同种异体原位肝移植14例次治疗经验

目的：总结终末期肝病患者同种异体肝移植手术的临床经验,介绍肝移植供体获取和受体手术的方法和术后处理方案。方法：对13例患者行14次手术(再次肝移植1例),其中乙肝肝硬化并肝癌7例,终末期乙肝肝硬化1例,丙肝肝硬化并“意外癌”1例,重症肝炎肝衰4例(1例为肝移植术后10个月,因乙肝复发,重型肝炎行二次肝移植术)。手术行改良背驮式5例,经典非转流术式9例次,其中1例行减体积肝移植(左肝外叶切除)。结果：手术移植物成活率100％,无原发性移植肝无功能和功能延迟恢复发生。手术成功率：良性终末期肝病和肝癌100％(9／9),重症肝炎为60％(3／5),总成功率为85．7％(12／14)。远期存活8例,存活1年以上5例。结论肝移植是治疗由各种急、慢性肝病导致的终末期肝功能衰竭和肝癌的有效方法。良性终末期肝病和早期肝癌的手术效果良好,明显优于重症肝炎和晚期肝癌。选择适当的手术时机,合理的手术方式,良好的供体质量,术中麻醉管理和术后早期ICU的围手术期管理,术后免疫抑制剂的应用,术后并发症处理是保证手术成功的重要条件。乙肝和肝癌等移植后易复发疾病的控制,对于提高肝移植术后患者的长期存活率非常重要。     

Selection criteria and decisions in 375 patients with liver disease,considered for liver transplantation during 1977–1985

ABSTRACT— We performed a prospective study on 375 patients with liver disease, 60% female, for whom orthotopic liver transplantation (OLT) was considered during 1977–1985. Fifty-four per cent had cirrhosis, 8.5% congenital/hereditary disorders, 25% malignant tumour, 6% benign tumour, 2% Budd-Chiari syndrome, 1.5% acute hepatic failure, 3% other diagnoses, and 10% were under 15 years of age. As of July Ist, 1985, 99 patients (47 chronic active/inactive cirrhosis (CAC/CIC), 28 primary biliary cirrhosis (PBC), five hepatocellular carcinoma (HCC), 19 other diagnoses) were accepted for OLT (median age 40 years, 10% under age 15). By that date, 45 patients (median age 42), had had an OLT (20 CAC/CIC, 15 PBC, three biliary atresia, two HCC, five other diagnoses). Fifty-four per cent (201 patients) were rejected for transplantation. The primary reasons for rejection were: no indication (11%), age (5%), other surgical procedures possible (3%), severe liver failure (14%), extrahepatic spread of liver tumour (11%), cardiovascular or pulmonary problems (2%), severe hepatic bone disease (1%), and miscellaneous (7%). Thirty per cent of the patients with CAC/CIC, 38% with PBC, 88% with HCC and 71% with biliary atresia were rejected. In the CAC/CIC, PBC and biliary atresia patients severe liver failure was the most frequent reason for rejection (62%, 50% and 60%, respectively). In HCC, extrahepatic tumour spread was the most frequent reason (72%) for rejection. In this category only two patients (7%) ultimately underwent liver transplantation.     

Diagnostic sensitivity of hepatocellular carcinoma imaging and its application to non-cirrhotic patients

Background and Aims: The American Association for the Study of Liver Disease issued guidelines that proposed that hepatocellular carcinoma (HCC) can be diagnosed if a mass is larger than 2 cm in a cirrhotic liver and shows typical features of HCC at triphasic liver computed tomography (CT) or dynamic magnetic resonance imaging (MRI). In non‐cirrhotic livers, the criteria were not applicable. The aim of the present study was to retrospectively analyze the sensitivity of imaging by samples of definite HCC postoperatively and test their application to diagnose HCC in non‐cirrhotic livers. Methods: From January 2006 to November 2008, a total of 343 pathologically‐diagnosed HCC patients via surgical resection were reviewed. Among the 343 patients, 204 patients had undergone liver CT examination, and 80 patients underwent MRI examination; serum α‐fetoprotein had been checked for all 343 patients prior to operation. The diagnostic sensitivity of HCC by imaging was evaluated and compared in patients with/without cirrhosis by ultrasound and histology. Results: The diagnostic sensitivity of HCC by single imaging was approximately 65–80% (liver CT or MRI). A higher sensitivity of HCC diagnosis was found in patients with ultrasound‐diagnosed cirrhosis than non‐cirrhosis, but the difference in sensitivity disappeared after histologically‐cirrhotic validation. The results indicated that regardless of the presence or absence of cirrhosis (histology), a typical vascular pattern could diagnose HCC with equally high sensitivity. Conclusions: We provide evidence that the sensitivity of HCC diagnosis by imaging is not influenced by the cirrhotic background. Further study is needed to validate the specificity and accuracy.     

Hepatic resection with and without surgical margins for hepatocellular carcinoma in patients with impaired liver function.

BACKGROUND/AIMS: The significance of a surgical margin for hepatic resection of hepatocellular carcinoma (HCC) in patients with impaired liver function was evaluated. METHODOLOGY: Sixty-eight patients, each with a solitary HCC, who had not received any prior treatments were divided into 2 groups, according to surgical margin: Group A included 25 patients who underwent resection with no margin (although the tumor was not exposed) and Group B included 43 patients with a sufficient surgical margin (mean distance: 9 mm). There were no significant differences in clinicopathologic variables between the 2 groups. The rate of stump recurrence, survival and recurrence-free survival were analyzed. RESULTS: Among the 38 patients who had cancer recurrence after a median follow-up of 58 months, 9 (Group A, n=4; Group B, n=5) (24%) had recurrent lesions at the stump. The surgical margin was not a significant factor related to survival or recurrence, irrespective of cirrhosis, capsule formation, cancer spread, or tumor size. CONCLUSIONS: Our results indicated that the HCC-free surgical margin is unlikely to be related to the survival of patients with impaired liver function unless the tumor is exposed on the raw liver surface.     

Surgical resection of hepatocellular carcinoma in elderly cirrhotic patients.

BACKGROUND/AIMS: Both cirrhosis and old age have been reported to be risk factors for hepatic resection. This study evaluated the clinical results of hepatic resection in elderly hepatocellular carcinoma (HCC) patients with cirrhosis. METHODOLOGY: During a 5-year period, 248 patients with HCC underwent curative hepatic resection. Among them, 24 elderly patients (age: > or = 70 years) with cirrhosis (Group I), 24 patients (age: > or = 70 years) without cirrhosis (Group II), and 98 patients (age: < 70 years) with cirrhosis (Group III) were selected for the study. The clinical and pathologic parameters, including pre-operative demographic features, surgical factors, pathological factors, DNA flow-cytometric analysis of the resected specimen, and post-resection prognosis were compared among the three groups. RESULTS: Group I patients had a significantly higher incidence of small-size tumors, hepatitis C infection, concomitant esophageal varices, and minor resection with a shorter surgical margin in the resected specimen. The surgical morbidity and mortality of Group I was similar to that of Group II and III patients. However, the disease-free survival rate was significantly lower in the Group I patients than in Group II (p = 0.02) and Group III patients (p = 0.04). CONCLUSIONS: Our findings indicate that although hepatic resection can be done safely in elderly cirrhotic HCC patients, the prognosis for these patients was less favorable even when curative resection was performed.     

Efficacy of major hepatic resection for large hepatocellular carcinoma

BACKGROUND/AIMS: A large hepatocellular carcinoma (HCC) generally carries a poor prognosis despite curative hepatic resection. However, some cases have had good outcomes without recurrences. In this study, we investigated the factors which predicted a good prognosis. METHODOLOGY: Sixty-six patients with large HCC greater than 5 cm who underwent curative hepatic resections were divided into two groups. There were 55 patients who had recurrences within 5 years after surgery (group A) and 11 patients who did not have recurrences at the fifth year after surgery (group B). We compared the clinicopathological features between the two groups. RESULTS: No differences were seen in the pre-operative liver function tests and the incidence of histological cirrhosis. The incidence of positive rate of histological recurrence factors, such as intrahepatic metastasis and incomplete surgical margins, was significantly less in group B. Five (45%) and 10 (91%) of 11 patients in group B underwent pre-operative portal vein embolization and major hepatic resection, respectively, while 10 (18%) and 29 (53%) of 55 patients in group A underwent these procedures (p < 0.05). CONCLUSIONS: In order to increase tumor-free survival rates for patients with large HCC greater than 5 cm, major hepatic resection after portal vein embolization with complete surgical margins should be performed.     

Preoperative transarterial chemoembolization for barcelona clinic liver cancer stage A/B hepatocellular carcinoma beyond the milan criteria: a propensity score matching analysis

BackgroundDebate continues about the benefits of preoperative transarterial chemoembolization (TACE) for treatment of hepatocellular carcinoma (HCC). This study aimed to assess the impact of preoperative TACE on long-term outcomes after curative resection for HCC beyond the Milan criteria.MethodsPatients who underwent HCC resection exceeding the Milan criteria without macrovascular invasion between 2015 and 2018 were identified (n = 393). Short- and long-term outcomes were compared between patients who underwent preoperative TACE and patients who did not before and after propensity score matching (PSM). Factors associated with recurrence after resection were analyzed.Results100 patients (25.4%) underwent preoperative TACE. Recurrence-free survival (RFS) and overall survival (OS) were comparable with patients who underwent primary liver resection. 7 patients (7.0%) achieved total necrosis with better RFS compared with patients who had an incomplete response to TACE (P=0.041). PSM created 73 matched patient pairs. In the PSM cohort, preoperative TACE improved RFS (P=0.002) and OS (P=0.003). The maximum preoperatively diagnosed tumor diameter (HR 3.230, 95% CI: 1.116–9.353; P=0.031) and hepatitis B infection (HR 2.905, 95%CI: 1.281–6.589; P=0.011) were independently associated with favorable RFS after HCC resection.ConclusionPreoperative TACE made no significant difference to perioperative complications and was correlated with an improved prognosis after surgical resection for patients with HCC beyond the Milan criteria.     

手术切除与射频消融治疗小肝癌的疗效比较

目的比较小肝癌手术切除与射频消融（RFA）初治后疗效及复发情况。方法收集吉林大学白求恩第一医院2002年1月至2008年12月接受手术或RFA初治的97例小肝癌患者资料,并对治疗后满2年的患者进行随访,共随访到63例,手术和RFA治疗分别为34和29例,回顾性分析两种方法治疗小肝癌患者的预后复发情况。计量资料采用χ2检验,利用Cox回归分析比较影响患者复发相关的危险因素,并应用Log-rank进行两种无瘤生存率检验。结果手术与射频消融治疗小肝癌3个月、1、2 a复发率分别15%、38%、64%,21%、35%、45%,两者差异无统计学意义。初治后复发与治疗方法、性别、年龄、Child-Pugh分级、肿瘤大小、结节数目、是否合并有肝硬化、甲胎蛋白水平相关性差异无统计学意义,两者无瘤生存率差异无统计学意义。结论 RFA与肝癌切除术在治疗小肝癌取得相近的治疗效果,RFA有望成为替代手术治疗的一种理想的治疗方法。     

Comparison of outcomes between patients with alcoholic cirrhosis and those with hepatitis C virus-related cirrhosis

Background and Aim:  The natural history of alcoholic cirrhosis, especially in Asian countries, has not been completely understood thus far.
Methods:  We retrospectively compared the outcomes of compensated cirrhosis between Japanese alcoholic and hepatitis C virus (HCV)-infected patients.
Results:  A total of 227 patients (75 alcoholic and 152 HCV-infected patients) with compensated cirrhosis were enrolled. The median follow-up period was 4.9 years. The cumulative rates of hepatocellular carcinoma (HCC) development were significantly lower in the alcoholic patients than in the HCV-infected patients (6.8% vs 50.3% at 10 years, P  = 0.0003), while the cumulative rates of hepatic decompensation (37.4% vs 51.7% at 10 years) and survival (53.8% vs 47.4% at 10 years) did not significantly differ between the two groups (Kaplan-Meir analysis). The main causes of death were hepatic failure and non-hepatic diseases in the alcoholic patients and HCC and hepatic failure in the HCV-infected patients. Multivariate analyses using the Cox proportional hazard model revealed that the risk of HCC was lower in alcoholic cirrhosis than in HCV-related cirrhosis (hazard ratio (HR), 0.46), while the risk of hepatic decompensation and mortality was the same. Predictors of decreased survival were non-abstinence (HR, 2.53) in the alcoholic patients and low serum albumin level (1.58) in the HCV-infected patients.
Conclusions:  Survival of patients with alcoholic cirrhosis was similar to that of patients with HCV-related cirrhosis. The risk of HCC development was lower in alcoholic cirrhosis than in HCV-related cirrhosis. Abstinence from alcohol was important for improving the survival of patients with alcoholic cirrhosis.     

FibroSURE and elastography poorly predict the severity of liver fibrosis in Fontan-associated liver disease

Objective: As the population of patients with Fontan circulation surviving into adult‐ hood increases, hepatic cirrhosis has grown to be a significant cause of morbidity and mortality. Early detection of advanced hepatic fibrosis is imperative for proper inter‐ vention and consideration for heart or combined heart/liver transplantation. Noninvasive biomarkers and elastography have been evaluated for their diagnostic utility with variable results in the Fontan population.
Design: The cohort included 14 patients age 26.4 SD 7.5 who underwent Fontan surgery. All patients were evaluated with FibroSURE, shear wave elastography (SWE), hepatic duplex sonography, and liver biopsy. Liver fibrosis on biopsy was evaluated according to the congestive hepatic fibrosis system.
Results: In our cohort, 100% of patients had fibrosis with 36% demonstrating ad‐ vanced fibrosis. FibroSURE agreed with liver biopsy in only 5 out of 14 cases (36%): underestimating in 7 and overestimating in 2 individuals. SWE agreed with liver bi‐ opsy in 0% of cases: overestimating in 10 and underestimating in 4 cases. None of the duplex sonography indices predicted the presence or severity of liver fibrosis.
Conclusion: This study demonstrates that children who have undergone a Fontan procedure universally develop some hepatic fibrosis and a significant number have advanced fibrosis by adulthood. The FibroSURE blood test, SWE, and hepatic duplex sonography were unable to accurately predict the presence or severity of hepatic fibrosis when compared with liver biopsy. Further studies are needed to investigate novel noninvasive methods and/or biomarkers that can adequately detect advanced hepatic fibrosis before the development of cirrhosis and hepatic decompensation.     

Diagnostic laparoscopy in the evaluation of the viral hepatitis patient with potentially resectable hepatocellular carcinoma

Background. Despite significant recent improvements in liver imaging, preoperative evaluation of the potentially resectable patient with viral Hepatitis and Hepatocellular Carcinoma (HCC) is often inaccurate. Diagnostic laparoscopy may change management for patients with under-appreciated nodular cirrhosis or intrahepatic metastases, preventing unnecessary open exploration. The purpose of this study is to determine the effectiveness of routine laparoscopy as a separate procedure prior to resection in the evaluation of patients with potentially resectable HCC. Methods. Patients with potentially resectable HCC were evaluated preoperatively with routine blood tests and axial imaging. All study patients also underwent diagnostic laparoscopy with laparoscopic ultrasonography. Laparoscopy was performed in an inpatient hospital setting, with 23 hour stays in most cases. Results. Among 65 patients evaluated with Hepatocellular Carcinoma between July 2001 and November 2003, 20 patients with potentially resectable disease were evaluated by diagnostic laparoscopy. All patients had viral Hepatitis: 16 with Hepatitis B and 4 with Hepatitis C. All study patients had cirrhosis; 18 classified as Child''s-Pugh A and 2 as Child''s-Pugh B. Diagnostic laparoscopy changed the management in 9/20 (45%) cases. Management was changed because of severe nodular cirrhosis in 4 cases, inaccurate assessment of intrahepatic metastases in 2 cases, inability to identify an HCC in 1 case, peritoneal carcinomatosis in 1 case, and inability to tolerate induction to general anesthesia in 1 case. Discussion. Diagnostic laparoscopy is useful in the evaluation of the potentially resectable patient with HCC. Information obtained from laparoscopy may change the clinical management in up to 45% of cases.     

Hepatic primary and secondary malignancies: comparison of helical CT and helical CT during arterial portography

BACKGROUND/AIMS: To compare the sensitivity of helical CT to that of helical CT arterial portography in the detection of hepatic primary or secondary malignancies, in 20 patients who subsequently underwent surgery to confirm findings. METHODOLOGY: Twenty patients with suspected primary hepatic or secondary malignancies who all underwent helical CT and helical CT arterial portography preoperatively were prospectively evaluated. All the images were reviewed by two radiologists. The results were subsequently correlated with surgical and pathological findings. The sensitivity and the positive predictive values for lesion detection were determined for each modality. RESULTS: There were 39 pathologically confirmed hepatic malignant lesions. The overall sensitivity and positive predictive value of helical CT arterial portography were 87.1% and 82.5%, respectively, while of helical CT were 84.6% and 94.2%, respectively. CONCLUSIONS: Helical CT arterial portography and helical CT of the liver were approximately equivalent for lesion detection in patients who were evaluated preoperatively for resection of liver malignancies. The lower cost and non-invasive nature of helical CT suggest that it should be the preferred modality.     

Effects of branched-chain amino acids-enriched nutrient support for patients undergoing liver resection for hepatocellular carcinoma

Background and Aims: Most patients with hepatocellular carcinoma (HCC) have underlying liver cirrhosis that is frequently associated with a state of protein energy malnutrition. The aim of this study was to evaluate the clinical benefit of perioperative supplementation of a branched‐chain amino acid–enriched nutrient‐mixture for patients undergoing liver resection for HCC. Methods: A total of 112 patients with HCC who underwent hepatic resection were enrolled in this study. These patients were divided into two groups: 40 patients received perioperative supplementation of branched‐chain amino acid–enriched nutrient‐mixture (AEN group) and 72 patients did not (control group). Laboratory data, postoperative complications, duration of hospitalization, and survival were assessed for each group and compared. Results: The overall incidence of postoperative complications was lower in the AEN group (17.5%) than in the control group (44.4%) (P = 0.01). Among the postoperative complications, surgical site infection and bile leakage was observed in 5% of patients in the AEN group and in 15.3% and 12.5% of patients in the control group, respectively. Ascites appeared after the surgery in 7.5% of patients in the AEN group and in 16.7% of patients in the control group. The duration of hospitalization was significantly shorter in the AEN group was than in the control group (P < 0.05). Conclusions: This study strongly suggests that perioperative supplementation of a branched‐chain amino acid–enriched nutrient‐mixture is clinically beneficial in reducing the morbidity associated with postoperative complications and in shortening the duration of hospitalization of patients with chronic liver disease who undergo liver resection for HCC.     

Risk factors and surgical outcomes for spontaneous rupture of BCLC stages A and B hepatocellular carcinoma: A case-control study

AIM: To investigate the risk factors and surgical outcomes for spontaneous rupture of Barcelona Clinic Liver Cancer (BCLC) stages A and B hepatocellular carcinoma (HCC).METHODS: From April 2002 to November 2006, 92 consecutive patients with spontaneous rupture of BCLC stage A or B HCC undergoing hepatic resection were included in a case group. A control arm of 184 cases (1:2 ratio) was chosen by matching the age, sex, BCLC stage and time of admission among the 2904 consecutive patients with non-ruptured HCC undergoing hepatic resection. Histological confirmation of HCC was available for all patients and ruptured HCC was confirmed by focal discontinuity of the tumor with surrounding perihepatic hematoma observed intraoperatively. Patients with microvascular thrombus in the hepatic vein branches were excluded from the study. Clinical data and survival time were collected and analysed.RESULTS: Sixteen patients were excluded from the study based on exclusion criteria, of whom 3 were in the case group and 13 in the control group. Compared with the control group, more patients in the case group had underlying diseases of hypertension (10.1% vs 3.5%, P = 0.030) and liver cirrhosis (82.0% vs 57.9%, P < 0.001). Tumors in 67 (75.3%) patients in the case group were located in segments II, III and VI, and the figure in the control group was also 67 (39.7%) (P < 0.001). On multivariate analysis, hypertension (HR = 7.38, 95%CI: 1.91-28.58, P = 0.004), liver cirrhosis (HR = 6.04, 95%CI: 2.83-12.88, P < 0.001) and tumor location in segments II, III and VI (HR = 5.03, 95%CI: 2.70-6.37, P < 0.001) were predictive for spontaneous rupture of HCC. In the case group, the median survival time and median disease-free survival time were 12 mo (range: 1-78 mo) and 4 mo (range: 0-78 mo), respectively. The 1-, 3- and 5-year overall survival rates and disease-free survival rates were 66.3%, 23.4% and 10.1%, and 57.0%, 16.8% and 4.5%, respectively. Only radical resection remained predictive for overall survival (HR = 0.32, 95%CI: 0.08-0.61, P = 0.015) and disease-free survival (HR = 0.12, 95%CI: 0.01-0.73, P = 0.002).CONCLUSION: Tumor location, hypertension and liver cirrhosis are associated with spontaneous rupture of HCC. One-stage hepatectomy should be recommended to patients with BCLC stages A and B disease.     

Liver resection for HCC: analysis of causes and risk factors linked to postoperative complications

BACKGROUND/AIMS: Hepatic resection is widely accepted as the best treatment for localized hepatocellular carcinoma (HCC), even in those patients affected by cirrhosis after a sharp selection. Notwithstanding technical advances and high experience of liver resection of specialized centers, the rate of complication after surgical resection could be high. Herein we analyzed causes and foreseeable risk factors on the grounds of data derived from a single center surgical population. METHODOLOGY: From September 1989 to March 2005, 134 consecutive patients had liver resection for HCC on cirrhosis at our department. We performed 54 major liver resections and 80 limited resections. RESULTS: In-hospital mortality rate was 7.4%, about 50% of these cases were Child-Pugh B patients. Morbidity rate was 47.7%, caused by the rising of ascites, hepatic insufficiency, biliary fistula, hepatic abscess, hemoperitoneum and pleural effusion. Intraoperative mortality resulted to be influenced by the amount of resected liver volume (p < 0.05), and the rising of complication (p = 0.006). Some technical aspects of surgical procedure are responsible of the rising of complication as: Pringle maneuver length (p = 0.02), the amount of resected liver volume (p = 0.03) and the request of blood transfusion (p = 0.03). CONCLUSIONS: Complications that arise during the postoperative period, although treatable, delay patient's recovery and resumption of liver function; the evaluation of causes and foreseeable risk factors linked to postoperative morbidity during the planning of surgical treatment should play the same role as other factors weighted in the selection of patients eligible for liver resection.     

Indications for hepatectomy for hepatocellular carcinoma — What stage of the disease is the best indication for surgery?

To determine the clinical and tumor stage of hepatocellular carcinoma (HCC) that is the best indication for surgery, the postoperative long-term outcomes of patients who underwent hepatic resection were examined retrospectively. Of 975 patients with HCC who underwent regional therapy, 384 patients (39%) received hepatic resection (HR), 534 (55%) had transcatheter arterial chemoembolization (TACE), and the remaining 57 (6%) received percutaneous ethanol injection (PEI) into the tumor. The criteria defined by liver Cancer Study Group of Japan was used for staging and liver functional reserve (i.e., clinical staging).¹ In the 133 patients with stage I HCC, there were no significant differences among the survivals of the HR, TACE, and PEI groups. In the 314 patients with stage II HCC, the 5- and 7-year survival rates were 51% and 46% in the HR group, 23% and 10% in the TACE group, and 0% and 0% in the PEI group. The survival of the HR group was significantly better than the survivals of the TACE and PEI groups (P < 0.001). The 5- and 10-year survivals of the stage II HCC patients who had HR were 64% and 47% in the clinical stage I (i.e., good liver function) group, significantly better than the 5; and 10-year survivals (32% and 23%) in the clinical stage II (i.e., bad liver function) group (P < 0.0001). Patients with good liver function in stage II are expected to have better survival and are considered to be the most suitable for HR.     

Emergency liver resection for ruptured hepatocellular carcinoma complicating cirrhosis.

BACKGROUND/AIMS: From a consecutive series of 51 patients surgically treated from January 1993 to August 1997 for hepatocellular carcinoma (HCC) complicating cirrhosis, 6 subjects (12%) presented with acute hemoperitoneum due to spontaneous rupture of the tumor: 3 patients were suffering from chronic hepatitis C, 2 were affected by alcoholic cirrhosis, and one by chronic hepatitis B. The present paper reports experience of the treatment of ruptured HCC complicating cirrhosis in 6 patients undergoing emergency hepatectomy. METHODOLOGY: Hemoperitoneum was successfully diagnosed pre-operatively with the combination of abdominal ultrasound (US) and paracentesis. All subjects had a known history of chronic liver disease, but undiagnosed HCC. Child-Pugh classification assessed the hepatic functional reserve to predict operative risk. Surgical indication was based on hemodynamic instability and/or persistent bleeding. Time from admission to operation was recorded as well as tumor site, size and number, the site of bleeding, and the duration of surgery and hepatic devascularization. Tumor location was defined according to segmental anatomy. All patients underwent one-stage liver resection (segmentectomy VII-VIII in one patient; non-anatomical wedge resections in 5). Operative mortality was defined as death within 30 days of surgery. RESULTS: No intra-operative death occurred. In 4 patients the post-operative course was uneventful. Two patients died 2 weeks after surgery from liver failure (one patient) eventually complicated by renal failure (one patient). Three patients are alive and 2 of them disease-free at 24 months after surgery, whilst one patient has died from liver failure 21 months after surgery in the presence of intrahepatic recurrence of HCC. CONCLUSIONS: Present experience, combined with a literature review on 755 ruptured HCC cases, indicates that emergency liver resection is feasible in patients with limited tumor and preserved liver function (Child-Pugh A or B grade); surgical resection is the only procedure possibly associated with long-term survival, as shown by 4/6 patients of ours surviving more than 12 months, with 2 subjects disease-free at 24 months. Conservative management, such as surgical/radiological devascularization, packing or plication, can be conducted on high risk patients, though long-term survivors have not been reported.     

The role of living-donor liver transplantation in surgical treatment for hepatocellular carcinoma

Background/Purpose

The role of living-donor liver transplantation (LDLT) in the surgical treatment of patients with hepatocellular carcinoma (HCC) has not been established as yet.

Methods

Preliminary experience gained from 24 patients who underwent LDLT for HCC between March 2002 and November 2004, and the results of the 131 patients who underwent hepatic resection (HR) for HCC between January 1990 and December 2003 were retrospectively analyzed. The exclusion criteria for LDLT for HCC included extrahepatic metastasis and major vascular invasion.

Results

(1) LDLT: the median age of the patients was 57 years and the Child-Pugh grades (A/B/C) of the patients were 6, 12, and 6, respectively. The tumor size was 3?cm or less in 15 patients, multinodular tumors were present in 23 patients, and 11 patients (45.8%) met the Milan Criteria. The overall 2-year survival rate was 72.3%, without a significant difference as to whether or not patients met the Milan criteria. (2) HR: on multivariate analysis, the Child-Pugh grade, the presence of cirrhosis, and the number of tumor nodules were considered as independent risk factors for unfavorable survival (P < 0.05). The 84 patients who met the Milan criteria and were Child-Pugh grade A had a 5-year survival rate of 71.3%; this was significantly better than those of the other patients (P < 0.005). Among the 57 patients with intrahepatic recurrence, 18 patients who were Child-Pugh grade A, met the Milan criteria, and were treated by re-resection or ablation therapy achieved a significantly better 5-year survival rate, of 73.1%, as compared to 19.7% in the other 39 patients (P < 0.0045).

Conclusions

HR could be a first-line treatment with a favorable prognosis for patients who have resectable HCC, preserved liver function, and who meet the Milan criteria. Salvage LDLT could be employed in patients with recurrent tumors that cannot be controlled by conventional treatment or in patients in whom liver function has deteriorated to Child-Pugh grade B or C.     

Current management of patients with hepatocellular carcinoma

The current management therapies for hepatocellular carcinoma(HCC) patients are discussed in this review. Despite the development of new therapies, HCC remains a "difficult to treat" cancer because HCC typically occurs in advanced liver disease or hepatic cirrhosis. The progression of multistep and multicentric HCC hampers the prevention of the recurrence of HCC. Many HCC patients are treated with surgical resection and radiofrequency ablation(RFA), although these modalities should be considered in only selected cases with a certain HCC number and size. Although there is a shortage of grafts, liver transplantation has the highest survival rates for HCC. Several modalities are salvage treatments; however, intensive care in combination with other modalities or in combination with surgical resection or RFA might offer a better prognosis. Sorafenib is useful for patients with advanced HCC. In the near future, HCC treatment will include stronger molecular targeted drugs, which will have greater potency and fewer adverse events. Further studies will be ongoing.     

Hepatic resection for hepatocellular carcinoma in diameter of > or = 10 cm

BACKGROUND/AIMS: Definitive efficacy of hepatic resection for hepatocellular carcinoma larger than or equal to 10 cm in diameter remains to be resolved. METHODOLOGY: The surgical outcomes in 33 consecutive patients with hepatocellular carcinoma in diameter of > or = 10 cm who underwent hepatic resection were retrospectively clarified. Postresection prognostic factors were evaluated by univariate and multivariate analysis using Cox's proportional hazards model. RESULTS: The overall incidence of postoperative complications was 39%, and 5 patients among them had hospital deaths (15%) including 2 (6%) operative deaths. The 3-year, 5-year, and 9-year overall survival rates after hepatic resection were 32%, 27%, and 17%, respectively. Univariate analysis revealed that liver cirrhosis and stage IV-A (pTNM staging) were significant factors of poor overall survival. By Cox's proportional hazards model, liver cirrhosis was an independently unfavorable prognostic factor of long-term survival. Hospital mortality rate in patients with cirrhosis was 31%. The 5-year overall survival rate in patients with cirrhosis (7%) was significantly shorter than that in patients without cirrhosis (43%) (P = 0.006). In addition, the 5-year overall survival rate in patients with stage IV-A (11%) was significantly shorter than that in patients with stage II and III (48%) (P = 0.024). The incidence of stage IV-A in patients with cirrhosis (77%) was significantly higher than those without cirrhosis (35%) (P = 0.032). CONCLUSIONS: Hepatic resection for hepatocellular carcinoma in diameter of > or = 10 cm was effective for patients without liver cirrhosis and with stage II or III. Appropriate selection of the candidates for partial hepatectomy based on the above prognostic factors may play an important role in the improvement of high mortality rate and poor long-term survival for such patients. Prospective randomized trials are needed to define the role of hepatic resection for cirrhotic patients with large HCC.