No-mortality liver resection for hepatocellular carcinoma in cirrhotic and noncirrhotic patients: is there a way? A prospective analysis of our approach

Surgical treatment for hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is an epithelial tumor derived from hepatocytes; it accounts for 80% of all primary liver cancers and ranks globally as the fourth leading cause of cancer-related deaths. HCC treatment is a multidisciplinary and a multimodal task, with surgery in the form of liver resection and liver transplantation (LT) representing the only potentially curative modality. However, there are variable opinions and discussions about applying these surgical options and using other supporting treatments. This article is a narrative review that includes articles published from 1984 to 2013 located by searching scientific databases such as PubMed, SCOPUS, and Elsevier, with the main keyword of hepatocellular carcinoma in addition to other keywords such as liver transplantation, liver resection, transarterial chemoembolization, portal vein embolization, bridging therapy, and downstaging. In this review, we focus mainly on the surgical treatment options offered for HCC, in order to illustrate the current relevant data available in the literature to help in applying these surgical options and to use other supporting treatment modalities when appropriate.

Artificial neural networking model for the prediction of post-hepatectomy survival of patients with early hepatocellular carcinoma

BACKGROUND AND AIMS

This study aimed to establish a prognostic artificial neural network model (ANN) for early hepatocellular carcinoma (HCC) following partial hepatectomy.

METHODS

Consecutive patients who were operated between February 2005 and March 2012 were prospectively studied. Seventy-five and 25% of these patients were randomly selected as a training cohort and an internal validation cohort. Similar patients from another hospital formed an external validation cohort. The predictive accuracy of the ANN for postoperative survival was measured by the area under the curve (AUC) on receiver operating characteristic (ROC) curve analysis. The results were compared with those obtained using the conventional Cox proportional hazard model, and the Hepato-Pancreato-Biliary Association (IHPBA), TNM 6th, and Barcelona-Clinic-Liver-Cancer (BCLC) staging systems.

RESULTS

The number of patients in the training, internal validation and external validation cohorts were 543, 182, and 104, respectively. On linear regression analysis, tumor size, number, alpha¬fetoprotein, microvascular invasion, and tumor capsule were independent factors affecting survival (P < 0.05). The ANN model was established based on these factors. In the training cohort, the AUC of the ANN was larger than that of the Cox model (0.855 vs 0.826, P = 0.0115), and the staging systems (0.784 vs TNM 6th: 0.639, BCLC: 0.612, IHPBA: 0.711, P < 0.0001 for all). These findings were confirmed with the internal and external validation cohorts.

CONCLUSION

The ANN was significantly better than the other commonly used model and systems in predicting survival of patients with early HCC who underwent partial hepatectomy.

Poor outcomes after hepatectomy in patients with ascites infected by methicillin-resistant staphylococci

BACKGROUND

This study was designed to investigate the association between infectious ascites, clinical parameters and treatment outcomes after hepatectomy.

METHODS

Of 891 patients who underwent hepatectomy between 2006 and 2013, 74 who underwent paracentesis for bacterial cultivation of postoperative ascites after hepatectomy were analyzed.

RESULTS

Of the 74 patients, 42 had positive bacterial cultures (positive group) and 32 patients had negative cultures (negative group). Hospital mortality was significantly higher in the positive group than in the negative group [9/42 (21.4%) vs. 2/32 (6.3%); P = 0.035]. Hospital mortality associated with each bacterial strain was as follows: methicillin-resistant staphylococci (MRS) (5/13, 38.5%), staphylococci (2/11, 18.2%), enterococci (2/12, 16.7%), Enterobacter (0/3, 0%), Klebsiella (0/2, 0%), and others (0/1, 0%). Cox proportional multivariate analysis revealed that MRS infection in ascites was the only risk factor of hospital death (HR = 5.08, P = 0.041) and MRS wound infection was the only risk factor to predict MRS infection in ascites (HR = 5.67, P = 0.015).

CONCLUSION

Postoperative MRS infection in postoperative ascites after hepatectomy is a potentially fatal complication; therefore, the prevention of MRS wound infection is critical to decrease postoperative hospital mortality.

New perspectives in the assessment of future remnant liver

In order to achieve microscopic radical resection margins and thus better survival, surgical treatment of hepatic tumors has become more aggressive in the last decades, resulting in an increased rate of complex and extended liver resections. Postoperative outcomes mainly depend on the size and quality of the future remnant liver (FRL). Liver resection, when performed in the absence of sufficient FRL, inevitably leads to postresection liver failure. The current gold standard in the preoperative assessment of the FRL is computed tomography volumetry. In addition to the volume of the liver remnant after resection, postoperative function of the liver remnant is directly related to the quality of liver parenchyma. The latter is mainly influenced by underlying diseases such as cirrhosis and steatosis, which are often inaccurately defined until microscopic examination after the resection. Postresection liver failure remains a point of major concern that calls for accurate methods of preoperative FRL assessment. A wide spectrum of tests has become available in the past years, attesting to the fact that the ideal methodology has yet to be defined. The aim of this review is to discuss the current modalities available and new perspectives in the assessment of FRL in patients scheduled for major liver resection.

Liver resection for HCC: patient's selection and controversial scenarios

Liver resection is a valuable curative option for patients with hepatocellular carcinoma (HCC). Yet, the balance between the operative risk following hepatectomy for HCC occurring on chronic liver disease and the oncologic prognosis of advanced lesions have led treatment recommendations to limiting the place of liver resection to selected patients with preserved liver function harbouring early-stage tumours. However, better understanding of the natural history of both tumour and underlying liver disease, sophisticated assessment of the liver function, improvements in the preoperative management of the patients with the use of liver volume modulation, refinements in surgical technique including anatomic resection and laparoscopic approach along with tailored management of recurrences have led expert centres to better define and extend the indications for liver resection. In this setting, the reported favourable operative results and long-term outcomes following resection of HCC in a number of controversial scenarios support that current guidelines could be refined.

Resection of hepatitis B virus-related hepatocellular carcinoma: Evolving strategies and emerging therapies to improve outcome

The incidence of hepatocellular carcinoma (HCC) is increasing worldwide, largely due to hepatitis B virus (HBV), hepatitis C virus and liver cirrhosis. Chronic HBV infection is estimated to cause 55%-60% of the cases of HCC worldwide and over 70% in Asian countries. Liver resection is currently the mainstay of treatment due to the low surgical mortality, a wider treatment indication, and simplicity of post-treatment follow-up. There is an ever-increasing demand on surgeons to perform curative liver resection in HCC, with the hope of avoiding tumor recurrences. Hepatitis B-related-HCC has distinct clinicopathological features, which should be considered when treating the disease. The author presents a review of the recently evolving strategies and emerging therapies to improve HCC postresectional outcomes and focus on perioperative measures to improve patient outcome, with particular reference to the current status of adjuvant therapies in HCC patients after liver resection.

Ischemic preconditioning provides no additive clinical value in liver resection of cirrhotic and non-cirrhotic patients under portal triad clamping: a prospective randomized controlled trial

BACKGROUND AND OBJECTIVE

The clinical value of ischemic preconditioning (IP) on patients undergoing hepatectomy under portal triad clamping (PTC) is uncertain, especially for patients with liver cirrhosis. Hence, we conducted a prospective randomized controlled trial to test whether IP could protect liver against ischemic reperfusion (IR) injury after hepatectomy under PTC.

METHOD

One hundred patients, including 67 with cirrhosis, undergoing hepatectomy with PTC were randomly divided into IP and control groups. Liver function tests at postoperative days 1, 3, and 7 as well as postoperative morbidity, mortality, and duration of hospitalization were compared between the two groups.

RESULTS

The general clinical characteristics between both groups were comparable. The duration of the operation, the amount of intraoperative blood loss, and the need and amount of perioperative blood transfusion were similar in both groups. The postoperative levels of serum alanine aminotransferase (ALT), aspartate aminotransferase (AST), total bilirubin, and albumin were not statistically different between the two groups. In addition, the morbidity and mortality rates and the duration of hospitalization were similar in both groups.

CONCLUSIONS

IP did not improve liver tolerance to IR injury after hepatectomy under PTC. Therefore, the clinical use of IP cannot be recommended as a standard procedure before PTC.

Decreased blood loss reduces postoperative complications in resection for hepatocellular carcinoma

BACKGROUND

The correlation between blood loss and the risk of postoperative complications was unclear in patients undergoing resection of hepatocellular carcinoma (HCC).

METHODS

We studied 539 patients who had resection of HCC. Postoperative complications were recorded according to the modified Clavien-Dindo classification. Variables were compared between patients with grade III to V complications and those with no or grade I to II. A spline regression analysis was used to estimate the probability of grade III to V complications.

RESULTS

Among variables, blood loss (P = 0.0001), operating time (P = 0.0001), blood transfusion (P = 0.0001), and tumor size (P = 0.02) differed significantly between patients with grade III to V and those with no or I to II. Multivariate analysis revealed that the factor most strongly related to complications was blood loss (odds ratio 1.68; 95% confidence interval [CI] 1.45-1.96, P = 0.0001). Spline regression analysis showed that an increase in blood loss was accompanied by increase in the risk of complication; when the estimated probability of grade III to V complications exceeded 50% (95% CI 30.0-70.0), the corresponding blood loss was 820 ml.

CONCLUSION

Decrease in blood loss in resection of HCC is accompanied by reduced risk of complications. Surgeons need to minimize blood loss as less as 820 ml.

Surgical treatment of extrahepatic recurrence of hepatocellular carcinoma

PURPOSE

The purpose of this study was to clarify the clinicopathological features of extrahepatic hepatocellular carcinoma (HCC) recurrence after hepatectomy in order to schedule optimal treatment strategies for better long-term outcomes.

METHODS

A cohort of 206 patients who had undergone curative hepatectomy for HCC was analysed; 133 patients had developed relapse. Among them, 101 patients had intrahepatic recurrence only (IHR), and 32 patients had extrahepatic recurrence (EHR). Clinicopathological and survival data were compared between the two groups.

RESULTS

The overall survival rate after hepatectomy was better in the IHR than in the EHR group (p<0.0001). The recurrence-free interval after hepatectomy was significantly shorter in the EHR than in the IHR group (258 vs. 487 days, p<0.0043). Patients in the EHR group were more likely to have a high PIVKA II, a large tumour, and microscopic portal vein invasion when compared with patients in the IHR group. Microscopic portal vein invasion was the most important independent risk factor for EHR after hepatectomy (p=0.0295). Patients with more than two risk factors for EHR showed poor prognosis in comparison with patients without any risk factors (p<0.001). In the EHR group, patients who underwent repeated resection had significantly better survival than patients receiving only the best supportive care (539 vs. 133 days, p=0.0098). Furthermore, among EHR patients with concomitant IHR, patients with controllable IHR had significantly better survival than those with uncontrollable IHR (524 vs. 147 days, p=0.0131).

CONCLUSIONS

EHR of HCC was associated with early recurrence, and risk factors for the occurrence of EHR included the presence of high PIVKA II, large tumours, and microscopic portal vein invasion. Resection of recurrent tumour and local control of concomitant IHR may improve the prognosis of EHR patients.

Liver resection and transplantation in hepatocellular carcinoma

Liver resection is the most available, efficient treatment for patients with hepatocellular carcinoma. Better liver function assessment, increased understanding of segmental liver anatomy using more accurate imaging studies, and surgical technical progress are the most important factors that have led to reduced mortality, with an expected 5 year survival of 70%. Impairment of liver function and the risk of tumor recurrence lead to consideration of liver transplantation (LT) as the ideal treatment for removal of the existing tumor and the preneoplastic underlying liver tissue. However, LT, which is not available in many countries, is restricted to patients with minimum risk of tumor recurrence under immunosuppression. Limited availability of grafts as well as the risk and the cost of the LT procedure has led to considerable interest in combined treatment involving resection and LT. An increasing amount of evidence has shown that initial liver resection in transplantable patients with a single limited tumor and good liver function is a valid indication. Histological analysis of specimens allows identification of the subgroup of patients who could benefit from follow-up with LT in case of recurrence.

Recent advances in liver resection for hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is the most common primary liver malignancy. The association of HCC with chronic liver disease (CLD) is well known and making treatment complex and challenging. The treatment of HCC must take into consideration, the severity of CLD, the stage of HCC, and the clinical condition of the patient. Liver resection (LR) is one of the most efficient treatments for patients with HCC. Better liver function assessment, increased understanding of segmental liver anatomy using more accurate imaging studies, and surgical technical progress are the important factors that have led to reduced mortality, with an expected 5 year survival of 38-61% depending on the stage of the disease. However, the procedure is applicable to <30% of all HCC patients, and 80% of the patients after LR recurred within 5 years. There are recent advances and prospects in LR for HCC in several aspects. Three-dimensional computed tomography imaging assisted preoperative surgical planning facilitates unconventional types of LR. Emerging evidences of laparoscopic hepatectomy and prospects for the use of newly developing chemotherapies as a combined therapy may lead to expanding indication of LR. LR and liver transplantation could be associated rather than considered separately with the current concepts of "bridging LR" and "salvage transplantation."

A new Child-Turcotte-Pugh class 0 for patients with hepatocellular carcinoma: determinants, prognostic impact and ability to improve the current staging systems

Background/Aim

Majority of patients with hepatocellular carcinoma (HCC) belonged to Child-Turcotte-Pugh (CTP) class A. We aimed to identify a new class of patients with very well-preserved liver function and analyze its impact on outcome prediction, tumor staging and treatment allocation.

Methods

A total of 2654 HCC patients were retrospectively analyzed. The prognostic ability was compared by the Akaike information criterion (AIC).

Results

The CTP class 0 was defined by fulfilling all criteria of albumin ≧4 g/dL, bilirubin ≦0.8 mg/dL, prothrombin time prolongation <0 seconds, no ascites and encephalopathy. A total of 23% of patients of CTP class A were reclassified as CTP class 0. Patients with CTP class 0 had a higher serum sodium level, lower serum creatinine, alanine aminotransferase, α-fetoprotein levels, shorter prothrombin time, better general well-being, smaller tumor burden with more solitary nodules, lower rates of vascular invasion, ascites formation, hepatic encephalopathy, more frequently treated with curative interventions and better Barcelona Clinic Liver Cancer (BCLC) stages (all p<0.001). In the Cox proportional hazards model, the adjusted hazard ratios for CTP class A, B and C were 1.739, 3.120 and 5.107, respectively, compared to class 0 (all p<0.001). Reassigning patients with CTP class 0, A, B, B and C to stage 0, A, B, C and D, respectively, provided the lowest AIC score among all BCLC-based models.

Conclusions

The proposal of CTP class 0 independently predicted better survival in HCC patients. Modification of tumor staging systems according to the modified CTP classification further enhances their prognostic ability.

Green light for liver function monitoring using indocyanine green? An overview of current clinical applications

The dye indocyanine green is familiar to anaesthetists, and has been studied for more than half a century for cardiovascular and hepatic function monitoring. It is still, however, not yet in routine clinical use in anaesthesia and critical care, at least in Europe. This review is intended to provide a critical analysis of the available evidence concerning the indications for clinical measurement of indocyanine green elimination as a diagnostic and prognostic tool in two areas: its role in peri-operative liver function monitoring during major hepatic resection and liver transplantation; and its role in critically ill patients on the intensive care unit, where it is used for prediction of mortality, and for assessment of the severity of acute liver failure or that of intra-abdominal hypertension. Although numerous studies have demonstrated that indocyanine green elimination measurements in these patient populations can provide diagnostic or prognostic information to the clinician, 'hard' evidence - i.e. high-quality prospective randomised controlled trials - is lacking, and therefore it is not yet time to give a green light for use of indocyanine green in routine clinical practice.

Hepatocellular carcinoma: a comprehensive overview of surgical therapy

Hepatocellular carcinoma (HCC) is one of the most common malignancies worldwide, with a rising incidence in the United States. The increase in medical and locally ablative therapies have improved prognosis, however surgery, either liver resection or transplantation, remains the mainstay of therapy. An increased understanding of liver anatomy, improved imaging modalities and refinements of surgical technique have all led to improved outcomes after surgery. Both resection and transplantation may be used in a complementary manner. Resection remains the treatment of choice for HCC when feasible. Liver transplantation, which removes both the tumor and the underlying diseased liver offers excellent outcomes in patients that meet the Milan criteria. While both these modalities have relatively well defined roles, the treatment of these patients must be tailored individually, using a multidisciplinary approach, to maximize survival, quality of life and allocation of scarce organs.

Liver resection in the elderly: significance of comorbidities and blood loss

OBJECTIVE

Liver resection is increasingly performed in elderly patients who are suspected of increased postoperative morbidity (PM) and reduced overall survival (OS). Patient selection based on the identification of age-adjusted risk factors may help to decrease PM and OS.

DESIGN AND PARTICIPANTS

Prospectively collected data of 879 patients undergoing elective hepatic resection were analyzed. This population was stratified into three age cohorts: >70 years (n = 228; 26 %), 60-69 years (n = 309; 35 %), and <60 years (n = 342; 39 %). Multivariate survival analysis was performed.

RESULTS

The incidence of severe (p < 0.01) and non-surgical (p < 0.001) postoperative complications was higher in older compared to younger patients. Major estimated blood loss (EBL; p = 0.039) and comorbidities (p = 0.002) independently increased PM. EBL was comparable between all age cohorts. However, preexisting comorbidities, major EBL, and postoperative complications markedly decreased OS in contrast to younger patients. Adjusted for age, independent predictors of OS were comorbidities (HR = 1.51; p = 0.001), major hepatectomy (HR = 1.33; p = 0.025), increased EBL (HR = 1.32; p = 0.031), and postoperative complications (HR = 1.64; p < 0.001).

CONCLUSION

Although increased age should not be a contraindication for liver resection, this study accents the avoidance of major blood loss in elderly patients and a stringent patient selection based on preexisting comorbidities.

Usefulness of a new inflammation-based scoring system for prognostication of patients with hepatocellular carcinoma after hepatectomy

BACKGROUND

We investigated whether a preoperative scoring system (the "CRP-AFP Score [CAS]") based on the serum levels of C-reactive protein and alpha-fetoprotein would predict outcome in patients undergoing hepatectomy for hepatocellular carcinoma.

METHODS

The CAS was defined as follows: patients with an elevated level of both C-reactive protein (>.3 mg/dL) and alpha-fetoprotein (>20 ng/mL) were assigned a score of 2, and patients showing one or none of these abnormalities were assigned a score of 1 or 0, respectively.

RESULTS

A total of 349 patients were identified. Pathologic findings, in terms of tumor size, histologic grade, vascular invasion, intrahepatic metastasis, and recurrence rate, worsened as the CAS increased. CAS 2 patients had a poorer 5-year overall survival than CAS 0 or 1 patients (32.2% vs 59.7% vs 49.2%, respectively; P < .001).

CONCLUSIONS

The CAS is an informative scoring system that can predict outcome in patients with hepatocellular carcinoma after hepatectomy.

Local effect of stereotactic body radiotherapy for primary and metastatic liver tumors in 130 Japanese patients

BACKGROUND AND AIMS

Stereotactic body radiotherapy (SBRT) is a relatively new treatment for liver tumor. The outcomes of SBRT for liver tumor unfit for ablation and surgical resection were evaluated.

METHODS

Liver tumor patients treated with SBRT in seven Japanese institutions were studied retrospectively. Patients given SBRT for liver tumor between 2004 and 2012 were collected. Patients treated with SBRT preceded by trans-arterial chemoembolization (TACE) were eligible. Seventy-nine patients with hepatocellular carcinoma (HCC) and 51 patients with metastatic liver tumor were collected. The median biologically effective dose (BED) (α/β = 10 Gy) was 96.3 Gy for patients with HCC and 105.6 Gy with metastatic liver tumor.

RESULTS

The median follow-up time was 475.5 days in patients with HCC and 212.5 days with metastatic liver tumor. The 2-year local control rate (LCR) for HCC and metastatic liver tumor was 74.8% ± 6.3% and 64.2 ± 9.5% (p = 0.44). The LCR was not different between BED10 ≥ 100 Gy and < 100 Gy (p = 0.61). The LCR was significantly different between maximum tumor diameter > 30 mm vs. ≤ 30 mm (64% vs. 85%, p = 0.040) in all 130 patients. No grade 3 laboratory toxicities in the acute, sub-acute and chronic phases were observed.

CONCLUSIONS

There was no difference in local control after SBRT in the range of median BED10 around 100 Gy for between HCC and metastatic liver tumor. SBRT is safe and might be an alternative method to resection and ablation.

SUMMARY

There was no difference in local control after SBRT in the range of median BED10 around 100 Gy for between HCC and metastatic liver tumor and SBRT is safe and might be an alternative method to resection and ablation.

Latin American Association for the Study of the Liver (LAASL) clinical practice guidelines: management of hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is the fifth most common cancer in the world and the third most common cause of cancer death, and accounts for 5.6% of all cancers. Nearly 82% of the approximately 550,000 liver cancer deaths each year occur in Asia. In some regions, cancer-related death from HCC is second only to lung cancer. The incidence and mortality of HCC are increasing in America countries as a result of an ageing cohort infected with chronic hepatitis C, and are expected to continue to rise as a consequence of the obesity epidemic. Clinical care and survival for patients with HCC has advanced considerably during the last two decades, thanks to improvements in patient stratification, an enhanced understanding of the pathophysiology of the disease, and because of developments in diagnostic procedures and the introduction of novel therapies and strategies in prevention. Nevertheless, HCC remains the third most common cause of cancer-related deaths worldwide. These LAASL recommendations on treatment of hepatocellular carcinoma are intended to assist physicians and other healthcare providers, as well as patients and other interested individuals, in the clinical decision-making process by describing the optimal management of patients with liver cancer.

Hepatic resection for hepatocellular carcinoma patients on hemodialysis for uremia: a nationwide cohort study

BACKGROUND

The association between uremia and survival outcomes of patients undergoing hepatic resection for hepatocellular carcinoma (HCC) has not been well investigated, particularly for perioperative complications. This nationwide cohort study aimed to compare survival outcomes as well as perioperative mortality and complications between uremia-HCC patients and non-uremia-HCC patients who underwent hepatic resection.

METHODS

Using Taiwan's National Health Institute Research Database, 149 uremia-HCC patients who underwent hepatic resection between 1996 and 2008 were enrolled. The control group comprised 596 HCC patients who also received hepatic resection during the same time period. The two groups were matched for age, gender, viral hepatitis status, and underlying liver cirrhosis. Disease-free survival, overall survival, and perioperative complications were compared between the two groups.

RESULTS

For the uremia-HCC cohort, the 1-, 5-, and 10-year overall and disease-free survival rates were 86, 52, and 38 %, as well as 77, 27, and 18 %, respectively. The survival outcomes were comparable between uremia-HCC cohort and the HCC cohort, regardless of extent of hepatic resection. As for perioperative complications, the uremia-HCC cohort had a higher risk of postoperative infections requiring invasive interventions as well as an increased risk of life-threatening heart-associated complications, compared to the HCC cohort.

CONCLUSIONS

Uremia did not influence survival outcomes between the uremia-HCC and the HCC cohorts, irrespective of extent of hepatic resection. This study urges a better perioperative care strategy to avoid potential cardiac and infectious complications in uremia-HCC patients.

Enhanced-reality video fluorescence: a real-time assessment of intestinal viability

OBJECTIVE

Our aim was to evaluate a fluorescence-based enhanced-reality system to assess intestinal viability in a laparoscopic mesenteric ischemia model.

MATERIALS AND METHODS

A small bowel loop was exposed, and 3 to 4 mesenteric vessels were clipped in 6 pigs. Indocyanine green (ICG) was administered intravenously 15 minutes later. The bowel was illuminated with an incoherent light source laparoscope (D-light-P, KarlStorz). The ICG fluorescence signal was analyzed with Ad Hoc imaging software (VR-RENDER), which provides a digital perfusion cartography that was superimposed to the intraoperative laparoscopic image [augmented reality (AR) synthesis]. Five regions of interest (ROIs) were marked under AR guidance (1, 2a-2b, 3a-3b corresponding to the ischemic, marginal, and vascularized zones, respectively). One hour later, capillary blood samples were obtained by puncturing the bowel serosa at the identified ROIs and lactates were measured using the EDGE analyzer. A surgical biopsy of each intestinal ROI was sent for mitochondrial respiratory rate assessment and for metabolites quantification.

RESULTS

Mean capillary lactate levels were 3.98 (SD = 1.91) versus 1.05 (SD = 0.46) versus 0.74 (SD = 0.34) mmol/L at ROI 1 versus 2a-2b (P = 0.0001) versus 3a-3b (P = 0.0001), respectively. Mean maximal mitochondrial respiratory rate was 104.4 (±21.58) pmolO2/second/mg at the ROI 1 versus 191.1 ± 14.48 (2b, P = 0.03) versus 180.4 ± 16.71 (3a, P = 0.02) versus 199.2 ± 25.21 (3b, P = 0.02). Alanine, choline, ethanolamine, glucose, lactate, myoinositol, phosphocholine, sylloinositol, and valine showed statistically significant different concentrations between ischemic and nonischemic segments.

CONCLUSIONS

Fluorescence-based AR may effectively detect the boundary between the ischemic and the vascularized zones in this experimental model.

Surgery versus transarterial chemoembolization for solitary large hepatocellular carcinoma of BCLC stage A

BACKGROUND/AIMS

The aim of this study was to compare the outcomes of surgery and transarterial chemoembolization (TACE) for a solitary huge hepatocellular carcinoma (HCC) of Barcelona Clinic Liver Cancer (BCLC) stage A.

METHODS

One hundred twenty-three consecutive patients with a solitary large (>5 cm) HCC classified at the BCLC stage A were analyzed. The posttreatment survival outcomes of patients that underwent surgery or TACE were compared.

RESULTS

The median age was 58 years (range, 29-90 years). The most common cause of HCC is hepatitis B virus infection (61.8%). Median tumor size was 8.0 cm (range, 5.1-25 cm), and 97 patients (78.9%) were of Child-Turcotte-Pugh class A. Median posttreatment follow-up duration was 18 months (range, 0.1-136 months). Of the 123 patients, 62 (50.4%) underwent surgery and 61 (49.6%) underwent TACE. Cumulative overall survival rates in the surgical group at 1, 3, and 5 years were significantly higher than those in the TACE group (83.2, 75.7, and 65.0% vs 68.5, 45.0, and 17.5%, respectively, P < 0.01). In subgroup analysis, the cumulative overall survival in both surgical groups was significantly greater than in corresponding TACE subgroups (P = 0.04 for ≥ 8-cm subgroup and P < 0.01 for 5- to 8-cm-sized subgroups). Multivariate analysis showed that a larger tumor size (≥ 8 cm) (hazard ratio [HR] 2.14, P = 0.02) was significantly associated with posttreatment mortality, whereas surgery (HR 0.37, P < 0.01) compared with TACE was inversely associated with posttreatment mortality.

CONCLUSIONS

Surgery may be the more effective treatment modality than TACE for a solitary large HCC of the BCLC stage A, regardless of tumor size.

Stereotactic ablative body radiotherapy for previously untreated solitary hepatocellular carcinoma

BACKGROUND AND AIMS

Stereotactic ablative body radiotherapy (SABR) is a relatively new treatment for hepatocellular carcinoma (HCC). The outcomes of SABR for previously untreated solitary HCC unfit for ablation and surgical resection were evaluated.

METHODS

Untreated solitary HCC patients treated with SABR were retrospectively studied. Between 2005 and 2012, 221 HCC patients underwent SABR. Among them, patients with untreated solitary HCC, treated with only SABR or SABR preceded by transarterial chemoembolization, were eligible. Based on baseline liver function and liver volume receiving ≥ 20 Gy, 35-40 Gy in five fractions was prescribed to the planning target volume surface.

RESULTS

Sixty-three patients were eligible, with a median follow-up duration of 31.1 (range 12.0-88.1) months. No patients were lost to follow-up. Twenty patients were treated with only SABR. In 43 patients treated with SABR preceded by transarterial chemoembolization, accumulation of lipiodol in the tumor remained complete in five, a partial defect in 38 on pre-SABR computed tomography. The 1-, 2-, and 3-year local control rates were 100%, 95%, and 92%, respectively; the intrahepatic recurrence-free rates were 76%, 55%, and 36%, respectively; and the overall survival rates were 100%, 87%, and 73%, respectively. Grade 3 laboratory toxicities in the acute, subacute, and chronic phases were observed in 10, 9, and 13 patients, respectively, and ascites occurred in one patient.

CONCLUSIONS

Local control and overall survival after SABR for untreated solitary HCC were excellent despite the candidates being unfit for resection and ablation. SABR is safe and might be an alternative to resection and ablation.

Use of pre-operative steroids in liver resection: a systematic review and meta-analysis

BACKGROUND

By attenuating the systemic inflammatory response to major surgery, the pre-operative administration of steroids may reduce the incidence of complications.

METHODS

A systematic review was conducted to identify randomized controlled trials (RCT) comparing pre-operative steroid administration with placebo during a liver resection. Meta-analyses were performed.

RESULTS

Five RCTs were identified including a total of 379 patients. Pre-operative steroids were associated with statistically significant reductions in the levels of serum bilirubin and interleukin 6 (IL-6) on post-operative day one. There was a trend towards a lower incidence of post-operative complications and prothrombin time (PT), but this did not reach statistical significance.

CONCLUSION

Pre-operative steroids may be associated with a clinically significant benefit in liver resection.

Thoracoabdominal approach in liver surgery: how, when, and why

Liver resection can be performed with different surgical approaches whether abdominal or combined thoracoabdominal. This work focuses on the surgical technique for the thoracoabdominal approach in liver surgery, describing the technique, the rationale, and making a review of the current literature on such subject.

Efficacy and safety of hepatectomy performed with intermittent portal triad clamping with low central venous pressure

Background. This retrospective study was designed to investigate the efficacy and safety of intermittent portal triad clamping (PTC) with low central venous pressure (CVP) in liver resections. Methods. Between January 2007 and August 2013, 115 patients underwent liver resection with intermittent PTC. The patients' data were retrospectively analyzed. Results. There were 58 males and 57 females with a mean age of 55 years (±13.7). Cirrhosis was found in 23 patients. Resections were performed for malignant disease in 62.6% (n = 72) and for benign disease in 37.4% (n = 43). Major hepatectomy was performed in 26 patients (22.4%). Mean liver ischemia period was 27.1 min (±13.9). The mortality rate was 1.7% and the morbidity rate was 22.6%. Cumulative clamping time (t = 3.61, P < 0.001) and operation time (t = 2.38, P < 0.019) were significantly correlated with AST alterations (D-AST). Cumulative clamping time (t = 5.16, P < 0.001) was significantly correlated with D-ALT. Operation time (t = 5.81, P < 0.001) was significantly correlated with D-LDH. Conclusions. Intermittent PTC under low CVP was performed with low morbidity and mortality. Intermittent PTC can be safely applied up to 60 minutes in both normal and impaired livers.

Pure laparoscopic hepatectomy for hepatocellular carcinoma with chronic liver disease

Pure laparoscopic hepatectomy is a less invasive procedure than conventional open hepatectomy for the resection of hepatic lesions. Increases in experiences with the technique, in combination with advances in technology, have promoted the popularity of pure laparoscopic hepatectomy. However, indications for usage and potential contraindications of the procedure remain unresolved. The characteristics and specific advantages of the procedure, especially for hepatocellular carcinoma (HCC) patients with chronic liver diseases, are reviewed and discussed in this paper. For cirrhotic patients with liver tumors, pure laparoscopic hepatectomy minimizes destruction of the collateral blood and lymphatic flow from laparotomy and mobilization, and mesenchymal injury from compression. Therefore, pure laparoscopic hepatectomy has the specific advantage of minimal postoperative ascites production that leads to lowering the risk of disturbance in water or electrolyte balance and hypoproteinemia. It minimizes complications that routinely trigger postoperative serious liver failure. Under adequate patient positioning and port arrangement, the partial resection of the liver in the area of subphrenic space, peri-inferior vena cava area or next to the attachment of retro-peritoneum is facilitated in pure laparoscopic surgery by providing good vision and manipulation in the small operative field. Furthermore, the features of reduced post-operative adhesion, good vision, and manipulation within the small area between the adhesions make this procedure safer in the context of repeat hepatectomy procedures. These improved features are especially advantageous for patients with liver cirrhosis and multicentric and/or metachronous HCCs.

Anatomic considerations in the surgical resection of hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is the most common primary malignancy of the liver and is a common cause of cancer death worldwide. Treatment of HCC usually consists of combinations of locoregional therapy, surgical resection, orthotopic liver transplantation, and in advanced cases, systemic chemotherapy. The best rates of cure are achieved with surgical resection or orthotopic liver transplantation in well-selected patients. The success of surgical resection depends on the adequacy of the extent of resection, balanced with the need to preserve functional hepatic parenchyma. Nonanatomic resection for HCC has been proposed as a surgical technique to maximize residual liver mass, but has been shown by some to yield inferior oncologic outcomes compared with formal anatomic resection. This review discusses relevant surgical anatomy of the liver, classifications of hepatic resection, and the current literature regarding outcomes of anatomic and nonanatomic resection of the liver.

External validation of a simplified BCLC staging system for early hepatocellular carcinoma

BACKGROUND AND AIMS

The aim was to externally validate the capability of a simplified Barcelona Clinic Liver Cancer (s-BCLC) staging system in allocating patients to hepatic resection (HR) and the effect on survival: S-BCLC was defined by only 2 groups: AA included BCLC A1 + A2 classes with alpha-fetoprotein (AFP) ≤ 20 ng/ml and AB included A1 + A2 with AFP > 20 ng/ml plus A3 + A4 subgroups.

METHODS

This study compared a training group (TG) with hepatocellular carcinoma (HCC) submitted to hepatic resection (HR) in Milan with another group of patients, the validation group (VG) in Creteil. All patients underwent ultrasound-guided anatomical resection (<3 segments).

RESULTS

Overall survival got worse from A1 to A4 (p = 0.0271) in TG (n = 132), as well as in VG (n = 100) (p = 0.0044) with a more important overlapping of each curves. According s-BCLC classification, the survival curves of TG (p = 0.0001) and VG (p = 0.0250) showed a definitive separation in two different staging groups. The s-BCLC provided the best predictive accuracy and it also presented the highest separability index and C-statistics in both TG and VG. On the other hand, in the evaluation of discriminatory ability for death, measured by ROC curve areas, the s-BCLC system gave better results than the others.

CONCLUSION

This experience stressed the high value of BCLC system in staging of HCC, but the s-BCLC system seems to be more useful for therapeutic decision making.

A snapshot of the effective indications and results of surgery for hepatocellular carcinoma in tertiary referral centers: is it adherent to the EASL/AASLD recommendations?: an observational study of the HCC East-West study group

OBJECTIVE

The aim of this study was to investigate in a retrospective setting the patients' profile and results of those undergoing surgery for hepatocellular carcinoma (HCC) in high-volume surgical centers throughout the world.

BACKGROUND

Whether surgery for HCC is a suitable approach and for which subset of patients is still controversial. The EASL/AASLD (European Association for the Study of Liver Disease/American Association for the Study of Liver Disease) guidelines, based on the Barcelona Clinic Liver Cancer (BCLC) classification, leave little room for hepatic resection; inversely, other reports promote its wider application.

METHODS

On the basis of the network "Hepatocellular Carcinoma: Eastern & Western Experiences," data for 2046 consecutive patients resected for HCC in 10 centers were collected. According to the BCLC classification, 1012 (50%) were BCLC 0-A, 737 (36%) BCLC B, and 297 (14%) BCLC C. Analysis of overall survival and disease-free survival and multivariate analysis of prognostic factors were performed.

FINDINGS

The 90-day mortality rate was 2.7%. Overall morbidity was 42%. After a median follow-up of 25 months (range, 1-209 months), the 1-, 3-, and 5-year overall survival rates were 95%, 80%, and 61% for BCLC 0-A; 88%, 71%, and 57% for BCLC B; and 76%, 49%, and 38% for BCLC C (P = 0.000). The 1-, 3-, and 5-year disease-free survival rates were as follows: 77%, 41%, and 21% for BCLC 0-A; 63%, 38%, and 27% for BCLC B; and 46%, 28%, and 18% for BCLC C (P = 0.000). The multivariate analysis identified bilirubin, cirrhosis, esophageal varices, tumor size, and macrovascular invasion to be statistical and independent prognostic factors for overall survival.

CONCLUSIONS

This large multicentric survey shows that surgery is in current practice widely applied among patients with multinodular, large, and macrovascular invasive HCC, providing acceptable short- and long-term results and justifying an update of the EASL/AASLD therapeutic guidelines in this sense.

Recurrence after anatomic resection versus nonanatomic resection for hepatocellular carcinoma: a meta-analysis

The impact of anatomic resection (AR) as compared to non-anatomic resection (NAR) for hepatocellular carcinoma (HCC) as a factor for preventing intra-hepatic and local recurrence after the initial surgical procedure remains controversial. A systematic review and meta-analysis of nonrandomized trials comparing anatomic resection with non-anatomic resection for HCC published from 1990 to 2010 in PubMed and Medline, Cochrane Library, Embase, and Science Citation Index were therefore performed. Intra-hepatic recurrence, including early and late, and local recurrence were considered as primary outcomes. As secondary outcomes, 5 year survival and 5 year disease-free survival were considered. Pooled effects were calculated utilizing either fixed effects or random effects models. Eleven non-randomized studies including 1,576 patients were identified and analyzed, with 810 patients in the AR group and 766 in the NAR group. Patients in the AR group were characterized by lower prevalence of cirrhosis, more favorable hepatic function, and larger tumor size and higher prevalence of macrovascular invasion compared with patients in the NAR group. Anatomic resection significantly reduced the risks of local recurrence and achieved a better 5 years disease-free survival. Also, anatomic resection was marginally effective for decreasing the early intra-hepatic recurrence. However, it was not advantageous in preventing late intra-hepatic recurrence compared with non-anatomic resection. No differences were found between AR and NAR with respect to postoperative morbidity, mortality, and hospitalization. Anatomic resection can be recommended as superior to non-anatomic resection in terms of reducing the risks of local recurrence, early intra-hepatic recurrence and achieving a better 5 year disease-free survival in HCC patients.

Resection or transplantation for early hepatocellular carcinoma in a cirrhotic liver: does size define the best oncological strategy?

BACKGROUND

Resection and liver transplantation (LT) are the only curative options for hepatocellular carcinoma in cirrhotic patients (HCC-cirr).

OBJECTIVE

We tried to define the best primary intention-to-treat strategy in patients undergoing either resection or LT for early single HCC-cirr (≤5 cm).

METHODS

From 1990 to 2010, 198 patients with early HCC-cirr underwent either resection (group R, n = 97) or LT (group T, n = 101) as the primary procedure. Our policy was to prioritize Childs A patients with peripheral lesions for resection rather than LT. Patient and tumor characteristics, and outcomes (recurrence-free survival [RFS] and overall survival [OS]), were studied.

RESULTS

A longer diagnosis-to-surgery interval, more Child Pugh B/C patients, and more tumor nodules (on histopathological examination) were found in group T patients. The postoperative mortality (4.1% vs 3.0%, P = 0.72) and rate of major complications (19.1% vs 24.7%, P = 0.35) were similar in groups R and T, respectively, whereas tumor recurrence was higher in group R (62% vs 10% in group T, P < 0.0001). The 5-year OS (75% vs 52%, P = 0.0008) and RFS (72% vs 20%, P < 0.0001) were better in group T; similarly, more patients were disease free at last follow-up (27% vs 62%, P < 0.0001). Resection as the surgical procedure, tumor diameter 3 cm or more on histology, and microvascular tumor invasion were poor prognostic factors for OS and RFS. Including dropout patients from LT list in the analysis, the outcomes in group T were still better (70% and 61% vs 51% and 36% at 5 and 10 years, P = 0.01).

CONCLUSIONS

On an intention-to-treat basis, LT is associated with the best survival outcomes in patients with early HCC-cirr. Resection may achieve comparable OS in patients with single HCC-cirr of size smaller than 3 cm; however, the RFS still remains lower than that in patients of group T. This study could serve as a guide for HCC-cirr patients who are candidates for either resection or LT.

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.

PATIENTS AND METHODS

Clinicopathologic data for 1,115 patients with HCC who underwent hepatectomy between 1981 and 2008 at five hepatobiliary centers in France, China, and the USA were assessed. In addition to other performance metrics, outcomes were evaluated using resection of ≥4 liver segments as a novel definition of major hepatectomy.

RESULTS

Major hepatectomy was performed in 539 patients. In the major hepatectomy group, median tumor size was 10 cm (range: 1-27 cm) and 22 % of the patients had bilateral lesions. The TNM Stage distribution included 29 % Stage I, 31 % Stage II, 38 % Stage III, and 2 % Stage IV. The postoperative histologic examination indicated that chronic liver disease was present in 35 % of the patients and tumor microvascular invasion was identified in 60 % of the patients. The 90-day postoperative mortality rate was 4 %. After a median follow-up time of 63 months, the 5-year overall survival rate was 40 %. Patients treated with right hepatectomy (n = 332) and those requiring extended hepatectomy (n = 207) had similar 90-day postoperative mortality rates (4 % and 4 %, respectively, p = 0.976) and 5-year overall survival rates (42 % and 36 %, respectively, p = 0.523). Postoperative mortality and overall survival rates after major hepatectomy were similar among the participating countries (p > 0.1) and improved over time with 5-year survival rates of 30 %, 40 %, and 51 % for the years 1981-1989, 1990-1999, and the most recent era of 2000-2008, respectively (p = 0.004). In multivariate analysis, factors that were significantly associated with worse survivals included AFP level >1,000 ng/mL, tumor size >5 cm, presence of major vascular invasion, presence of extrahepatic metastases, positive surgical margins, and earlier time period in which the major hepatectomy was performed.

CONCLUSIONS

This multinational, long-term HCC survival analysis indicates that expansion of surgical indications to include major hepatectomy is justified by the significant improvement in outcomes over the past three decades observed in both the East and the West.

Laparoscopic resection of hepatocellular carcinoma

The current treatment of HCC is truly multidisciplinary. Notwithstanding, surgical management remains the gold standard which other therapies are compared to. Operative management is divided into transplantation and resection; the latter is further subdivided among open and laparoscopic approaches. Resection has become safer, remains superior to locoregional treatments, and can be a life-prolonging bridge to transplantation. The decision to pursue laparoscopic resection for HCC is driven by safety and a view toward the long-term management of both the malignancy and the underlying liver disease. For patients with a solitary HCC <5 cm in segments 2, 3, 4b, 5, and 6, no evidence of extrahepatic tumor burden, compensated liver disease, and the absence of significant portal hypertension, laparoscopy has an important role. Under these circumstances, resection can be performed with reduced mortality and morbidity and equivalent oncologic outcomes, disease-free survival, and overall survival when compared with similarly selected cirrhotic patients undergoing open resection. Blood loss and transfusion requirements are low, and laparoscopy itself does not expose the patient to complications and does not increase the risk of cancer recurrence or dissemination. Finally, because HCC recurrence remains high in the cirrhotic liver, treatment following surgical resection mandates routine surveillance and treatment by locoregional therapy, reresection, or transplantation as required-the latter two of which are facilitated by an initial laparoscopic resection.

Meta-analysis of laparoscopic vs open liver resection for hepatocellular carcinoma

AIM: To conduct a meta-analysis to determine the safety and efficacy of laparoscopic liver resection (LLR) and open liver resection (OLR) for hepatocellular carcinoma (HCC).

METHODS: PubMed (Medline), EMBASE and Science Citation Index Expanded and Cochrane Central Register of Controlled Trials in the Cochrane Library were searched systematically to identify relevant comparative studies reporting outcomes for both LLR and OLR for HCC between January 1992 and February 2012. Two authors independently assessed the trials for inclusion and extracted the data. Meta-analysis was performed using Review Manager Version 5.0 software (The Cochrane Collaboration, Oxford, United Kingdom). Pooled odds ratios (OR) or weighted mean differences (WMD) with 95%CI were calculated using either fixed effects (Mantel-Haenszel method) or random effects models (DerSimonian and Laird method). Evaluated endpoints were operative outcomes (operation time, intraoperative blood loss, blood transfusion requirement), postoperative outcomes (liver failure, cirrhotic decompensation/ascites, bile leakage, postoperative bleeding, pulmonary complications, intraabdominal abscess, mortality, hospital stay and oncologic outcomes (positive resection margins and tumor recurrence).

RESULTS: Fifteen eligible non-randomized studies were identified, out of which, 9 high-quality studies involving 550 patients were included, with 234 patients in the LLR group and 316 patients in the OLR group. LLR was associated with significantly lower intraoperative blood loss, based on six studies with 333 patients [WMD: -129.48 mL; 95%CI: -224.76-(-34.21) mL; P = 0.008]. Seven studies involving 416 patients were included to assess blood transfusion requirement between the two groups. The LLR group had lower blood transfusion requirement (OR: 0.49; 95%CI: 0.26-0.91; P = 0.02). While analyzing hospital stay, six studies with 333 patients were included. Patients in the LLR group were found to have shorter hospital stay [WMD: -3.19 d; 95%CI: -4.09-(-2.28) d; P < 0.00001] than their OLR counterpart. Seven studies including 416 patients were pooled together to estimate the odds of developing postoperative ascites in the patient groups. The LLR group appeared to have a lower incidence of postoperative ascites (OR: 0.32; 95%CI: 0.16-0.61; P = 0.0006) as compared with OLR patients. Similarly, fewer patients had liver failure in the LLR group than in the OLR group (OR: 0.15; 95%CI: 0.02-0.95; P = 0.04). However, no significant differences were found between the two approaches with regards to operation time [WMD: 4.69 min; 95%CI: -22.62-32 min; P = 0.74], bile leakage (OR: 0.55; 95%CI: 0.10-3.12; P = 0.50), postoperative bleeding (OR: 0.54; 95%CI: 0.20-1.45; P = 0.22), pulmonary complications (OR: 0.43; 95%CI: 0.18-1.04; P = 0.06), intra-abdominal abscesses (OR: 0.21; 95%CI: 0.01-4.53; P = 0.32), mortality (OR: 0.46; 95%CI: 0.14-1.51; P = 0.20), presence of positive resection margins (OR: 0.59; 95%CI: 0.21-1.62; P = 0.31) and tumor recurrence (OR: 0.95; 95%CI: 0.62-1.46; P = 0.81).

CONCLUSION: LLR appears to be a safe and feasible option for resection of HCC in selected patients based on current evidence. However, further appropriately designed randomized controlled trials should be undertaken to ascertain these findings.

Laparoscopic versus open liver surgery: a single center analysis of post-operative in-hospital and post-discharge results

PURPOSE

Laparoscopic hepatectomy (LH) is established as a safe and feasible surgical procedure for benign and malignant liver lesions showing many benefits in terms of short-term post-operative outcomes. Nevertheless, it remains unclear if these benefits extend beyond the hospital stay. The aim of this study was to compare in-hospital and post-discharge outcomes between two groups of patients who have undergone either laparoscopic or open hepatectomy (OH).

METHODS

Forty-six patients who have undergone LH from September 2008 to September 2011 were compared to 46 matched-pair control patients who have undergone OH. The two groups were compared in terms of in-hospital and 6-month outcomes. Post-discharge outcomes were analyzed in terms of the number of outpatient clinic appointments (OCAs) and readmissions (RAs). Analyses were performed excluding and including conversion cases.

RESULTS

The two groups resulted in homogeneous patients' and lesions' characteristics. Patients who underwent LH showed statistically lower intra-operative blood loss, less total and major morbidity and shorter hospital stay. Regarding post-discharge outcomes, significantly less patients of LH group compared to patients of OH group required more than two post-discharge OCAs (in the intention to treat analysis, 28.3 versus 63%, respectively; P = 0.006) or RA (4.3 versus 15.2%, respectively; P = 0.008). The benefits of LH appeared to be maximized in cirrhotic patients; those represented the large part of patients readmitted after hepatectomy regardless of the type of surgical approach (77.8%).

CONCLUSIONS

Advantages related to LH extend over the post-discharge period suggesting potential better patient's satisfaction and lower hospital cost.

Risk factors for major morbidity after liver resection for hepatocellular carcinoma

Background

Bile leakage, and organ and/or space surgical-site infection (SSI) are common causes of major morbidity after partial hepatectomy for hepatocellular carcinoma (HCC). The purpose of this study was to analyse risk factors for major morbidity and to explore strategies for its reduction after partial hepatectomy for HCC.

Methods

Risk factors for bile leakage and organ/space SSI were analysed in patients who underwent partial hepatectomy for HCC between 2001 and 2010. The causes, management and outcomes of intractable bile leakage requiring endoscopic therapy or percutaneous transhepatic biliary drainage were analysed. In addition, causative bacteria, outcomes and characteristics of organ/space SSI were investigated. Risk factors were identified using multivariable analysis.

Results

Some 359 patients were included in the analysis. The prevalence of bile leakage and organ/space SSI was 12·8 and 8·6 per cent respectively. Repeat hepatectomy and an operating time of at least 300 min were identified as independent risk factors for bile leakage. The main causes of intractable bile leakage were latent strictures of the biliary system caused by previous treatments for HCC and intraoperative injury of the hepatic duct during repeat hepatectomy. Independent risk factors for organ/space SSI were repeat hepatectomy and bile leakage. Methicillin-resistant Staphylococcus aureus was detected more frequently in organ/space SSI after repeat hepatectomy than after initial partial hepatectomy.

Conclusion

Repeat hepatectomy and prolonged surgery were identified as risk factors for bile leakage after liver resection for HCC. Bile leakage and repeat hepatectomy increased the risk of organ/space SSI.

Are Tumor Exposure and Anatomical Resection Antithetical during Surgery for Hepatocellular Carcinoma? A Critical Review

Hepatic resection is the most potentially curative local therapy for patients with hepatocelluar carcinoma (HCC). However, the high rate of postoperative recurrence, 50-70% at 3 years, remains a major concern. Such recurrences usually occur in the liver owing to the high propensity of HCC to invade the portal vein branches and the underlying liver cirrhosis, which is the ideal background for HCC development. Two pivotal surgical techniques are commonly used to reduce such recurrences: anatomical resection (AR) and achievement of negative margins. However, controversies exist about the definition of anatomical resection and the requisite width of negative margins. Consequently, a consensus on these issues is far from being achieved in the specialized surgical community. Review of the literature and author's discernment support AR for HCC larger than 2cm, and tumor exposure when the tumor is in contact with major vessels. Therefore, tumor exposure is not a contradiction to an AR properly carried out.

Salvage hepatectomy for local recurrent hepatocellular carcinoma after ablation therapy

BACKGROUND

The results of salvage hepatectomy for local recurrent hepatocellular carcinoma after incomplete percutaneous ablation therapy are still unclear.

METHODS

We conducted a retrospective analysis of 197 consecutive patients with hepatocellular carcinoma who underwent either salvage hepatectomy after prior incomplete percutaneous ablation therapy (salvage group; n=23) or primary hepatectomy as the initial treatment (primary group; n=174). The two groups were compared with respect to intraoperative data, operative mortality and morbidity, and long-term survival.

RESULTS

The salvage group showed a significantly longer operation time (385 vs. 300 min; P=0.006) and a significantly greater intraoperative blood loss volume (402 vs. 265 ml; P=0.024). The postoperative mortality rate was zero in both groups, and the morbidity rates were similar. Although the 1-, 3-, and 5-year disease-free survival rates after hepatectomy were significantly worse in the salvage group than in the primary group (65%, 41%, and 33% vs. 81%, 51%, and 45%, respectively; P=0.031), the overall survival rates after hepatectomy did not differ significantly (91%, 91%, and 67% vs. 96%, 79%, and 65%, respectively; P=0.790). The 1-, 3-, and 5-year overall survival and disease-free survival rates after percutaneous ablation therapy were also not different from those in the primary group (100, 96, and 83%, P=0.115; and 96, 60, and 45%, P=0.524, respectively).

CONCLUSIONS

The short-term and long-term results of salvage hepatectomy after incomplete percutaneous ablation therapy are equivalent to those of primary hepatectomy. Salvage hepatectomy is an acceptable treatment for patients with local recurrence of hepatocellular carcinoma after ablation therapy.

Liver resection and transplantation in hepatocellular carcinoma

Liver resection is the most available, efficient treatment for patients with hepatocellular carcinoma. Better liver function assessment, increased understanding of segmental liver anatomy using more accurate imaging studies, and surgical technical progress are the most important factors that have led to reduced mortality, with an expected 5 year survival of 70%. Impairment of liver function and the risk of tumor recurrence lead to consideration of liver transplantation (LT) as the ideal treatment for removal of the existing tumor and the preneoplastic underlying liver tissue. However, LT, which is not available in many countries, is restricted to patients with minimum risk of tumor recurrence under immunosuppression. Limited availability of grafts as well as the risk and the cost of the LT procedure has led to considerable interest in combined treatment involving resection and LT. An increasing amount of evidence has shown that initial liver resection in transplantable patients with a single limited tumor and good liver function is a valid indication. Histological analysis of specimens allows identification of the subgroup of patients who could benefit from follow-up with LT in case of recurrence.

Equivalent outcomes after anatomical and non-anatomical resection of small hepatocellular carcinoma in patients with preserved liver function

BACKGROUND

Although anatomical resection (AR) is considered better than non-anatomical resection (NAR) for the treatment for hepatocellular carcinoma (HCC), there is only limited evidence in support of this argument.

AIM

The aim of this study was to investigate whether AR is superior to NAR regarding postoperative outcomes in patients with small solitary HCC and preserved liver function.

METHODS

The study subjects were 92 curatively-resected patients with adequate liver function reserve (indocyanine green retention rate at 15 min <15%, prothrombin time >70%, serum albumin >3.5 g/dl) and macroscopically small (≤3.0 cm) solitary HCC without macroscopic vascular invasion; 30 patients underwent AR and 62 patients NAR. Postoperative short-term outcomes including mortality and morbidity and long-term outcomes were compared in the two groups.

RESULTS

There was no significant difference in clinicopathological background in the two groups. Although resected liver volume was significantly larger in the AR group than the NAR group (p < 0.0001), no significant differences were detected in the incidence of mortality or morbidity. For long-term outcomes, there were no significant differences between the two groups in disease-free survival or overall survival. Multivariate analysis showed that the extent of surgical procedure was not a significant prognostic factor for disease-free or overall survival.

CONCLUSIONS

AR of a solitary small HCC did not carry postoperative outcome advantages compared with NAR in patients with preserved liver function. We recommend NAR for hepatic resection of small solitary HCC in patients with preserved liver function.

A comprehensive meta-regression analysis on outcome of anatomic resection versus nonanatomic resection for hepatocellular carcinoma

BACKGROUND

It remains unclear whether hepatectomy for hepatocellular carcinoma should be performed as an anatomic resection (AR) or a nonanatomic resection (NAR). Because no randomized controlled trials are currently available on this topic, a meta-regression analysis was performed on available observational studies to control for confounding variables.

METHODS

A systematic review of studies published from 1990 to 2011 in the PubMed and Embase databases was performed. Patient and disease-free survival (DFS), postoperative mortality, and morbidity were considered as outcomes. Results are expressed as relative risk (RR) or weighted mean differences with 95 % of confidence interval.

RESULTS

Eighteen observational studies involving 9,036 patients were analyzed: 4,012 were in the AR group and 5,024 in the NAR group. Meta-analysis suggested that AR provided better 5-year patient survival (RR 1.14; P = 0.001) and DFS than NAR (RR 1.38; P = 0.001). However, patients in the NAR group were characterized by a higher prevalence of cirrhosis (RR 1.27; P = 0.010), more advanced hepatic dysfunction (RR 0.90 for Child-Pugh class A; P = 0.001) and smaller tumor size (weighted mean difference 0.36 cm; P < 0.001) compared with patients in the AR group. Meta-regression analysis showed that the different proportion of cirrhosis in the NAR group significantly affected both 5-year patient survival (RR 1.28; P = 0.016) and DFS (RR 1.74; P = 0.022). Tumor size only slightly affected DFS (RR 1.72; P = 0.076). Postoperative mortality and morbidity were unaffected (P > 0.05 in all cases).

CONCLUSIONS

Patient survival and DFS after AR seem to be superior to NAR because the worse liver function reserve in the NAR group significantly affects prognosis.

Anesthetic Considerations in Hepatectomies under Hepatic Vascular Control

Background. Hazards of liver surgery have been attenuated by the evolution in methods of hepatic vascular control and the anesthetic management. In this paper, the anesthetic considerations during hepatic vascular occlusion techniques were reviewed. Methods. A Medline literature search using the terms "anesthetic," "anesthesia," "liver," "hepatectomy," "inflow," "outflow occlusion," "Pringle," "hemodynamic," "air embolism," "blood loss," "transfusion," "ischemia-reperfusion," "preconditioning," was performed. Results. Task-orientated anesthetic management, according to the performed method of hepatic vascular occlusion, ameliorates the surgical outcome and improves the morbidity and mortality rates, following liver surgery. Conclusions. Hepatic vascular occlusion techniques share common anesthetic considerations in terms of preoperative assessment, monitoring, induction, and maintenance of anesthesia. On the other hand, the hemodynamic management, the prevention of vascular air embolism, blood transfusion, and liver injury are plausible when the anesthetic plan is scheduled according to the method of hepatic vascular occlusion performed.