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Umemura A, Nitta H, Takeda D, Katagiri H, Kanno S, Sasaki A. Transthoracic transdiaphragmatic approach in laparoscopic liver resection for hepatocellular carcinoma in a patient with severe obesity and history of deceased donor liver transplantation. Asian J Endosc Surg 2024; 17:e13305. [PMID: 38508162 DOI: 10.1111/ases.13305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Revised: 02/22/2024] [Accepted: 03/10/2024] [Indexed: 03/22/2024]
Abstract
BACKGROUND The transthoracic transdiaphragmatic approach (TTA) for hepatic tumors in laparoscopic liver resection (LLR) is not usually employed because the caudal approach via the abdominal cavity is the gold standard in LLRs. Here, we present a case of LLR via TTA for hepatocellular carcinoma (HCC) in a patient with severe obesity and a history of deceased donor liver transplantation (DDLT). MATERIALS AND SURGICAL TECHNIQUE The patient, a 64-year-old man with severe obesity and a history of DDLT, was referred to our hospital to undergo LLR for HCC located at the cranial side of segment IV. We decided to perform LLR via TTA because of concerns about the effect of severe adhesion, the difficulty of encircling the hepatoduodenal ligament, and the impact of severe obesity on the completion of LLR. Under general anesthesia with differential lung ventilation, we started to perform transthoracic ultrasonography to determine the diaphragmatic transection line. Then, we transected the diaphragm and revealed the tumor. We marked the parenchymal transection line with a 1-cm margin and then employed precoagulation of the hepatic parenchyma along the transection line. We performed parenchymal transection and clipped the responsible Glissonean pedicle at the bottom of the tumor. The diaphragm was closed using 3-0 nonabsorbable sutures with suture clips after the resected specimen was extracted. DISCUSSION We successfully performed LLR via TTA without hepatic inflow control. However, further studies are warranted to define the indications and recommendations for TTA in LLRs in the near future.
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Affiliation(s)
- Akira Umemura
- Department of Surgery, Iwate Medical University School of Medicine, Yahaba, Japan
| | - Hiroyuki Nitta
- Department of Surgery, Iwate Medical University School of Medicine, Yahaba, Japan
| | - Daiki Takeda
- Department of Surgery, Iwate Medical University School of Medicine, Yahaba, Japan
| | - Hirokatsu Katagiri
- Department of Surgery, Iwate Medical University School of Medicine, Yahaba, Japan
| | - Shoji Kanno
- Department of Surgery, Iwate Medical University School of Medicine, Yahaba, Japan
| | - Akira Sasaki
- Department of Surgery, Iwate Medical University School of Medicine, Yahaba, Japan
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Qin L, Fei L, YongGang W, Bo L. Use of Transthoracic Transdiaphragmatic Approach Assisted with Radiofrequency Ablation for Thoracoscopic Hepatectomy of Hepatic Tumor Located in Segment VIII. J Gastrointest Surg 2019; 23:1547-1548. [PMID: 31152347 DOI: 10.1007/s11605-019-04172-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Accepted: 02/20/2019] [Indexed: 02/05/2023]
Abstract
BACKGROUND Resection of segment VIII remains challenging despite the widespread laparoscopic hepatectomies in past decades,1,2 especially for patients with cirrhosis. In this case, we combined radiofrequency ablation (RFA) with transthoracic approach, which was a novel approach for laparoscopic-guided hepatectomy of segment VIII in a cirrhotic patient. PATIENT A 42-year-old male patient with a body mass index of 22.0 kg/m2 suffered from HBV-related cirrhosis was admitted to our institution. The preoperative MRI showed a 1.3 cm liver mass located in segment VIII. The preoperative AFP is 192 ng/ml. The patient was considered to have hepatectomy using transthoracic transdiaphragmatic approach with the assist of RFA. TECHNIQUE The patient was placed in a left lateral position with artificial pneumothorax in the right lung and left side ventilation. Three trocars were placed into the right thoracic space. Transdiaphragmatic intraoperative ultrasonography (IOUS) was performed to confirm the size and location of the lesion. In order to decrease the blood loss during parenchymal dissection and to reach tumor-free margins, the RFA was performed around the tumor before hepatectomy. After that the resection was carried out along the ablative margin. After the specimen was removed, the diaphragm was sutured and a closed thoracic drainage tube was placed. The operative time was 210 min with an estimated blood loss of 50 mL. The postoperative course was uneventful. Antibiotics was used in the first 24 h post-operation to prevent thoracic infection. Drainage tube was pulled out on the fourth day post-operation when we observed the daily fluid volume was less than 100 ml for 2 days and X-ray showed no gases and effusion in chest cavity. The pathology confirmed the diagnosis of hepatocellular carcinoma and the surgical margin was negative. The patient was discharged on the 8th day after surgery. DISCUSSION Lesions in the postero-superior segments still be challenging as we know.3 Previous studies showed that the procedure's results, such as the blood loss and operative time, were similar between thoracoscopic hepatectomy and laparoscopic hepatectomy, even the former was better.2,4 Thus, for the superficial lesions in the postero-superior segments, and not more than 3 cm in diameter, thoracoscopic hepatectomy is recommended. Furthermore, a patient with a hostile abdomen who has a lesion in S7 or S8, transthoracic approach may be particularly helpful. However, functional lung is required due to the unilateral ventilation. Besides, anatomic resections are difficult to perform from the top.5 In this case, we used RFA before liver resection, and the tumor cells were destroyed to ensure the negative margin of the cut, and the bleeding blood vessels were also closed. This method can make a significant reduction of blood loss in the patients with cirrhosis compared with conventional hepatectomy (whether through thoracoscopic6 or laparoscopic7 approach). CONCLUSION The novel approach for transthoracic hepatectomy was safe and feasible for lesions of segment VIII in selected patients with cirrhosis,8 which was associated with reduced blood loss and a safe surgical margin.
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Affiliation(s)
- Li Qin
- Department of Liver Surgery and Liver Transplantation Center, West China Hospital of Sichuan University, Chengdu, 610041, China
| | - Liu Fei
- Department of Liver Surgery and Liver Transplantation Center, West China Hospital of Sichuan University, Chengdu, 610041, China
| | - Wei YongGang
- Department of Liver Surgery and Liver Transplantation Center, West China Hospital of Sichuan University, Chengdu, 610041, China.
| | - Li Bo
- Department of Liver Surgery and Liver Transplantation Center, West China Hospital of Sichuan University, Chengdu, 610041, China
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Surgical Indications and Procedures for Resection of Hepatic Malignancies Confined to Segment VII. Ann Surg 2016; 263:529-37. [PMID: 25563884 DOI: 10.1097/sla.0000000000001118] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
OBJECTIVE To establish a strategy for surgical resection of hepatic malignancies confined to segment VII. BACKGROUND Various surgical procedures can be used to resect hepatic malignancies in segment VII, the deepest region of the liver, by open and/or laparoscopic approaches: nonanatomic wedge resection (WR), segmentectomy VII, right lateral sectionectomy (RLS), and right hepatectomy. METHODS WR and segmentectomy VII were applied as first-line surgical procedures for colorectal liver metastasis (CRLM) and hepatocellular carcinoma (HCC), respectively. RLS and right hepatectomy were indicated only when tumor infiltration to the proximal Glissonian sheath was suspected. Operative outcomes were evaluated in 200 consecutive patients who underwent hepatic resection for HCC (n = 120) or CRLM (n = 80). RESULTS WR, segmentectomy VII, RLS, and right hepatectomy were performed in 104 (52.0%), 57 (28.5%), 22 (11.0%), and 17 (8.5%) patients, respectively. Local hepatectomy (WR and segmentectomy VII) led to shorter operation times and lower blood loss volumes than did extensive hepatectomy (RLS and right hepatectomy). Thoracotomy was performed in half of the WR and two-thirds of the segmentectomy VII procedures. The availability of a laparoscopic approach was 40% (8 patients) after its application in October 2012. CONCLUSIONS Even for hepatic malignancies located in segment VII, WR and segmentectomy should be prioritized over extensive hepatectomy to preserve the postoperative functional hepatic volume. Full mobilization of the right liver and a good surgical field provided by a large thoracoabdominal or abdominal incision or a laparoscopic approach are key factors for safe performance of deep hepatic transection.
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Del Fabbro D, Alloisio M, Procopio F, Cimino M, Donadon M, Palmisano A, Vigano L, Torzilli G. Surgical treatment of synchronous colorectal liver and lung metastases: the usefulness of thoracophrenolaparotomy for single stage resection. Hepatobiliary Pancreat Dis Int 2016; 15:216-9. [PMID: 27020639 DOI: 10.1016/s1499-3872(15)60422-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
When suitable, surgery still remains the therapeutic option to be preferred for patients carrier of colorectal liver and lung metastases. Since thoracophrenolaparotomy should be helpful during liver resection for some of these patients, simultaneous removal of right lung metastases can be proposed through this approach. Eleven consecutive patients (median age of 53 years) carrier of colorectal liver and lung metastases, underwent single session surgical resection of both liver and right lung lesions by means of J-shaped thoracophrenolaparotomy. The median number of liver metastases removed was 5 (range 2-30) and of lung metastases removed was 2 (range 1-3). Lung metastases were located in the upper lobe in 1 patient, in the middle lobe in 2, in the lower lobe in 6, and in the upper and lower lobe in 2. Mortality and major morbidity were nil. Two patients had a minor morbidity: one had wound infection and bile leakage treated conservatively and the other had transient fever. Mean overall survival was 24.4 months. An aggressive surgical approach should be undertaken for colorectal metastases: in case of multifocal liver disease with complex presentations, J-shaped thoracophrenolaparotomy could be considered as safe approach for combined liver and right lung metastasectomies.
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Affiliation(s)
- Daniele Del Fabbro
- Department of Hepatobiliary Surgery, Humanitas Research Hospital, University of Milan School of Medicine, Rozzano, Milan, Italy.
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Cauchy F, Soubrane O, Belghiti J. Liver resection for HCC: patient's selection and controversial scenarios. Best Pract Res Clin Gastroenterol 2014; 28:881-96. [PMID: 25260315 DOI: 10.1016/j.bpg.2014.08.013] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2014] [Revised: 08/06/2014] [Accepted: 08/19/2014] [Indexed: 02/07/2023]
Abstract
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.
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Affiliation(s)
- François Cauchy
- Beaujon Hospital, Assistance Publique Hôpitaux de Paris, Clichy, France; University Denis Diderot, Paris 7, France
| | - Olivier Soubrane
- Beaujon Hospital, Assistance Publique Hôpitaux de Paris, Clichy, France; University Denis Diderot, Paris 7, France
| | - Jacques Belghiti
- Beaujon Hospital, Assistance Publique Hôpitaux de Paris, Clichy, France; University Denis Diderot, Paris 7, France.
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Thoracoabdominal approach in liver surgery: how, when, and why. Updates Surg 2013; 66:121-5. [PMID: 24338089 DOI: 10.1007/s13304-013-0244-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2013] [Accepted: 12/03/2013] [Indexed: 02/06/2023]
Abstract
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.
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7
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Dokmak S, Agostini J, Jacquin A, Cauchy F, Farges O, Belghiti J. High Risk of Biliary Fistula After Isolated Segment VIII Liver Resection. World J Surg 2012; 36:2692-8. [DOI: 10.1007/s00268-012-1725-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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8
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Cauchy F, Fuks D, Belghiti J. HCC: current surgical treatment concepts. Langenbecks Arch Surg 2012; 397:681-95. [DOI: 10.1007/s00423-012-0911-2] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2012] [Accepted: 01/17/2012] [Indexed: 12/28/2022]
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Cloyd JM, Visser BC. Video-assisted thoracoscopic transdiaphragmatic liver resection for hepatocellular carcinoma. Surg Endosc 2011; 26:1772-6. [DOI: 10.1007/s00464-011-2062-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2011] [Accepted: 11/10/2011] [Indexed: 01/10/2023]
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Golse N, Ducerf C, Rode A, Gouillat C, Baulieux J, Mabrut JY. Transthoracic approach for liver tumors. J Visc Surg 2011; 149:e11-22. [PMID: 22154179 DOI: 10.1016/j.jviscsurg.2011.10.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Abdominal approach is commonly used for resection of liver tumors. However, in rare cases, transthoracic approach may be a valuable option for management of lesions located in the hepatic dome or involving the cavo-hepatic junction for very selected patients. This approach can be an open procedure (thoracotomomy), a video-assisted minimally invasive technique (thoracoscopy), or a strictly percutaneously treatment (CT-guided radiofrequency ablation). This approach seems useful for high-risk patients, with previous major abdominal surgery, or awaiting for liver transplantation (bridge concept) with cranially located single lesions. A limited liver resection (tumorectomy or segmentectomy) can be performed, but this approach is also suitable for percutaneous ablation therapy (radiofrequency or cryotherapy), with an acceptable morbidity.
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Affiliation(s)
- N Golse
- Service de chirurgie digestive et de transplantation hépatique, hôpital de la Croix-Rousse, université Claude-Bernard Lyon 1, 103, Grande rue de La-Croix-Rousse, 69317 Lyon cedex 04, France
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11
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Delis SG, Madariaga J, Bakoyiannis A, Avgerinos C, Touloumis Z, Vasileios V, Dervenis C. Combined liver and lung metastasectomy through an exclusive transthoracic approach. J Surg Oncol 2007; 96:178-82. [PMID: 17372921 DOI: 10.1002/jso.20723] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND In a very selected group of patients, resection of metachronous liver and lung metastases, prolongs survival despite the aggressive nature of these lesions. We present here our experience with metastasectomy in patients with metachronous liver and lung metastases in whom, an exclusive transthoracic approach was performed. METHODS Between 2002 and 2005, five patients with metachronous colorectal liver and right-lung metastases, underwent an exclusive transthoracic approach. There were three men and two women, with a median age of 68 years (range, 55-76 years). Liver resections performed included segmentectomy of segments VII, VIII, or both. Previous operations include colon resection, adhesiolysis, or ventral hernia repair were performed in all patients. RESULTS No mortality was documented. Morbidity included pleural effusion (n = 2) and post-operative pneumonia (n = 1) which responded to conservative management. Median hospital stay was 8 days (range 5-12 days). With a median follow-up of 26 months all patients are alive without recurrent disease. CONCLUSION An aggressive surgical approach should be undertaken for CRC metastases. An exclusive transthoracic approach is feasible for combined lung and subdiaphragmatic liver metastasectomy in selected cases with previous abdominal surgery.
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Affiliation(s)
- Spiros G Delis
- 1st Surgical Department, Liver Surgical Unit, Agia Olga Hospital, Athens, Greece
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12
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Xia F, Poon RTP, Fan ST, Wong J. Thoracoabdominal approach for right-sided hepatic resection for hepatocellular carcinoma. J Am Coll Surg 2003; 196:418-27. [PMID: 12648694 DOI: 10.1016/s1072-7515(02)01763-5] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Resection of a large hepatocellular carcinoma in the right liver or a small tumor located at the superior and posterior part of the right liver requires extensive hepatic mobilization. A thoracoabdominal approach might facilitate hepatic resection in such situations, but the safety and benefits of this approach remain unclear. STUDY DESIGN A retrospective study based on a prospectively collected database of 488 patients was performed to evaluate the perioperative outcomes of right-sided hepatic resection for hepatocellular carcinoma using the thoracoabdominal approach (n = 92) in comparison with the conventional abdominal approach (n = 396). RESULTS The two groups were comparable in age, comorbid illnesses, liver function, tumor size, and underlying cirrhosis. There were more extended right hepatectomies in the thoracoabdominal approach group than in the abdominal approach group, but the difference was not significant (33.7% versus 26.0%, p = 0.14). A significantly higher proportion of patients in the thoracoabdominal approach group did not require blood transfusion compared with the abdominal approach group (66.3% versus 54.8%, p = 0.04). The operating time for the former group was longer (median 450 min versus 360 min, p < 0.001). There were no significant differences in hospital stay (median 12.5 days versus 13.0 days, p = 0.82), overall morbidity (41.3% versus 38.6%, p = 0.64), or hospital mortality (4.3% versus 7.3%, p = 0.37) between the two groups. CONCLUSIONS The thoracoabdominal approach is a safe operative approach that can facilitate resection of massive tumors in the right liver or tumors involving segments 7 and 8 without increased morbidity.
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Affiliation(s)
- Feng Xia
- Centre for the Study of Liver Disease and Department of Surgery, Queen Mary Hospital, Hong Kong, China
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13
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Abstract
OBJECTIVE To identify 10 critical elements of accurate and comprehensive reports of surgical complications. SUMMARY BACKGROUND DATA Despite a venerable tradition of weekly morbidity and mortality conferences, inconsistent complication reporting is common in the surgical literature. METHODS An analysis of articles reporting short-term outcomes after pancreatectomy, esophagectomy, and hepatectomy was performed. Randomized clinical trials (RCTs) published from 1975 to 2001 and retrospective series of more than 100 patients published from 1990 to 2001 were reviewed. RESULTS A total of 119 articles reporting outcomes in 22,530 patients were analyzed. This included 42 RCTs and 77 retrospective series. Of the 10 criteria developed, no articles met all criteria; 2% met 9 criteria, 38% 7 or 8, 34% 5 or 6, 40% 3 or 4, and 12% 1 or 2. Outpatient information (22% of articles), definitions of complications provided (34% of articles), severity grade used (20% of articles), and risk factors included in analysis (29% of articles) were the most commonly unmet quality reporting criteria. Type of study (RCT vs. retrospective), site of institution (U.S. vs. non-U.S.) and journal (U.S. vs. non-U.S.) did not influence the quality of complication reporting. CONCLUSIONS Short-term surgical outcomes are routinely included in the data reported in the surgical literature. This is often used to show improvements over time or to assess the impact of therapeutic changes on patient outcome. The inconsistency of reporting and the lack of accepted principles of accrual, display, and analysis of complication data argue strongly for the creation and generalized use of standards for reporting this information.
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Affiliation(s)
- Robert C G Martin
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York 10021, USA
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14
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Abstract
OBJECTIVE The authors report on the surgical techniques and protocol for perioperative care that have yielded a zero hospital mortality rate in 110 consecutive patients undergoing hepatectomy for hepatocellular carcinoma (HCC). The hepatectomy results are analyzed with the aim of further reducing the postoperative morbidity rate. SUMMARY BACKGROUND DATA In recent years, hepatectomy has been performed with a mortality rate of <10% in patients with HCC, but a zero hospital mortality rate in a large patient series has never been reported. At Queen Mary Hospital, Hong Kong, the surgical techniques and perioperative management in hepatectomy for HCC have evolved yearly into a final standardized protocol that reduced the hospital mortality rate from 28% in 1989 to 0% in 1996 and 1997. METHODS Surgical techniques were designed to reduce intraoperative blood loss, blood transfusion, and ischemic injury to the liver remnant in hepatectomy. Postoperative care was focused on preservation and promotion of liver function by providing adequate tissue oxygenation and immediate postoperative nutritional support that consisted of branched-chain amino acid-enriched solution, low-dose dextrose, medium-chain triglycerides, and phosphate. The pre-, intra-, and postoperative data were collected prospectively and analyzed each year to assess the influence of the evolving surgical techniques and perioperative care on outcome. RESULTS Of 330 patients undergoing hepatectomy for HCC, underlying cirrhosis and chronic hepatitis were present in 161 (49%) and 108 (33%) patients, respectively. There were no significant changes in the patient characteristics throughout the 9-year period, but there were significant reductions in intraoperative blood loss and blood transfusion requirements. From 1994 to 1997, the median blood transfusion requirement was 0 ml, and 64% of the patients did not require a blood transfusion. The postoperative morbidity rate remained the same throughout the study period. Complications in the patients operated on during 1996 and 1997 were primarily wound infections; the potentially fatal complications seen in the early years, such as subphrenic sepsis, biliary leakage, and hepatic coma, were absent. By univariate analysis, the volume of blood loss, volume of blood transfusions, and operation time were correlated positively with postoperative morbidity rates in 1996 and 1997. Stepwise logistic regression analysis revealed that the operation time was the only parameter that correlated significantly with the postoperative morbidity rate. CONCLUSION With appropriate surgical techniques and perioperative management to preserve function of the liver remnant, hepatectomy for HCC can be performed without hospital deaths. To improve surgical outcome further, strategies to reduce the operation time are being investigated.
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Fan ST, Lo CM, Liu CL, Lam CM, Yuen WK, Yeung C, Wong J. Hepatectomy for hepatocellular carcinoma: toward zero hospital deaths. Ann Surg 1999. [PMID: 10077043 DOI: 10.1097/00000658-199903000-0004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVE The authors report on the surgical techniques and protocol for perioperative care that have yielded a zero hospital mortality rate in 110 consecutive patients undergoing hepatectomy for hepatocellular carcinoma (HCC). The hepatectomy results are analyzed with the aim of further reducing the postoperative morbidity rate. SUMMARY BACKGROUND DATA In recent years, hepatectomy has been performed with a mortality rate of <10% in patients with HCC, but a zero hospital mortality rate in a large patient series has never been reported. At Queen Mary Hospital, Hong Kong, the surgical techniques and perioperative management in hepatectomy for HCC have evolved yearly into a final standardized protocol that reduced the hospital mortality rate from 28% in 1989 to 0% in 1996 and 1997. METHODS Surgical techniques were designed to reduce intraoperative blood loss, blood transfusion, and ischemic injury to the liver remnant in hepatectomy. Postoperative care was focused on preservation and promotion of liver function by providing adequate tissue oxygenation and immediate postoperative nutritional support that consisted of branched-chain amino acid-enriched solution, low-dose dextrose, medium-chain triglycerides, and phosphate. The pre-, intra-, and postoperative data were collected prospectively and analyzed each year to assess the influence of the evolving surgical techniques and perioperative care on outcome. RESULTS Of 330 patients undergoing hepatectomy for HCC, underlying cirrhosis and chronic hepatitis were present in 161 (49%) and 108 (33%) patients, respectively. There were no significant changes in the patient characteristics throughout the 9-year period, but there were significant reductions in intraoperative blood loss and blood transfusion requirements. From 1994 to 1997, the median blood transfusion requirement was 0 ml, and 64% of the patients did not require a blood transfusion. The postoperative morbidity rate remained the same throughout the study period. Complications in the patients operated on during 1996 and 1997 were primarily wound infections; the potentially fatal complications seen in the early years, such as subphrenic sepsis, biliary leakage, and hepatic coma, were absent. By univariate analysis, the volume of blood loss, volume of blood transfusions, and operation time were correlated positively with postoperative morbidity rates in 1996 and 1997. Stepwise logistic regression analysis revealed that the operation time was the only parameter that correlated significantly with the postoperative morbidity rate. CONCLUSION With appropriate surgical techniques and perioperative management to preserve function of the liver remnant, hepatectomy for HCC can be performed without hospital deaths. To improve surgical outcome further, strategies to reduce the operation time are being investigated.
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Affiliation(s)
- S T Fan
- Department of Surgery, The University of Hong Kong, Queen Mary Hospital, Hong Kong
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Fan ST, Lo CM, Liu CL, Lam CM, Yuen WK, Yeung C, Wong J. Hepatectomy for hepatocellular carcinoma: toward zero hospital deaths. Ann Surg 1999; 229:322-30. [PMID: 10077043 PMCID: PMC1191696 DOI: 10.1097/00000658-199903000-00004] [Citation(s) in RCA: 553] [Impact Index Per Article: 22.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE The authors report on the surgical techniques and protocol for perioperative care that have yielded a zero hospital mortality rate in 110 consecutive patients undergoing hepatectomy for hepatocellular carcinoma (HCC). The hepatectomy results are analyzed with the aim of further reducing the postoperative morbidity rate. SUMMARY BACKGROUND DATA In recent years, hepatectomy has been performed with a mortality rate of <10% in patients with HCC, but a zero hospital mortality rate in a large patient series has never been reported. At Queen Mary Hospital, Hong Kong, the surgical techniques and perioperative management in hepatectomy for HCC have evolved yearly into a final standardized protocol that reduced the hospital mortality rate from 28% in 1989 to 0% in 1996 and 1997. METHODS Surgical techniques were designed to reduce intraoperative blood loss, blood transfusion, and ischemic injury to the liver remnant in hepatectomy. Postoperative care was focused on preservation and promotion of liver function by providing adequate tissue oxygenation and immediate postoperative nutritional support that consisted of branched-chain amino acid-enriched solution, low-dose dextrose, medium-chain triglycerides, and phosphate. The pre-, intra-, and postoperative data were collected prospectively and analyzed each year to assess the influence of the evolving surgical techniques and perioperative care on outcome. RESULTS Of 330 patients undergoing hepatectomy for HCC, underlying cirrhosis and chronic hepatitis were present in 161 (49%) and 108 (33%) patients, respectively. There were no significant changes in the patient characteristics throughout the 9-year period, but there were significant reductions in intraoperative blood loss and blood transfusion requirements. From 1994 to 1997, the median blood transfusion requirement was 0 ml, and 64% of the patients did not require a blood transfusion. The postoperative morbidity rate remained the same throughout the study period. Complications in the patients operated on during 1996 and 1997 were primarily wound infections; the potentially fatal complications seen in the early years, such as subphrenic sepsis, biliary leakage, and hepatic coma, were absent. By univariate analysis, the volume of blood loss, volume of blood transfusions, and operation time were correlated positively with postoperative morbidity rates in 1996 and 1997. Stepwise logistic regression analysis revealed that the operation time was the only parameter that correlated significantly with the postoperative morbidity rate. CONCLUSION With appropriate surgical techniques and perioperative management to preserve function of the liver remnant, hepatectomy for HCC can be performed without hospital deaths. To improve surgical outcome further, strategies to reduce the operation time are being investigated.
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Affiliation(s)
- S T Fan
- Department of Surgery, The University of Hong Kong, Queen Mary Hospital, Hong Kong
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