Safety of hepatectomy for elderly patients with hepatocellular carcinoma

The number of elderly patients with hepatocellular carcinoma (HCC) has been increasing. Characteristics of elderly HCC patients are a higher proportion of females, a lower rate of positive hepatitis B surface antigen, and a higher rate of positive hepatitis C antibodies. Careful patient selection is vital for performing hepatectomy safely in elderly HCC patients. Treatment strategy should be decided by not only considering tumor stage and hepatic functional reserve, but also physiological status, including comorbid disease. Various assessment tools have been applied to predict the risk of hepatectomy. The reported mortality and morbidity rates after hepatectomy in elderly HCC patients ranged from 0% to 42.9% and from 9% to 51%, respectively. Overall survival rate after hepatectomy in elderly HCC patients at 5 years ranged from 26% to 75.9%. Both short-term and long-term results after hepatectomy for strictly selected elderly HCC patients are almost the same as those for younger patients. However, considering physiological characteristics and the high prevalence of comorbid disease in elderly patients, it is important to assess patients more meticulously and to select them strictly if scheduled to undergo major hepatectomy.     

Ultrasonic aspiration hepatectomy for 136 patients with hepatocellular carcinoma

AIM：To study the operativ injury,post-operative complications,the hospitalization time,the post-operative survival rate of ultrasonic aspiration hepatectomy with a domestic new type of ultrasonic surgical device in comparison with that of conventional techniques of hepatectomy.METHODS:A total136patients with hepatocellular carcinoma(HCC,including 13patinents in 1991and 124consecutive patients from July1995to December2000)underwent ultrasonic aspiration in liver resection(groupT)and 179 HCCpatients received conventional hepatectomy during the corresponding period(groupC).The results of the two groups were compared statistically.RESULTS:There was no significant difference in the mean operation time between groupT(152±11min)and C(144±11min).No operation or hospital edath occurred in both groups.In groupT,the mean volumes of bleeding(463±15ml)and bolld transfusion(381±12ml)were markedly less than those in groupC(557±20ml,and507±18ml,respectively,P<0.05).The mean hospitalization time of groupT(8.9±0.6d)was markedly shorter than that of groupC(11.7d±0.6d)(P<0.05).The incidence of complications in groupTwas markedly lower than in groupC,post-operative jaundice occurred in4/136and31/179,respectively(P<0.05).liver failurein0/136and2/179,cholorrhea in0/136and6/179,hydrothoraxin21/136and39/179(P<0.05).ascices in9/136and2/179,cholrrheain0/136and6/179,hydrothorax in21/136and 39/179(P<0.05),ascices in 9/136and 54/179,respectively(P<0.05),while the 3-year survival rate of groupT(64.2%)increased markedly as compared with that of groupC(55.7%)(P<0.01).CONCLUSION:The ultrasonic aspiration hepatectomy with a domestic new type of ultrasonic surgical device could evidently reduce the operative injury and post-operative complications,shorten the hospitalization,time and prolong the survivals of HCC,patients.     

Laparoscopic hepatectomy for hepatocellular carcinoma in cirrhotic patients

Introduction

We have used laparoscopic hepatectomy as a surgical treatment for HCC in patients with cirrhosis. We describe the indications, evaluate invasiveness and analyze the outcomes of laparoscopic hepatectomy.

Methods and Results

With respect to operative method, laparoscopic hepatectomy involving either partial hepatectomy or left lateral sectionectomy is a less invasive procedure in patients with cirrhosis than conventional hepatectomy. Among our laparoscopic hepatectomy cases, operative time was shorter and bleeding was less in recent, as compared to earlier, cases. Furthermore, laparoscopic hepatectomy was less invasive than conventional hepatectomy, as determined by the E-PASS scoring system. Patients also recovered more quickly, which resulted in shorter hospital stays even for patients with cirrhosis. Both the 5-year survival rate and the rate of survival without recurrence of HCC were nearly identical to those of open conventional hepatectomy.

Conclusion

These findings indicate that laparoscopic hepatectomy avoids the disadvantages of standard hepatectomy for HCC in properly selected patients with cirrhosis and that its minimal invasiveness improves patients’ quality of life.     

Analysis of factors affecting long-term survival of patients with hepatocellular carcinoma following hepatectomy

The survival of 200 patients (172 males, 28 females; mean age ± SD: 53.6 ± 12 years) who underwent hepatectomy for hepatocellular carcinoma (HCC) was analyzed retrospectively to identify prognostic determinants to guide patient selection for appropriate treatment. All patients studied had had complete macroscopic extirpation of their tumor, histologic information regarding their lesions and the adjacent non-tumorous liver parenchyma, and no evidence of residual or recurrent disease 30 days after surgery. Survival was analyzed with reference to 25 different clinical (n=7), serological (n=2), macroscopic (n=4), and histological (n=12) features of the resected specimens, by using multivariate analysis. Recurrent HCC was detected in 138 patients within a median follow-up period of 12.6 months. While 33 patients had extra-hepatic disease alone, in 74, the recurrence was confined to the hepatic remnant. Survival at 1, 3, and 5 years was 58%, 34%, and 26%, respectively. The presence of residual histologic disease at the resection margin was found to be the only important prognostic determinant (P < 0.02). The distance of the macroscopic resection margin, either at 1 or 2 cm, made no difference to the long-term outcome of our patients. Following hepatectomy, a detailed pathologic examination of the resected liver specimen is mandatory to verify the status of disease clearance, as the distance of the gross surgical margin is an unreliable index.     

Outcome of hepatectomy in super-elderly patients with hepatocellular carcinoma

Aim: The aim of this study was to investigate the characteristics of super‐elderly hepatocellular carcinoma (HCC) patients aged 80 years or more who underwent hepatectomy and to clarify whether elderly patients with HCC benefit from hepatectomy. Methods: Between March 1992 and December 2008, 278 patients who underwent curative hepatectomy for HCC were investigated. Super‐elderly patients were defined as those aged 80 years or more. Clinicopathological data and outcomes after hepatectomy were compared between super‐elderly and non‐super‐elderly groups. Results: Preoperative parameters, such as biochemical examinations, and liver function tests in the non‐super‐elderly group were comparable with those of the super‐elderly group (n = 11). Exceptionally, albumin level in the super‐elderly group was lower than that in the non‐super‐elderly group (P = 0.03). Surgical data and the prevalence of postoperative complications did not differ significantly between the two groups. No mortality was observed in the super‐elderly and non‐super‐elderly group. Conclusions: Hepatectomy for HCC was a feasible option even in super elderly patients aged 80 years or older with accurate selection.     

Outcome of hepatectomy for hepatocellular carcinoma in patients with renal dysfunction

Objectives

There are few reports on the efficacy of hepatectomy for hepatocellular carcinoma (HCC) in patients with renal dysfunction (RD). This study aimed to clarify the validity of hepatectomy for treating HCC in RD patients, and to compare postoperative courses in RD and non-RD patients.

Methods

The clinical features of 722 HCC patients who underwent curative hepatectomy between 1986 and 2009 were retrospectively reviewed. Seventeen patients (2.4%) with preoperative serum creatinine levels of >2.0 mg/dl were defined as the RD group, and, of these, seven who did not receive preoperative haemodialysis were defined as borderline patients. Clinicopathological characteristics and postoperative outcomes were compared between the RD group (n = 17) and the non-RD group (n = 705). The postoperative courses of borderline patients were reviewed in detail.

Results

Overall survival (P = 0.177) and disease-free survival (P = 0.942) after hepatectomy did not differ significantly between the groups. Incidences of massive ascites (35.3% vs. 14.3%; P = 0.034) and pleural effusion (52.9% vs. 17.6%; P = 0.001), defined as massive effusion (ME), were significantly higher in the RD group than in the non-RD group. Hypoalbuminaemia (≤2.8 g/dl; P = 0.031), heavy blood loss (≥1000 ml; P = 0.012) and intraoperative blood transfusion (P = 0.007) were risk factors for ME. Among the borderline patients, serum creatinine values were not increased immediately after surgery and four patients underwent haemodialysis.

Conclusions

Preoperative hypoalbuminaemia, heavy blood loss and blood transfusion are independent risk factors for ME in RD patients. Preoperative improvement of anaemia and reduction of blood loss by meticulous surgical techniques may prevent ME in RD patients who require hepatectomy for HCC.     

Incidence and risk factors for hepatocellular carcinoma in 967 patients with cirrhosis

Purpose: To determine the incidence of hepatocellular carcinoma in cirrhosis and to examine the influence of age and sex, and the contribution of etiological factors. Methods: 967 patients with liver cirrhosis and free of hepatocellular carcinoma were enrolled in this longitudinal, retrospective and observational study. Monitoring for hepatocellular carcinoma was scheduled at 3- to 6-month intervals. The mean (±SD) length of follow-up was 60.3 ± 51.7 months (range 6–258). Results: During the observation period, hepatocellular carcinoma developed in 64 patients. The calculated annual incidence was 2.1%. The probability of being free of liver cancer was 92% at 5 years, 80% at 10 years, and 69% at 15 years. Age was the only independent risk factor for the development of malignancy in the multivariate analysis. There were no differences according to male sex, alcohol abuse, and chronic hepatitis B and C virus infection. Conclusions: The annual incidence of hepatocellular carcinoma was 2.1%. These results, although confirming that age is a risk factor for hepatocellular carcinoma in cirrhosis, indicate that alcohol abuse, male sex, and concurrent hepatitis B and C virus infection do not involve a higher risk of developing liver cancer.     

Poor prognostic factors of hepatectomy in patients with resectable small hepatocellular carcinoma and cirrhosis

Purpose Some patients with hepatocellular carcinoma (HCC) at an early stage cannot attain long-term survival after hepatectomy. The aim of the present study was to investigate the poor prognostic factors for hepatectomy in patients with resectable small HCC with cirrhosis.Methods We studied 95 patients with cirrhosis with HCC, which consisted of a single tumor 5 cm or smaller or two or three tumor nodules each 3 cm or less; an absence of extrahepatic metastasis; and an absence of radiological evidence of macroscopic portal vein or hepatic vein invasion. We used Coxs proportional hazard model to identify risk factors associated with prognosis to determine the contra-indications for hepatectomy in patients with resectable small HCC.Results Preoperative risk factors were: (1) serum AFP concentration of more than 400 ng/ml; (2) infiltrative-, massive-, or multinodular-type (multiple) HCC; and (3) the presence of intrahepatic metastasis. Patients who had had more than one of the three preoperative risk factors were poor candidates for hepatic resection, with a 4-year survival of 16.3%.Conclusion If patients with resectable small HCC are diagnosed as having more than one of three preoperative risk factors, they should not receive hepatectomy or should be considered for primary liver transplantation as a therapeutic option for HCC.     

肝细胞癌发病危险因素Logistic回归分析*

目的 探讨肝细胞癌发病的危险因素。方法 2019年1月～2021年1月青海省第四人民医院消化科和青海大学附属医院介入科确诊为肝细胞癌(HCC)患者150例,收集患者临床资料,采用Logistic回归分析法行单因素和多因素分析。结果 单因素Logistic回归分析显示,年龄、肝癌家族史、饮酒史、血小板计数、HBsAg阳性、血清HBV DNA和肝硬化等7个因素具有显著性意义,多因素Logistic回归分析显示,年龄(P=0.001,OR=1.077)、肝癌家族史(P=0.008,OR=4.351)、血小板计数异常(P=0.004,OR=9.071)、HBsAg阳性(P＜0.001,OR=16.418)、HBV DNA(P=0.004,OR=6.345)和肝硬化(P＜0.001,OR=9.315)为HCC发生的独立危险因素。结论 了解HCC发生的危险因素有助于预防,及时抗病毒和预防肝硬化的发生可能非常有意义。     

Prospective analysis of risk factors for hepatocellular carcinoma in patients with liver cirrhosis

Better knowledge of the risk factors associated with the appearance of hepatocellular carcinoma (HCC) could improve the efficacy of surveillance programs. A total of 463 patients aged 40 to 65 years with liver cirrhosis in Child-Pugh class A or B were included in a program of early diagnosis. The predictive value of different risk factors was evaluated using the Kaplan-Meier method and Cox regression model. Thirty-eight patients developed HCC. In the multivariate analysis, 4 variables showed an independent predictive value for the development of HCC: age 55 years or older, antibody to hepatitis C virus (anti-HCV) positivity, prothrombin activity 75% or less, and platelet count less than 75 x 10(3)/mm(3). According to the contribution of each of these factors to the final model, a score ranging between 0 and 4.71 points was constructed to allow the division of patients into 2 different risk groups. The low-risk group included those with a score of 2.33 points or less (n = 270; 4 with HCC; cumulative incidence of HCC at 4 years, 2.3%), and the high-risk group included those with a score greater than 2.33 (n = 193; 34 with HCC; cumulative incidence of HCC at 4 years, 30.1%) (P =.0001). In conclusion, a simple score made up of 4 clinical and biological variables allowed us to distinguish 2 groups of cirrhotic patients at high and low risk for the development of HCC. We believe this score can be useful in establishing a subset of cirrhotic patients in whom a surveillance program for early detection of HCC could be unjustified.     

Malnutrition associated with an increased risk of postoperative complications following hepatectomy in patients with hepatocellular carcinoma

BackgroundThe aim of this study was to analyze the nutritional risk factors for postoperative complications following hepatic resection for hepatocellular carcinoma (HCC).MethodsThe preoperative nutritional status of patients with HCC who underwent hepatic resection was evaluated using the scored Patient-Generated Subjective Global Assessment (PG-SGA). The perioperative variables were compared between well-nourished and malnourished patients. Regression analysis was employed to identify the risk factors for postoperative complications.ResultsThe overall operative mortality and morbidity of 287 patients who underwent resection for HCC were 1.7% and 44.3%, respectively. Upon admission, 96 (33.4%) study participants were malnourished, which was associated with a significantly higher PG-SGA score (P < 0.001), higher frequency of comorbidity (P < 0.001), more postoperative complications (P < 0.001) and a longer length of hospital stay (P < 0.001). In addition, major complications (Clavien-Dindo classification ≥ IIIa) occurred significantly more frequently in the malnourished group (P < 0.01). Age ≥70 years (risk ratio [RR] = 2.50, P = 0.008) and PG-SGA score ≥ 4 ([RR] = 9.85, P < 0.001) were significant risk factors for postoperative complications.ConclusionsThe PG-SGA score is an effective tool for predicting postoperative complications in patients with HCC following hepatic resection.     

Ten-year survival of patients with hepatocellular carcinoma after hepatectomy

BACKGROUND/AIMS: The characteristics in patients with hepatocellular carcinoma who survive more than 10 years after hepatectomy remain unclear. METHODOLOGY: Eighty-five cases of hepatocellular carcinoma were retrospectively identified as short-term survivors (S-group: <5 years, n=41), medium-term survivors (M-group: > or =5 and <10 years, n=25), and long-term survivors (L-group: > or =10 years, n=19) to examine the clinicopathologic factors for the 10-year survival after curative hepatectomy. RESULTS: In the L-group, platelet count and albumin level were higher and total bilirubin level was lower than those in the S-group. In the S-group, the total bilirubin level was higher and vascular invasion was more frequent than those in the M-group. Multiple regression analysis revealed that only host-related factors such as age, albumin level, and total bilirubin level were selected as significant factors to determine the 10-year survival. However, no tumor-related factor was selected. CONCLUSIONS: The present study suggests that the important factor linked to the 10-year survival of hepatocellular carcinoma patients is the host-related factor, but not the tumor-related factor. Especially, younger age, higher albumin level, and lower total bilirubin level are quite important to determine the 10-year survival.     

肝癌肝切除术后肝衰竭危险因素的Meta分析

目的探讨我国肝癌肝切除术后肝衰竭(PHLF)发生的危险因素,为预测和预防术后肝衰竭的发生提供理论依据。方法检索中国生物医学文献服务系统、维普、中国知网、万方等数据库,并辅以手工检阅相关论文及其参考文献,收集我国自1990年1月至2013年6月期间公开发表的有关PHLF危险因素的相关文献,运用Meta分析方法进行合并分析。结果共纳入11项研究,2859例肝癌手术切除患者。Meta分析结果显示术前Child-Pugh A级PHLF发生率明显低于对照组(合并OR值为6.28,95%CI:4.55~8.65);术前前白蛋白水平低于170 mg/dl组患者术后肝衰竭发生率增高(合并OR值为4.96,95%CI:3.03~8.10);合并肝硬化组术后肝衰竭发生率高于未合并肝硬化组(合并OR值为4.14,95%CI:2.46~6.98);术中失血量1000 ml组术后肝衰竭发生率较对照组低(合并OR值为5.62,95%CI:3.46~9.11);肿瘤直径10 cm组(合并OR值为2.69,95%CI:1.58~4.57)及切肝范围半肝组(合并OR值为1.64,95%CI:1.12~2.40)肝衰竭发生率均低于对照组;年龄≥60岁(合并OR值为1.73,95%CI:1.25~2.39)、术中输血(合并OR值为3.79,95%CI:2.20~6.51)增加术后肝衰竭发生率。性别、术中是否阻断入肝血流与术后肝衰竭发生无相关性(P0.05)。结论年龄、术前Child-Pugh分级、前白蛋白水平、术中失血量、肿瘤直径、切肝范围、合并肝硬化、术中输血等是影响PHLF发生的危险因素。     

Risk factors for postoperative liver failure after hepatectomy for hepatocellular carcinoma

BACKGROUND/AIMS: Selection of patients for hepatectomy for hepatocellular carcinoma conventionally has been based upon Child-Pugh grading. However, postoperative liver failure after hepatectomy is a major cause of hospital mortality. A new predictor of postoperative liver failure is required. The objective of this study was to identify risk factors for postoperative liver failure after hepatectomy. METHODOLOGY: Perioperative risk factors for liver failure after hepatectomy were analyzed in 112 patients with hepatocellular carcinoma Eight of these patients died of liver failure. Stepwise multivariate logistic regression was performed to investigate significant independent factors among 17 variables, including the serum alkaline phosphatase ratio (ALPR) on the first day after hepatectomy. ALPR was calculated as the postoperative ALP level divided by the ALP level before surgery. RESULTS: Significant risk factors of postoperative liver failure were ALPR on postoperative day 1 (ALPR1), sex, operative blood loss, and operative procedure. As an indicator of liver failure, the diagnostic accuracy of the ALPR1 was 93.7% when the ALPR was less than 0.4 on the first postoperative day. The ALPR and the serum total bilirubin concentration after hepatectomy were uncorrelated. CONCLUSIONS: ALPR1 is a useful predictor of liver failure after hepatectomy.     

Incidence and risk factors for surveillance failure in patients with regular hepatocellular carcinoma surveillance

Background

Initial presentation of hepatocellular carcinoma (HCC) at an advanced stage in patients under a regular surveillance program is a devastating problem.

Aims

We assessed the prevalence and factors associated with this surveillance failure.

Methods

A total of 304 HCC patients who received regular surveillance were retrospectively reviewed. Surveillance failure was defined when the tumor was diagnosed at beyond the Milan criteria.

Results

Surveillance failure rate was 5.9 %. Macronodular cirrhosis (MC), ultrasonography-only surveillance (US-S) and infiltrative tumor type were independent factors associated with surveillance failure. The surveillance failure rate was higher in patients with MC (10.3 vs. 3.2 %, p = 0.022), US-S (14.6 vs. 4.3 %, p = 0.013) and when the tumor was infiltrative type (57.1 vs. 2.1 %, p < 0.001). Based on the two baseline factors (MC and US-S), the surveillance failure rates were 35.7, 6.8, 5.9 and 2.6 % for MC(+)/US-S(+), MC(+)/US-S(?), MC(?)/US-S(+) and MC(?)/US-S(?), respectively (p < 0.001).

Conclusion

The HCC surveillance failure was not rare in clinical practice. These data suggest that special attention for surveillance failure might be needed for patients with MC who receive US-S.     

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.