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Comparison of Anatomic and Non-Anatomic Liver Resection for Hepatocellular Carcinoma: A Retrospective Cohort Study. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:medicina58091305. [PMID: 36143982 PMCID: PMC9505104 DOI: 10.3390/medicina58091305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 09/09/2022] [Accepted: 09/12/2022] [Indexed: 11/29/2022]
Abstract
Background and Objectives: The survival benefit of anatomical liver resection for hepatocellular carcinoma has not been elucidated yet. In this study, we aimed to investigate the effects of anatomic and non-anatomic liver resection on surgical outcomes in patients with hepatocellular carcinoma. Materials and Methods: A retrospective analysis of patients undergoing anatomic or non-anatomic resections due to hepatocellular carcinoma between March 2006 and October 2019 was conducted. Demographics, preoperative laboratory assessments, treatment strategies, and postoperative outcomes were analyzed. Results: The total cohort consisted of 94 patients, with a mean age of 63.1 ± 8.9 years, and 74.5% were male. A total of 41 patients underwent anatomic liver resection, and 53 patients underwent non-anatomic resection. The overall survival rates were found to be similar (5-year overall survival was 49.3% for anatomic resection and 44.5% for non-anatomic resection). Estimated median overall survival times were 58.5 months and 57.3 months, respectively (p = 0.777). Recurrence-free 1-, 3-, and 5-year survival rates were found to be 73.6%, 39.1%, and 32.8% in the non-anatomic resection group and 48.8%, 22.7%, and 22.7% in the anatomic resection group, respectively. Grade three or higher complication rates were found to be similar among the groups. Conclusions: This study did not find a difference between two surgical methods, in terms of survival. A tailored selection of the resection method should be made, with the aim of complete removal of tumoral lesions and leaving a suitable functional liver reserve, according to the parenchymal quality and volume of the liver remnant.
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Dai XM, Xiang ZQ, Wang Q, Li HJ, Zhu Z. Oncological outcomes of anatomic versus non-anatomic resections for small hepatocellular carcinoma: systematic review and meta-analysis of propensity-score matched studies. World J Surg Oncol 2022; 20:299. [PMID: 36117165 PMCID: PMC9484142 DOI: 10.1186/s12957-022-02770-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Accepted: 09/11/2022] [Indexed: 11/17/2022] Open
Abstract
Background Primary liver cancer is the second-most commonly occurring cancer and has resulted in numerous deaths worldwide. Hepatic resection is of two main types, i.e., anatomic resection (AR) and non-anatomic resection (NAR). The oncological outcomes of hepatocellular carcinoma (HCC) patients after AR and NAR are still considered controversial. Therefore, we aimed to compare the impact of AR and NAR on the oncological outcomes of HCC patients with tumor diameters ≤ 5 cm using the propensity score matching method and research-based evidence. Method A systematic literature search was conducted. The main outcomes were disease-free survival (DFS), overall survival (OS), intrahepatic recurrence rate, and extrahepatic metastasis rate. Relative risk (RR) was calculated from forest plots and outcomes using random-effects model (REM). Result AR significantly improved DFS at 1, 3. and 5 years after surgery, compared to NAR (RR = 1.09, 95% CI = 1.04–1.15, P = 0.0003; RR = 1.16, 95% CI = 1.07–1.27, P = 0.0005; RR = 1.29, 95% CI = 1.07–1.55, P = 0.008). However, both of the difference in DFS at 7 years and OS at 1 and 3 years after AR versus that after NAR were not statistically significant. Nevertheless, the long-term OS associated with AR (5, 7, and 10 years) was superior to that associated with NAR (RR = 1.12, 95% CI = 1.03–1.21, P = 0.01; RR = 1.19, 95% CI = 1.04–1.36, P = 0.01; RR = 1.18, 95% CI = 1.05–1.34, P = 0.008). The difference in the intrahepatic recurrence rate after AR versus that after NAR was not statistically significant, but the extrahepatic metastasis rate after AR was significantly lower than that observed after NAR (RR = 0.61, 95% CI = 0.40–0.94, P = 0.03). Conclusion Therefore, AR should be the preferred surgical approach for HCC patients with tumor diameters ≤ 5 cm. Trial registration PROSPERO registration number CRD42022330596.
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Affiliation(s)
- Xiao-Ming Dai
- Department of Hepatobiliary Surgery, The First Affiliated Hospital, Hengyang Medical School, University of South China, No. 69 ChuanShan Road, Shigu District, Hengyang, 421001, Hunan, China
| | - Zhi-Qiang Xiang
- Department of Hepatobiliary Surgery, The First Affiliated Hospital, Hengyang Medical School, University of South China, No. 69 ChuanShan Road, Shigu District, Hengyang, 421001, Hunan, China
| | - Qian Wang
- Department of Reproductive Medicine, The First Affiliated Hospital, Hengyang Medical School, University of South China, No. 69 ChuanShan Road, Shigu District, Hengyang, 421001, Hunan, China
| | - Hua-Jian Li
- Department of Hepatobiliary Surgery, The First Affiliated Hospital, Hengyang Medical School, University of South China, No. 69 ChuanShan Road, Shigu District, Hengyang, 421001, Hunan, China
| | - Zhu Zhu
- Department of Hepatobiliary Surgery, The First Affiliated Hospital, Hengyang Medical School, University of South China, No. 69 ChuanShan Road, Shigu District, Hengyang, 421001, Hunan, China. .,Department of Education and Training, The First Affiliated Hospital, Hengyang Medical School, University of South China, No. 69 ChuanShan Road, Shigu District, Hengyang, 421001, Hunan, China.
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Impact on Prognosis Following Nonanatomical Resection of Hepatocellular Carcinoma Postoperatively Proven as Micro Portal Vein Tumor Thrombus on Histology. Int Surg 2022. [DOI: 10.9738/intsurg-d-18-00018.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Objective
The prognostic impact of intrahepatic recurrence pattern and/or operative procedure (anatomical resection [AR] and nonanatomical resection [NAR]) for hepatocellular carcinoma (HCC) in patients with postoperatively proven portal vein tumor thrombus on histology has not yet been clearly examined.
Summary of background data
A total of 52 HCC patients who had no visible macroscopic vascular invasion preoperatively and histologically proven portal vein tumor thrombus distal to second-order portal branches after surgery were analyzed.
Methods
The overall survival and disease-free survival rates were analyzed using the Kaplan-Meier method. The risk factors for intrahepatic recurrence and distant metastasis were analyzed using the log-rank test.
Results
There was no significant difference in the overall survival rates at 5 years, based on the operative procedure. The disease-free survival rates at 3 years were 59.2% (AR group) and 30.1% (NAR group), respectively, and were statistically significant. Intrahepatic recurrence in the same remnant segment was seen in 5 patients undergoing NAR. These cases developed multiple bilobar recurrences simultaneously, including the same segment, and recurrence only in the same remnant segment was not seen in any case, irrespective of solitary or multiple recurrence.
Conclusions
Intrahepatic recurrence in the same remnant segment does not influence the disease-free survival rate in patients after NAR. Although AR would be an ideal procedure, the current study suggests NAR can achieve identical outcomes for patients who cannot be considered for AR.
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Liu H, Hu FJ, Li H, Lan T, Wu H. Anatomical vs nonanatomical liver resection for solitary hepatocellular carcinoma: A systematic review and meta-analysis. World J Gastrointest Oncol 2021; 13:1833-1846. [PMID: 34853654 PMCID: PMC8603461 DOI: 10.4251/wjgo.v13.i11.1833] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 05/08/2021] [Accepted: 07/13/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The long-term survival of patients with solitary hepatocellular carcinoma (HCC) following anatomical resection (AR) vs non-anatomical resection (NAR) is still controversial. It is necessary to investigate which approach is better for patients with solitary HCC.
AIM To compare perioperative and long-term survival outcomes of AR and NAR for solitary HCC.
METHODS We performed a comprehensive literature search of PubMed, Medline (Ovid), Embase (Ovid), and Cochrane Library. Participants of any age and sex, who underwent liver resection, were considered following the following criteria: (1) Studies reporting AR vs NAR liver resection; (2) Studies focused on primary HCC with a solitary tumor; (3) Studies reporting the long-term survival outcomes (> 5 years); and (4) Studies including patients without history of preoperative treatment. The main results were overall survival (OS) and disease-free survival (DFS). Perioperative outcomes were also compared.
RESULTS A total of 14 studies, published between 2001 and 2020, were included in our meta-analysis, including 9444 patients who were mainly from China, Japan, and Korea. AR was performed on 4260 (44.8%) patients. The synthetic results showed that the 5-year OS [odds ratio (OR): 1.19; P < 0.001] and DFS (OR: 1.26; P < 0.001) were significantly better in the AR group than in the NAR group. AR was associated with longer operating time [mean difference (MD): 47.08; P < 0.001], more blood loss (MD: 169.29; P = 0.001), and wider surgical margin (MD = 1.35; P = 0.04) compared to NAR. There was no obvious difference in blood transfusion ratio (OR: 1.16; P = 0.65) or postoperative complications (OR: 1.24, P = 0.18).
CONCLUSION AR is superior to NAR in terms of long-term outcomes. Thus, AR can be recommended as a reasonable surgical option in patients with solitary HCC.
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Affiliation(s)
- Hu Liu
- Department of Liver Surgery, Liver Transplantation Division, Laboratory of Liver Surgery, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Feng-Juan Hu
- The Center of Gerontology and Geriatrics, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Hui Li
- Department of Liver Surgery, Liver Transplantation Division, Laboratory of Liver Surgery, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Tian Lan
- Department of Liver Surgery, Liver Transplantation Division, Laboratory of Liver Surgery, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Hong Wu
- Department of Liver Surgery, Liver Transplantation Division, Laboratory of Liver Surgery, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
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What is the optimal surgical treatment for hepatocellular carcinoma beyond the debate between anatomical versus non-anatomical resection? Surg Today 2021; 52:871-880. [PMID: 34392420 DOI: 10.1007/s00595-021-02352-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 06/22/2021] [Indexed: 12/24/2022]
Abstract
The optimal type of hepatectomy for hepatocellular carcinoma (HCC)-anatomical or non-anatomical resection-remains controversial despite numerous comparative studies. There are common fundamental issues in published studies comparing anatomical resection with non-anatomical resection: (1) confounding by indication, (2) setting primary outcomes, and (3) a lack of a clear definition of non-anatomical resection. This degrades the quality of the comparison of the two types of surgery. To measure the therapeutic effect of hepatectomy, it is essential to understand the accumulated knowledge underlying these issues, such as the mechanism of hepatocellular carcinoma spread, tumor blood flow drainage theory, and the three patterns of hepatocellular carcinoma recurrence: (1) local intrahepatic metastasis, (2) systemic metastasis, and (3) multicentric carcinogenesis recurrence. Based on evidence that the incidence of local intrahepatic metastasis was so low it was almost negligible, the therapeutic effect of anatomical resection on the oncological survival was determined to be similar to that of non-anatomical resection. Recent research progress demonstrating the clinical impact of subclinical dissemination of HCC after surgery may stimulate new debate on the optimal surgical treatment for HCC beyond the comparison of anatomical and non-anatomical resection.
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Sasaki K, Matsuda M, Ohkura Y, Hashimoto M, Watanabe G. Anatomical versus Nonanatomical Resection in Patients with Hepatocellular Carcinoma Located in the Left Lateral Segment. Am Surg 2020. [DOI: 10.1177/000313481307901119] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
To date, no reported studies comparing anatomical resection (AR) and nonanatomical resection (NAR) for hepatocellular carcinoma (HCC) have restricted cases by tumor location. Thus, right hepatectomy and left lateral sectionectomy are both analyzed together as AR, whereas limited resection of both peripherally and centrally located liver tumors is categorized as NAR. This categorization may result in inaccurate conclusions in the analyses comparing AR and NAR. We conducted a retrospective comparison between AR (n = 30) and NAR (n = 57) for solitary and small (5 cm or less) HCC limited to the left lateral segment (LLS) to clarify whether AR is superior to NAR for HCC in LLS. The 1-, 3-, and 5-year recurrence-free survival rates were 83.3, 71.3, and 52.9 per cent for the AR group and 82.5, 51.0, and 40.7 per cent for the NAR group, respectively ( P = 0.10). The 3-, 5-, and 7-year overall survival rates were 96.0, 82.8, and 77.9 per cent for the AR group and 84.1, 77.0, and 54.2 per cent for the NAR group, respectively ( P = 0.07). The postoperative complication, recurrence patterns, and secondary treatment types after recurrence were not significantly different between the two groups. The multivariate analysis including the confounders related to background liver function indicated AR to be a significant protective factor against recurrence, although AR did not influence overall survival. AR was superior to NAR in preventing recurrence without increasing postoperative risks among patients with small solitary HCC limited to the LLS, although AR could not improve overall survival.
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Affiliation(s)
- Kazunari Sasaki
- Department of Digestive Surgery, Hepato Pancreato Biliary Surgery Unit, Toranomon Hospital Tokyo, Japan
| | - Masamichi Matsuda
- Department of Digestive Surgery, Hepato Pancreato Biliary Surgery Unit, Toranomon Hospital Tokyo, Japan
| | - Yu Ohkura
- Department of Digestive Surgery, Hepato Pancreato Biliary Surgery Unit, Toranomon Hospital Tokyo, Japan
| | - Masaji Hashimoto
- Department of Digestive Surgery, Hepato Pancreato Biliary Surgery Unit, Toranomon Hospital Tokyo, Japan
| | - Goro Watanabe
- Department of Digestive Surgery, Hepato Pancreato Biliary Surgery Unit, Toranomon Hospital Tokyo, Japan
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Feasibility of purely laparoscopic right anterior sectionectomy. Surg Endosc 2020; 35:192-199. [PMID: 31932936 DOI: 10.1007/s00464-020-07379-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Accepted: 01/07/2020] [Indexed: 01/22/2023]
Abstract
BACKGROUND Right anterior sectionectomy is complex in comparison to other liver resections. Thus, the operation has not been widely performed via a laparoscopic approach. We herein present a purely laparoscopic method for right anterior sectionectomy using the standardized techniques. METHODS Between May 2017 and December 2018, ten pure laparoscopic right anterior sectionectomies were performed for hepatic malignancy. To perform laparoscopic anatomical liver resection safely and securely, we developed an original surgical procedure based on the isolation of the targeted Glissonean pedicle at the hilum, with appropriate transection planes built sequentially according to anatomical landmarks. The extrahepatic right anterior Glissonean pedicle was isolated without parenchymal destruction by utilizing a unique view in the laparoscopic approach. The selective right anterior segment inflow was temporary occluded, consequently liver parenchymal transection consisted of four planes according to the demarcation line, middle hepatic vein (MHV), right anterior Glissonean pedicle, and right hepatic vein (RHV), which were used as anatomical landmarks. Transection was started between the demarcation line and ventral of the MHV (plane 1). Transection of the parenchyma was then performed from dorsal of the MHV to the right anterior Glissonean pedicle (plane 2). Parenchyma was then transected from dorsal of the RHV to the right anterior Glissonean pedicle (plane 3). We subsequently divide the right anterior Glissonean pedicle with a linear stapler. Finally, the resection plane was completed by performing parenchymal transection between the demarcation line and ventral of the RHV (plane 4). RESULTS The mean operation time was 446 min with 334 ml of estimated blood loss. No cases required conversion to open surgery. Bile leakage occurred as a postoperative complication in one patient. There was no mortality. CONCLUSION Isolating the extrahepatic Glissonean pedicle at the hilum and transection along four planes determined according to anatomical landmarks made purely laparoscopic right anterior sectionectomy feasible.
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Xu H, Liu F, Hao X, Wei Y, Li B, Wen T, Wang W, Yang J. Laparoscopically anatomical versus non-anatomical liver resection for large hepatocellular carcinoma. HPB (Oxford) 2020; 22:136-143. [PMID: 31320241 DOI: 10.1016/j.hpb.2019.06.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Revised: 06/03/2019] [Accepted: 06/20/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND The role of laparoscopically anatomical resection (LAR) for hepatocellular carcinoma (HCC) remains unclear due to the more demanding technique required in laparoscopy. This study is to analyze the clinical impact of LAR compared to laparoscopically non-anatomical resection (LNAR) for HCC. METHODS All patients received laparoscopic hepatectomy for HCC (diameter 5-10 cm) from January 2015 to December 2018 were retrospectively enrolled in this study. Patients were divided into LAR and LNAR groups. The perioperative and oncological outcomes were evaluated based on propensity score matching (PSM) method. RESULTS After PSM, 51 patients in each group were enrolled. The operative time in LAR group was longer (240 vs 195.0 min, p = 0.012) and blood loss was more (200.0 vs 150.0 mL, p = 0.030) than those of LNAR group, respectively. The total complication rates were comparable between them (21.6% vs 17.6%, p = 0.500). The 3-year overall survival rates were 59.4% in LAR group and 38.7% in LNAR group, respectively (p = 0.045). The 3-year disease-free survival rates were 52.3% in LAR group and 27.0% in LNAR group, respectively (p = 0.042). CONCLUSION LAR could be feasibly performed with comparable perioperative outcomes and contributed to improve long-term survival in patients with HCC (diameter 5-10 cm) when compared to LNAR.
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Affiliation(s)
- HongWei Xu
- Department of Liver Surgery, Center of Liver Transplantation, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China
| | - Fei Liu
- Department of Liver Surgery, Center of Liver Transplantation, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China
| | - XiangYong Hao
- Department of General Surgery, Gansu Provincial Hospital, Lanzhou, Gansu Province, China
| | - YongGang Wei
- Department of Liver Surgery, Center of Liver Transplantation, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China.
| | - Bo Li
- Department of Liver Surgery, Center of Liver Transplantation, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China.
| | - TianFu Wen
- Department of Liver Surgery, Center of Liver Transplantation, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China
| | - WenTao Wang
- Department of Liver Surgery, Center of Liver Transplantation, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China
| | - JiaYin Yang
- Department of Liver Surgery, Center of Liver Transplantation, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China
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Significance of the surgical hepatic resection margin in patients with a single hepatocellular carcinoma. Br J Surg 2019; 107:113-120. [DOI: 10.1002/bjs.11329] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Revised: 06/26/2019] [Accepted: 07/09/2019] [Indexed: 02/06/2023]
Abstract
Abstract
Background
The impact of a wide surgical margin on the outcome of patients with hepatocellular carcinoma (HCC) has not been evaluated in relation to the type of liver resection performed, anatomical or non-anatomical. The aim of this study was to evaluate the impact of surgical margin status on outcomes in patients undergoing anatomical or non-anatomical resection for solitary HCC.
Methods
Data from patients with solitary HCC who had undergone non-anatomical partial resection (Hr0 group) or anatomical resection of one Couinaud segment (HrS group) between 2000 and 2007 were extracted from a nationwide survey database in Japan. Overall and recurrence-free survival associated with the surgical margin status and width were evaluated in the two groups.
Results
A total of 4457 patients were included in the Hr0 group and 3507 in the HrS group. A microscopically positive surgical margin was associated with poor overall survival in both groups. A negative but 0-mm surgical margin was associated with poorer overall and recurrence-free survival than a wider margin only in the Hr0 group. In the HrS group, the width of the surgical margin was not associated with patient outcome.
Conclusion
Anatomical resection with a negative 0-mm surgical margin may be acceptable. Non-anatomical resection with a negative 0-mm margin was associated with a less favourable survival outcome.
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The Utility of Anatomical Liver Resection in Hepatocellular Carcinoma: Associated with Improved Outcomes or Lack of Supportive Evidence? Cancers (Basel) 2019; 11:cancers11101441. [PMID: 31561585 PMCID: PMC6826719 DOI: 10.3390/cancers11101441] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Revised: 09/19/2019] [Accepted: 09/24/2019] [Indexed: 01/27/2023] Open
Abstract
Hepatocellular carcinoma (HCC) is the second leading cause of cancer-related deaths worldwide. Surgical resection of HCC remains one of the mainstays of curative therapies and is associated with five-year overall survival rates approaching 60%. Despite improved perioperative outcomes, locoregional recurrence within the first two years following hepatic resection is of significant concern with recurrence rates of up to 50%. The use of anatomical resection surgical approaches, whereby the portal venous blood flow is ligated proximal to the tumor bed, is postulated to reduce recurrence rates due to reduction of micrometastatic disease. The aim of this review is to characterize the definition of an anatomical resection (AR) during partial hepatectomy, discuss the theoretical advantages of AR during hepatic resection for HCC, and to present evidence of the impact of AR on outcome measures in patients with HCC. Based on current data, there is a lack of conclusive evidence to support the universal use of AR in cirrhotic patients with HCC. A randomized clinical trial is warranted to further clarify the debate between AR versus non-anatomical resection (NAR) for HCC.
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Yamazaki S, Takayama T. Current topics in liver surgery. Ann Gastroenterol Surg 2019; 3:146-159. [PMID: 30923784 PMCID: PMC6422805 DOI: 10.1002/ags3.12233] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Revised: 11/02/2018] [Accepted: 12/04/2018] [Indexed: 01/01/2023] Open
Abstract
Liver resection is one of the main treatment strategies for liver malignancies. Mortality and morbidity of liver surgery has improved significantly with progress in selection criteria, development of operative procedures and improvements in perioperative management. Safe liver resection has thus become more available worldwide. We have identified four current topics related to liver resection (anatomical liver resection, laparoscopic liver resection, staged liver resection and chemotherapy-induced liver injury). The balance between treatment effect and patient safety needs to be considered when planning liver resection. Progress in this area has been rapid thanks to the efforts of many surgeons, and outcomes have improved significantly as a result. These topics remain to be solved and more robust evidence is needed. Precise selection of the optimal procedure and risk evaluation should be standardized with further development of each topic. The present article reviews these four current topics with a focus on safety and efficacy in recent series.
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Affiliation(s)
- Shintaro Yamazaki
- Department of Digestive SurgeryNihon University School of MedicineTokyoJapan
| | - Tadatoshi Takayama
- Department of Digestive SurgeryNihon University School of MedicineTokyoJapan
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Shin S, Kim TS, Lee JW, Ahn KS, Kim YH, Kang KJ. Is the anatomical resection necessary for single hepatocellular carcinoma smaller than 3 cm?: single-center experience of liver resection for a small HCC. Ann Hepatobiliary Pancreat Surg 2018; 22:326-334. [PMID: 30588523 PMCID: PMC6295376 DOI: 10.14701/ahbps.2018.22.4.326] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Revised: 09/28/2018] [Accepted: 10/04/2018] [Indexed: 02/07/2023] Open
Abstract
Backgrounds/Aims The superiority of anatomical resection (AR) for a small HCC remains controversial. In this study, we investigated the clinical outcomes after AR and non-anatomical liver resection (NAR) for single HCC smaller than 3 cm and the risk factors for HCC recurrence. Methods A total of 116 consecutive patients who underwent liver resection for single HCC (<3 cm) between Jan 2006 and Dec 2015 were included in this study. The medical records of these patients were reviewed and analyzed retrospectively. Results There was no significant difference in tumor recurrence and survival between AR and NAR group. Multivariate analysis showed that hepatitis B (p=0.035, HR=8.72), presence of satellite nodule (p=0.029, HR=3.97) and microvascular invasion (MVI) (p=0.039, HR=2.79) were independent risk factors for early recurrence within 1 year. The overall recurrence was independently related to the presence of satellite nodule (p=0.001, HR=4.98) and background liver cirrhosis (p=0.032, HR=1.96). In patients with MVI, HCC recurrence was significantly more frequent in width of safety margin <1 cm group than ≥1 cm group (p=0.049). Conclusions The outcomes of NAR are comparable with those of AR in single HCC smaller than 3 cm. The presence of satellite nodule, MVI and hepatitis B are the independent risk factors for early recurrence, however overall recurrence is correlated with background liver cirrhosis and the presence of satellite nodule rather than pathobiologic factors in single HCC smaller than 3 cm. Hepatic resection with sufficient margin (≥1 cm) is recommended for decreasing risk of recurrence in patients with suspected MVI.
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Affiliation(s)
- Sungwook Shin
- Department of Surgery, Dongsan Medical Center, Keimyung Univsersity School of Medicine, Daegu, Korea
| | - Tae-Seok Kim
- Department of Surgery, Dongsan Medical Center, Keimyung Univsersity School of Medicine, Daegu, Korea
| | - Jeong Woo Lee
- Department of Surgery, Dongsan Medical Center, Keimyung Univsersity School of Medicine, Daegu, Korea
| | - Keun Soo Ahn
- Department of Surgery, Dongsan Medical Center, Keimyung Univsersity School of Medicine, Daegu, Korea
| | - Yong Hoon Kim
- Department of Surgery, Dongsan Medical Center, Keimyung Univsersity School of Medicine, Daegu, Korea
| | - Koo Jeong Kang
- Department of Surgery, Dongsan Medical Center, Keimyung Univsersity School of Medicine, Daegu, Korea
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Moris D, Tsilimigras DI, Kostakis ID, Ntanasis-Stathopoulos I, Shah KN, Felekouras E, Pawlik TM. Anatomic versus non-anatomic resection for hepatocellular carcinoma: A systematic review and meta-analysis. Eur J Surg Oncol 2018; 44:927-938. [DOI: 10.1016/j.ejso.2018.04.018] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Revised: 03/30/2018] [Accepted: 04/20/2018] [Indexed: 02/07/2023] Open
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Famularo S, Di Sandro S, Giani A, Lauterio A, Sandini M, De Carlis R, Buscemi V, Romano F, Gianotti L, De Carlis L. Long-term oncologic results of anatomic vs. parenchyma-sparing resection for hepatocellular carcinoma. A propensity score-matching analysis. Eur J Surg Oncol 2018; 44:1580-1587. [PMID: 29861336 DOI: 10.1016/j.ejso.2018.05.018] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Revised: 04/30/2018] [Accepted: 05/11/2018] [Indexed: 12/29/2022] Open
Abstract
PURPOSE The extent of liver resection for the optimal treatment of hepatocellular carcinoma (HCC) is debated. The purpose of this study was to compare the impact of anatomic resection (AR) vs. parenchyma-sparing resection (PSR) on disease recurrence and patient survival. METHODS We retrospectively analyzed patients with HCC who underwent liver resection from January 2001 to August 2015. Patients receiving AR or PSR were compared by a propensity score analysis (PSA) (caliper = 0.1). The primary outcomes were disease-free survival (DFS) and overall survival (OS) rates, and assessed by the Kaplan-Meier method. RESULTS 455 consecutive patients were evaluated. After PSA 354 patient were studied (177 pairs for each group). The median follow-up time was 28.2 months. The median OS was 47.5 months (95% CI: 30.0-65.9) for AR and 56.5 months (95% CI 33.2-79.6) for PSR (p = 0.169). The median DFS was 29.2 months (95% CI 17.6-40.8) for AR and 24.8 months (95% CI: 15.2-34.2) for PSR (p = 0.337). The multivariate regression model showed that cirrhosis (HR 2.85, 95% CI: 1.53-5.32; p = 0.001), BCLC grade B (HR 4.15, 95% CI: 1.33-12.95; p = 0.014), microvascular invasion (HR 1.55, 95% CI: 1.03-2.31; p = 0.033), presence of satellitosis (HR 1.94, 95% CI: 1.25-3.01; p = 0.003), severe complications (HR 6.09, 95% CI: 2.26-16.40; p > 0.001) were independently associated with poor long-term oncologic outcomes. CONCLUSIONS The extent of resection did not significantly affect overall and disease-free survival while tumor characteristics and underlying liver function appeared significant determinants.
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Affiliation(s)
- Simone Famularo
- School of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy; Department of Surgery, San Gerardo Hospital, Monza, Italy
| | - Stefano Di Sandro
- Department of General Surgery and Transplantation, Ca'Granda Niguarda Hospital, Milan, Italy
| | - Alessandro Giani
- School of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy; Department of Surgery, San Gerardo Hospital, Monza, Italy
| | - Andrea Lauterio
- Department of General Surgery and Transplantation, Ca'Granda Niguarda Hospital, Milan, Italy
| | - Marta Sandini
- School of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy; Department of Surgery, San Gerardo Hospital, Monza, Italy
| | - Riccardo De Carlis
- Department of General Surgery and Transplantation, Ca'Granda Niguarda Hospital, Milan, Italy
| | - Vincenzo Buscemi
- Department of General Surgery and Transplantation, Ca'Granda Niguarda Hospital, Milan, Italy
| | - Fabrizio Romano
- School of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy; Department of Surgery, San Gerardo Hospital, Monza, Italy
| | - Luca Gianotti
- School of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy; Department of Surgery, San Gerardo Hospital, Monza, Italy.
| | - Luciano De Carlis
- School of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy; Department of General Surgery and Transplantation, Ca'Granda Niguarda Hospital, Milan, Italy
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Kang WH, Kim KH, Jung DH, Park GC, Kim SH, Cho HD, Lee SG. Long-term results of laparoscopic liver resection for the primary treatment of hepatocellular carcinoma: role of the surgeon in anatomical resection. Surg Endosc 2018; 32:4481-4490. [PMID: 29691651 DOI: 10.1007/s00464-018-6194-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Accepted: 04/20/2018] [Indexed: 12/22/2022]
Abstract
BACKGROUND Liver resection is a potentially curative therapy for hepatocellular carcinoma (HCC). LLR is a newly developed and safe technique associated with shorter hospital stay, less pain, better cosmetic outcomes, and similar complication rates as open surgery; however, data on its long-term outcomes remain scarce. METHODS We retrospectively examined the clinical and follow-up data of 234 patients who underwent LLR (performed by a single surgeon in all cases) for the primary treatment of HCC between July 2007 and December 2015 at Asan Medical Center. RESULTS The mean patient age was 55.63 (range 31-76) years; 167 were men. The median follow-up duration was 38 (range 6-116) months. A total of 227 patients (97.0%) had Child-Turcotte-Pugh grade A disease. Of them, 167 (71.4%) underwent anatomical resections and 63 (28.6%) underwent non-anatomical partial hepatectomies. Overall survival rates were 98.3, 91.7, and 87.1%, and recurrence-free survival rates were 82.1, 67.5, and 55.3% at 1, 3, and 5 years, respectively. In Cox regression analysis, anatomical resection was a risk factor for recurrence (univariate analysis: hazard ratio [HR] 0.49; 95% confidence interval [CI] 0.31-0.75; p = 0.001; multivariate analysis: HR 0.59; 95% CI 0.38-0.94; p = 0.025). CONCLUSIONS LLR is an acceptable primary treatment for patients with HCC with good hepatic function and with an appropriate anatomical structure, and is associated with improved prognosis. LLR can achieve lower recurrence rates through anatomical resection.
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Affiliation(s)
- Woo-Hyoung Kang
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Ki-Hun Kim
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea.
| | - Dong-Hwan Jung
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Gil-Chun Park
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Seok-Hwan Kim
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Hwui-Dong Cho
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Sung-Gyu Lee
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
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Tan Y, Zhang W, Jiang L, Yang J, Yan L. Efficacy and safety of anatomic resection versus nonanatomic resection in patients with hepatocellular carcinoma: A systemic review and meta-analysis. PLoS One 2017; 12:e0186930. [PMID: 29073257 PMCID: PMC5658101 DOI: 10.1371/journal.pone.0186930] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Accepted: 10/10/2017] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND The surgical decision of performing anatomic resection (AR) or nonanatomic resection (NAR) in patients with hepatocellular carcinoma remains controversial. The aim of the current study is to conduct a meta-analysis on published results to compare surgical outcomes after AR and NAR. METHODS A comprehensive search of the Pubmed, Ovid-Medline, Embase, Cochrane library, and Science Citation indexes was performed. Overall and disease free survival (DFS), perioperative mortality and morbidity were the main outcomes. The meta-analysis was performed using Revman 5.3 statistical software, and the results are expressed as the relative risk (RR) or weighted mean differences with 95% of confidence intervals. RESULTS After application of the exclusion and inclusion criteria, 25 studies published between 1996~2015 that compared outcomes after AR and NAR in patients with HCC were identified. A total of 10216 patients were included in the meta-analysis, 4576 in the AR group and 5640 in the NAR group. Liver cirrhosis was found in 54.8% (range from 18.8% to 100%) of patients in the AR group and 67.8% (range from 34.3% to 100%) of patients in the NAR group, resulting in a RR of 0.45 (I2 = 18%, fixed model, 95% CI 0.39-0.52; Z = 10.31; P = <0.00001). The meta-analysis revealed a statistically significant 5-year survival (RR of 1.10, 95% CI 1.03-1.17; Z = 2.92, P = 0.004) and DFS (RR: 1.33, 95% CI 1.18-1.51; Z = 4.46, P <0.00001) advantage for patients undergoing AR resection compared to NAR. In regards to safety, no statistical significance was found in mortality and morbidity between the two groups. Eight studies including 1812 patients with small (<5 cm) solitary HCC indicated a better 5-year DFS in the AR group (41.4%) than in the NAR group (28.6%), with a RR of 1.32 (I2 = 42, fixed model, 95%CI: 1.15-1.52, Z = 3.86, P = 0.0001). CONCLUSION The current study demonstrates better surgical outcomes after AR than NAR in patients with HCC. Therefore, AR is recommended in resectable HCC, especially with small (<5 cm) solitary tumours.
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Affiliation(s)
- Yifei Tan
- Liver Transplantation Center, Department of Liver Surgery, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China
| | - Wei Zhang
- Liver Transplantation Center, Department of Liver Surgery, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China
| | - Li Jiang
- Liver Transplantation Center, Department of Liver Surgery, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China
| | - Jiayin Yang
- Liver Transplantation Center, Department of Liver Surgery, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China
| | - Lunan Yan
- Liver Transplantation Center, Department of Liver Surgery, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China
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Huang X, Lu S. A Meta-analysis comparing the effect of anatomical resection vs. non-anatomical resection on the long-term outcomes for patients undergoing hepatic resection for hepatocellular carcinoma. HPB (Oxford) 2017; 19:843-849. [PMID: 28739076 DOI: 10.1016/j.hpb.2017.06.003] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Revised: 06/14/2017] [Accepted: 06/20/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND This study aimed to compare the outcomes of patients undergoing anatomical resection (AR) versus non-anatomical resection (NAR) for hepatocellular carcinoma (HCC) from the published comparative studies within the literatures. METHODS A meta-analysis of studies published from 2001 to 2010 were conducted using RevMan 5.0. Measured outcomes were morbidity, mortality, recurrence and 5 year overall (OS) and disease free (DFS) survival. RESULTS Seventeen observational studies involving 3129 patients were analyzed: 1626 (52%) in AR group and 1503 (48%) in NAR group. The 5-year OS (RR, 1.18; 95% CI, 1.03-1.36; P = 0.018) and DFS (RR, 1.56; 95% CI, 1.23-1.97; P < 0.001) were significantly greater in the AR group than the NAR group, while the overall recurrence was significantly lower (RR, 0.84; 95% CI, 0.75-0.94; P < 0.001). There were no significant differences in mortality (RR, 1.00; 95% CI, 0.80-1.25; P = 0.980) or morbidity (OR, 0.97; 95% CI, 0.48-1.99; P = 0.943) between the AR and NAR groups. CONCLUSION AR for HCC is superior to NAR considering its higher 5-year OS and DFS rates and lower overall recurrence rate. Heterogeneity detection within the analysis suggests these results should be interpreted with caution and further well designed studies are required to address this issue.
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Affiliation(s)
- Xinli Huang
- Center of Liver Transplantation, The First Affiliated Hospital of Nanjing Medical University, The Key Laboratory of Living Donor Liver Transplantation, Ministry of Health, Nanjing, 210029, China
| | - Sen Lu
- Center of Liver Transplantation, The First Affiliated Hospital of Nanjing Medical University, The Key Laboratory of Living Donor Liver Transplantation, Ministry of Health, Nanjing, 210029, China.
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19
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Sugioka A, Kato Y, Tanahashi Y. Systematic extrahepatic Glissonean pedicle isolation for anatomical liver resection based on Laennec's capsule: proposal of a novel comprehensive surgical anatomy of the liver. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2017; 24:17-23. [PMID: 28156078 PMCID: PMC5299460 DOI: 10.1002/jhbp.410] [Citation(s) in RCA: 100] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Anatomical liver resection with the Glissonean pedicle isolation is widely approved as an essential procedure for safety and curability. Especially, the extrahepatic Glissonean pedicle isolation without parenchymal destruction should be an ideal procedure. However, the surgical technique has not been standardized due to a lack of anatomical understanding. Herein, we proposed a novel comprehensive surgical anatomy of the liver based on Laennec's capsule that would give a theoretical background to the extrahepatic Glissonean pedicle isolation. Laennec's capsule is the proper membrane that covers not only the entire surface of the liver including the bare area but also the intrahepatic parenchyma surrounding the Glissonean pedicles. Consequently, there exists a gap between the Glissonean pedicle and Laennec's capsule that could be reached extrahepatically and allows us to isolate the extrahepatic Glissonean pedicle without parenchymal destruction systematically. For standardization, it is essential to approach the “six gates” indicated by the “four anatomical landmarks”: the Arantius plate, the umbilical plate, the cystic plate and the Glissonean pedicle of the caudate process (G1c). This novel anatomy would contribute to standardize the surgical techniques of the systematic extrahepatic Glissonean pedicle isolation for anatomical liver resection including laparoscopic or robotic liver resection and to bring innovative changes in hepatobiliary surgery for spreading safe and curable liver resection.
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Affiliation(s)
- Atsushi Sugioka
- Department of Surgery, Fujita Health University, 1-98 Dengakugakubo, Kutsukake, Toyoake, Aichi, 470-1192, Japan
| | - Yutaro Kato
- Department of Surgery, Fujita Health University, 1-98 Dengakugakubo, Kutsukake, Toyoake, Aichi, 470-1192, Japan
| | - Yoshinao Tanahashi
- Department of Surgery, Fujita Health University, 1-98 Dengakugakubo, Kutsukake, Toyoake, Aichi, 470-1192, Japan
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20
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Kang KJ, Ahn KS. Anatomical resection of hepatocellular carcinoma: A critical review of the procedure and its benefits on survival. World J Gastroenterol 2017; 23:1139-1146. [PMID: 28275294 PMCID: PMC5323439 DOI: 10.3748/wjg.v23.i7.1139] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2016] [Revised: 10/18/2016] [Accepted: 11/14/2016] [Indexed: 02/06/2023] Open
Abstract
Hepatocellular carcinoma (HCC) is the sixth most common type of cancer and the third most frequent cause of cancer-related death. Advances in preoperative assessment of HCC (e.g., imaging studies and liver function tests), surgical techniques, and postoperative care have improved the surgical outcomes and survival of patients who undergo hepatic resection for HCC. However, in the last 20 years, the long-term survival after hepatectomy has remained unsatisfactory owing to the high rates of local recurrence and multicentric occurrence. Anatomical liver resection (AR) was introduced in the 1980s. Although several studies have revealed tangible benefits of AR for HCC, these benefits are still debated. Because most HCCs occur in patients with liver cirrhosis and poor hepatic function, there are many factors that affect survival, including the surgical method. Nevertheless, many studies have documented the perioperative and long-term benefits of AR in various conditions. In this article, we review the results of several recently published, well-designed comparative studies of AR, to investigate whether AR provides real benefits on survival outcomes. We also discuss the potential pitfalls associated with this approach.
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21
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Kim JM, Kwon CHD, Joh JW, Na BG, Lee KW, Choi GS, Lee JH. Nonanatomical resection is comparable with anatomical resection in solitary hepatocellular carcinoma <5 cm in the right posterior section. Medicine (Baltimore) 2016; 95:e5382. [PMID: 28002324 PMCID: PMC5181808 DOI: 10.1097/md.0000000000005382] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2015] [Revised: 08/31/2016] [Accepted: 10/19/2016] [Indexed: 02/06/2023] Open
Abstract
Anatomical resection (AR) is superior to nonanatomical resection (NAR) in theory, but the actual clinical benefit of AR for hepatocellular carcinoma (HCC) is controversial due to the substantial heterogeneity of HCC. Here, we retrospectively compared AR and NAR outcomes for solitary hepatocellular carcinoma (HCC) <5 cm in the right posterior section (RPS) and investigated the risk factors for HCC recurrence and liver-related mortality.The study included 99 consecutive patients who underwent curative surgical resection of an HCC in the RPS (S6 and S7) between January 2003 and December 2009. Each patient had a solitary HCC <5 cm and a noncirrhotic liver.The median estimated blood loss during operation and median operative time were significantly worse in the AR group. In addition, the median tumor size and incidence of microvascular invasion were significantly worse in the AR group. The 1-, 3-, and 5-year disease-free survival rates were 74.1%, 66.3%, and 58.2% in the AR group and 84.7%, 64.4%, and 48.2% in the NAR group, respectively (P = 0.172). The corresponding liver-related overall survival rates were 96.3%, 84.7%, and 77.0% in the AR group and 97.2%, 90.1%, and 88.7% in the NAR group, respectively (P = 0.335). NAR was not associated with HCC recurrence or liver-related mortality in multivariate analysis.The outcomes of NAR for a solitary HCC <5 cm in the RPS are comparable to those achieved with AR with respect to long-term liver-related overall survival and disease-free survival.
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Affiliation(s)
- Jong Man Kim
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine
| | - Choon Hyuck David Kwon
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine
| | - Jae-Won Joh
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine
| | - Byung-Gon Na
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine
| | - Kyo-Won Lee
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine
| | - Gyu-Seong Choi
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine
| | - Joon Hyeok Lee
- Division of Gastroenterology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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22
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Li SQ, Huang T, Shen SL, Hua YP, Hu WJ, Kuang M, Peng BG, Liang LJ. Anatomical versus non-anatomical liver resection for hepatocellular carcinoma exceeding Milan criteria. Br J Surg 2016; 104:118-127. [PMID: 27696379 DOI: 10.1002/bjs.10311] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Revised: 07/28/2016] [Accepted: 08/04/2016] [Indexed: 01/27/2023]
Abstract
BACKGROUND Liver resection is effective for hepatocellular carcinoma (HCC) exceeding the Milan criteria in selected patients. However, the benefit of anatomical resection (AR) versus non-anatomical resection (NAR) has not been clarified in this patient subgroup. This study aimed to compare outcomes between AR and NAR for HCC exceeding the Milan criteria. METHODS Data on consecutive patients with HCC exceeding the Milan criteria who underwent liver resection with curative intent over a recent 6-year interval were extracted from a prospective single-centre HCC database and examined retrospectively. The postoperative outcomes of patients were compared before and after propensity score matching. RESULTS Some 546 patients were included: 264 in the AR and 282 in the NAR group. In the original cohort, the AR group contained more patients with larger tumours, multiple tumours, macroscopic portal vein tumour thrombi, incomplete tumour capsules and microscopic vascular invasion. After propensity score matching, 177 pairs of patients were selected. The baseline data, including liver function and tumour burden, were similar in the matched groups. The 3-year recurrence-free survival rate was comparable between the matched NAR and AR groups (36·5 versus 28·5 per cent; P = 0·448). Similar results were observed for 3-year overall survival (57·5 versus 50·3 per cent; P = 0·385), recurrence patterns and early recurrence rates (57·6 per cent versus 59·9 per cent; P = 0·712). CONCLUSION AR and NAR achieved favourable and similar outcomes for HCC exceeding the Milan criteria in selected patients.
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Affiliation(s)
- S-Q Li
- Department of Liver Surgery, First Affiliated Hospital, Sun Yat-sen University, 58 Zhongshan Er Road, Guangzhou, 510080, China
| | - T Huang
- Department of Liver Surgery, First Affiliated Hospital, Sun Yat-sen University, 58 Zhongshan Er Road, Guangzhou, 510080, China
| | - S-L Shen
- Department of Liver Surgery, First Affiliated Hospital, Sun Yat-sen University, 58 Zhongshan Er Road, Guangzhou, 510080, China
| | - Y-P Hua
- Department of Liver Surgery, First Affiliated Hospital, Sun Yat-sen University, 58 Zhongshan Er Road, Guangzhou, 510080, China
| | - W-J Hu
- Department of Liver Surgery, First Affiliated Hospital, Sun Yat-sen University, 58 Zhongshan Er Road, Guangzhou, 510080, China
| | - M Kuang
- Department of Liver Surgery, First Affiliated Hospital, Sun Yat-sen University, 58 Zhongshan Er Road, Guangzhou, 510080, China
| | - B-G Peng
- Department of Liver Surgery, First Affiliated Hospital, Sun Yat-sen University, 58 Zhongshan Er Road, Guangzhou, 510080, China
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Hwang S, Lee YJ, Kim KH, Ahn CS, Moon DB, Ha TY, Song GW, Jung DH, Lee SG. The Impact of Tumor Size on Long-Term Survival Outcomes After Resection of Solitary Hepatocellular Carcinoma: Single-Institution Experience with 2558 Patients. J Gastrointest Surg 2015; 19:1281-90. [PMID: 25956724 DOI: 10.1007/s11605-015-2849-5] [Citation(s) in RCA: 111] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2015] [Accepted: 04/30/2015] [Indexed: 01/31/2023]
Abstract
BACKGROUND According to the 7th AJCC TNM staging system, solitary hepatocellular carcinoma (HCC) is classified as T1 or T2 based on microvascular invasion (MVI) regardless of tumor size. This study intended to evaluate the prognostic impact of tumor size on survival outcomes after macroscopic curative resection of solitary HCC. METHODS Patients who underwent R0 resection of solitary HCC <10 cm (n = 2558) were selected for study. Follow-up lasted ≥24 months or until death. RESULTS HCC was detected during regular health screening or routine follow-up in 2054 cases (80.3%). Hepatitis B virus (HBV) infection was associated in 2127 (83.2%). Mean patient age was 54.4 ± 9.9 years. Anatomical resection was performed in 1786 (69.8%). MVI was identified in 407 (16.0%) which therefore became stage T2; the other 2150 became stage T1. Tumor recurrence and patient survival rates were 24.9 and 95.0% after 1 year, 49.6 and 84.1% after 3 years, 57.7 and 75.0 % after 5 years, and 67.3 and 56.6% after 10 years, respectively. Multivariate analysis showed that non-anatomical resection, MVI, and tumor size >5 cm were independent risk factors for both tumor recurrence and overall patient survival. Long-term survival correlated negatively with tumor size and MVI. Subgroup analysis with MVI and size cutoff of 5 cm revealed a significant survival difference (p = 0.000). Tumor size >5 cm was not a significant prognostic factor in non-HBV patients. CONCLUSIONS These results suggest that the prognostic impact of tumor size may be underestimated in the current version of the AJCC staging system and that solitary HCC staging could be improved with inclusion of tumor size cutoff of 5 cm in HBV-associated patients. Further validation is necessary with multicenter studies.
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Affiliation(s)
- Shin Hwang
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 138-736, South Korea,
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Yamamoto Y, Ikoma H, Morimura R, Konishi H, Murayama Y, Komatsu S, Shiozaki A, Kuriu Y, Kubota T, Nakanishi M, Ichikawa D, Fujiwara H, Okamoto K, Sakakura C, Ochiai T, Otsuji E. Clinical analysis of anatomical resection for the treatment of hepatocellular carcinoma based on the stratification of liver function. World J Surg 2014; 38:1154-63. [PMID: 24305927 DOI: 10.1007/s00268-013-2369-y] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND This study aimed to clarify the efficacy of anatomical resection (AR) for the treatment of hepatocellular carcinoma (HCC) compared with that of nonanatomical resection (NAR) based on the stratification of liver function (LF). METHODS The clinical records of 174 patients with a single HCC, 2-5 cm in diameter and without macroscopic vascular invasion, were analyzed. AR was performed in 132 patients and NAR was performed in 42 patients. The indocyanine green retention rate at 15 min (ICGR15) of the 78 patients classified as the good-LF group was 10-20 % and the ICGR15 of the 54 patients classified as the poor-LF group was 20-40 %. RESULTS The 5-year overall survival (OS) and disease-free survival rates of the 174 patients were 67.6 and 33.4 %, respectively. Cox proportional hazard analysis identified ICGR15 ≥ 20 %, liver cirrhosis, α-fetoprotein ≥ 100 mg/dL, and infiltrating growth as independent prognostic factors. Liver cirrhosis was significantly less frequent in patients who underwent AR than in patients who underwent NAR (52 vs. 79 %, p = 0.002). In the subgroup analysis of the good-LF group, there were no significant differences in 5-year OS after AR and NAR (73.3 vs. 65.2 %, p = 0.857). By contrast, in the subgroup analysis of the poor-LF group, the 5-year OS after AR was significantly worse than after NAR (45.3 vs. 77.4 %, p = 0.044). CONCLUSION In patients with an ICGR15 ≥ 20 %, we recommend NAR rather than AR for the treatment of a solitary 2-5-cm-diameter HCC and without macroscopic vascular invasion.
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Affiliation(s)
- Yusuke Yamamoto
- Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine, 465 Kajii-cho, Kamigyo-ku, Kyoto, 6028566, Japan,
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Guerrini GP, Gerunda GE, Montalti R, Ballarin R, Cautero N, De Ruvo N, Spaggiari M, Di Benedetto F. Results of salvage liver transplantation. Liver Int 2014; 34:e96-e104. [PMID: 24517642 DOI: 10.1111/liv.12497] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2013] [Accepted: 02/05/2014] [Indexed: 12/14/2022]
Abstract
BACKGROUND & AIMS Salvage liver transplantation (SLT) is an attractive sequential strategy which combines liver resection (LR) for hepatocellular carcinoma (HCC), followed by liver transplant (LT) in the event of HCC recurrence or progressive liver deterioration. To compare the long-term results of SLT with primary liver transplant (PLT). METHODS Between 2000 and 2011, 125 patients (72 transplantable) underwent LR and 226 underwent LT in our unit. The outcome of SLT was analysed in a two-step fashion: firstly, SLT (n = 28) was compared with PLT (n = 198), secondly an intention-to-treat analysis was performed on all transplantable HCC patients who underwent LR (LRT group = 72) compared to PLT (n = 198). RESULTS The five-year overall survival (OS) was 65.4% vs. 49.2% (P = 0.63), and disease-free survival (DFS) was 89.7% vs. 80.6% (P = 0.31) for PLT and SLT respectively. Predictive factors for DFS after LT included HCC total diameter [hazard ratio (HR) 1.29 P = 0.003], alpha-foetoprotein (HR 1.002 P < 0.001) and number of HCC nodules (HR 1.317 P = 0.035), whereas viral hepatitis C positivity (HR 1.911 P = 0.03) and outside Up-to-seven criteria (HR 2.652 P < 0.001) were negative independent prediction factors of OS. Intention-to-treat analysis showed that OS at 5 years was improved in PLT vs. LRT (LRT n = 72 including SLT plus LR group) and was 69.4% vs. 42.2% (P < 0.004), with an additional increase in DFS (89.2% vs. 54.5% respectively P < 0.001). CONCLUSION Salvage liver transplantation is a safe treatment strategy, as it does not impair long-term survival. At intention-to-treat analysis, PLT showed improved survival compared with LRT.
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Affiliation(s)
- Gian Piero Guerrini
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, Department of Surgery and Transplantation, University of Modena and Reggio Emilia, Modena, Italy
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Ye JZ, Miao ZG, Wu FX, Zhao YN, Ye HH, Li LQ. Recurrence after anatomic resection versus nonanatomic resection for hepatocellular carcinoma: a meta-analysis. Asian Pac J Cancer Prev 2013; 13:1771-7. [PMID: 22901120 DOI: 10.7314/apjcp.2012.13.5.1771] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
The impact of anatomic resection (AR) as compared to non-anatomic resection (NAR) for hepatocellular carcinoma (HCC) as a factor for preventing intra-hepatic and local recurrence after the initial surgical procedure remains controversial. A systematic review and meta-analysis of nonrandomized trials comparing anatomic resection with non-anatomic resection for HCC published from 1990 to 2010 in PubMed and Medline, Cochrane Library, Embase, and Science Citation Index were therefore performed. Intra-hepatic recurrence, including early and late, and local recurrence were considered as primary outcomes. As secondary outcomes, 5 year survival and 5 year disease-free survival were considered. Pooled effects were calculated utilizing either fixed effects or random effects models. Eleven non-randomized studies including 1,576 patients were identified and analyzed, with 810 patients in the AR group and 766 in the NAR group. Patients in the AR group were characterized by lower prevalence of cirrhosis, more favorable hepatic function, and larger tumor size and higher prevalence of macrovascular invasion compared with patients in the NAR group. Anatomic resection significantly reduced the risks of local recurrence and achieved a better 5 years disease-free survival. Also, anatomic resection was marginally effective for decreasing the early intra-hepatic recurrence. However, it was not advantageous in preventing late intra-hepatic recurrence compared with non-anatomic resection. No differences were found between AR and NAR with respect to postoperative morbidity, mortality, and hospitalization. Anatomic resection can be recommended as superior to non-anatomic resection in terms of reducing the risks of local recurrence, early intra-hepatic recurrence and achieving a better 5 year disease-free survival in HCC patients.
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Affiliation(s)
- J Z Ye
- Guangxi Tumor Institute, Department of Hepato-Billiary Surgery, Affiliated Tumor Hospital of Guangxi Medical University, Guangxi, China
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Torzilli G, Donadon M, Cimino M. Are Tumor Exposure and Anatomical Resection Antithetical during Surgery for Hepatocellular Carcinoma? A Critical Review. Liver Cancer 2012; 1:177-82. [PMID: 24159582 PMCID: PMC3760464 DOI: 10.1159/000343831] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Hepatic resection is the most potentially curative local therapy for patients with hepatocelluar carcinoma (HCC). However, the high rate of postoperative recurrence, 50-70% at 3 years, remains a major concern. Such recurrences usually occur in the liver owing to the high propensity of HCC to invade the portal vein branches and the underlying liver cirrhosis, which is the ideal background for HCC development. Two pivotal surgical techniques are commonly used to reduce such recurrences: anatomical resection (AR) and achievement of negative margins. However, controversies exist about the definition of anatomical resection and the requisite width of negative margins. Consequently, a consensus on these issues is far from being achieved in the specialized surgical community. Review of the literature and author's discernment support AR for HCC larger than 2cm, and tumor exposure when the tumor is in contact with major vessels. Therefore, tumor exposure is not a contradiction to an AR properly carried out.
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Affiliation(s)
- Guido Torzilli
- *Liver Surgery Unit, Department of General Surgery, University of Milan, School of Medicine, Humanitas Cancer Center, Via Manzoni 56, Rozzano, Milan 20089 (Italy), Tel. +39 02 8224 4083, E-Mail
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Cucchetti A, Cescon M, Ercolani G, Bigonzi E, Torzilli G, Pinna AD. A comprehensive meta-regression analysis on outcome of anatomic resection versus nonanatomic resection for hepatocellular carcinoma. Ann Surg Oncol 2012; 19:3697-705. [PMID: 22722807 DOI: 10.1245/s10434-012-2450-z] [Citation(s) in RCA: 96] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2011] [Indexed: 12/13/2022]
Abstract
BACKGROUND It remains unclear whether hepatectomy for hepatocellular carcinoma should be performed as an anatomic resection (AR) or a nonanatomic resection (NAR). Because no randomized controlled trials are currently available on this topic, a meta-regression analysis was performed on available observational studies to control for confounding variables. METHODS A systematic review of studies published from 1990 to 2011 in the PubMed and Embase databases was performed. Patient and disease-free survival (DFS), postoperative mortality, and morbidity were considered as outcomes. Results are expressed as relative risk (RR) or weighted mean differences with 95 % of confidence interval. RESULTS Eighteen observational studies involving 9,036 patients were analyzed: 4,012 were in the AR group and 5,024 in the NAR group. Meta-analysis suggested that AR provided better 5-year patient survival (RR 1.14; P = 0.001) and DFS than NAR (RR 1.38; P = 0.001). However, patients in the NAR group were characterized by a higher prevalence of cirrhosis (RR 1.27; P = 0.010), more advanced hepatic dysfunction (RR 0.90 for Child-Pugh class A; P = 0.001) and smaller tumor size (weighted mean difference 0.36 cm; P < 0.001) compared with patients in the AR group. Meta-regression analysis showed that the different proportion of cirrhosis in the NAR group significantly affected both 5-year patient survival (RR 1.28; P = 0.016) and DFS (RR 1.74; P = 0.022). Tumor size only slightly affected DFS (RR 1.72; P = 0.076). Postoperative mortality and morbidity were unaffected (P > 0.05 in all cases). CONCLUSIONS Patient survival and DFS after AR seem to be superior to NAR because the worse liver function reserve in the NAR group significantly affects prognosis.
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Affiliation(s)
- Alessandro Cucchetti
- Liver and Multiorgan Transplant Unit, Alma Mater Studiorum, University of Bologna, Bologna, Italy.
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Shindoh J, Seyama Y, Umekita N. Three-dimensional staining of liver segments with an ultrasound contrast agent as an aid to anatomic liver resection. J Am Coll Surg 2012; 215:e5-10. [PMID: 22683072 DOI: 10.1016/j.jamcollsurg.2012.05.017] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2012] [Revised: 05/16/2012] [Accepted: 05/16/2012] [Indexed: 12/16/2022]
Affiliation(s)
- Junichi Shindoh
- Department of Surgery, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan.
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Meta-analysis of anatomic resection versus nonanatomic resection for hepatocellular carcinoma. Langenbecks Arch Surg 2011. [PMID: 21476060 DOI: 10.1007/s00423-011-0784-9.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/29/2022]
Abstract
PURPOSE The choice between anatomic resection (AR) versus nonanatomic resection (NAR) for hepatocellular carcinoma (HCC) is controversial. This study is a meta-analysis of the available evidence. METHODS A systematic review and meta-analysis of trials comparing AR with NAR for HCC published from 1985 to 2009 in PubMed and Medline database, Cochrane database, Embase database, and Science Citation index were conducted. Overall survival, disease-free survival, and local recurrence rate were considered as primary outcomes. Pooled effect was calculated using either the fixed effects model or random effects model. RESULTS Sixteen nonrandomized studies involving 2,917 patients were analyzed; 1,577 patients were in the AR group, and 1,340 were in the NAR group. Patients in the AR group were characterized by lower prevalence of cirrhosis and hepatitis virus infection, more favorable hepatic function, and larger tumor size compared with patients in the NAR group. AR provided a better 5-year overall survival than NAR (OR, 1.63; 95% CI, 1.15-2.32). Local recurrence (OR, 0.28; 95% CI, 0.16-0.50) and early (≤2 years) recurrence (OR, 0.55; 95 CI, 0.34-0.89) were all significantly lower in the AR group. AR improved disease-free survival significantly at 3 years (OR, 2.09; 95% CI, 1.52-2.88) and 5 years (OR, 2.24; 95% CI, 1.85-2.72). No differences were found between the two groups with respect to postoperative morbidity, mortality, and length of hospital stay. CONCLUSIONS AR was superior to NAR in terms of better survival and preventing local recurrence for the treatment of HCC.
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Meta-analysis of anatomic resection versus nonanatomic resection for hepatocellular carcinoma. Langenbecks Arch Surg 2011; 396:1109-17. [PMID: 21476060 DOI: 10.1007/s00423-011-0784-9] [Citation(s) in RCA: 72] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2011] [Accepted: 03/08/2011] [Indexed: 02/07/2023]
Abstract
PURPOSE The choice between anatomic resection (AR) versus nonanatomic resection (NAR) for hepatocellular carcinoma (HCC) is controversial. This study is a meta-analysis of the available evidence. METHODS A systematic review and meta-analysis of trials comparing AR with NAR for HCC published from 1985 to 2009 in PubMed and Medline database, Cochrane database, Embase database, and Science Citation index were conducted. Overall survival, disease-free survival, and local recurrence rate were considered as primary outcomes. Pooled effect was calculated using either the fixed effects model or random effects model. RESULTS Sixteen nonrandomized studies involving 2,917 patients were analyzed; 1,577 patients were in the AR group, and 1,340 were in the NAR group. Patients in the AR group were characterized by lower prevalence of cirrhosis and hepatitis virus infection, more favorable hepatic function, and larger tumor size compared with patients in the NAR group. AR provided a better 5-year overall survival than NAR (OR, 1.63; 95% CI, 1.15-2.32). Local recurrence (OR, 0.28; 95% CI, 0.16-0.50) and early (≤2 years) recurrence (OR, 0.55; 95 CI, 0.34-0.89) were all significantly lower in the AR group. AR improved disease-free survival significantly at 3 years (OR, 2.09; 95% CI, 1.52-2.88) and 5 years (OR, 2.24; 95% CI, 1.85-2.72). No differences were found between the two groups with respect to postoperative morbidity, mortality, and length of hospital stay. CONCLUSIONS AR was superior to NAR in terms of better survival and preventing local recurrence for the treatment of HCC.
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