; 95% confidence interval (CI), 0.517–1.881; p = 0.966). The 1-, 3- and 5-year OS were 98.9%, 62.6% and 42.3% respectively for the thermal ablation group and 93.8%, 74.5% and 49.3% for the repeat resection group. No differences in DPFS (p = 0.942), LTPFS (p = 0.397) and complication rate (p = 0.063) were found. Mean length of hospital stay was 2.1 days in the repeat thermal ablation group and 4.8 days in the repeat partial hepatectomy group (p = 0.009). Subgroup analyses identified no heterogeneous treatment effects according to patient, initial and repeat local treatment characteristics. Repeat partial hepatectomy was not statistically different from repeat thermal ablation with regard to OS, DPFS, LTPFS and complications, whereas length of hospital stay favored repeat thermal ablation. Thermal ablation should be considered a valid and potentially less invasive alternative for small-size (0–3 cm) CRLM in the treatment of recurrent new CRLM. While, the eagerly awaited results of the phase III prospective randomized controlled COLLISION trial (NCT03088150) should provide definitive answers regarding surgery versus thermal ablation for CRLM.

Thirty-Day Unplanned Readmission and Its Effect on 90-Day Mortality in Hepatocellular Carcinoma Patients Undergoing Partial Hepatectomy

Background : Despite advances of surgical techniques, hepatectomy continues to be potentially dangerous and is associated with postoperative mortality, morbidity and readmission. The objective of this study was to determine the effect of 30-day unplanned readmission on ‘conditional’ 90-day mortality among hepatocellular carcinoma (HCC) patients that underwent partial hepatectomy. Methods : National Cancer Database (NCDB) was queried from 2004 to 2012 for patients with hepatocellular carcinoma (HCC) who underwent partial hepatectomy. Thirty-day unplanned readmission rate, and associated risk factors, was determined for 7,696 patients. The association between 30-day unplanned readmission and conditional 90-day mortality was further addressed. Results : The 30-day unplanned readmission rate for patients with HCC that underwent partial hepatectomy was 5.2%. Risk factors associated with 30-day unplanned readmission were sex, race/ethnicity, Charlson-Deyo score, and annual hospital hepatectomy volume. An overall adjusted odds ratio of having conditional 90-day mortality was 2.325 times higher (95% CI 1.643 - 3.219) among patients with a history of 30-day unplanned readmission than those without. This association was dependent on age, sex, race/ethnicity, insurance status, alpha-fetoprotein (AFP), liver fibrosis, Charlson-Deyo comorbidity score and annual hospital hepatectomy volume. Conclusion : Efforts in patient care should be taken to reduce 30-day unplanned readmission after partial hepatectomy for patients with HCC to reduce conditional 90-day mortality.

Value of partial hepatectomy for the treatment of hilar cholangiocarcinoma: a Meta-analysis study*

Abstract Objective To discuss the value of partial hepatectomy in patients with hilar cholangiocarcinoma. Methods English articles related to hilar cholangiocarcinoma were screened from January 1, 1990 to May 12, 2019 in the PubMed, MEDLINE, EMBASE, and Cochrane Library databases. Information on postoperative radical cure, survival, morbidity, and mortality after surgery were extracted from articles that met the inclusion criteria for the meta-analysis. Results Twenty-two articles that met the inclusion criteria were classified into 4 study groups: the hepatectomy radical cure group (19 articles), the hepatectomy survival group (16 articles), the hepatectomy morbidity group (9 articles), and the hepatectomy mortality group (17 articles). We found that the rate of radical cure after partial hepatectomy (odds ratio [OR] 0.32, 95% confidence interval [CI] 0.20-0.51) and the survival rate (hazard ratio [HR] 0.67, 95% CI 0.58-0.79) were significantly higher than after simple bile duct resection, but that morbidity (OR 1.99, 95% CI 1.37-2.90) and mortality (OR 2.71, 95% CI 1.47-4.98) in patients within the partial hepatectomy group were also higher than in the simple bile duct resection group, taking into account the significant heterogeneity in the articles pertaining to the hepatectomy radical cure group (I 2 = 68.3%, P = 0.000), a sub-group analysis was subsequently conducted. Its results showed that when the branches of the secondary bile ducts were not involved during hilar cholangiocarcinoma, then a bile duct resection had a similar radical cure outcome as combined partial hepatectomy (OR 0.94, 95% CI 0.54-1.65). Conclusion Partial hepatectomy can increase the proportion of radical cure in patients with hilar cholangiocarcinoma and extend the survival time after surgery. However, the morbidity and mortality after surgery are higher than those in simple bile duct resections. Therefore, simple bile duct resection is still a relevant and efficient tool in the treatment of Bismuth-Corlette Type I and II hilar cholangiocarcinomas.

Long-term survival after partial hepatectomy for sub-stage patients with intermediate stage hepatocellular carcinoma

BackgroundThe current study aimed to examine the long-term survival after partial hepatectomy for patients with BCLC intermediate stage hepatocellular carcinoma (HCC) stratified by the Bolondi's sub-staging model. Materials and MethodsThis cohort consisted of 360 patients with BCLC intermediate stage HCC who underwent partial hepatectomy between January 2008 and February 2010. Patients were stratified into 3 subgroups (B1-B3) based on the Bolondi's sub-staging model. The last follow-up was conducted at February 2014. ResultsOf these patients, 166, 171 and 23 patients had B1, B2, and B3 sub-stage HCC, respectively. The postoperative 5-year Overall survival (OS) rate for patients with these three sub-stages was 49.5%, 33.7% and 12.9%, respectively (P < 0.001). Compared with the reported survival outcomes from previous studies which used transarterial chemoembolization (TACE) as first-line treatment, hepatectomy had a better median survival than TACE in B1 and B2 patients. On multivariable analysis, presence of esophageal and gastric varices, higher NDR score, presence of microvascular invasion, differentiation grade III-IV, and patterns of AFP decreases after surgery were the independent risk factors of OS in the sub-stages B1 and B2 patients. A nomogram which integrated all these independent risk factors was developed, with a C-index of 0.71 for OS prediction. The calibration curve showed an optimal agreement between prediction by the nomogram and actual observation. ConclusionsThe patients with intermediate stage HCC clarified as sub-stages B1 and B2 according to Bolondi's model had an optimal long-term survival following partial hepatectomy than TACE. Their postoperative prognosis could be accurately predicted by our proposed nomogram.

A clinical study on transcatheter arterial chemoembolization plus portal vein chemoembolization after partial hepatectomy for patients with hepatocellular carcinoma with portal vein tumor thrombosis

Objective To study the short and long term outcomes in patients after partial hepatectomy carried out for primary hepatocellular carcinoma (PHC) with portal vein tumor thrombosis (PVTT) who were treated with transcatheter arterial chemoembolization (TACE) plus portal vein chemoembolization (PVCE). Methods 57 patients who underwent partial hepatectomy for PHC with PVTT were treated with TACE+ PVCE. These patients formed the study group. Another 55 such patients who received TACE only were matched by age and gender to form the control group. Blood samples before and after treatment for these 2 groups were collected to study the serum tumor markers. Any chemotherapy-related toxicity and complications were recorded. The hepatocellular carcinoma recurrence rate and recurrence time were recorded on follow up. Survival analysis was conducted. Results There was no significant difference between the two groups in TACE treatment times (P>0.05). In the study group, the levels of AFP, IGF-Ⅱ, and IGFBP-2 were significantly lower than those in the control group at 1 month after chemotherapy [respectively, (4.3±0.5) μg/L vs. (4.8±0.6) μg/L, (3.3±0.4) μg/L vs. (4.0±0.5) μg/L, (5.3±0.6) μg/L vs. (5.8±0.6) μg/L; all P 0.05). In the study group, 2 patients (3.5%) developed bleeding from esophageal and gastric fundus vein rupture, while there were no such cases in the control group. Conclusion Compared with TACE alone, the combination of PVCE and TACE after partial hepatectomy for patients with PHC with PVTT effectively reduced tumor burden, prevented liver recurrence and improved long-term survival rates, with no significant increase in toxicity and complication rates. Key words: Hepatocellular carcinoma; Portal vein tumor thrombus; Portal vein chemoembolization; Transcatheter arterial chemoembolization; Survival rate

Systematic review of the influence of chemotherapy-associated liver injury on outcome after partial hepatectomy for colorectal liver metastases.

The impact of chemotherapy-associated liver injury (CALI) on postoperative outcome in patients undergoing partial hepatectomy for colorectal liver metastases (CRLM) remains controversial. The objective of this study was to clarify the effect of CALI (sinusoidal dilatation (SD), steatosis and steatohepatitis) on postoperative morbidity and mortality by investigating a large data set from multiple international centres. PubMed and Embase were searched for studies published between 1 January 2004 and 31 December 2013 with keywords 'chemotherapy', 'liver resection', 'outcome' and 'colorectal metastases' to identify potential collaborating centres. Univariable and multivariable analyses were performed using binary logistic regression models, with results presented as odds ratios (ORs) with 95 per cent confidence intervals. A consolidated database comprising 788 patients who underwent hepatectomy for CRLM in eight centres was obtained. In multivariable analyses, severe SD was associated with increased major morbidity (Dindo-Clavien grade III-V; OR 1·73, 95 per cent c.i. 1·02 to 2·95; P = 0·043). Severe steatosis was associated with decreased liver surgery-specific complications (OR 0·52, 95 per cent c.i. 0·27 to 1·00; P = 0·049), whereas steatohepatitis was linked to an increase in these complications (OR 2·08, 1·18 to 3·66; P = 0·012). Subgroup analysis showed that lobular inflammation was the sole component associated with increased overall morbidity (OR 2·22, 1·48 to 3·34; P = 0·001) and liver surgery-specific complications (OR 3·35, 2·11 to 5·32; P < 0·001). Finally, oxaliplatin treatment was linked to severe SD (OR 2·74, 1·67 to 4·49; P < 0·001). An increase in postoperative major morbidity and liver surgery-specific complications was observed after partial hepatectomy in patients with severe SD and steatohepatitis. Postoperative liver failure occurred more often in patients with severe SD.

The influence of chemotherapy-associated sinusoidal dilatation on short-term outcome after partial hepatectomy for colorectal liver metastases: A systematic review with meta-analysis

Summary background dataHepatic sinusoidal dilatation (SD) is a histopathological entity that occurs in up to 75% of patients undergoing oxaliplatin-based chemotherapy for colorectal liver metastases (CRLM). ObjectiveTo study the influence of SD on outcome after partial hepatectomy in patients with CRLM. MethodsMedline, Embase, CENTRAL, LILACS and CINAHL were searched for studies published between 01.01.2004 and 09.06.2015 with keywords: “sinusoidal obstruction syndrome”, “hepatic veno-occlusive disease”, and “Stuart-Bras syndrome”. Studies comprising adults who underwent partial hepatectomy for CRLM with grading of SD and registration of postoperative morbidity and/or mortality were included. Risk of bias and quality of studies were evaluated with the Quality In Prognosis Studies Instrument (QUIPS) and modified GRADE framework. ResultsSearch strategies produced 2007 hits from which 23 and 13 articles were extracted for qualitative and quantitative analyses, respectively. Meta-analysis on the influence of SD grade 2–3 vs. SD grade 0–1 on postoperative overall morbidity showed an odds ratio (OR) of 1.26 [95% CI 0.74, 2.15](p = 0.40), an OR of 1.03 [0.15, 6.89](p = 0.98) for liver failure, an OR of 1.21 [0.23, 6.35](p = 0.82) for overall mortality, and an OR of 3.52 [0.31, 39.91](p = 0.31) for liver-related morbidity. QUIPS showed a low to high risk of bias for studies, and GRADE showed very low quality of evidence per outcome. ConclusionsNo significant effect of SD grade 2–3 on short-term outcome after partial hepatectomy was found. However, the data on which this conclusion was based were not very robust and therefore no solid conclusions could be drawn.

Effect of Intramuscular Adipose Tissue Content on Prognosis in Patients Undergoing Hepatocellular Carcinoma Resection

BackgroundIt has recently been reported that myosteatosis, the infiltration of fat in skeletal muscle, is associated with insulin resistance and type 2 diabetes mellitus. The present study investigated the effect of skeletal muscle fat accumulation on short- and long-term outcomes following partial hepatectomy for hepatocellular carcinoma (HCC) and aimed to identify prognostic factors. MethodsThe records of 141 HCC patients who underwent hepatectomy were retrospectively reviewed. Clinicopathological and outcome data from 71 patients with high intramuscular adipose tissue content (IMAC) were compared with those from 70 patients with low IMAC. ResultsThe 5-year overall survival rate was 46 % among patients with high IMAC and 75 % among those with low IMAC. The 5-year disease-free survival rates in these groups were 18 and 38 %, respectively. Multivariate analysis revealed that high IMAC was predictive of an unfavorable prognosis. High IMAC was significantly correlated with liver dysfunction, higher intraoperative blood loss, the need for blood transfusion, and comorbid diabetes mellitus. ConclusionsGreater fat accumulation in skeletal muscle was predictive of worse overall survival after partial hepatectomy in patients with HCC, even with adjustment for other known predictors. The identification of patients with greater skeletal muscle fat accumulation before hepatectomy could permit early preventive strategies to maintain muscle quality and thus improve prognosis and patient selection for hepatectomy.

Pringle manoeuvre versus selective hepatic vascular exclusion in partial hepatectomy for tumours adjacent to the hepatocaval junction: A randomized comparative study

ObjectiveTo compare the efficacy of selective hepatic vascular exclusion versus Pringle manoeuvre in partial hepatectomy for tumours adjacent to the hepatocaval junction. MethodsA randomized comparative trial was carried out. The primary endpoint was intraoperative blood loss. The secondary endpoints were operation time, blood transfusion, postoperative liver function recovery, procedure-related morbidity and in-hospital mortality. Results160 patients were randomized into 2 groups: the Pringle manoeuvre group (n = 80) and the selective hepatic vascular exclusion (SHVE) group (n = 80). Intraoperative blood loss and transfusion requirements were significantly less in the SHVE group. In the SHVE group, laceration of hepatic veins happened in 18 patients. Profuse intraoperative blood loss of over 2 L happened in 2 patients but no patient suffered from air embolism because the hepatic veins were controlled. In the Pringle group, the hepatic veins were lacerated in 20 patients, with profuse blood loss of over 2 L in 7 patients and air embolism in 3 patients. The rates of postoperative bleeding, reoperation, liver failure and mortality were significantly higher and the ICU stay and hospital stay were significantly longer in the Pringle group. ConclusionsSHVE was more efficacious than Pringle manoeuvre for partial hepatectomy in patients with tumours adjacent to the hepatocaval junction.

Preoperative total cholesterol predicts postoperative outcomes after partial hepatectomy in patients with chronic hepatitis B- or C-related hepatocellular carcinoma

Total cholesterol (TC) can reflect the degree of liver damage in patients with chronic hepatitis B or C; its role in evaluating liver functional reserve and predicting postoperative complications remains unknown. The prospectively collected data of 996 consecutive patients with chronic hepatitis B or C undergoing partial hepatectomy for hepatocellular carcinoma in a tertiary institution were retrospectively reviewed. The relationship between preoperative TC and postoperative liver insufficiency, morbidity and mortality were analyzed. TC showed significant correlation with postoperative complications on receiver operating characteristic curves, with area under the curve of 0.81 (P < .001), 0.79 (P < .001), and 0.85 (P < .001) for postoperative liver insufficiency, morbidity, and mortality, respectively. Using the calculated cutoff at 2.80 mmol/L, Patients with low TC had worse preoperative liver functional reserve and suffered from more postoperative complications when compared with patients with normal TC (≥2.8 mmol/L). Multivariate analysis revealed that low preoperative TC was more powerful in predicting poor postoperative outcomes than Child-Pugh's classification, indocyanine green (ICG) retention test, and Mayo End-Stage Liver Disease (MELD) score. It was an independent risk factor for postoperative morbidity (odds ratio [OR], 4.87; P < .001) and mortality (OR, 14.60; P < .001). Among patients with chronic virus B or C hepatitis receiving partial hepatectomy, a low TC (<2.8 mmol/L) predicted poor postoperative outcomes. It was better than Child-Pugh's classification, ICG, and MELD score in the prediction of postoperative complications, and was useful in the preoperative evaluation of liver functional reserve.

Posthepatectomy HBV Reactivation in Hepatitis B–Related Hepatocellular Carcinoma Influences Postoperative Survival in Patients With Preoperative Low HBV-DNA Levels

This study aimed to clarify the incidence of hepatitis B virus (HBV) reactivation and its significance on long-term survival after partial hepatectomy in patients with HBV-related hepatocellular carcinoma (HCC), who had preoperative low HBV-DNA level of less than 2000 IU/mL. HBV reactivation is a frequent complication of systemic chemotherapy in hepatitis B surface antigen-positive patients. Surgery and anesthesia result in a generalized state of immunosuppression in the immediate postoperative period. Data on HBV reactivation and its significance after partial hepatectomy are unclear. Consecutive patients from January 2006 to December 2007 were retrospectively studied. HBV reactivation happened in 19.1% of patients in 1 year. There were 28 patients whose HBV reactivation was detected after the diagnosis of HCC recurrence. On multivariate analysis, hepatitis B e antigen (HBeAg) positivity, preoperative HBV-DNA above the lower limit of quantification (≥200 IU/mL), Ishak inflammation score of greater than 3, preoperative transarterial chemoembolization (TACE), operation time of more than 180 minutes, blood transfusion, and without prophylactic antiviral therapy were significantly associated with an increased risk of HBV reactivation. HBV reactivation negatively influenced postoperative hepatic functions. The posthepatectomy liver failure rate in patients with HBV reactivation was significantly higher than in those without reactivation (11.8% vs 6.4%; P = 0.002). The 3-year disease-free survival (DFS) rate and overall survival (OS) rates after resection in patients with HBV reactivation were significantly lower than those without reactivation (34.1% vs 46.0%; P = 0.009, and 51.6% vs 67.2%; P < 0.001, respectively). HBeAg positivity, detectable preoperative HBV-DNA level, high Ishak inflammation score, preoperative TACE, long operation time, and blood transfusion were independent risk factors for HBV reactivation, whereas prophylactic antiviral therapy was a protective factor. HBV reactivation, HBeAg positivity, HBV-DNA level of 200 IU/mL or more, tumor diameter greater than 5 cm, presence of satellite nodules, presence of portal vein tumor thrombus, blood transfusion, and resection margin less than 1.0 cm were independent risk factors for DFS. A HBV-DNA level of 200 IU/mL or more, an Ishak fibrosis score of 4 or greater, a tumor diameter greater than 5 cm, the presence of satellite nodules, the presence of portal vein tumor thrombus, a resection margin less than 1.0 cm, no prophylactic antiviral therapy, and HBV reactivation were independent risk factors for OS. HBV reactivation was common after partial hepatectomy for HBV-related HCC with a preoperative low HBV-DNA level of less than 2000 IU/mL. Routine prophylactic antiviral treatment should be given before partial hepatectomy.

Partial hepatectomy for liver metastases from breast cancer: a retrospective study of 47 patients

Objective To study the outcomes of partial hepatectomy in patients with liver metastases from breast cancer.Methods The data of 47 patients who underwent partial hepatectomy for liver metastases from breast cancer between 2000 and 2009 were studied.The relationship between the clinical features and outcomes were analyzed retrospectively.Results The mortality of surgery was 0％.The 1-,3-,and 5-year survival rates for these 47 patients were 74.5％,42.5％ and 17.0％ respectively.The median survival was 29 months.Patients with less than 3 metastatic nodules survived longer than those with more than 3 metastatic nodules.The 1-,3-,and 5-year survival rates were 86.7％,53.3％,23.3 ％ versus 52.8％,23.5％,5.9 ％,and the mean survival was 79.4 months versus 34.6 months (P=0.001),respectively.Patients without local lymph node metastases had longer survival than those with local lymph nodes metastases.The 1-,3-,and 5-year survival rates were 82.3％,50.0％,23.5％ versus 53.8％,23.1 ％,0％,and the mean survival was 71.9 mouths versus 28.6 months (P＝0.002),respectively.There was no relationship between survival and tumor differ entiation,expression of ER,PR and Her 2.Conclusion Surgical treatment was safe for patients with liver metastases from breast cancer.The long-term survival was better for patients with liver metastases with less than 3 nodules compared to those with more than 3 nodules.The survival was poorer in patients with local lymph node metastases than those without lymph node metastases. Key words: Breast cancer; Liver metastases; Surgery; Prognosis

Continuous occlusion of hepatic artery for prevention of blood loss in partial hepatectomy for ruptured hepatocellular carcinoma

Objective To investigate the value of continuous occlusion of hepatic artery proper to intermittent Pringle maneuver in partial hepatectomy for ruptured hepatocellular carcinoma(HCC).Methods The clinical data of 36 patients(test group)who received partial hepatectomy for ruptured HCC by adding continuous occlusion of hepatic artery proper to intermittent Pringle maneuver at the Southwest Hospital were retrospectively analyzed.Thirty-six patients(control group)who received intermittent Pringle maneuver only were selected as the control.All data were analyzed using the chi-square test,Fisher exact probability and analysis of variance.Results The mean hepatic artery occlusion time of the test group was 58 minutes(range,36-98 minutes).The median blood loss of the test group was 400 ml,which was significantly less than 750 ml of the control group(F =16.47,P ＜ 0.05);78%(28/36)of patients in the test group did not receive blood transfusion,which was significantly more than 53%(19/36)of the control group(x2 =6.01,P ＜0.05).The levels of postoperative serumaspartate transaminase and total bilirubin of the 2 groups were peaked at postoperative day 2 and then decreased to the normal level 1 week later.There were no significant differences in the incidences and levels of complications between the 2 groups(x2 = 1.83,0.89,P ＞ 0.05).Conclusion The addition of continuous occlusion of hepatic artery proper to intermittent Pringle maneuver significantly reduces intraoperative blood loss and doesn't bring any adverse effects to hepatic function for partial hepatectomy in patients with ruptured HCC when compared with intermittent Pringle maneuver alone. Key words: Liver neoplasms; Hepatectory; Continuous occlusion of hepatic artery proper; Ruptured tumor

Continuous Occlusion of Hepatic Artery Proper for Prevention of Blood Loss in Partial Hepatectomy for Ruptured Hepatocellular Carcinoma: A Case-Matched Comparative Study

To investigate the efficacy and safety of adding continuous occlusion of hepatic artery proper to intermittent Pringle maneuver in partial hepatectomy for ruptured hepatocellular carcinoma. This is a retrospective study on data that were prospectively collected and entered into a computer database. A total of 36 patients who underwent partial hepatectomy for ruptured HCC by adding continuous occlusion of hepatic artery proper to intermittent Pringle maneuver at a tertiary care university hospital were compared with a historical case-matched control group of 36 patients who received intermittent Pringle maneuver only. The patient characteristics were comparable for the 2 groups of patients. The mean hepatic artery occlusion time was 58min (range 36-98min). Intraoperative blood loss and blood transfusion rate in the study group were significantly lower than the control group (P<.001 and P=.004, respectively). There were no significant differences in the postoperative serum aspartate transaminase and total bilirubin levels (P=.087, P=.135, respectively), and in the postoperative hospital stay and surgical complications according to Clavien's classification between the two groups (P=0.213, P=1.000, respectively). The disease-free survival rates in the study group was significantly better than the control group (P=.023). Overall, HCC patients with rupture had poor prognosis. The addition of continuous occlusion of hepatic artery proper to intermittent Pringle maneuver significantly reduced intraoperative blood loss for partial hepatectomy in patients with ruptured HCC when compared with intermittent Pringle maneuver alone. The procedure was found to be safe even for patients with liver cirrhosis.

Biliary Cyst (aka Choledochal Cyst): A Case Report of an Unusual Cause of End Stage Liver Disease in an 11-year old Female

Results: A previously healthy 11-year old female with a two year history of intermittent sharp epigastric pain was found to have malrotation on barium examination of the upper gastrointestinal tract. At the time of laparoscopic surgical repair, her liver was noted to be grossly cirrhotic. Post-operatively, she developed jaundice and pruritus. On exam, she was jaundiced and had splenomegaly. Her total bilirubin was 14.8 mg/dL, with a conjugated fraction of 6.6 mg/dL, ALT was 75 U/L, AST was 98 U/L, alkaline phosphatase was 590 U/L, albumin was 2.3 g/dL, and INR was 1.22. Evaluation for chronic liver diseases was performed and negative. White blood count was 5.3 k/uL, hemoglobin was 12.3 g/dL, and platelets were 85/uL. She developed ascites and a right-sided pleural effusion; cell count and culture were not suggestive of infection. Abdominal ultrasound demonstrated cirrhosis, splenomegaly, dilated extrahepatic biliary ducts, and portal hypertension. MRCP showed a grossly dilated extrahepatic biliary tree, as well as marked intrahepatic biliary dilation, compatible with a choledochal, or biliary cyst. ERCP was performed, showing a massively dilated biliary tree, with an aberrant low takeoff of the cystic duct and distal stenosis of the common bile duct. Two stents were placed with relief of her obstruction. Her ascitic pleural effusion and ankle edema were controlled with diuretic therapy. After the procedure, her bilirubin showed a downward trend, but she developed recurrent episodes of cholangitis. Repeat liver biopsy demonstrated cirrhosis, with proliferation of bile ducts and neutrophilic infiltration, consistent with biliary cyst and ascending cholangitis. Due to her recurrent symptoms and underlying cirrhosis, she underwent liver transplantation. Conclusion: Congential biliary cysts are irregular dilations of the bile ducts which are due to an abnormality in the ductal wall, possibly ductal stricture and thought to result from pancreaticobiliary malunion, which allows reflux of pancreatic juice into the bile duct, that can cause chemical and inflammatory changes in the duct wall, leading to weakness and dilation. To avoid the complications of these cysts, which include cholelithiasis, cholangitis, pancreatitis, intrahepatic abscess, biliary cirrhosis, portal hypertension and cancer, cysts should be excised surgically. This will involve bile duct resection with hepaticojejunostomy, as well as, partial hepatectomy in patients with intrahepatic involvement. In cases such as ours, with end stage liver disease, or those with Caroli disease, liver transplant is necessary.

Liver Regeneration Stimulates Tumor Metastases

Partial hepatectomy for patients with colorectal liver metastases is associated with a tumor recurrence rate approaching 80% post-resection. Different factors and phases associated with regeneration of the liver are implicated in tumor recurrence. This study investigates the effects of the early and late phases of liver regeneration and the impact of the degree of liver resection on stimulating tumor growth and metastasis. Groups of mice underwent partial hepatectomy (37% or 70%) and were then challenged with colorectal liver carcinoma (CRC) tumors immediately after liver resection (early and late phase effect) or 6 days post liver resection (late phase effect). Tumor growth, degree of proliferation, tumor morphology, and the presence of extrahepatic metastases were investigated 21 days post-tumor induction. The late phase of liver regeneration plays a significant role in tumor stimulation and metastasis. The degree of hepatectomy also appears to be an important factor. The degree of hepatic resection significantly influences tumor growth and the extent of extrahepatic metastases, particularly in the lungs. Elucidation of the processes involved in the late phase of liver regeneration may assist in the development and timing of adjuvant agents to minimize tumor recurrence during this phase.