Appraisal of concomitant splenectomy in liver resection for hepatocellular carcinoma in cirrhotic patients with hypersplenic thrombocytopenia

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

Background

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

Methods

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

Results

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

Conclusions

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

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

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

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

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

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

AIMS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Liver resection for hepatocellular carcinoma in oldest old patients

Background

For hepatocellular carcinoma (HCC), liver resection is a classical curative modality, despite its technical complexity. The incidence of HCC in the oldest old people (aged ≥ 85 years) is rising along with the global increase in life expectancy. Currently, no report has addressed liver resection for HCC in this aged population.

Patients and methods

We conducted a retrospective review of 1889 patients receiving curative liver resection for newly diagnosed HCC from 1992 to 2016. At the time of operation, 1858 of them were aged < 85 years (group A), and 31 were aged ≥ 85 years (group B). Another 18 oldest old patients, whose HCC was considered resectable but were not operated on due to the patient’s refusal, served as the control group (group C). The clinicopathological characteristics and early and long-term outcomes were compared between groups A and B. All associated co-morbidities of the patients were well-treated before liver resection. The overall survival (OS) rates were also compared between groups B and C.

Result

Group B had a significantly higher incidence of associated co-morbidities and hepatitis C infection. Postoperative complication rates and 90-day mortality rates after liver resection did not differ between groups A and B (p = 0.834 and p = 1.000, respectively), though group B had a longer postoperative stay (p = 0.001). In groups A and B, the 5-year disease-free survival rates were 29.7% and 22.6% (p = 0.163), respectively, and their overall survival rates were 43.5% and 35.5% (p = 0.086). The overall survival rate of group B was significantly different from group C (35.5% vs. 0%, p = 0.001).

Conclusion

Despite a longer postoperative recovery period, liver resection for HCC in the oldest old patients may be justified if co-morbidities are well controlled.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Therapeutic implication of platelets in liver regeneration -hopes and hues

Mounting evidence highlights platelet involvement in liver regeneration via interaction with liver cells, growth factors release, and signaling contributions. Existing research suggests a compelling biological rationale for utilizing platelet biology, with the goal of improving liver function and accelerating its regenerative potential. Despite its expanding application in several clinical areas, the contribution of the platelet and its therapeutic implementation in liver regeneration so far has not yet fulfilled the initial high expectations. Areas covered: This review scrutinizes the progress, current updates, and discusses how recent understanding - particularly in the clinical implications of platelet-based therapy - may enable strategies to introduce and harness the therapeutic potential of the platelet during liver regeneration. Expert commentary: Several clinical and translational studies have facilitated a platform for the development of platelet-based therapy to enhance liver regeneration. While some of these therapies are effective to augment liver regeneration, the others have had some detrimental outcomes. The existing evidence represents a challenge for future projects that are focused on directly incorporating platelet-based therapies to induce liver regeneration.

Liver resection for hepatocellular carcinoma in patients with hematological malignancies

Background

Improvements in antimetabolite drugs have prolonged the survival of patient with hematological malignancies. However, these drugs may have hepatotoxic side effects and may induce acute liver failure, chronic liver fibrosis, cirrhosis, or even hepatocellular carcinoma (HCC). Although liver resection remains a curative option for HCC, its role in HCC with hematological malignancies has never been fully explored.

Methods

A retrospective review of 1725 patients who underwent curative liver resection for newly diagnosed HCC between 1994 and 2016 was conducted. Among these patients, 16 had a history of hematological malignancies (HM group). Their hematological malignancies were well-controlled at the time of liver resection. The clinicopathological characteristics of the HM group, along with their short- and long-term outcomes after liver resection, were compared with those of the other 1709 patients without hematological malignancy (non-HM group).

Results

All HM group patients were seropositive for hepatitis marker surface for hepatitis B and C. No significant differences were observed in any background characteristics between the two groups. The postoperative complication rate and 90-day mortality in the HM and non-HM groups were 25 and 20.4%, P = 0.754, and 0 and 0.6%, P = 1.000, respectively. The 5-year disease-free and overall survival rates for the HM and non-HM groups were 42.3 and 35.1%, P = 0.552, and 69.5 and 56.9%, P = 0.192, respectively.

Conclusions

Hepatitis markers should be examined during chemotherapy for hematological malignancies. Regular liver imaging studies are recommended for seropositive cases. When HCC occurs secondary to a well-controlled hematological malignancy, liver resection is suggested in selected patients.

Progress of liver resection for hepatocellular carcinoma in Taiwan

Taiwan is a well-known endemic area of hepatitis B. Hepatocellular carcinoma (HCC) has consistently been the first or second highest cause of cancer death over the past 20 years. This review article describes the progress of liver resection for HCC in Taiwan in the past half century. The mortality rate for HCC resection was 15-30% in Taiwan in the 1970s. The rate decreased to 8-12% in the early 1990s, and it declined to <1-3% recently. The development of new operative instruments, and surgical techniques, increased knowledge of liver anatomy and pathophysiology after hepatectomy, and more precise patient selection have contributed to this improvement. The use of intermittent hepatic inflow blood occlusion, a restrictive blood transfusion policy and intraoperative ultrasonography, have also led to substantial improvements in resectability and safety for HCC resection in Taiwan. Advances in non-operative modalities for HCC treatment have also helped to improve long-term outcomes of HCC resection. Technical innovations have allowed the application of complex procedures such as mesohepatectomy, unroofing hepatectomy, major portal vein thrombectomy, hepatic vein reconstruction in resection of the cranial part with preservation of the caudal part of the liver, and inferior vena cava and right atrium tumor thrombectomy under cardiopulmonary bypass. In selected patients, including patients with end-stage renal failure, renal graft recipients, patients with portal hypertension, hypersplenic thrombocytopenia and/or associated gastroesophageal varices, octogenarian, ruptured HCC, recurrent HCC and metastatic HCC can also be resected with satisfactory survival benefits. We conclude that the results of liver resection for HCC in Taiwan are improving. The indications for HCC resection continue extending with lower the surgical risks and increasing the long-term survival rate.

Concomitant Laparoscopic Perisplenic Artery Ligation Facilitates Surgery for Hepatobiliary Disease Coexisting with Portal Hypertension

BACKGROUND

Although liver cirrhosis with portal hypertension (PH) contributes significantly to morbidity and mortality in abdominal surgery, many authors still consider this disease as an indication for surgery. In many reports, however, numerous treatment modalities focus on hypersplenism secondary to PH, irrespective of splenomegaly and PH. The proven benefits of laparoscopy seem especially applicable to patients with this complex disease. This study evaluates the safety and efficacy of laparoscopic perisplenic artery ligation (SAL) in patients with hepatobiliary disease and PH.

METHODS

From July 2004 to May 2012, the medical records of all patients with hepatobiliary disease in the context of PH at the authors' institutes, including patient demography, operative outcomes, and change of liver function, were retrospectively reviewed.

RESULTS

A total of 101 patients were included in the series: 85 patients with cirrhotic Child A, B class, who underwent no intervention (Control group n = 22), splenectomy (SP group n = 29), laparoscopic SAL (SAL-1 group, n = 34) for splenomegaly, and 16 patients with cirrhotic Child C class, who only underwent laparoscopic SAL (SAL-2 group, n = 16). Among these patients, both laparoscopic SAL and open SP for splenomegaly were available to decrease morbidity rate, loss of bleeding, and improve liver function, whereas laparoscopic SAL had a lower rate of surgical-related complications.

CONCLUSIONS

Although technically challenging in patients with hepatobiliary disease coexisting with PH, the present series demonstrated the safety and feasibility of laparoscopic SAL, even facilitating simultaneous surgery for hepatobiliary diseases, with a clear advantage over SP and no intervention.

Laparoscopic RFA with splenectomy for hepatocellular carcinoma

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

CD4 T lymphocyte counts in patients undergoing splenectomy during living donor liver transplantation

The role of splenectomy in increasing the CD4-positive T lymphocyte counts (hereafter: CD4 counts) and the CD4 to CD8 ratio have not yet been fully investigated, especially in the case of HIV-positive patients undergoing liver transplantation (LT).

METHODS

The change in the total lymphocyte counts of 32 patients who underwent one-stage splenectomy with living donor (LD) LT with (n=13) or without rituximab (RTX, n=19) therapy were examined to validate our cohort of ABO-incompatible LDLT with RTX. Subsequently, perioperative changes in CD4 counts and the CD 4 to CD8 ratio were measured in 13 patients who underwent ABO-incompatible LDLT/RTX with splenectomy.

RESULTS

(1) The administration of RTX did not significantly affect the total lymphocyte counts of patients after LDLT/splenectomy in any of the observation periods. (2) The CD4 counts were significantly higher at 2years after LDLT in comparison to the perioperative CD4 counts but not within the 3-month period (p=0.039). The CD4/CD8 ratio gradually decreased after LDLT/splenectomy under RTX treatment.

CONCLUSIONS

An immediate increase in the CD4 counts therefore cannot be expected after LDLT with splenectomy. The total lymphocyte and CD4 counts were rather stable in the peritransplant period even in ABO incompatible LDLT with RTX.

Impact of severe oesophagogastric varices on liver resection for hepatocellular carcinoma in cirrhotic patients

BACKGROUND

The aim of the present study was to clarify both short-term and long-term results of patients with concomitant hepatocellular carcinoma (HCC) and high-risk oesophagogastric varices (OGV).

METHODS

This retrospective study identified 927 cirrhotic patients who underwent curative resection of HCC between 1995 and 2012 in single institution. Patients were separated into 3 groups (A, B, and C) according to general rules for recording endoscopic findings of oesophagogastric varices proposed in Japan in 1991. Groups A, B, and C consisted of patients without OGV (F0), patients with mild to moderate OGV (F1 to F2), and patients with high-risk OGV (F3 and/or red color sign), respectively. All patients in group C underwent prophylactic endoscopic variceal ligation/sclerotherapy. Post-operative complications, mortality, overall survival, and disease-free survival were compared among 3 groups.

RESULTS

No patient had post-operative variceal bleeding. Complication rates of Clavien-Dindo grade II to V in three groups were 13.6, 14.0, and 6.9 %, respectively (P > 0.05). Operative mortality, 5-year overall survival rate, and disease-free survival rate among the 3 groups were not significantly different (P > 0.05).

CONCLUSIONS

Prophylactic endoscopic variceal ligation/sclerotherapy effectively prevented from post-operative variceal bleeding in patients with high-risk OGV. Operative mortality, major morbidity, and survival of patients with high-risk OGV were similar to those of patients without OGV or those with mild OGV. Liver resection remains a feasible choice for cirrhotic patients with concomitant HCC and high-risk OGV.

Management before hepatectomy for hepatocellular carcinoma with cirrhosis

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

Simultaneous hepatectomy and splenectomy versus hepatectomy alone for hepatocellular carcinoma complicated by hypersplenism: a meta-analysis

Background

This study systematically compared the efficacy and safety of simultaneous hepatectomy and splenectomy (HS) with hepatectomy (H) alone in patients with hepatocellular carcinoma (HCC) and hypersplenism.

Methods

The PubMed, Web of Science, Science Direct, EMBASE, and Cochrane Library databases were systematically searched by two independent researchers through to March 31, 2015 to identify relevant studies. All the extracted literature were managed by Bibliographic citation management software. Quality assessment of the included studies was performed using a modified Newcastle–Ottawa Scale judgment. The data were analyzed using RevMan5.2 software.

Results

Eight studies including a total of 761 patients with HCC and hypersplenism (360 in the HS group, 401 in the H group) were finally included in the analysis. Outcomes, including postoperative complications, perioperative mortality, operation time, 5-year survival rate, and need for blood transfusion did not differ significantly between the two groups. HS was associated with significantly more intraoperative bleeding (mean difference [MD] 57.15, 95% confidence interval [CI] 18.83–95.46, P=0.003), and CD4/CD8 ratio (MD 0.69, 95% CI 0.61–0.77, P<0.00001), CD4 subset, platelet count (MD 213.06, 95% CI 202.59–223.53, P<0.0001), white blood cell count (MD 4.85, 95% CI 4.58–5.13, P<0.0001), interferon-gamma levels (MD 18.52, 95% CI 13.93–23.11, P<0.00001), and interleukin-2 levels (MD 20.73, 95% CI 16.05–25.41, P<0.0001). In addition, lower CD8 subset (MD −7.85, 95% CI −9.07, −6.63, P<0.00001) and interleukin-10 levels (MD −18.56, 95% CI −22.61, −14.50, P<0.00001) were observed for HS.

Conclusion

We identified that simultaneous HS do not increase postoperative complications, operation time, or perioperative mortality in patients with HCC and hypersplenism. Simultaneous splenectomy can increase postoperative white blood cell and platelet counts significantly, improve blood coagulation, reduce the incidence of postoperative bleeding, and enhance immunity. Therefore, HS is safe, effective, and feasible for patients with HCC and hypersplenism.

Laparoscopic splenectomy for patients with liver cirrhosis: Improvement of liver function in patients with Child-Pugh class B

BACKGROUND

We aimed to assess the short-term outcomes of laparoscopic splenectomy (LS) and liver function at 1 year after splenectomy in the patients with liver cirrhosis.

METHODS

Forty-five patients with liver cirrhosis and hypersplenism underwent LS. We reviewed electronic medical records regarding the liver functional reserve, the etiology of liver cirrhosis, and the presence of hepatocellular carcinoma and esophago-gastric varices. Prospectively collected data of perioperative variables, postoperative complications, and long-term liver function were analyzed.

RESULTS

Forty-five patients had a chronic liver disease classified into Child-Pugh classes (A/B/C: 23/20/2). The etiologies of disease were hepatitis C virus infection in 34 patients, hepatitis B virus infection in 4, and others in 7. Fourteen patients underwent procedures in addition to LS, including hepatectomy (n = 7) and devascularization for esophagogastric varices (n = 8). Postoperative complications occurred in 11 patients (24%). Neither postoperative liver failure nor in-hospital mortality occurred. White blood cell and platelet counts determined 7 days, 1 month, and 1 year after LS doubled or increased more than twice compared with the preoperative values (P < .001). One year after LS, patients who had been classified preoperatively into Child-Pugh class B had decreased total serum bilirubin levels (P = .03), and increased prothrombin activity (P = 003) and decreased Child-Pugh scores (P = .001). The Child-Pugh classifications improved in 14 of 18 patients (78%) who had Child-Pugh class B preoperatively.

CONCLUSION

LS is a safe and feasible procedure for hypersplenism in patients with liver cirrhosis. In addition, LS most likely ameliorates liver function at 1 year after LS in patients with Child-Pugh class B liver cirrhosis.

Unroofing hepatectomy: a facilitating approach for resection of deep-seated hepatocellular carcinoma adjacent to major intrahepatic vessels in cirrhotic patients

BACKGROUND AND OBJECTIVES

Unroofing hepatectomy, an alternative approach to remove a deep-seated hepatocellular carcinoma (HCC) adjacent to major intrahepatic vessels by peel-off technique after sacrificing the overlying noncancerous liver, may result in tumor exposure without resection margin. The aim of the study was to examine the value of this approach in cirrhotic patients.

METHODS

Between 1998 and 2012, 51 cirrhotic patients underwent unroofing hepatectomy for deep-seated newly-diagnosed HCC adjacent to major intrahepatic vessels (group A). Another 274 cirrhotic patients with similar tumor size and without gross major vessel involvement in the same period were selected as the control cohort (group B). The patients' clinicopathological characteristics, the early and long-term outcomes of the two groups were compared.

RESULTS

The HCCs in group A had a significantly higher rate of tumor encapsulation, smaller number of associated satellite nodules, and smaller amount of resected liver weight. Postoperative complication and 90-day mortality rates were similar, but group A patients had a significant better 5-year disease-free (56% vs. 32%, P = 0.011) and overall survival rates (82% vs. 53%, P = 0.008).

CONCLUSIONS

In selected cirrhotic patients, unroofing hepatectomy facilitates resection of deep-seated HCC adjacent to major intrahepatic vessels with acceptable early and long-term results.

Influence of splenectomy in patients with liver cirrhosis and hypersplenism

AIM

Splenectomy improves hypersplenic thrombocytopenia in cirrhotic patients with hypersplenism. However, the long-term influence of splenectomy has not been clarified. We examined whether splenectomy improved liver fibrosis and caused immunological changes.

METHODS

We collected liver and spleen specimens and peripheral blood (PB) from 26 patients with hepatitis C virus-related liver cirrhosis. An immunohistochemical examination of CD4, CD8, forkhead box P3, granzyme B and transforming growth factor-β1, and Masson-trichrome stain were performed in spleen and liver tissues and in seven cases of follow-up liver biopsy sections obtained after splenectomy. We obtained PB before and at various intervals after splenectomy. We also examined the ratio of CD4(+) and CD8(+) lymphocytes in PB using flow cytometry.

RESULTS

We observed improvements in liver fibrosis in four biopsy specimens obtained after splenectomy, in which fibrotic areas significantly decreased from 19.5% to 8.2% (P < 0.05). Increases were also observed in the ratio of CD8(+) cells in PB after splenectomy, which resulted in a significant decrease in the CD4(+) /CD8(+) ratio (P < 0.001). The carcinogenic rate in patients with a CD4(+)  : CD8(+) ratio that decreased by more than 0.5 at 1 month after splenectomy was significantly lower than that in patients with a ratio that decreased by less than 0.5 (P < 0.05).

CONCLUSION

Splenectomy may improve liver fibrosis and cause beneficial immunological changes in cirrhotic patients with hepatitis. Improvements in antitumor mechanisms can be also expected.

Concurrent partial splenic embolization with transcatheter arterial chemoembolization for hepatocellular carcinoma can maintain hepatic functional reserve

AIM

Hepatocellular carcinoma (HCC) is frequently complicated with cirrhosis, and it is not unusual for treatment options to be limited as a result of pancytopenia due to hypersplenism. Partial splenic embolization (PSE) has been performed for thrombocytopenia resulting from hypersplenism. We studied the efficacy in terms of hepatic functional reserve and safety in patients who underwent concurrent transcatheter arterial chemoembolization (TACE) with PSE for HCC.

METHODS

The study population consisted of 101 HCC patients with thrombocytopenia. Fifty-three patients were treated with concurrent TACE/PSE (PSE group), and the remaining 48 TACE patients without PSE (non-PSE group) were investigated hepatic functional reserve.

RESULTS

Platelet counts were significantly higher in the PSE group after 2 weeks, 2 months and 6 months after TACE than the non-PSE group. Child-Pugh score significantly deteriorated from 7.13 ± 1.16 to 7.60 ± 1.20 at 2 weeks, to 7.71 ± 1.25 at 2 months, and 7.71 ± 1.35 at 6 weeks after TACE in the non-PSE group. Hence, it worsened from 7.04 ± 1.05 to 7.21 ± 0.99 at 2 weeks temporally, but improved to 7.00 ± 1.17 after 2 months and 6.70 ± 1.16 at 6 weeks after TACE in the PSE group.

CONCLUSION

Thrombocytopenia has been improved and treatment continued using concurrent PSE. In addition, hepatic functional reserve could be maintained even after treatment for HCC. Concurrent TACE and PSE for HCC with thrombocytopenia can be expected to help maintain hepatic reserve, and may contribute to improving the prognosis of HCC.

Hand-assisted laparoscopic splenectomy for thrombocytopenia in patients with cirrhosis

PURPOSE

Although splenectomy plays an important role in the management of patients with liver cirrhosis, the optimal technique, open surgery, total laparoscopic surgery or hand-assisted laparoscopic surgery (HALS), has not yet been defined. The present study evaluated the outcomes of HALS splenectomy for cirrhotic patients.

METHODS

A total of 28 consecutive patients with cirrhosis that underwent HALS splenectomy were enrolled into this study. The preoperative laboratory and morphometric data, intraoperative variables and postoperative outcomes were reviewed from the hospital charts.

RESULTS

The postoperative platelet count was remarkably elevated in all cases. A re-operation was required in 1 patient complicated with postoperative hemorrhage. Enhanced CT on POD 7 revealed a high incidence of portal or splenic vein thrombosis (PSVT; 22 patients, 78.6 %). PSVT was significantly associated with higher serum bilirubin, higher indocyanine green retention value at 15 min (ICG R-15), and larger splenic vein diameter.

CONCLUSION

HALS splenectomy was a very feasible and appropriate procedure for cirrhotic patients with hypersplenism. PSVT was a frequent complication and large splenic vein diameter, high serum bilirubin, and high ICG R-15 were found to be significant risk factors for PSVT after HALS splenectomy in cirrhotic patients.

Laparoscopic surgery in the management of hypersplenism and esophagogastric varices: our initial experiences

BACKGROUND

Owing to recent advances in laparoscopic surgery, devascularization of the upper stomach with splenectomy (Spx) or Hassab's procedure (Has) as well as Spx for patients with portal hypertension have been attempted laparoscopically in some facilities, the results of which have been reported. This article describes the authors' surgical techniques and their results.

METHODS

Between August 1999 and August 2010, the authors treated 110 cases of portal hypertension with Spx or Has. Among these patients, 56 who simultaneously underwent additional major operations were eliminated from the study, leaving 54 patients eligible. They included 38 with open surgeries and 16 with laparoscopic surgeries, which consisted of 10 splenectomies and 6 Has operations. The perioperative data for the 2 groups were compared.

RESULTS

Purely laparoscopic Spx (L-Spx) was completed for 9 patients. Conversion from laparoscopic to hand-assisted laparoscopic surgery (HALS) was necessary for 1 patient because of poor visualization. Operative time was significantly longer in L-Spx than in the open method. Postoperative hospital stays were shorter for L-Spx. HALS was used for all 6 laparoscopic Has patients. There was no conversion from the laparoscopic to the open method. Operative time was significantly longer for laparoscopic Has than for open Has. Postoperative complication rates were significantly reduced, and postoperative hospital stays were significantly shorter for laparoscopic Has.

CONCLUSIONS

Although the data are still preliminary, laparoscopic surgery for patients with portal hypertension may prove to be a successful strategy.

Coagulopathy in liver disease

The liver plays a central role in hemostasis, as it is the site of synthesis of clotting factors, coagulation inhibitors, and fibrinolytic proteins. The most common coagulation disturbances occurring in liver disease include thrombocytopenia and impaired humoral coagulation. Therapy's overall goal is not to achieve complete correction of laboratory value abnormalities but to gain hemostasis. Therapy with vitamin K may be a useful option in patients with increased prothrombin time due to vitamin K deficiency; in patients with malnutrition; in patients using antibiotics; and in patients with cholestatic liver disease, particularly prior to invasive procedures. Infusion of fresh frozen plasma is more often effective and is recommended in patients with liver disease before invasive procedures or surgery, as such patients require transient correction in their prothrombin time. Therapy with plasma exchange may be considered in patients who cannot be treated with fresh frozen plasma due to volume overload risk. In patients with severe coagulopathy and hypofibrinogenemia, cryoprecipitate therapy is ideal. Therapy with prothrombin-complex concentrate is seldom pursued in patients with liver disease due to high risk of thrombotic complications. Transfusions of platelets are appropriate for patients with thrombocytopenia (< 50,000/mm(3)) associated with active bleeding or before invasive procedures in which a short-term platelet count increase is noted. Trial with desmopressin may be considered before invasive procedures in patients with liver disease and with refractory and prolonged bleeding time. Recombinant activated factor VIIa administration is suggested for patients with significantly prolonged prothrombin time and contraindications to fresh frozen plasma therapy; however, this is expensive. Thrombopoietin and interleukin-11 are currently investigational for patients with thrombocytopenia of chronic liver disease. Liver transplantation completely restores impaired coagulation abnormalities and is the ultimate intervention that corrects coagulopathy of advanced liver disease and liver failure.

Laparoscopic splenectomy is an effective and safe intervention for hypersplenism secondary to liver cirrhosis

BACKGROUND

Laparoscopic splenectomy has become the standard procedure for the normal to moderately enlarged spleens. We performed this study to investigate the safety, feasibility, and effectiveness of laparoscopic splenectomy for hypersplenism secondary to liver cirrhosis.

METHODS

We performed a retrospective chart review of 24 cases of laparoscopic splenectomy (group 1), 24 cases of open splenectomy (group 2) for hypersplenism secondary to liver cirrhosis, and 68 cases of laparoscopic splenectomy for immune thrombocytopenic purpura (group 3). We performed comparisons between groups 1 and 2 and groups 1 and 3 in terms of demographic, intraoperative, postoperative variables, and changes in blood counts and liver function.

RESULTS

Patients in groups 1 and 2 had comparable demographic characteristics, but those in group 1 had less estimated blood loss, fewer complications, and shorter duration of oral intake, and they required less analgesia and shorter post-hospital stays. In both groups, leukocyte and platelet counts increased significantly and transaminase and total bilirubin decreased postoperatively, but not significantly, and there was no significant difference between the two groups. Compared with group 3, patients in group 1 were older, had lower preoperative hemoglobin levels and leukocyte counts, poorer Child-Pugh class, required more operation time, and suffered more estimated blood loss; however, there were no statistically significant differences in terms of conversion rates, transfusion rates, complication rates, and postoperative course.

CONCLUSIONS

Laparoscopic splenectomy is a safe, feasible, and effective procedure for hypersplenism secondary to liver cirrhosis.

Portal vein thrombosis after splenectomy for hypersplenism in patients with liver cirrhosis: an analysis of 22 cases

AIM: To determine the incidence rate of portal vein thrombosis (PVT) in cirrhotic patients after splenectomy for hypersplenism and to assess the efficacy of low molecular weight heparin (LMWH) for the treatment of PVT.

METHODS: A total of 58 consecutive cirrhotic patients who underwent splenectomy for hypersplenism from January 2008 to December 2010 were enrolled into this study. All the patients received prophylactic anticoagulation therapy after the operation. Based on the presence of thrombus or not, the patients were divided into thrombosis group and non-thrombosis group. The incidence rate of PVT, thrombophilic factors, and thrombus location were analyzed in these patients.

RESULTS: All patients developed thrombosis, Thrombosis of the splenic vein, superior mesenteric vein and multiple veins was found in 5, 1 and 13 patients, respectively. Above 37.93% of the patients developed PVT. Identified risk factors for the development of PVT included high platelet count, low blood flow and increased spleen weight.

CONCLUSION: Blood platelet count and spleen weight are important risk factors for the development of PVT. Prophylactic treatment with low molecular weight heparin and Warfarin is likely to prevent the development of PVT in cirrhotic patients after splenectomy.

Impact of antithrombin III concentrates on portal vein thrombosis after splenectomy in patients with liver cirrhosis and hypersplenism

OBJECTIVE

The aim of this study was to determine the role of antithrombin III (AT-III) in portal vein thrombosis (PVT) after splenectomy in cirrhotic patients.

SUMMARY BACKGROUND DATA

There is no standard treatment for PVT after splenectomy in liver cirrhosis.

METHODS

A total of 50 consecutive cirrhotic patients who underwent laparoscopic splenectomy for hypersplenism were enrolled into this study. From January 2005 to December 2005, 25 cirrhotic patients received no prophylactic anticoagulation therapy after the operation (AT-III [-] group). From January 2006 to July 2006, 25 cirrhotic patients received prophylactic administration of AT-III concentrates (1500 U/d) on postoperative day (POD) 1, 2, and 3 (AT-III [+] group).

RESULTS

In AT-III (-) group, 9 (36.0%) patients developed PVT up to POD 7, and risk factors for PVT were identified as: low platelet counts, low AT-III activity, and increased spleen weight. Although there were no significant differences in the clinical characteristics, including the above risk factors, between the 2 groups, only 1 (4.0%) patient developed PVT on POD 30 in AT-III (+) group, and the incidence of PVT was significantly lower than in AT-III (-) group (P = 0.01). In AT-III (-) group, AT-III activity was significantly decreased from POD 1 to POD 7, as compared with the preoperative level, whereas AT-III concentrates prevented the postoperative decrease in AT-III activity.

CONCLUSIONS

These results demonstrate that low AT-III activity and further decreases in this activity are associated with PVT after splenectomy in cirrhotic patients, and that treatment with AT-III concentrates is likely to prevent the development of PVT in these patients.

Second and third hepatectomies for recurrent hepatocellular carcinoma are justified

BACKGROUND

Liver resection is the main curative treatment for hepatocellular carcinoma (HCC), but recurrence rates are high. The remnant liver is the most common site of recurrence, but the role of repeat hepatectomy in the treatment of recurrent HCC is controversial.

METHODS

Patients who underwent curative hepatectomy for HCC and subsequent repeat hepatectomy for recurrent HCC between 1990 and 2007 were reviewed retrospectively. Clinicopathological characteristics, and early- and long-term outcomes of patients who had a first, second, third and fourth hepatectomy were compared.

RESULTS

Some 1177 patients underwent a first hepatectomy for HCC, and 149, 35 and eight patients respectively had a second, third and fourth hepatectomies for recurrence. There were no significant differences in early postoperative outcomes after first and repeat hepatectomies. Five-year disease-free and overall survival rates after first, second and third hepatectomies were 43.6, 31.8 and 33.8 per cent (P = 0.772), and 52.4, 56.4 and 59.4 per cent (P = 0.879), respectively. Patients undergoing second and third hepatectomies for recurrence had better survival rates than those who did not have a repeat hepatectomy, but not those after fourth hepatectomy.

CONCLUSION

Second and third hepatectomies seem justified for hepatic recurrence of HCC. The role of fourth hepatectomy needs further investigation.

Technical standardization of laparoscopic splenectomy harmonized with hand-assisted laparoscopic surgery for patients with liver cirrhosis and hypersplenism

BACKGROUND/PURPOSE

The aims of this study were to standardize the techniques of laparoscopic splenectomy (LS) to improve safety in liver cirrhosis patients with portal hypertension.

METHODS

From 1993 to 2008, 265 cirrhotic patients underwent LS. Child-Pugh class was A in 112 patients, B in 124, and C in 29. Since January 2005, we have adopted the standardized LS including the following three points: hand-assisted laparoscopic surgery (HALS) should be performed in patients with splenomegaly (> or =1,000 mL), perisplenic collateral vessels, or Child-Pugh score 9 or more; complete division and sufficient elevation of the upper pole of the spleen should be performed before the splenic hilar division; and when surgeons feel the division of the upper pole of the spleen is too difficult, conversion to HALS should be performed.

RESULTS

There were no deaths related to LS in this study. After the standardization, conversion to open surgery significantly reduced from 11 (10.3%) of 106 to 3 (1.9%) of 159 patients (P < 0.05). The average operation time and blood loss significantly reduced from 259 to 234 min (P < 0.01) and from 506 to 171 g (P < 0.01), respectively.

CONCLUSIONS

With the technical standardization, LS becomes a feasible and safe approach in the setting of liver cirrhosis and portal hypertension.

Appraisal of hepatic resection in the treatment of hepatocellular carcinoma with severe thrombocytopenia

BACKGROUND

Hepatic resection for hepatocellular carcinoma (HCC) patients with liver cirrhosis and severe hypersplenic thrombocytopenia is risky and controversial.

METHODS

From 1989 to 2005, 341 patients underwent hepatic resection for HCC in our hospital. Of these, 15 patients were concomitant with severe thrombocytopenia (platelet count, <or=5 x 10(4)/mm(3)), and their clinical outcomes were retrospectively reviewed.

RESULTS

Among the 15 patients, 11 underwent hepatectomy alone and 4 underwent concomitant splenectomy. The mean preoperative platelet count was 4.2 +/- 0.8 x 10(4)/mm(3) (range, 1.9-5 x 10(4)/mm(3)). The surgical procedures performed were partial resection in five patients, subsegmentectomy in three, and segmentectomy in seven. A blood transfusion was required for 11 of 15 patients, and 8 of these received a platelet-rich plasma transfusion. With the exception of one patient who suffered from postoperative liver failure, all the patients had an uneventful postoperative course. The 3-year cumulative survival rate of these patients was comparable to those without thrombocytopenia.

CONCLUSIONS

Severe thrombocytopenia alone is not a contraindication for hepatectomy in patients with HCC associated with liver cirrhosis. For these patients, hepatic resection-hepatectomy alone or concomitant splenectomy-should be considered as a treatment option.

Appraisal of hepatic resection in the treatment of hepatocellular carcinoma with severe thrombocytopenia

BACKGROUND

Hepatic resection for hepatocellular carcinoma (HCC) patients with liver cirrhosis and severe hypersplenic thrombocytopenia is risky and controversial.

METHODS

From 1989 to 2005, 341 patients underwent hepatic resection for HCC in our hospital. Of these, 15 patients were concomitant with severe thrombocytopenia (platelet count, <or=5 x 10(4)/mm(3)), and their clinical outcomes were retrospectively reviewed.

RESULTS

Among the 15 patients, 11 underwent hepatectomy alone and 4 underwent concomitant splenectomy. The mean preoperative platelet count was 4.2 +/- 0.8 x 10(4)/mm(3) (range, 1.9-5 x 10(4)/mm(3)). The surgical procedures performed were partial resection in five patients, subsegmentectomy in three, and segmentectomy in seven. A blood transfusion was required for 11 of 15 patients, and 8 of these received a platelet-rich plasma transfusion. With the exception of one patient who suffered from postoperative liver failure, all the patients had an uneventful postoperative course. The 3-year cumulative survival rate of these patients was comparable to those without thrombocytopenia.

CONCLUSIONS

Severe thrombocytopenia alone is not a contraindication for hepatectomy in patients with HCC associated with liver cirrhosis. For these patients, hepatic resection-hepatectomy alone or concomitant splenectomy-should be considered as a treatment option.

Liver surgery in the presence of cirrhosis or steatosis: Is morbidity increased?

Background data

The prevalence of steatosis and hepatitis-related liver cirrhosis is dramatically increasing together worldwide. Cirrhosis and, more recently, steatosis are recognized as a clinically important feature that influences patient morbidity and mortality after hepatic resection when compared with patients with healthy liver.

Objective

To review present knowledge regarding how the presence of cirrhosis or steatosis can influence postoperative outcome after liver resection.

Methods

A critical review of the English literature was performed to provide data concerning postoperative outcome of patients presenting injured livers who required hepatectomy.

Results

In clinical studies, the presence of steatosis impaired postoperative outcome regardless the severity and quality of the hepatic fat. A great improvement in postoperative outcome has been achieved using modern and multidisciplinary preoperative workup in cirrhotic patients. Due to the lack of a proper classification for morbidity and a clear definition of hepatic failure in the literature, the comparison between different studies is very limited. Although, many surgical strategies have been developed to protect injured liver surgery, no one have gained worldwide acceptance.

Conclusion

Surgeons should take the presence of underlying injured livers into account when planning the extent and type of hepatic surgery. Preoperative and perioperative interventions should be considered to minimize the additional damage. Further randomized trials should focus on the evaluation of novel preoperative strategies to minimize risk in these patients. Each referral liver center should have the commitment to report all deaths related to postoperative hepatic failure and to use a common classification system for postoperative complications.

Portal hypertension: contraindication to liver surgery?

INTRODUCTION

In recent decades liver resection has become a safe procedure, mainly because of better patient selection. Despite this progress, however, outcomes of hepatectomy in cirrhotic patients with portal hypertension are still uncertain. The aim of this study was to elucidate early and long-term outcomes of liver resection in these patients.

METHODS

Between 1985 and 2003, a total of 245 cirrhotic patients underwent hepatectomy for HCC. Altogether, 217 patients were eligible for this analysis and were divided into two groups according to the presence of portal hypertension at the time of surgery: 99 patients with portal hypertension and 118 without it.

RESULTS

Patients with portal hypertension had worse preoperative liver function (Child-Pugh A class patients: 66.7% vs. 94.9%; P<0.0001). No differences were encountered in terms of intraoperative and pathology data. Operative mortality was similar (11.1% vs. 5.1%; P=0.100), but patients with portal hypertension had higher morbidity (43.4% vs. 30.5%; P=0.049) and received a higher rate of blood and plasma transfusions (51.5% vs. 32.2%, P=0.004; 77.8% vs. 57.6%, P=0.0017). Considering only Child-Pugh A patients, short-term results were similar in the two groups in terms of mortality, morbidity, and transfusion rates. The 5-year survival rate was significantly higher in patients without portal hypertension (39.8% vs. 28.9%; P=0.020), although when considering only Child-Pugh A patients no difference of survival was encountered. Multivariate analysis identified Child-Pugh classification, tumor diameter, and vascular invasion as independent predicting factors for survival.

CONCLUSIONS

Portal hypertension should not be considered an absolute contraindication to hepatectomy in cirrhotic patients. Child-Pugh A patients with portal hypertension have short- and long-term results similar to patients with normal portal pressure.

Portal hypertension: contraindication to liver surgery?

INTRODUCTION

In recent decades liver resection has become a safe procedure, mainly because of better patient selection. Despite this progress, however, outcomes of hepatectomy in cirrhotic patients with portal hypertension are still uncertain. The aim of this study was to elucidate early and long-term outcomes of liver resection in these patients.

METHODS

Between 1985 and 2003, a total of 245 cirrhotic patients underwent hepatectomy for HCC. Altogether, 217 patients were eligible for this analysis and were divided into two groups according to the presence of portal hypertension at the time of surgery: 99 patients with portal hypertension and 118 without it.

RESULTS

Patients with portal hypertension had worse preoperative liver function (Child-Pugh A class patients: 66.7% vs. 94.9%; P<0.0001). No differences were encountered in terms of intraoperative and pathology data. Operative mortality was similar (11.1% vs. 5.1%; P=0.100), but patients with portal hypertension had higher morbidity (43.4% vs. 30.5%; P=0.049) and received a higher rate of blood and plasma transfusions (51.5% vs. 32.2%, P=0.004; 77.8% vs. 57.6%, P=0.0017). Considering only Child-Pugh A patients, short-term results were similar in the two groups in terms of mortality, morbidity, and transfusion rates. The 5-year survival rate was significantly higher in patients without portal hypertension (39.8% vs. 28.9%; P=0.020), although when considering only Child-Pugh A patients no difference of survival was encountered. Multivariate analysis identified Child-Pugh classification, tumor diameter, and vascular invasion as independent predicting factors for survival.

CONCLUSIONS

Portal hypertension should not be considered an absolute contraindication to hepatectomy in cirrhotic patients. Child-Pugh A patients with portal hypertension have short- and long-term results similar to patients with normal portal pressure.

Coagulation abnormalities in patients who have liver disease

The liver plays a central role in the maintenance of normal hemostatic function. Because liver disease alters pathways of coagulation and anticoagulation, patients who have advanced disease can experience severe bleeding or thrombotic complications. Complications of advanced liver disease may also contribute to bleeding or thrombosis. This article reviews and discusses the management of the most common coagulation problems encountered in patients who have end-stage liver disease, which are thrombocytopenia and impaired humoral coagulation as measured by prolongation of the prothrombin time and international normalized ratio.

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Liver resection for hepatocellular carcinoma in patients with cirrhosis

BACKGROUND

Although liver resection is now a safe procedure, its role for hepatocellular carcinoma (HCC) in patients with cirrhosis remains controversial.

METHODS

This study compared the results of liver resection for HCC in patients with cirrhosis over two time intervals. One hundred and sixty-one patients had resection during period 1 (1991-1996) and 265 in period 2 (1997-2002). Early and long-term results after liver resection in the two periods were compared, and clinicopathological characteristics that influenced survival were identified.

RESULTS

Tumour size was smaller, indocyanine green retention rate was higher, patients were older and a greater proportion of patients were asymptomatic in period 2 than period 1. Operative blood loss, need for blood transfusion, operative mortality rate, postoperative hospital stay and total hospital costs were significantly reduced in period 2. The 5-year disease-free survival rates were 28.2 and 33.9 per cent in periods 1 and 2 respectively (P = 0.042), and 5-year overall survival rates were 45.9 and 61.2 per cent (P < 0.001). Multivariate analysis identified serum alpha-fetoprotein level, need for blood transfusion and Union Internacional Contra la Cancrum tumour node metastasis stage as independent determinants of disease-free and overall survival.

CONCLUSION

The results of liver resection for HCC in patients with cirrhosis improved over time. Liver resection remains a good treatment option in selected patients with HCC arising from a cirrhotic liver.