Safety and efficacy of trisectionectomy for hepatocellular carcinoma

Morbidity analysis of left hepatic trisectionectomy for hepatobiliary disease and live donor

BACKGROUND

Despite remarkable advances in surgical techniques and perioperative management, left hepatic trisectionectomy (LHT) remains a challenging procedure with a somewhat high postoperative morbidity rate compared with less-extensive resections. This study aimed to analyze the short- and long-term outcomes of LHT and identify factors associated with the postoperative morbidity of this technically demanding surgical procedure.

METHODS

The medical records of 53 patients who underwent LHT between June 2005 and October 2019 at a single institution were retrospectively reviewed. The independent prognostic factor of postoperative morbidity was analyzed using the logistic regression model.

RESULTS

Hepatocellular carcinoma was the most common indication for surgery (n = 21), followed by hilar cholangiocarcinoma (n = 14), intrahepatic cholangiocarcinoma (n = 10), and other pathologies (including colorectal liver metastasis, hepatolithiasis, gallbladder cancer, living donor, hemangioma, and multilocular biliary cyst; n = 8). The rates of postoperative morbidities of Clavien-Dindo grade 3 or higher and 90-day mortality were 39.6% and 1.9%, respectively. The 1-, 3-, and 5-year overall survival rates were 81.1%, 61.4%, and 44.6%, respectively. Multivariate analysis revealed that preoperative jaundice [hazard ratio (HR) = 6.15, 95% confidence interval (CI): 1.57-24.17, P = 0.009] and operative time > 420 min (HR = 4.66, 95% CI: 1.27-17.17, P = 0.021) were independent predictors of postoperative morbidity.

CONCLUSIONS

The in-hospital mortality of LHT surgery can be minimalized by a reliable preoperative evaluation of liver function and selection of the dominant anatomic features of right posterior sector, active and appropriate preoperative management for obstructive cholangitis and compensatory hypertrophy of the future remnant posterior sector, and the experience of the surgeon.

Left hepatic trisectionectomy for hepatobiliary malignancies: Its' role and outcomes. A retrospective cohort study

Background

Left hepatic trisectionectomy (LHT) is a complex hepatic resection; its’ role and outcomes in hepatobiliary malignancies remains unclear.

Materials and methods

All patients undergoing LHT at the tertiary HPB referral unit at RSCH, Guildford, UK from September 1996 to October 2015 were included. Data were collected from a prospectively maintained database.

Results

Twenty-eight patients underwent LHT. The M:F ratio was 1.8:1. Median age was 60 years (range 43–76 years). Diagnoses included colorectal liver metastases (CRLM; n = 20); cholangiocarcinoma (CCA; n = 4); and other (neuroendocrine tumour metastases (NET; n = 3) and breast metastases (n = 1)). Median duration of surgery was 270 min (range 210–585 min). Median blood loss was 750 ml (300–2400 ml) with a perioperative transfusion rate of 21% (n = 6/28). The rate of all post-operative complications was 21% for all patients, and given the extensive resection performed four patients (14%) developed varying degrees of hepatic insufficiency. One patient with cholangiocarcinoma developed severe hepatic insufficiency, which was fatal within 90 days of surgery. 1 and 3-year survivals were 92% and 68% respectively.

Conclusion

This study supports LHT in patients with significant tumour burden. Despite extensive resection, our favourable morbidity and mortality rates show this is a safe and beneficial procedure for patients with all hepatobiliary malignancies. Given the nature of resection the incidence of post-operative hepatic insufficiency is higher than less extensive hepatic resections.

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LHT is an extended resection reported to have higher incidences of morbidity and mortality compared with less extensive hepatic resections.

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This procedure is useful for the surgical management of patients with hepatic lesions that were previously considered unresectable.

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We report favourable outcomes following LHT at our institution compared with less extensive hepatic resections.

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An initial post-operative lactate of >1.5 mmol/L was associated with an increased risk of developing post-operative complications (p = 0.035).

Comparison of the Extent Classification and the New Complexity Classification of Hepatectomy for Prediction of Surgical Outcomes: a Retrospective Cohort Study

BACKGROUND

In predicting the risk for posthepatectomy complications, hepatectomy is traditionally classified into minor or major resection based on the number of resected segments. Recently, a new hepatectomy complexity classification was proposed. This study aimed to compare the value of the traditional and that of the new classification in perioperative outcomes prediction.

METHODS

Demographics, perioperative laboratory tests, intraoperative and postoperative outcomes, and follow-up data of patients with hepatocellular carcinoma who underwent liver resection were retrospectively analyzed.

RESULTS

A total of 302 patients were included in our study. Multivariable analysis of intraoperative variables showed that the complexity classification could independently predict the occurrence of blood loss > 800 mL, operation time > 4 h, intraoperative transfusion, and the use of Pringle's maneuver (all p < 0.05). For postoperative outcomes, the high-complexity group was independently associated with severe complications, and hepatic-related complications (all p < 0.05); the traditional classification was independently associated only with posthepatectomy liver failure (PHLF) (p = 0.004).

CONCLUSIONS

Complexity classification could be used to assess the difficulty of surgery and was independently associated with postoperative complications. The traditional classification did not reflect operation complexity and was associated only with PHLF.

Role of hepatic trisectionectomy in advanced hepatocellular carcinoma

BACKGROUND

Advanced hepatocellular carcinoma (HCC) with underlying cirrhosis poses a major operative challenge. Patients have a dismal prognosis without curative resection. The role of hepatic trisectionectomy in these patients is not established. The aim of this study was to analyze and compare the perioperative outcome and prognosis of patients undergoing trisectionectomy with hepatic resection of a lesser extent.

METHODS

From 2000 to 2014, 48 patients underwent hepatic trisectionectomy for HCC with background cirrhosis or chronic hepatitis (Group A). Another (Group B) 520 patients underwent liver resection of a lesser extent. Patient demographics, clinicopathological data, perioperative outcome and long-term survival were compared between the 2 groups.

RESULTS

Intraoperative bloodloss, operating time and total hospital stay were significantly higher in trisectionectomy patients. Tumors were larger and more advanced in group A. The morbidity rate was 43.8% in group A compared to 27.5% in group B, p = 0.027. In-hospital mortality was 6.3% for group A. Group A had a significantly shorter time to recurrence (4.5months vs 6.2months, p = 0.036), as well as a poorer disease-free survival (DFS) than group B (6.3 months vs 15.7 months, p = 0.02). Overall survival was comparable. Tumor number, size, albumin, INR, microvascular invasions and positive resection margins were predictors of disease-free survival.

CONCLUSION

Hepatic trisectionectomy may be associated with a higher morbidity and lower DFS. However, these patients would not be suitable candidates for ablative therapy or liver transplantation. With careful patient selection and meticulous surgical technique, trisectionectomy is feasible and gives these patients the only hope of cure.

Preoperative Antibiotic Prophylaxis Does Not Reduce the Risk of Postoperative Infectious Complications in Patients Undergoing Elective Hepatectomy

BACKGROUND AND AIM

Postoperative infection is not uncommon after hepatectomy. This study assessed the effectiveness of preoperative antibiotic prophylaxis in elective hepatectomy in a randomized clinical trial setting.

METHODS

A total of 120 patients who were scheduled to undergo elective hepatectomy were equally randomized to receive either intravenous cefuroxime 1.5 g (group A) or placebo (group B) within 30 min prior to skin incision.

RESULTS

Overall, postoperative infection occurred in 26 (21.6 %) of the 120 patients. There was no statistically significant difference between groups A and B in the incidence of overall infection (23.3 vs. 20.0 %, P = 0.658), surgical site infection (13.3 vs. 15 %, P = 0.793), and remote site infection (13.3 vs. 11.7 %, P = 0.783).

CONCLUSION

The use of preoperative antibiotic prophylaxis as a routine practice in patients undergoing elective hepatectomy is unnecessary because it does not reduce the risk of postoperative infectious complications.

Clinical outcomes of left hepatic trisectionectomy for hepatobiliary malignancy

Background

Left hepatic trisectionectomy (LHT) is a challenging major anatomical hepatectomy with a high complication rate and a worldwide experience that remains limited. The aim of this study was to describe changes in surgical practice over time, to analyse the outcomes of patients undergoing LHT for hepatobiliary malignancy, and to identify factors associated with morbidity and mortality.

Methods

A cohort study was undertaken of patients who underwent LHT at a single tertiary hepatobiliary referral centre between January 1993 and March 2013. Univariable and multivariable analysis was used to identify factors associated with short- and long-term outcomes following LHT.

Result

Some 113 patients underwent LHT for colorectal liver metastasis (57), hilar cholangiocarcinoma (22), intrahepatic cholangiocarcinoma (12) and hepatocellular carcinoma (11); 11 patients had various other indications. Overall morbidity and 90-day mortality rates were 46·0 and 9·7 per cent respectively. Overall 1- and 3-year survival rates were 71·3 and 44·4 per cent respectively. Total hepatic vascular exclusion and intraoperative blood transfusion were independent predictors of postoperative morbidity, whereas blood transfusion was the only factor predictive of in-hospital mortality. Time period analysis revealed a decreasing trend in blood transfusion, duration of hospital stay, and postoperative morbidity and mortality in the last 5 years.

Conclusion

Morbidity, mortality and long-term survival after LHT support its use in selected patients with a significant tumour burden.

Postoperative complications affect early recurrence of hepatocellular carcinoma after curative resection

Background

Postoperative recurrence remains the major cause of death after curative resection for hepatocellular carcinoma (HCC). This study was conducted to evaluate the impact of postoperative complications on HCC recurrence after curative resection.

Methods

The postoperative outcomes of 274 HCC patients who underwent curative resection were analysed retrospectively.

Results

Of the 247 HCC patients, 103 (37.6 %) patients developed postoperative complications. The occurrence of postoperative complications was found to be associated with a significantly higher tumor recurrence (76.2 % vs. 56.6 %, P = 0.002) and a lower 5-year overall survival rate (27.7 % vs. 42.1 %; P = 0.037) as compared with those without complications. Regarding the recurrence pattern, early recurrence (≤2 years) was more frequently seen in patients with complications than that in patients without complications (54.5 % vs.38.6 %; P = 0.011). Multivariate analysis indicated that postoperative complications occurrence was an independent risk factor for early recurrence (odds ratio [OR] 2.223; 95 % confidence intervals [95 % CI] 1.161–4.258, P = 0.016) and poor overall survival (OR 1.413; 95 % CI, 1.012–1.971, P = 0.042).

Conclusions

The results of the present study indicate that the occurrence of postoperative complications is a predictive factor for HCC recurrence after curative hepatectomy, especially for early recurrence.

Safety and long-term outcomes of anatomic left hepatic trisectionectomy for intermediate and advanced hepatocellular carcinoma

BACKGROUND AND AIM

Anatomic left hepatic trisectionectomy (ALHT) is a complex hepatic resection, and its outcomes in hepatocellular carcinoma (HCC) still remain unclear. This paper focuses on the assessment of the safety and long-term effects of ALHT on intermediate and advanced HCC patients with tumors that occupy the left liver lobe.

METHODS

This study performed a retrospective analysis of consecutive HCC patients who underwent ALHT in a single-center cohort between December 2004 and December 2011.

RESULTS

ALHT was performed on 34 intermediate and advanced HCC patients (0.05%) of 17064 HCC patients who had undergone hepatic resection. Among them, 12 (33.3%) developed postoperative complications. Based on the multivariate analysis, we found that a serum prealbumin level of 170 mg/L is associated with an increased risk of morbidity (P=0.008). The one-year, two-year, three-year, and five-year overall survival rates were 61%, 27%, 11%, and 11%, respectively. The median overall survival was 13 months (range, 2-89 months). Based on the multivariate analysis, we also found that patients with an A/G ratio <1.5 are more likely to have poor prognosis than those with an A/G ratio ≥ 1.5 (P=0.014). Multiple tumors are associated with worse outcomes (P=0.020).

CONCLUSIONS

ALHT is safe for intermediate and advanced HCC patients with tumors that occupy the left lobe and with preoperative Child-Pugh class A liver function. Low preoperative serum prealbumin level may increase the risk of postoperative complications. Although early intrahepatic recurrence rate is high, some patients, especially those with a single tumor and normal A/G ratio, exhibit long-term survival.

Adjuvant Intrahepatic Injection Iodine-131-Lipiodol Improves Prognosis of Patients with Hepatocellular Carcinoma After Resection: a Meta-Analysis

High incidence of intrahepatic recurrence is a major surgical limitation following hepatectomy of hepatocellular carcinoma (HCC). This study was intended to investigate the effects of adjuvant intrahepatic injection of iodine-131-lipiodol on disease recurrence and survival in patients with HCC who underwent resection. A computerized literature search was performed to identify relevant articles. Data synthesis was performed using Review Manager 5.0 software, and results are presented as odds ratio (OR) with 95 % confidence intervals. Two randomized controlled trials and three case-control studies with a total of 334 participants were analyzed. Iodine-131-lipiodol treatment achieved significantly lower rates of intrahepatic recurrence (OR = 0.48, 95 % confidence interval (95 % CI) = 0.30-0.74; P = 0.001) and early recurrence (<2 year) (OR = 0.45, 95 % CI = 0.23-0.89; P = 0.02). Likewise, iodine-131-lipiodol treatment improved both the 5-year disease-free survival and overall survival significantly (OR = 1.85, 95 % CI = 1.13-3.03; P = 0.01; OR = 2.00, 95 % CI = 0.99-4.04; P = 0.05, respectively). Adjuvant intrahepatic injection of iodine-131-lipiodol resulted in a preventive effect on recurrence and improved survival after resection of HCC. Further larger, multi-centred, randomized prospective trial is warranted.

Efficacy and safety of thalidomide combined with transcatheter arterial chemoembolization for primary hepatic carcinoma: A systematic review

AIM: To evaluate the efficacy and safety of thalidomide (TLD) combined with transcatheter arterial chemoembolization (TACE) for primary hepatic carcinoma (PHC).

METHODS: We searched all randomized controlled trials (RCTs) about TLD combined with TACE for PHC from the Cochrane Library (2014, Issue 3), Web of Science (1986 to March 2014), PubMed (1966 to March 2014), CNKI (1917 to March 2014), VIP (1989 to March 2014) and WanFang Databases (1998 to March 2014). The retrieved articles were screened by two reviewers according to the inclusion criteria, and the data were then extracted. The quality of the included RCTs was evaluated with reference to the Cochrane systematic review. Meta-analysis of overall response rate (ORR), disease control rate (DCR), change of KPS score, survival rate, the change of VEGF and rate of adverse effects was conducted using RevMan 5.2 software.

RESULTS: A total of 22 RCTs involving 1590 patients were included. The meta-analysis showed that compared with TACE alone, TLD combined with TACE was superior in ORR [relative risk (RR) = 1.29, 95% confidence interval (CI): 1.15-1.44], DCR (RR = 1.27, 95%CI: 1.16-1.39), change of KPS score [mean difference (MD) = 9.23, 95%CI: 6.90-11.55], 6-month survival rate (RR = 1.10, 95%CI: 1.01-1.20), 1-year survival rate (RR = 1.25, 95%CI: 1.13-1.39), 2-year survival rate (RR = 1.45, 95%CI: 1.18-1.78), 3-year survival rate (RR = 1.70, 95%CI: 1.16-2.50), and change of VEGF score (MD = -123.64, 95%CI: -143.72--103.55) (P < 0.05). TLD combined with TACE was associated with a higher incidence of drug rash compared with TACE alone (RR = 4.50, 95%CI: 2.34-8.64, P < 0.00001), although the two groups had comparable incidence of gastrointestinal reactions (RR = 1.08, 95%CI: 0.93-1.25), myelosuppression (RR = 1.12, 95%CI: 0.82-1.52), and liver dysfunction (RR = 1.00, 95%CI: 0.72-1.39) (P > 0.05).

CONCLUSION: The current research shows that compared with TACE alone, TLD combined with TACE was associated with higher ORR, DCR, change of KPS score, 0.5-, 1-, 2- and 3-year survival rates, and change of VEGF score, as well as a higher incidence of drug rash, although the incidence of gastrointestinal reactions, myelosuppression, and liver dysfunction was similar between the two groups.

Meta-analysis: preoperative transcatheter arterial chemoembolization does not improve prognosis of patients with resectable hepatocellular carcinoma

BACKGROUND

Long-term outcomes of partial liver resection of hepatocellular carcinoma (HCC) remain satisfactory due to high incidences of recurrence. This study was intended to see whether preoperative transcatheter arterial chemoembolization (TACE) reduces postoperative tumor recurrences and prolongs survival of patients with resectable HCC.

METHODS

A computerized literature search was performed to identify relevant articles. The quality of nonrandomized comparative studies (NRCTs) was assessed using the methodological index for nonrandomized studies (MINORS). Data synthesis was performed using Review Manager 5.0 software.

RESULTS

Twenty-one studies (4 randomized controlled trials and 17 NRCTs) with a total of 3,210 participants were suitable for analysis. There was no significant difference in disease-free and overall survival at 5-year (32.1% vs. 30.0% and 40.2% vs. 45.2%), and intra- and extra-hepatic recurrence (51.2% vs.53.6% and 12.9% vs.10.3%) between patients with and without preoperative TACE. Postoperative morbidity (28.9% vs. 26.8%) and in-hospital mortality (4.1% vs. 3.1%) were also similar between the two groups.

CONCLUSIONS

Preoperative TACE does not seem to improve prognosis and therefore it is prudent to recommend it as a preoperative routine procedure for resectable HCC.