Use of hepatectomy and splenectomy to treat hepatocellular carcinoma with cirrhotic hypersplenism

Predictors of portal vein thrombosis after simultaneous hepatectomy and splenectomy: A single-center retrospective study

BACKGROUND

Although postoperative portal vein thrombosis (PVT) is a frequent complication of splenectomy, few studies have examined PVT after simultaneous hepatectomy and splenectomy (HS). The aim of this study was to clarify the risk factors for and characteristics of PVT after HS.

METHODS

This retrospective observational study included 102 patients, including 76 with liver cirrhosis (LC) and 26 without, who underwent HS between April 2004 and April 2021. The incidence and location of postoperative PVT detected on contrast-enhanced CT 1 week after surgery were analyzed. In addition, pre- and intraoperative parameters were compared between patients with postoperative PVT and those without in order to determine risk factors for PVT after HS.

RESULTS

Among the 102 patients, 29 (28.4 %), including 32.9 % with LC and 15.4 % without LC, developed PVT after surgery. Among the 29 patients with PVT, 21 (72.4 %), 4 (13.8 %), and 4 (13.8 %) developed thrombus in the intrahepatic portal vein only, extrahepatic portal vein only, and both the extra- and intrahepatic portal veins, respectively. Multivariable analysis showed that preoperative splenic vein dilatation was an independent risk factor for PVT after HS (odds ratio: 1.53, 95 % confidence interval: 1.156-2.026, P = 0.003).

CONCLUSION

Our results suggest that splenic vein dilatation is an independent risk factor for PVT after simultaneous HS, and that PVT after HS occurs more frequently in the intrahepatic portal vein. After HS for cases with dilated splenic veins, we should pay particular attention to the PVT development in the intrahepatic portal vein regardless of the type of liver resection.

The decreased risk of hepatocellular carcinoma in hepatitis B virus-related cirrhotic portal hypertension patients after laparoscopic splenectomy and azygoportal disconnection

BACKGROUND

Posthepatitic cirrhosis is one of the leading risk factors for hepatocellular carcinoma (HCC) worldwide, among which hepatitis B cirrhosis is the dominant one. This study explored whether laparoscopic splenectomy and azygoportal disconnection (LSD) can reduce the risk of HCC among patients with hepatitis B virus (HBV)-related cirrhotic portal hypertension (CPH).

METHODS

A total of 383 patients with HBV-related CPH diagnosed as gastroesophageal variceal bleeding and secondary hypersplenism were identified in our hepatobiliary pancreatic center between April 2012 and April 2022, and conducted an 11-year retrospective follow-up. We used inverse probability of treatment weighting (IPTW) to correct for potential confounders, weighted Kaplan-Meier curves, and logistic regression to estimate survival and risk differences.

RESULTS

Patients were divided into two groups based on treatment method: LSD (n = 230) and endoscopic therapy (ET; n = 153) groups. Whether it was processed through IPTW or not, LSD group showed a higher survival benefit than ET group according to Kaplan-Meier analysis (P < 0.001). The incidence density of HCC was higher in the ET group compared to LSD group at the end of follow-up [32.1/1000 vs 8.0/1000 person-years; Rate ratio: 3.998, 95% confidence intervals (CI) 1.928-8.293]. Additionally, in logistic regression analyses weighted by IPTW, LSD was an independent protective predictor of HCC incidence compared to ET (odds ratio 0.516, 95% CI 0.343-0.776; P = 0.002).

CONCLUSION

Considering the ability of LSD to improve postoperative survival and prevent HCC in HBV-related CPH patients with gastroesophageal variceal bleeding and secondary hypersplenism, it is worth promoting in the context of the shortage of liver donors.

plenectomy and azygoportal disconnection decreases the risk of hepatocellular carcinoma for cirrhosis patients with portal hypertension bleeding: a 10-year retrospective follow-up study based on the inverse probability of treatment weighting method

BACKGROUND

Liver cirrhosis is the highest risk factor for hepatocellular carcinoma (HCC) worldwide. However, etiological therapy is the only option in cirrhosis patients to decrease the HCC risk. The aim of this study was to explore whether laparoscopic splenectomy and azygoportal disconnection (LSD) decreases the risk of HCC for patients with cirrhotic portal hypertension (CPH).

METHODS

Between April 2012 and April 2021, we identified 595 CPH patients in our hepatobiliary pancreatic center who were diagnosed with gastroesophageal variceal bleeding and secondary hypersplenism, and performed a 10-year retrospective follow-up. Inverse probability of treatment weighting (IPTW) was used to adjust for potential confounders, weighted Kaplan-Meier curves and logistic regression to estimate survival and risk differences.

RESULTS

According to the method of therapy, patients were divided into LSD (n = 345) and endoscopic therapy (ET; n = 250) groups. Kaplan-Meier analysis revealed that patients who underwent LSD had higher survival benefit with those who underwent ET (P < 0.001). At the end of the follow-up, ET group was associated with a higher HCC incidence density compared with LSD group (28.1/1000 vs 9.6/1000 person-years; Rate ratio [RR] 2.922, 95% confidence intervals [CI] 1.599-5.338). In addition, logistic regression analyses weighted by IPTW revealed that, compared with ET, LSD was an independent protective predictor of HCC incidence (odds ratio [OR] 0.440, 95% CI 0.316-0.612; P < 0.001).

CONCLUSIONS

Considering the better postoperative survival and the ability to prevent HCC in CPH patients with gastroesophageal variceal bleeding and secondary hypersplenism, LSD is worth popularization in situations where liver donors are scarce.

Liver transplantation with simultaneous splenectomy increases risk of cancer development and mortality in hepatocellular carcinoma patients

BACKGROUND

Splenectomy has previously been found to increase the risk of cancer development, including lung, non-melanoma skin cancer, leukemia, lymphoma, Hodgkin’s lymphoma, and ovarian cancer. The risk of cancer development in liver transplantation (LT) with simultaneous splenectomy remains unclear.

AIM

To compare hepatocellular carcinoma (HCC) recurrence and de novo malignancy between patients undergoing LT with and without simultaneous splenectomy.

METHODS

We retrospectively analyzed the outcomes of 120 patients with HCC within the University of California San Francisco criteria who received LT with (n = 35) and without (n = 85) simultaneous splenectomy in the Tri-Service General Hospital. Univariate and multivariate Cox regression analyses for cancer-free survival and mortality were established. The comparison of the group survival status and group cancer-free status was done by generating Kaplan–Meier survival curves and log-rank tests.

RESULTS

The splenectomy group had more hepatitis C virus infection, lower platelet count, higher -fetoprotein level, and longer operating time. Splenectomy and age were both positive independent factors for prediction of cancer development [hazard ratio (HR): 2.560 and 1.057, respectively, P < 0.05]. Splenectomy and hypertension were positive independent factors for prediction of mortality. (HR: 2.791 and 2.813 respectively, P < 0.05). The splenectomy group had a significantly worse cancer-free survival (CFS) and overall survival (OS) curve compared to the non-splenectomy group (5-year CFS rates: 53.4% vs 76.5%, P = 0.003; 5-year OS rate: 68.1 vs 89.3, P = 0.002).

CONCLUSION

Our study suggests that simultaneous splenectomy should be avoided as much as possible in HCC patients who have undergone LT.

The Benefits of Radical Treatments with Synchronous Splenectomy for Patients with Hepatocellular Carcinoma and Portal Hypertension

Simple Summary

Radical treatment combined with synchronous splenectomy has recently emerged as an effective therapy for patients with hepatocellular carcinoma (HCC), in the setting of portal hypertension secondary to liver cirrhosis, but its survival benefits remain to be elucidated. We retrospectively analyzed a longitudinal cohort of 96 patients receiving HCC radical treatment combined with splenectomy and a control group comprising 42 patients receiving radical treatment alone, comparing the oncological outcomes of the synchronous splenectomy for the two subgroups. Our analysis highlighted better recurrence-free survival (RFS), particularly in stage T1 patients. Cox multivariate analysis showed that preoperative irregular anti-viral therapy, Child-Pugh grade B liver function, vascular invasion, and microvascular invasion (MVI) were independent risk factors for early postoperative RFS (within 2 years), and preoperative irregular anti-viral therapy and vascular invasion were independent risk factors for 5-year overall survival (OS).

Abstract

Background: The survival benefits of radical treatment (resection or radiofrequency ablation) combined with splenectomy for primary hepatocellular carcinoma (HCC) in patients with liver-cirrhosis-associated portal hypertension (PH) remain to be clarified. Methods: 96 patients undertaking HCC radical treatment combined with splenectomy (HS group) were retrospectively analyzed, 48 of whom belonged to HCC stage T1 (HSS group). Another 42 patients at stage T1 with PH who received hepatectomy (or radiofrequency ablation) alone (HA group) during the same period served as the control group. Recurrence-free survival (RFS) and overall survival (OS) were compared at each time point between the HSS and HA group. The risk factors affecting early RFS and OS were confirmed through COX multivariate analysis. Results: The median RFS was 22.3 months and the mean median OS was 46 months in the HS group. As such, 1-year, 2-year, 3-year, and 5-year RFS rates in the HSS and HA group were 95% and 81% (p = 0.041), 81% and 67% (p = 0.05), 64% and 62% (p = 1.00), and 29% and 45% (p = 0.10), respectively. Further, 1-year, 3-year, and 5-year OS rates in the HSS and HA group were 98% and 98% (p = 1.00), 79% and 88% (p = 0.50), and 60% and 64% (p = 0.61), respectively. Cox multivariate analysis showed that preoperative irregular anti-viral therapy, Child-Pugh grade B liver function, vascular invasion, and microvascular invasion (MVI) were independent risk factors for early postoperative RFS (within 2 years), and preoperative irregular anti-viral therapy and vascular invasion were independent risk factors for 5-year OS. Conclusions: Radical treatment of HCC combined with synchronous splenectomy, especially applicable to patients with Child-Pugh grade A liver function, can significantly improve early postoperative RFS in patients with stage T1 HCC and liver-cirrhosis-associated portal hypertension, but fail to improve OS.

Prognostic Nomograms Based on the Cirrhotic Severity Scoring for Preoperative Prediction of Long-Term Outcomes in Patients with HBV-Related Hepatocellular Carcinoma and Child-Pugh Grade A Liver Function

Background

Cirrhotic severity scoring (CSS) is a noninvasive method that can predict histological severity of cirrhosis. This study is aimed at assessing the predictive value of CSS on long-term outcomes after curative hepatectomy for patients with hepatitis B virus- (HBV-) related hepatocellular carcinoma (HCC) and Child-Pugh grade A liver function and further developing novel nomograms to preoperatively predict posthepatectomy recurrence and survival.

Methods

Consecutive patients who underwent curative hepatectomy for HCC between 2008 and 2014 were retrospectively studied. According to the CSS, patients were subclassified into 3 groups: no/mild, moderate, and severe cirrhosis. The impact of CSS on recurrence-free survival (RFS) and overall survival (OS) was assessed. Furthermore, RFS and OS nomograms were developed.

Results

The 5-year RFS and OS rates were 36.1% and 62.8% in the no/mild cirrhosis group, compared with 28.4% and 56.2% in the moderate cirrhosis group, and 16.2% and 33.0% in the severe cirrhosis group. Long-term survival outcomes were significantly worse with the increment of cirrhotic severity. CSS, alpha-fetoprotein level, tumor size, tumor number, and macrovascular invasion were identified as independent predictors of both RFS and OS. Besides, albumin-bilirubin grade was an independent risk factor of OS not RFS. RFS- and OS-predictive nomograms based on these preoperative variables were built. For these 2 nomograms, the C-indexes were 0.696 and 0.732, respectively. Calibration curves exhibited good agreement between actual observation and nomogram prediction.

Conclusions

CSS was a predictor for long-term outcomes in HCC patients after curative hepatectomy. The novel nomograms exhibited accurate preoperative prediction of posthepatectomy recurrence and OS.

Surgery for hepatocellular carcinoma with tumor thrombosis in inferior vena cava: A case report

BACKGROUND

Hepatocellular carcinoma (HCC) accompanied by a tumor thrombus is very common. However, the treatment strategy is controversial and varies by the location of the thrombus.

CASE SUMMARY

We report herein a case of HCC with a tumor thrombus in the suprahepatic inferior vena cava (IVC), which was successfully treated by hepatectomy combined with thrombectomy following sorafenib chemotherapy. A 47-year-old woman with chronic hepatitis was diagnosed with HCC. Computed tomography and magnetic resonance imaging showed that the tumor lesion was located in the right half of the liver, and a tumor thrombus was detected in the suprahepatic IVC near the right atrium. After multi-departmental discussion and patient informed consent, right major hepatectomy and total removal of the tumor thrombus were successfully performed under cardiopulmonary bypass. There were no serious complications after surgery. Following sorafenib treatment, no recurrence has been detected so far (11 mo later).

CONCLUSION

Surgical treatment followed by adjuvant sorafenib therapy might be an acceptable choice for HCC patients with tumor thrombosis in the IVC.

Effect of Severity of Liver Cirrhosis on Surgical Outcomes of Hepatocellular Carcinoma After Liver Resection and Microwave Coagulation

BACKGROUND

Liver resection (LR) and percutaneous microwave coagulation therapy (PMCT) are both considered as radical treatments for small hepatocellular carcinoma (HCC). However, it is still unclear whether to select LR or PMCT in HCC patients with different degrees of liver cirrhosis. The purpose of this study was to compare the efficacy of LR and PMCT in the treatment of solitary and small HCC accompanied with different degrees of liver cirrhosis.

METHODS

In this study, 230 patients with solitary HCC lesions ≤ 3 cm and Child-Pugh A liver function were retrospectively reviewed. Among these patients, 122 patients underwent LR, and 108 received PMCT. The short- and long-term outcomes were compared between these two procedures. Severity of liver cirrhosis was evaluated by using clinical scoring system (CSS) as previously published. Subgroup analysis based on CSS was performed to evaluate the effect of severity of liver cirrhosis on surgical outcomes after LR and PMCT.

RESULTS

There was no mortality within 90 days in both groups. Major complications were significantly more frequent in the LR group than in the PMCT group (18.8% vs. 4.6%, p<0.001). However, LR provided better surgical outcomes than PMCT. The 5-year overall survival (OS) rates for the LR and PMCT groups were 65.2% and 42%, respectively (p=0.006), and the corresponding disease-free survival (DFS) rates were 51.7% and 31.5%, respectively (p=0.004). Nevertheless, subgroup analysis showed that PMCT provided long-term outcomes that were similar to LR and lower surgical complications in HCC patients with CSS score≥4.

CONCLUSIONS

LR may provide better OS and DFS rates than PMCT for patients with solitary HCC lesions ≤ 3 cm and Child-Pugh A liver function irrespective of liver cirrhosis. PMCT should be viewed as the optimal treatment for solitary and small HCC with severe cirrhosis.

Effect of splenectomy on the outcomes in patients with cirrhosis receiving transjugular intrahepatic portosystemic shunt

BACKGROUND AND AIM

Patients indicated to transjugular intrahepatic portosystemic shunt (TIPS) placement may have splenectomy history due to thrombocytopenia. This study aimed to evaluate the effect of prior splenectomy on TIPS procedure and post-TIPS outcomes.

METHODS

We conducted a longitudinal analysis based on a cohort of 284 patients with cirrhosis submitted to TIPS; 74 patients had splenectomy history (splenectomy group) and 210 did not (non-splenectomy group). Cox proportional hazards models were used to evaluate the association between splenectomy and outcomes after TIPS. The primary outcome was shunt dysfunction. Secondary outcomes included all-cause mortality, clinical recurrence of bleeding or ascites, and overt hepatic encephalopathy (OHE).

RESULTS

During a median follow-up of 16.2 months, the splenectomy group had significantly lower rates of postoperative shunt patency (85.5% vs 95.6% at 1 year and 75.2% vs 86.5% at 2 years; adjusted hazard ratio [HR] 2.53; 95% confidence interval [CI] 1.21-5.12; P = 0.01) and higher risk of OHE (adjusted HR 1.82; 95% CI 1.03-3.54; P = 0.04). But the risk of mortality (adjusted HR 0.87; 95% CI 0.41-1.87; P = 0.73) and recurrent bleeding or ascites (adjusted HR 1.17; 95% CI 0.53-2.35; P = 0.77) showed no statistical difference. Multivariate analysis confirmed splenectomy history and endoscopic therapy as independent predictors of shunt dysfunction. Besides, pre-TIPS splenectomy increased the difficulty of TIPS procedure by complicating portal vein puncture.

CONCLUSIONS

For patients with cirrhosis submitted to TIPS, prior splenectomy complicated TIPS procedure and increased the risk of shunt dysfunction and OHE after TIPS, but was not significantly associated with the occurrence of mortality and recurrent bleeding or ascites.

Tumor size may influence the prognosis of solitary hepatocellular carcinoma patients with cirrhosis and without macrovascular invasion after hepatectomy

Hepatocellular carcinoma (HCC) is usually associated with varying degrees of cirrhosis. Among cirrhotic patients with solitary HCC in the absence of macro-vascular invasion, whether tumor size drives prognosis or not after hepatectomy remains unknown. This study aimed to investigate the prognostic impact of tumor size on long-term outcomes after hepatectomy for solitary HCC patients with cirrhosis and without macrovascular invasion. A total of 813 cirrhotic patients who underwent curative hepatectomy for solitary HCC and without macrovascular invasion between 2001 and 2014 were retrospectively studied. We set 5 cm as the tumor cut-off value. Propensity score matching (PSM) was performed to minimize the influence of potential confounders including cirrhotic severity that was histologically assessed according to the Laennec staging system. Recurrence-free survival (RFS) and overall survival (OS) were compared between the two groups before and after PSM. Overall, 464 patients had tumor size ≤ 5 cm, and 349 had tumor size > 5 cm. The 5-year RFS and OS rates were 38.3% and 61.5% in the  ≤ 5 cm group, compared with 25.1% and 59.9% in the > 5 cm group. Long-term survival outcomes were significantly worse as tumor size increased. Multivariate analysis indicated that tumor size > 5 cm was an independent risk factor for tumor recurrence and long-term survival. These results were further confirmed in the PSM cohort of 235 pairs of patients. In cirrhotic patients with solitary HCC and without macrovascular invasion, tumor size may significantly affect the prognosis after curative hepatectomy.

Construction and Validation of a Nomogram for Predicting the Risk of Deep Vein Thrombosis in Hepatocellular Carcinoma Patients After Laparoscopic Hepatectomy: A Retrospective Study

Background

The incidence of deep vein thrombosis (DVT) in hepatocellular carcinoma (HCC) patients after laparoscopic hepatectomy (LH) is unclear, and there is no effective method for DVT risk assessment in these patients.

Methods

The data from the total of 355 consecutive HCC patients who underwent LH were included. A DVT risk algorithm was developed using a training set (TS) of 243 patients, and its predictive performance was evaluated in both the TS and a validation set (VS) of 112 patients. The model was then used to develop a DVT risk nomogram (TRN).

Results

The incidence of DVT in the present study was 18.6%. Age, sex, body mass index (BMI), comorbidities and operative position were independent risk factors for DVT in the TS. The model based on these factors had a good predictive ability. In the TS, it had an area under the receiver operating characteristic (AUC) curve of 0.861, Hosmer-Lemeshow (H-L) goodness of fit p value of 0.626, sensitivity of 44.4%, specificity of 96.5%, positive predictive value (PPV) of 74.1%, negative predictive value (NPV) of 88.4%, and accuracy of 86.8%. In the VS, it had an AUC of 0.818, H-L p value of 0.259, sensitivity of 38.1%, specificity of 98.9%, PPV of 88.9%, NPV of 87.4%, and accuracy of 87.5%. The TRN performed well in both the internal and the external validation, indicating a good clinical application value. The TRN had a better predictive value of DVT than the Caprini score (p < 0.001).

Conclusion

The incidence of DVT after LH was high, and should not be neglected in HCC patients. The TRN provides an efficacious method for DVT risk evaluation and individualized pharmacological thromboprophylaxis.

Does splenectomy significantly improve the prognosis of hepatocellular carcinoma patients with hypersplenism? A systematic review and meta-analysis

Background

Whether hepatocellular carcinoma (HCC) patients with hypersplenism can benefit from splenectomy is unclear. This study aimed at exploring the efficacy and safety of concurrent splenectomy for HCC patients with hypersplenism.

Methods

PubMed, EMBASE and Web of Science databases were systematically searched to compare data on the combination of hepatectomy or transhepatic arterial infusion (TAI) with splenectomy (the splenectomy group) with data on hepatectomy or TAI alone (the non-splenectomy group) for the treatment of HCC with hypersplenism. Prospective clinical trials or retrospective cohort studies from inception to May 10, 2020 were considered eligible for this analysis. The relevant outcomes, including patients’ demographics, clinicopathologic characteristics, perioperative indices and long-term outcomes, were independently extracted by two investigators. Publication bias for overall survival (OS) and disease-free survival (DFS) was qualitatively assessed by funnel plots and quantitatively evaluated by Begg’s and Egger’s tests.

Results

Nine retrospective studies including 1,650 patients were analyzed. Short-term outcomes suggested that the incidence rate of postoperative complications, including portal or splenic vein thrombosis [odds ratio (OR) =26.28, P<0.001] and pancreatic injury (OR =14.89, P=0.001), was significantly higher in the splenectomy group, whereas the perioperative mortality rate was similar between the splenectomy and non-splenectomy groups (P=0.541). Long-term outcomes indicated that the occurrence of variceal re-hemorrhage (OR =0.31, P<0.001) and tumor progress or recurrence (OR =0.62, P=0.001) was markedly reduced for patients who underwent splenectomy, while the long-term mortality rates were not statistically different between the two groups (P=0.087). The prognostic evaluation revealed that the OS and DFS were comparable between the splenectomy and non-splenectomy groups [for OS: hazard ratio (HR) =0.77, 95% confidence interval (CI): 0.53–1.13; for DFS: HR =0.87, 95% CI: 0.63–1.19]. Funnel plots suggested an HRs symmetric distribution for OS and DFS. Begg’s and Egger’s tests confirmed that there was no significant HR publication bias for OS and DFS.

Conclusions

Due to the significant progress in surgical techniques and perioperative care, concomitant splenectomy should be considered as an optional treatment for some HCC patients with hypersplenism.

Impact of splenomegaly and splenectomy on prognosis in hepatocellular carcinoma with portal vein tumor thrombus treated with hepatectomy

Background

Hepatocellular carcinoma (HCC) commonly occurs in patients with splenomegaly. This study aimed to investigate the impact of splenomegaly with or without splenectomy on long-term survival of HCC patients with portal vein tumor thrombus (PVTT) treated with liver resection (LR).

Methods

HCC patients with PVTT who underwent LR from 2005 to 2012 from 6 hospitals were retrospectively studied. The long-term overall survival (OS) and recurrence-free survival (RFS) were compared between patients with or without splenomegaly, and between patients who did or did not undergo splenectomy for splenomegaly. Propensity score matching (PSM) analysis was performed to match patients in a 1:1 ratio.

Results

Of 716 HCC patients with PVTT who underwent LR, 140 patients had splenomegaly (SM group) and 576 patients had no splenomegaly (non-SM group). The SM group was further subdivided into 49 patients who underwent splenectomy (SPT group), and 91 patients who did not received splenectomy (non-SPT group). PSM matched 140 patients in the SM group, and 49 patients in the SPT group. Splenomegaly was an independent risk factor of poor RFS and OS. The OS and RFS rates were significantly better for patients in the non-SM group than the SM group (OS: P<0.001; RFS: P<0.001), and for patients in the SPT group than the non-SPT group (OS: P<0.001; RFS: P<0.001).

Conclusions

Patients who had splenomegaly had significantly worse survival in HCC patients with PVTT. Splenectomy for splenomegaly significantly improved long-term survival in these patients.

Use of Direct Liver Stiffness Measurement in Evaluating the Severity of Liver Cirrhosis in Patients with Hepatocellular Carcinoma

BACKGROUND

Severity of liver cirrhosis plays an important role in determining the safe extents of hepatectomy in patients with hepatocellular carcinoma (HCC). The aim of this study was to investigate whether direct liver stiffness measurement can help surgeons to evaluate the severity of liver cirrhosis in HCC patients.

METHODS

Overall, 119 HCC patients who underwent open hepatectomy were retrospectively studied. The severity of liver cirrhosis was histologically staged using the Laennec staging system. Direct liver stiffness measurement was performed during operation using a sclerometer device named LX-C Shaw hardmeter, and its efficacy in assessing the severity of liver cirrhosis was compared with that of transient elastography (TE) and cirrhotic severity scoring (CSS) previously proposed by our team.

RESULTS

Liver stiffness measured by LX-C Shaw hardmeter was significantly correlated with the severity of liver cirrhosis. Spearman correlation coefficients for the correlation between the severity of liver cirrhosis and direct liver stiffness measurement, TE, and CSS were 0.751, 0.454, and 0.705, respectively (all P < 0.001). The areas under the receiver operating characteristic curves (AUCs) of direct liver stiffness measurement were 0.891 for moderate cirrhosis and 0.944 for severe cirrhosis and superior to those of TE (0.735 and 0.776, respectively) and CSS (0.888 and 0.905, respectively).

CONCLUSIONS

Direct liver stiffness measurement is a useful method in evaluating the severity of liver cirrhosis in HCC patients.

Splenectomy before hepatectomy for patients with hepatocellular carcinoma and hypersplenism: A retrospective study

The spleen plays an important role in tumor progression and the curative effects of splenectomy before hepatectomy for hypersplenism and hepatocellular carcinoma (HCC) are not clear. We investigated whether splenectomy before hepatectomy increases survival rate among patients with HCC and hypersplenism compared with that of patients who underwent synchronous hepatectomy and splenectomy or hepatectomy alone.Between January 2011 and December 2016, 266 patients who underwent hepatectomy as a result of HCC and portal hypertension secondary to hepatitis were retrospectively analyzed. Their perioperative complications and survival outcome were evaluated.Patients underwent synchronous hepatectomy and splenectomy (H-S group) and underwent splenectomy before hepatectomy (H-preS group) exhibited significantly higher disease-free survival (DFS) rates than those of patients underwent hepatectomy alone (H-O group). The DFS rates for patients in the H-S group, H-preS group, and H-O group were 74.6%, 48.4%, 39.8%, and 80.1%, 54.2%, 40.1%, and 60.5%, 30.3%, 13.3%, at 1, 3, and 5 years after surgery, respectively. Tumor size, tumors number, and levels of alpha fetoprotein (AFP) were independent risk factors for DFS. Gender and tumor size were independent prognostic factor for overall survival (OS). The preoperative white blood cell (WBC) and platelet (PLT) counts were significantly higher in the H-preS group than in those of the H-S group and the H-O group. After operation, the WBC and PLT counts in the H-S group and H-preS groups were significantly higher compared to those of the H-O group.No matter splenectomy before hepatectomy or synchronous hepatectomy and splenectomy, hepatectomy with splenectomy may improve DFS rates in patients with HCC and hypersplenism, and splenectomy before hepatectomy alleviates hypersplenism without an increased surgical risk.

Liver Collagen Contents Are Closely Associated with the Severity of Cirrhosis and Posthepatectomy Liver Failure in Patients with Hepatocellular Carcinoma and Child-Pugh Grade A Liver Function

BACKGROUND

Hepatocellular carcinoma (HCC) is usually accompanied by different severities of cirrhosis, which is a risk factor for posthepatectomy liver failure (PHLF). Collagen proportional area (CPA) measurements can quantitatively determine the collagen contents of liver tissue. This study explored the impact of CPA on PHLF, and further investigated the correlation between CPA and a non-invasive method, namely cirrhotic severity scoring (CSS), previously proposed by our team.

METHODS

A total of 224 HCC patients with Child-Pugh grade A liver function undergoing hepatectomy between 2017 and 2019 were retrospectively studied. Quantitative digital image analysis of resected liver tissues was used for the CPA measurement. Risk factors for PHLF were subjected to univariate and multivariate analyses, and the correlation between CPA and CSS was analyzed.

RESULTS

Overall, 28 (12.5%) patients experienced PHLF. Patients with PHLF had higher CPA values than those without PHLF (p < 0.001). Multivariate analysis showed CPA and extent of hepatectomy to be independent risk factors for PHLF. CPA values were divided into four stages based on their quartiles (C1: < 6.6%; C2: 6.6-10.7%; C3: 10.7-18.0%; C4: ≥ 18.0%). The incidence of PHLF increased with increasing CPA stages (p < 0.001). Furthermore, CSS was significantly correlated with CPA (r = 0.720; p < 0.001). The incidence of PHLF also increased with increasing severity of cirrhosis evaluated by CSS (p < 0.001).

CONCLUSIONS

In HCC patients with Child-Pugh grade A liver function, cirrhosis could be staged by liver collagen contents, which significantly influenced PHLF. Furthermore, CSS was useful in the preoperative evaluation of cirrhotic severity.

Patterns of Comorbidity in Hepatocellular Carcinoma: A Network Perspective

Hepatocellular carcinoma (HCC) is a common and fatal cancer. People with HCC report higher odds of comorbidity compared with people without HCC. To explore the association between HCC and medical comorbidity, we used routinely collected clinical data and applied a network perspective. In the network perspective, we used correlation analysis and community detection tests that described direct relationships among comorbidities. We collected 14,891 patients with HCC living in Jilin Province, China, between 2016 and 2018. Cirrhosis was the most common comorbidity of HCC. Hypertension and renal cysts were more common in male patients, while chronic viral hepatitis C, hypersplenism, hypoproteinemia, anemia and coronary heart disease were more common in female patients. The proportion of chronic diseases in comorbidities increased with age. The main comorbidity patterns of HCC were: HCC, cirrhosis, chronic viral hepatitis B, portal hypertension, ascites and other common complications of cirrhosis; HCC, hypertension, diabetes mellitus, coronary heart disease and cerebral infarction; and HCC, hypoproteinemia, electrolyte disorders, gastrointestinal hemorrhage and hemorrhagic anemia. Our findings provide comprehensive information on comorbidity patterns of HCC, which may be used for the prevention and management of liver cancer.

Effectiveness comparison of indocyanine green retention test with the cirrhotic severity scoring in evaluating the pathological severity of liver cirrhosis in patients with hepatocellular carcinoma and Child-Pugh grade A liver function

Background

Evaluating cirrhotic severity is essential for individualizing surgical modalities for patients with hepatocellular carcinoma (HCC). Our previous study proposed a non-invasive method named cirrhotic severity scoring (CSS) to stage liver cirrhosis. Indocyanine green retention rate at 15 min (ICG-R15) has been widely used for the preoperative evaluation of hepatic functional reserve; however, whether ICG-R15 is well correlated with cirrhotic severity, and especially whether comparable with CSS in predicting cirrhotic severity in HCC patients with Child-Pugh grade A liver function remains unknown.

Methods

Overall, 510 HCC patients with Child-Pugh grade A liver function undergoing hepatectomy between January 2011 and December 2014 were retrospectively studied. Cirrhotic severity was pathologically assessed using the Laennec staging system. The correlations between ICG-R15, CSS, and cirrhotic severity were analyzed. Furthermore, the performance of ICG-R15 and CSS in predicting posthepatectomy liver failure (PHLF) and 90-day mortality was compared.

Results

Patients with no, mild, moderate, and severe cirrhosis accounted for 15.9%, 29.2%, 35.9%, and 19.0%, respectively, in the entire cohort. ICG-R15 was found to be less than 10% in 100%, 93.3%, 86.3%, and 70.1% of the patients with no, mild, moderate, and severe cirrhosis, respectively. There was only a weak correlation between ICG-R15 and the pathological severity of liver cirrhosis (r = 0.325; P < 0.001). However, CSS showed a strong correlation with the pathological severity of liver cirrhosis (r = 0.788; P < 0.001). For those with ICG-R15 in the normal range, the accuracy of CSS in diagnosing no/mild, moderate, and severe cirrhosis was 89.1%, 72.8%, and 72.1%, respectively. In addition, CSS was superior to ICG-R15 in predicting PHLF and 90-day mortality.

Conclusions

CSS was more useful than ICG-R15 in the preoperative assessment of cirrhotic severity in HCC patients with Child-Pugh grade A liver function. More studies are needed to further validate CSS in patients with different Child-Pugh grades.

Effects of laparoscopic splenectomy and azygoportal disconnection on liver synthesis function and cirrhosis: a 2-year prospective study

BACKGROUND

Laparoscopic splenectomy and azygoportal disconnection (LSD) is widely used for the treatment of esophagogastric variceal haemorrhage and hypersplenism owing to cirrhotic portal hypertension. However, whether LSD improves liver synthesis function and cirrhosis remains unclear. The aim of this study is to investigate the effect of LSD on liver synthesis function and cirrhosis based on a prospective 2-year follow-up study.

METHODS

A total of 118 patients with cirrhotic portal hypertension who underwent LSD were included in this study. We analysed clinical data including routine blood parameters, liver function, liver-synthesised proteins (antithrombin III, protein S, and protein C), liver fibrotic markers (type IV collagen (IV-C), procollagen type III (PC-III), laminin, and hyaluronidase), portal vein diameter, and portal blood flow velocity.

RESULTS

Postoperative portal vein diameter and portal blood flow velocity all showed gradual declines during the 2-year follow-up; compared with preoperative values, these were all significantly decreased from postoperative week (POW) 1 (all P < 0.001). Postoperative Child-Pugh scores and total bilirubin, albumin, international normalised ratio, antithrombin III, protein S, protein C, IV-C, PC-III, laminin, and hyaluronidase levels also all showed gradual improvements during the 2-year follow-up; compared with preoperative levels, these were all significantly improved from postoperative month (POM) 6, POW 1, POM 3, POM 3, POM 3, POM 6, POM 18, POW 1, POM 3, POM 24, and POM 18, respectively (all P < 0.05).

CONCLUSION

LSD not only decreases portal hypertension and improves liver function, it also enhances liver synthesis function and reduces liver fibrosis.

Safety of Simultaneous Hepatectomy and Splenectomy in the Treatment of Hepatocellular Carcinoma Complicated with Hypersplenism: A Meta-analysis

Background

We conducted this meta-analysis to compare the efficacy and safety of simultaneous hepatectomy and splenectomy (HS) with hepatectomy alone (HA) in patients with hepatocellular carcinoma (HCC) and hypersplenism.

Materials and Methods

A systematic search was conducted in PubMed, Embase, Cochrane Library, and Wanfang Data through March 1, 2018, with no limits. Two investigators independently screened all retrieved studies. The investigators of the original publications were contacted if required information was absent. All the included studies were managed by EndNote X7. Quality assessment of the included studies was performed using a modified Newcastle-Ottawa Scale judgment. Extracted data for each endpoint were analyzed by using STATA 12.0 software.

Results

Thirteen studies, including a total of 1468 patients, comparing the effects of HS with HA were pooled in this meta-analysis. Outcomes including postoperative complications, perioperative mortality, intraoperative blood transfusion, and albumin (ALB) content at postoperation day (POD) 7 did not differ significantly between the two groups. Simultaneous approaches significantly promoted 1-, 3-, and 5-year disease-free survival (DFS) rates and overall survival (OS) rates, prolonged operation time, aggravated intraoperative blood loss, increased white blood cell (WBC) and platelet (PLT) counts at POD 7, and lowered total bilirubin (T-Bil) contents at POD 1 and 7.

Conclusion

Compared to HA, HS is safer and more effective in ameliorating liver function and improving survival of HCC patients complicated with hypersplenism. This trial is registered with CRD42018093779.

Hepatectomy for hepatocellular carcinoma after perioperative management of portal hypertension

Background

Indications for hepatectomy in patients with hepatocellular carcinoma (HCC) who have portal hypertension (PH) have been controversial. Some studies have concluded that PH is a contraindication to hepatectomy, whereas others have suggested that perioperative prophylactic management (PPM) can help overcome complications after hepatectomy associated with PH. The objective of this retrospective study was to assess the short- and long-term outcomes after hepatectomy for HCC in patients with PH, with or without PPM.

Methods

Records were reviewed of consecutive patients who underwent hepatectomy for HCC, with or without PPM of PH, in a single institution from 1994 to 2015. Patients were divided into three groups: those who received PPM for PH (PPM group), patients who had PH but did not receive PPM (no-PPM group) and those without PH (no-PH group).

Results

A total of 1259 patients were enrolled, including 123 in the PPM group, 181 in the no-PPM group and 955 in the no-PH group. Three- and 5-year overall survival rates were 74·3 and 53·1 per cent respectively in the PPM group, 69·2 and 54·9 per cent in the no-PPM group, and 78·1 and 64·2 per cent in the no-PH group (P = 0·520 for PPM versus no PPM, P = 0·027 for PPM versus no PH, and P &lt; 0·001 for no PPM versus no PH). Postoperative morbidity and mortality rates were 26·0 and 0·8 per cent respectively in the PPM group, 29·8 and 1·1 per cent in the no-PPM group, and 20·3 and 0 per cent in the no-PH group.

Conclusion

The present study has demonstrated acceptable outcomes among patients with HCC who received appropriate management for PH in an Asian population. Enhancement of the safety of hepatic resection through use of PPM may provide a rationale for expansion of indications for hepatectomy in patients with PH.

Synchronous hepatectomy and splenectomy vs hepatectomy for selected patients with hepatocellular carcinoma and clinically significant portal hypertension: A systematic review and meta-analysis

 This review aimed to evaluate the safety, feasibility, and effectiveness of synchronous hepatectomy and splenectomy for selected patients with hepatocellular carcinoma and clinically significant portal hypertension compared to hepatectomy alone. A systematic search in electronic databases was conducted. A total of 8 studies including 1445 patients were reviewed. While perioperative safety was satisfactory, synchronous hepatectomy and splenectomy were associated with a significant improvement of 5-year overall survival (odds ratio = 1.81; 95% confidence interval: 1.35, 2.42; P < 0.0001).

Improved survival following splenectomy combined with curative treatments for hepatocellular carcinoma in Child B patients: A propensity score matching study

AIMS

To explore the benefits of curative treatments (liver resection or local ablation) combined with splenectomy for patients with hepatocellular carcinoma (HCC) and Child grade B liver function.

METHODS

We reviewed 245 patients with Child grade B liver function who underwent treatment with curative intent for HCC. Among these patients, 116 patients underwent curative treatment combined with splenectomy (the splenectomy group); the other 129 patients only underwent curative treatment (the non-splenectomy group). A one-to-one matching produced 95 paired patients, perioperative and oncological outcomes were compared, and liver function changes were reassessed 1 year later.

RESULTS

The perioperative liver failure rates were 7.4% and 6.3% (P = 1.000) and the 90-day mortality was 4.2% and 6.3% (P = 0.747) in the splenectomy group and non-splenectomy group, respectively. The 1-, 3-, and 5-year overall survival rates were remarkably greater in the splenectomy group than in the non-splenectomy group (92.6% vs. 79.8%, 53.4% vs. 34.7%, and 19.9% vs. 11.0%, respectively; P = 0.004). In the univariate and multivariate analyses, splenectomy was identified as a protective factor for long-term survival. The proportion of patients whose liver function improved to Child A 1 year after surgery was also higher in the splenectomy group than in the non-splenectomy group (95.4% vs. 83.3%; P = 0.048).

CONCLUSIONS

Compared with non-splenectomy, curative treatments combined with splenectomy for patients with HCC and Child B grade liver function showed no different perioperative outcomes but achieved significant survival benefit. Splenectomy is a beneficial factor for patients with HCC and Child B liver function; liver function improved significantly 1 year after splenectomy.

Spleen-Associated Effects on Immunity in Hepatitis B Virus-Related Cirrhosis with Portal Hypertension

Our study aimed to investigate the histologic and immunological changes of portal hypertension (PH) pre- and postsplenectomy in hepatitis B virus (HBV)-related cirrhosis. Peripheral blood samples were obtained from 30 patients with HBV-related cirrhosis and PH at pre- and postsplenectomy time points and from 15 healthy subjects. Spleen tissue specimens were collected from 15 of the patients with HBV-related cirrhosis and from 8 control patients who had undergone splenectomy due to trauma. Immunohistochemical staining was performed to evaluate the immune effector cells and the expression of negative immune regulators. Flow cytometry was used to investigate the immunophenotypes and percentages. The spleen of cirrhotic patients with PH showed extensive depletion of splenic CD4, CD8, and human leukocyte antigen DR cells along with overexpression of the inhibitory receptors programmed death-1 (PD-1) and T cell immunoglobulin domain and mucin domain-3 and their ligands (PD-L2 and galectin-9). Peripheral blood of patients with PH showed remarkable decrease in proportions of CD8 T cell and natural killer (NK) cells and increase in regulatory T (Treg) cells, as well as high expression of PD-1 in CD4/8 T cells. Compared with presplenectomy patients, cirrhotic patients with PH showed increased proportions of CD8 and NK cells, decreased proportion of Treg cells, and decreased expression of PD-1 in peripheral blood CD4/8 T cells after splenectomy. PH-spleen could lead to peripheral tolerance and immunosuppression in HBV cirrhotic patients, and splenectomy may cause beneficial immunological changes.

Benefits of Splenectomy and Curative Treatments for Patients with Hepatocellular Carcinoma and Portal Hypertension: a Retrospective Study

BACKGROUND

We aimed to explore the benefit of splenectomy combined with curative treatments (liver resection or local ablation) for patients with hepatocellular carcinoma and portal hypertension.

METHODS

The records of 239 patients with hepatocellular carcinoma and portal hypertension undergoing either splenectomy combined with liver resection or local ablation were reviewed retrospectively. Perioperative complications and survival outcome were evaluated, and liver function 1 year later was reassessed according to the Child score.

RESULTS

The post-hepatectomy liver failure rates and 30-day mortality were 3.3% and 2.1%, respectively. The 1-, 3-, and 5-year overall survival rates were 95.1%, 73%, and 47.5% for patients with Child grade A and 92.2%, 51.2%, and 19.8% for Child grade B, respectively. The median survival time for patients with Child scores of 5, 6, 7, 8, and 9 were 61.5, 51.3, 44.8, 33.7, and 23.4 months, respectively. After multivariable analysis, tumor size, tumor number, post-hepatectomy liver failure, and Child score were independent risk factors for overall survival. Liver function was converted to Child grade A in 98 of 101 patients (97%) who had preoperative Child grade B 1 year after splenectomy.

CONCLUSION

Patients with hepatocellular carcinoma and portal hypertension can benefit from splenectomy combined with curative treatments, especially those with Child scores of 5, 6, and 7. Liver function improved significantly 1 year after splenectomy in patients with preoperative Child grade B.

Impact of Splenic Volume and Splenectomy on Prognosis of Hepatocellular Carcinoma Within Milan Criteria After Curative Hepatectomy

BACKGROUND

The prognosis of hepatocellular carcinoma (HCC) with portal hypertension (PH) is very poor. Splenomegaly is considered important evidence of PH. Our aim was to clarify the prognostic value of splenic volume (SV) and the effect of splenectomy on the prognosis of HCC within the Milan criteria after curative hepatectomy.

METHODS

In this single-center retrospective study, we reviewed 160 patients with HCC that met the Milan criteria, including 138 who had undergone hepatectomy and 22 who had undergone hepatectomy and splenectomy between July 2004 and December 2010. SV was measured by three-dimensional computed tomography and patients allocated to three groups (high SV ≥300 mL; low <300 mL; and splenectomy) to compare post-hepatectomy survival rates.

RESULTS

Multivariate analyses showed that SV is an independent prognostic factor for overall and disease-free survival. The overall survival rates at 5 years in the high SV, low SV, and splenectomy groups were 39, 75, and 88%, respectively. The overall survival rate in the high SV group was significantly worse than in the low SV and splenectomy groups (P < 0.001). There was no significant difference between the low SV and splenectomy groups (P = 0.831).

CONCLUSIONS

High SV is an independent predictor of post-hepatectomy HCC recurrence and overall survival. There is no significant difference in prognosis between low SV and splenectomy groups, even though the latter had high SV. Combined splenectomy with hepatectomy for HCC and PH may improve prognosis and be an appropriate alternative when liver transplantation cannot be performed.

Synchronous splenectomy and hepatectomy for patients with small hepatocellular carcinoma and pathological spleen: neutrophil to lymphocyte ratio changes can predict the prognosis

Background

Treatments about small hepatocellular carcinoma (HCC) and hypersplenism associated with good hepatic reserve are not well established. The aim of this study was to investigate the outcome of synchronous hepatectomy and splenectomy for those patients.

Study Design

Splenomegaly and hypersplenism were defined as a pathological spleen. Seven hundred fifty-six patients with small HCC (381 with a pathological spleen, 375 without a pathological spleen) were divided into three groups. One hundred ten of 381 patients underwent synchronous hepatectomy and splenectomy (group A), 271 of 381 patients underwent hepatectomy alone (Group B) and 375 patients without pathological spleen underwent hepatectomy alone (Group C).

The influence of pathological spleen, outcome of different treatments and systemic inflammatory response indexes were analyzed.

Results

Both overall survival (OS, P=0.023) and disease-free survival (DFS, P=0.020) were significantly increased in group C compared to group B. A pathological spleen was a significant independent prognostic factor for OS and DFS among those two groups. In addition, OS (P=0.025) and DFS (P=0.004) were increased in the group A compared to group B. Splenectomy and neutrophil to lymphocyte ratio changes (ΔNLR) were significant independent prognostic factors of the prognosis for patients in groups A and B.

Conclusions

A Pathological spleen influences the outcome of HCC patients. Synchronous hepatectomy and splenectomy should be performed among patients with small HCC and a pathological spleen. ΔNLR can predict the prognosis of these patients.

Effect of Splenectomy on Serum Cytokine Profiles in Hepatitis B Virus-Related Cirrhosis Patients with Portal Hypertension

Emerging evidences showed the promoting role of spleen in the development of cirrhosis and hepatocellular carcinoma, in the context of portal hypertension and hypersplenism due to hepatitis B virus-related cirrhosis. In this study, we tried to explore the precise mechanism of how spleen regulates this process from the serum cytokines profile level. Compared with the 16 healthy subjects, the RayBio Human Cytokine Antibody Array identified 136 cytokines differentially expressed in 36 cirrhotic patients. Splenectomy resulted in significant changes in 28 cytokines. Differentially expressed cytokines were mainly involved in cellular processes, responses to stimuli, immune processes, binding, extracellular regions, and extracellular matrix. These cytokines were mainly enriched in cytokine-cytokine receptor interactions, Jak-STAT and MAPK signaling pathways, and pathways in cancer. These results may provide new clues to the function of the spleen, and modulation of cytokine expression maybe a potential alternative therapeutic strategy for these patients.

A Novel Technique for Synchronous Laparoscopic Splenectomy and Azygoportal Disconnection With Hepatectomy

BACKGROUND

Liver resection was not formerly recommended in patients with both hepatocellular carcinoma (HCC) and portal hypertension because of difficult perioperative bleeding control and postoperative liver failure. Splenectomy is a proven method with which to overcome these problems. To investigate the safety and feasibility of synchronous laparoscopic splenectomy and azygoportal disconnection with hepatectomy (LSDH) for treatment of portal hypertension accompanied with HCC, we describe a clinical cohort of 10 patients who underwent a new technique of synchronous LSDH.

METHODS

A cohort of 10 cirrhotic patients with HCC, esophageal/gastric variceal bleeding, and hypersplenism received LSDH. A 6-port method was used for LSDH. This procedure comprises 5 steps: laparoscopic splenectomy, intraoperative splenic blood salvage, laparoscopic azygoportal disconnection, laparoscopic partial hepatectomy, and removal of spleen and liver specimens. Intraoperative autologous cell salvage was performed before hepatectomy.

RESULTS

LSDH was successful in all patients. There was no conversion to open operations. The operative time was 220.5 ± 19.8 minutes, blood loss was 264.0 ± 160.3 mL, and postoperative hospital stay was 10.2 ± 1.8 days.

CONCLUSIONS

Selective synchronous LSDH is a feasible, effective, and safe surgical procedure with satisfactory short-term efficacy. It is a promising minimally invasive treatment option for patients with cirrhotic HCC and portal hypertension.

42,573 cases of hepatectomy in China: a multicenter retrospective investigation

Hepatectomy is currently routinely performed in most hospitals in China. China owns the largest population of liver diseases and the biggest number of liver resection cases. A nationwide multicenter retrospective investigation involving 112 hospitals was performed, and focused on liver resection for patients with hepatocellular carcinoma (HCC). 42,573 cases of hepatectomy were enrolled, and 18,275 valid cases of liver resection for HCC patients were selected for statistical analysis. The epidemiology of HCC, distribution of hepatectomy, postoperative complications and prognosis were finally analyzed. In the 18,275 HCC patients, 81% had hepatitis B virus infection and 10% had hepatitis C virus infection. 38% of the HCC patients had normal Alphafetoprotein (AFP) level, and other 35% had an AFP level lower than 400 ng mL^-1. In the study period, 97% of the hepatectomy for HCC were treated with open surgery, and 23.81% had vascular exclusion techniques. The operation time was (191.7±105.6) min, the blood loss was (546.0±562.8) mL, and blood transfusion was (543.0±1,035.2) mL. The median survival for HCC patients was 631 days, with 1-, 3-, and 5-year overall survival of 73.2%, 28.8% and 19.6%, respectively. Liver cirrhosis, multiple nodules, tumor thrombosis and high AFP level were risk factors that affect postoperative survival.

Postoperative Prognostic Nutritional Index Predicts Survival of Patients with Hepatocellular Carcinoma within Milan Criteria and Hypersplenism

BACKGROUND

To investigate the predictable value of postprognostic nutritional index (PNI) for patients who are suffering hepatocellular carcinoma (HCC) within Milan criteria and hypersplenism with well-preserved liver function after curative resection.

METHODS

Patients were divided into two groups: group A (postoperative PNI < 53.05, n = 280) and group B (postoperative PNI ≥ 53.05, n = 109), according to cutoff value of receiver-operating characteristic curve. Clinical data, overall survival (OS), and disease-free survival (DFS) were statistically compared between the two groups, and a multivariate analysis was used to identify prognostic factors.

RESULTS

The 1-, 3-, 5-, 7-, and 9-year OS of patients in group A were 93.3, 74.2, 53.6, 39.6, and 33.0%, respectively, and 98.9, 89.5, 79.7, 63.9, and 63.9%, respectively, for patients in group B (P = 0.001). The corresponding 1-, 3-, 5-, 7-, and 9-year DFS was 74.1, 51.1, 41.5, 30.1, 24.0, and 83.8, 64.6, 79.7, 54.0, and 49.9% for patients in the two groups, respectively (P = 0.009). Multivariable analysis revealed postoperative PNI as independent predictors of OS (P = 0.004) and DFS (P = 0.007) in patients with HCC within Milan criteria and hypersplenism after liver resection.

CONCLUSIONS

Postoperative PNI, not preoperative PNI, could predict survival of patients with HCC within Milan criteria and hypersplenism after surgical resection.

The spleen in liver cirrhosis: revisiting an old enemy with novel targets

The spleen is a secondary lymphoid organ which can influence the progression of multiple diseases, notably liver cirrhosis. In chronic liver diseases, splenomegaly and hypersplenism can manifest following the development of portal hypertension. These splenic abnormalities correlate with and have been postulated to facilitate the progression of liver fibrosis to cirrhosis, although precise mechanisms remain poorly understood. In this review, we summarize the literature to highlight the mechanistic contributions of splenomegaly and hypersplenism to the development of liver cirrhosis, focusing on three key aspects: hepatic fibrogenesis, hepatic immune microenvironment dysregulation and liver regeneration. We conclude with a discussion of the possible therapeutic strategies for modulating splenic abnormalities, including the novel potential usage of nanomedicine in non-surgically targetting splenic disorders for the treatment of liver cirrhosis.

Laparoscopic and Open Splenectomy and Hepatectomy

Background and Objectives:

Patients undergoing synchronous open splenectomy and hepatectomy (OSH) for concurrent hepatocellular carcinoma (HCC) and hypersplenism usually have major surgical trauma caused by the long abdominal incision. Surgical procedures that contribute to rapid recovery with the least possible impairment are desired by both surgeons and patients. The objective of this study was to explore outcomes in patients treated with simultaneous laparoscopic or open splenectomy and hepatectomy for hepatocellular carcinoma (HCC) with hypersplenism.

Methods:

We retrospectively evaluated the treatment outcomes in 23 patients with cirrhosis, HCC, and hypersplenism, who underwent simultaneous laparoscopic splenectomy and hepatectomy (LSH; n = 12) or open splenectomy and hepatectomy (OSH; n = 11) from January 2012 through December 2015. Their perioperative variables were compared.

Results:

LSH was successful in all patients. There were nonsignificant similarities between the 2 groups in duration of operation, estimated blood loss, and volume of blood transfused (P > .05 each). Compared with OSH, LSH had a significantly shorter postoperative visual analog scale pain score (P < .001); shorter time to first oral intake (P < .001), passage of flatus (P < .05) and off-bed activity (P < .001); shorter postoperative duration of hospitalization (P < .001); fewer days of postoperative temperature >38.0°C (P < .01); fewer postoperative complications (P < .05); and better liver and renal function on postoperative days 7 (P < .05 each).

Conclusions:

Simultaneous LSH is safe for selected patients with HCC and hypersplenism associated with liver cirrhosis.

Postoperative Low Absolute Lymphocyte Counts may Predict Poor Outcomes of Hepatocellular Carcinoma After Liver Resection

Background:

The absolute lymphocyte counts (ALCs) have been reported as one of worse prognostic factors for hepatocellular carcinoma (HCC) patient after liver transplantation. The aim of this study was to assess the influence of ALCs on the outcomes of patients with hepatitis B virus (HBV)-related HCC within the Milan criteria following liver resection.

Methods:

Data of patients with HCC within the Milan criteria who received liver resection between January 2007 and June 2013 were reviewed, and perioperative ALCs were carefully monitored. All potential risk factors were statistically analyzed by uni- and multi-variate analyses. The receiver operating characteristic (ROC) curve was used to determine the optimal ALCs cut-off value to predict HCC recurrence after liver resection.

Results:

A total of 221 patients were enrolled in the current study. During the follow-up period, 106 patients experienced recurrence, and 38 patients died. Multivariate analysis suggested microvascular invasion (MVI), a tumor grade ≥2, and a low postoperative ALCs in the 1^st postoperative month increased the incidence of postoperative recurrence, besides, MVI, intraoperative transfusion, and a low postoperative ALCs in the 1^st postoperative month were associated with poor overall survival (OS). An ROC analysis showed that a cut-off value of 1.5 × 10⁹/L for ALCs in the 1^st postoperative month predicted postoperative recurrence. The 5-year recurrence-free survival (RFS) and OS rates of patients with low postoperative ALCs were 34.5% and 64.8%, respectively, which were significantly lower than those of patients with high postoperative ALC (58.5% for RFS and 86.5% for OS).

Conclusion:

Low ALCs in the 1^st postoperative month may be associated with high recurrence incidence and poor OS for patients with HBV-related HCC within the Milan criteria after liver resection.

Splenectomy suppresses growth and metastasis of hepatocellular carcinoma through decreasing myeloid-derived suppressor cells in vivo

The function of the spleen in tumor development has been investigated for years. The relationship of the spleen with hepatocellular carcinoma (HCC), a huge health burden worldwide, however, remains unknown. The present study aimed to examine the effect of splenectomy on the development of HCC and the possible mechanism. Mouse hepatic carcinoma lines H22 and Hepa1-6 as well as BALB/c and C57 mice were used to establish orthotopic and metastatic mouse models of liver cancer. Mice were divided into four groups, including control group, splenectomy control group (S group), tumor group (T group) and tumor plus splenectomy group (T+S group). Tumor growth, metastases and overall survival were assessed at determined time points. Meanwhile, myeloid-derived suppressor cells (MDSCs) were isolated from the peripheral blood (PB), the spleen and liver tumors, and then measured by flow cytometery. It was found that liver cancer led to splenomegaly, and increased the percentage of MDSCs in the PB and spleen in the mouse models. Splenectomy inhibited the growth and progression of liver cancer and prolonged the overall survival time of orthotopic and metastatic models, which was accompanied by decreased proportion of MDSCs in the PB and tumors of liver cancer-bearing mouse. It was suggested that splenectomy could be considered an adjuvant therapy to treat liver cancer.

Individualized Laparoscopic Therapy for Portal Hypertension: A Preliminary Single Center Experience

BACKGROUND

To investigate the effects and technical points of several individualized laparoscopic therapies for patients suffering from cirrhotic portal hypertension.

METHODS

In total, 385 cirrhotic patients who underwent the treatment of individualized laparoscopic therapy from February 2012 to December 2015 at the Clinical Medical College of Yangzhou University were enrolled in this study. We retrospectively analyzed the clinical data and the key technical points.

RESULTS

Individualized laparoscopic therapies were successfully performed on 379 of 385 cases. Six cases were converted to a laparotomy (the rate of conversion to laparotomy was 1.6%). Modified laparoscopic splenectomy (MLS) for cirrhotic patients with hypersplenism was successfully performed on 103 of 105 cases. Laparoscopic azygoportal disconnection for cirrhotic patients with esophagogastric variceal bleeding (EGVB) or F3 varices was successfully performed on 61 of 62 cases, and modified laparoscopic splenectomy and azygoportal disconnection (MLSD) for cirrhotic patients with hypersplenism and EGVB or F3 varices was successfully performed on 196 of 201 cases. Synchronous MLS and laparoscopic partial hepatectomy (SLSH) for cirrhotic patients with hypersplenism and hepatocellular carcinoma (HCC) and synchronous MLSD and laparoscopic partial hepatectomy (SLSDH) for cirrhotic patients with hypersplenism, EGVB or F3 varices and HCC were all successfully implemented on 12 and 5 patients, respectively. From May 2013, we used the intraoperative autologous cell salvage during each individualized laparoscopic procedure.

CONCLUSIONS

An individualized laparoscopic therapy was beneficial for different state of selected cirrhotic patients with portal hypertension with or without HCC.

Indocyanine green retention is a potential prognostic indicator after splenectomy and pericardial devascularization for cirrhotic patients

BACKGROUND

Splenectomy and pericardial devascularization (SPD) is an effective treatment of upper gastrointestinal bleeding and hypersplenism in cirrhotic patients with portal hypertension. Indocyanine green retention at 15 minutes (ICGR15) was reported to offer better sensitivity and specificity than the Child-Pugh classification in hepatectomy, but few reports describe ICGR15 in SPD. The present study was to evaluate the prognostic value of ICGR15 for cirrhotic patients with portal hypertension who underwent SPD.

METHODS

From January 2012 to January 2015, 43 patients with portal hypertension and hypersplenism caused by liver cirrhosis were admitted in our center and received SPD. The ICGR15, Child-Pugh classification, model for end-stage liver disease (MELD) score, and perioperative characteristics were analyzed retrospectively.

RESULTS

Preoperative liver function assessment revealed that 34 patients were Child-Pugh class A with ICGR15 of 13.6%-43.0% and MELD score of 7-20; 8 patients were class B with ICGR15 of 22.8%-40.7% and MELD score of 7-17; 1 patient was class C with ICGR15 of 39.7% and MELD score of 22. The optimal ICGR15 threshold for liver function compensation was 31.2%, which offered a sensitivity of 68.4% and a specificity of 70.8%. Univariate analysis showed preoperative ICGR15, MELD score, surgical procedure, intraoperative blood loss, and autologous blood transfusion were significantly different between postoperative liver function compensated and decompensated groups. Multivariate regression analysis revealed that ICGR15 was an independent risk factor of postoperative liver function recovery (P=0.020).

CONCLUSIONS

ICGR15 has outperformed the Child-Pugh classification for assessing liver function in cirrhotic patients with portal hypertension. ICGR15 may be a suitable prognostic indicator for cirrhotic patients after SPD.

Laparoscopic RFA with splenectomy for hepatocellular carcinoma

BACKGROUND

The treatment of hepatocellular carcinoma (HCC) is complicated and challenging because of the frequent presence of cirrhosis. Therefore, we propose a novel surgical approach to minimize the invasiveness and risk in patients with HCC, hypersplenism, and esophagogastric varices.

METHODS

This was a retrospective study carried out in 25 patients with HCC and hypersplenism and who underwent simultaneous laparoscopic-guided radio-frequency ablation and laparoscopic splenectomy with endoscopic variceal ligation. Tumor size was restricted to a single nodule of <3 cm. Characteristics of the patients (cirrhosis etiology, liver function, tumor size, spleen size), surgery (complications, blood loss, time of stay), and follow-up (recurrence and survival) were examined.

RESULTS

Mean operative time was 128 ± 18 min. Mean blood loss was 206 ± 57 mL. Length of stay was 7.0 ± 1.5 days. Mean total costs were 8064 USD. Cytopenia and thrombocytopenia recovered quickly after surgery. No procedure was converted to open surgery. Two patients showed worsening liver function after surgery, three patients showed worsening of ascites, and five patients suffered from portal vein thrombosis. The 1-year tumor-free survival was 78.8 %, and the 21-month tumor-free survival was 61.4 %. According to a literature review, these outcomes were comparable to those of simultaneous open hepatic resection and splenectomy.

CONCLUSIONS

Laparoscopic-guided radio-frequency ablation with laparoscopic splenectomy and endoscopic variceal ligation could be an available technique for patients with HCC <3 cm, hypersplenism, and esophagogastric varices. This approach may help to minimize the surgical risks and results in a fast increase in platelet counts with an acceptable rate of complications.

Predicting the severity of liver cirrhosis through clinical parameters

BACKGROUND

Severity of liver cirrhosis plays a vital role in determining an appropriate surgical strategy for HCC treatment. However, preoperative evaluation of the severity of cirrhosis has not been established in a surgical setting. This study aims to develop a model to predict the severity of cirrhosis.

METHODS

Overall, 604 patients with hepatocellular carcinoma (HCC) and hepatitis B virus-related cirrhosis undergoing liver resection from Jan 2005 to Jun 2013 were randomly divided into either the model building group (n = 304) or the test group (n = 300). The severity of cirrhosis of the resected specimens was pathologically staged according to the Laennec scoring system, which sub-classified cirrhosis into either stage F4A, F4B, or F4C.

RESULTS

A logistic regression analysis showed that varicosity, portal vein diameter, spleen thickness, and platelet count were significantly associated with the histologic sub-classification of cirrhosis in the model building group. Based on these four parameters, a scoring model for predicting the severity of cirrhosis was established. The model was then verified in the test group, the areas under the ROC (AUROC) for predicting mild (F4A), moderate (F4B), and severe cirrhosis (F4C) were 0.861 (95% confidence interval [CI], 0.810-0.911), 0.860 (95% CI, 0.819-0.901), and 0.968 (95% CI, 0.951-0.985), respectively. The accuracy of this model in predicting mild, moderate, and severe cirrhosis is 79.3%, 81.0%, and 85.3%, respectively.

CONCLUSIONS

By using this model, the severity of cirrhosis can be reliably staged preoperatively, which will provide more information on cirrhotic livers in surgical settings for the treatment of hepatitis B virus-related HCC.

Therapeutic efficacy of percutaneous microwave coagulation versus liver resection for single hepatocellular carcinoma ≤3 cm with Child-Pugh A cirrhosis

AIMS

This study aimed to compare the therapeutic efficacy of liver resection (LR) and percutaneous microwave coagulation therapy (PMCT) for single hepatocellular carcinoma ≤3 cm (HCC) in cirrhotic livers.

METHODS

In this study, 190 patients with single HCC ≤3 cm and Child-Pugh A cirrhosis were retrospectively reviewed. Among these patients, 122 patients underwent LR, and 68 patients received PMCT. The therapeutic efficacy and complications were compared between the two procedures.

RESULTS

There was no treatment-related hospital mortality in either group. Major complications were significantly more frequent in the LR group compared to the PMCT group (22.1% vs 5.9%, p = 0.004). The 1-, 3-, and 5-year OS rates for the LR group and PMCT group were 98.4%, 93.6%, 55.2% and 97.1%, 87.7%, 51%, respectively. There was no significant difference in OS rates between the LR group and PMCT group (p = 0.153). The 1-, 3-, and 5-year DFS rates were 96.7%, 70.5% and 43.7%, respectively, in the LR group, which were significantly higher compared to the PMCT group (92.6%, 50.5% and 26.3%, p = 0.006). Subgroup analyses revealed that HCC patients with portal hypertension (PH), OS and DFS were similar between the two groups.

CONCLUSIONS

LR may provide better DFS and lower recurrence rates than PMCT for single HCC ≤3 cm and Child-Pugh A cirrhosis. For HCC patients with PH, PMCT may provide therapeutic effects that are similar to LR.

Liver regeneration after splenectomy in patients with liver cirrhosis

AIM

Splenectomy is a well-known procedure to improve thrombocytopenia and liver function in patients with liver cirrhosis (LC). However, the effect of splenectomy on liver regeneration remains unclear. The aim of this study is to investigate the effect of splenectomy on liver regeneration.

METHODS

Twenty patients with LC who underwent splenectomy were included in this study. Liver and splenic volumes were measured by a 3-D simulation imaging system. Liver volume (LV) and clinicopathological data were compared before and 6 months after splenectomy. Thereafter, patients were divided into two groups: the elevated LV group and the reduced LV group. Patient characteristics were compared between the two groups.

RESULTS

Postoperative LV was increased in 14 patients compared with the preoperative state. Thrombocytopenia, leukopenia, total bilirubin and prothrombin time were improved after splenectomy. In the elevated LV group, four patients exhibited improved Child-Pugh grades after splenectomy, whereas no patients demonstrated improvement in the reduced LV group. The elevated LV group exhibited high albumin level, good indocyanine green retention rate at 15 min and large splenic volume compared with the same measurements in the decreased group. Patients with larger spleen volumes and higher albumin values before splenectomy showed increased rates of LV after splenectomy.

CONCLUSION

Splenectomy for patients with LC improved pancytopenia and liver function. Especially, in patients with large spleen and high albumin levels, considerable increases in LV and improved liver function were observed.

Surgery for hepatocellular carcinoma presenting with variceal bleeding: The eastern experience

BACKGROUND

Variceal bleeding can be the first manifestation of patients with newly diagnosed hepatocellular carcinoma (HCC), and effective treatments deserve to be explored for these patients.

METHODS

A prospectively collected database of HCC patients undergoing hepatectomy identified 75 patients who presented with variceal bleeding. Among them, 31 patients underwent concomitant Hassab's operation. The clinical variables and outcomes were compared between the Hassab and non-Hassab groups.

RESULTS

The postoperative morbidity and 90-days mortality were 44.0% and 6.7% respectively. Variceal re-bleeding and tumor recurrence occurred in 28.8% and 52.1% of surviving patients after surgery, and the 1-, 3-, and 5-year overall survival rates were 87.7, 66.8, and 50.3%. There were no significant differences in morbidity, mortality and postoperative recurrence between the Hassab and non-Hassab groups. However, patients in the Hassab group had significantly higher 1-, 3-, and 5-year overall survival rates (P = 0.038), and significantly lower rate of re-bleeding (13.3% vs. 39.5%, P = 0.014) than those in the non-Hassab group. On multivariable analysis, concomitant Hassab's operation was independently predicted longer overall survival.

CONCLUSION

Liver resection could safely be performed in selected patients with HCC who presented with variceal bleeding, and concomitant Hassab's operation may improve long-term prognosis for these patients.

Management before hepatectomy for hepatocellular carcinoma with cirrhosis

The global distribution of hepatocellular carcinoma (HCC) varies markedly among regions, and patients in East Asia and Central Africa account for about 80% of all cases. The risk factors are hepatitis B, hepatitis C, alcohol, and etc. The risk of carcinogenesis further increases with progression to hepatic cirrhosis in all liver disorders. Radical treatment of HCC by liver resection without causing liver failure has been established as a safe approach through selection of an appropriate range of resection of the damaged liver. This background indicates that both evaluation of hepatic functional reserve and measures against concomitant diseases such as thrombocytopenia accompanying portal hypertension, prevention of rupture of esophageal varices, reliable control of ascites, and improvement of hypoalbuminemia are important issues in liver resection in patients with hepatic cirrhosis. We review the latest information on perioperative management of liver resection in HCC patients with hepatic cirrhosis.