Influence of laparoscopy on postoperative recurrence and survival in patients with ruptured hepatocellular carcinoma undergoing hepatic resection

BACKGROUND: Use of laparoscopy in patients with gastrointestinal cancer has been associated with port-site and peritoneal tumour metastases. The effect of laparoscopy on tumour recurrence and long-term survival in patients undergoing resection of ruptured hepatocellular carcinoma (HCC) remains unknown. METHODS: Between June 1994 and December 2001, 59 patients with ruptured HCC underwent surgical exploration with a view to hepatic resection. Laparoscopy with laparoscopic ultrasonography was performed in 33 patients; the other 26 patients underwent exploratory laparotomy without laparoscopy. Perioperative and long-term outcomes were compared between the two groups. RESULTS: Exploratory laparotomy was avoided in 12 of 13 patients with irresectable HCC who had a laparoscopy. The hospital stay of these 12 patients was significantly shorter than that of eight patients found to have irresectable HCC at exploratory laparotomy (median 11 versus 15 days; P = 0.043). Twenty patients had a laparoscopy followed by open resection of HCC, whereas 18 patients underwent laparotomy and resection without laparoscopy. There were no significant differences in disease-free (16 versus 19 per cent; P = 0.525) and overall (32 versus 48 per cent; P = 0.176) survival at 3 years between the two groups. The tumour recurrence pattern was similar between the two groups, and there were no port-site or wound metastases. CONCLUSION: Use of diagnostic laparoscopy in patients with ruptured HCC helps avoid unnecessary exploratory laparotomy. The present data suggest that laparoscopy does not have an adverse effect on tumour recurrence or survival in patients who undergo resection.     

肝细胞癌破裂危险因素及其行肝切除术后临床预后分析

目的 探讨肝细胞癌（以下简称肝癌）破裂行根治性肝切除术后的独立预测因素,分析肿瘤破裂本身对肝癌接受肝切除术预后的影响。方法 回顾分析2007年4月至2011年11月海军军医大学东方肝胆外科医院和武汉大学中南医院接受肝切除治疗的106例肝癌破裂病人（破裂组）和201例肝癌病人（未破裂组）的临床病理资料,采用倾向性评分和多元logistic回归统计分析比较两组病人的临床资料、预后及相关因素。结果 伴有高血压、肝硬化、总胆红素水平、肿瘤大小和腹腔积液与肝癌破裂独立相关。倾向性评分匹配前所有307例肝癌病人1、3、5年总体生存率分别为54.0%、37.3%和33.8%,破裂组1、3、5年总体生存率分别为 37.7%、19.6%、14.7%低于未破裂组（分别为82.8%、58.3%、43.0%）（P＜0.001）,两组1、3、5年无瘤生存率分别为44.5%、29.7%、19.4%和66.6%、44.1%、30.1%,差异亦有统计学意义（P=0.0077）。倾向性评分匹配后破裂组和未破裂组1、3、5年总体生存率分别为41.5%、23.5%、17.5%和70.8%、47.1%、37.6%;两组1、3、5年无瘤生存率分别为50.4%、35.1%、27.1%和55.4%、38.2%、27.4%。倾向性评分匹配前后单、多因素分析均显示,肝癌破裂与病人总体生存独立相关,但与病人无瘤生存无相关性。倾向性评分匹配前后两组病人手术期并发症发生率及医院死亡率差异无统计学意义（P均＞0.05）。结论 伴有高血压、肝硬化、高水平的总胆红素、肿瘤直径>5 cm及腹腔积液是肝癌破裂的独立危险因素。肝癌破裂本身是影响肝切除术肝癌病人总体生存的独立预后因素,但不是病人无瘤生存的独立预后因素。肝癌破裂与否并未影响肝癌病人行肝切除术后并发症发生率及死亡率。     

Outcome of patients with huge hepatocellular carcinoma after primary resection and treatment of recurrent lesions

BACKGROUND: Tumour recurrence is common after hepatic resection of hepatocellular carcinomas (HCCs) greater than 10 cm in diameter. This study evaluated the outcome of patients with huge HCC after primary resection and treatment of recurrent lesions. METHODS: A retrospective review was undertaken of clinical data for 100 patients with huge HCC who underwent liver resection. RESULTS: Mean(s.d.) tumour diameter was 13.3(3.0) cm; 80 per cent were single lesions. Systematic and non-systematic resections were performed in 80 and 20 per cent of patients respectively, with R0 resection achieved in 86 per cent. Overall 1-, 3- and 5-year disease-free survival rates were 43, 26 and 20 per cent respectively. Risk factors for HCC recurrence were resection margin less than 1 cm and macrovascular invasion. Extensive tumour necrosis of 90 per cent or more after preoperative transarterial chemoembolization was not a prognostic factor. Some 85 per cent of patients with recurrence received various treatments, and these patients had a longer post-recurrence survival than those who were not treated. Overall 1-, 3- and 5-year survival rates were 66, 44 and 31 per cent respectively. CONCLUSION: In patients with huge HCC, hepatic resection combined with active treatment for recurrence resulted in longer-term survival. Frequent protocol-based follow-up appears to be beneficial for the early detection and timely treatment of recurrence.     

Prognostic factors and survival after hepatic resection for hepatocellular carcinoma without cirrhosis

BACKGROUND: Detailed follow-up of patients with chronic hepatitis has resulted in increased diagnosis of hepatocellular carcinoma (HCC) in patients without cirrhosis. Despite numerous studies on hepatic resection, the prognostic factors for intrahepatic recurrence and survival are not well known for patients with HCC without cirrhosis. METHODS: Among 349 patients with HCC treated in the past 13 years, cirrhosis was absent in 126 patients (36 per cent). Curative hepatic resection was carried out in 100 (79 per cent) of these patients. Risk factors for intrahepatic recurrence and prognostic factors for survival were evaluated by univariate and multivariate analyses. RESULTS: Postoperative morbidity and mortality rates were 22 and 3 per cent respectively. The 5- and 10-year disease-free and overall survival rates were 31 and 50 per cent, and 22 and 47 per cent respectively. Blood loss, surgical resection margin, intrahepatic metastasis, portal vein invasion and extent of hepatic resection were independently associated with overall survival. However, the only risk factors for intrahepatic recurrence were portal vein invasion and hepatitis C virus (HCV) infection. The former was related to early recurrence while the latter was related to later recurrence. The 5-year disease-free survival rate was 58 per cent in patients with hepatitis B virus infection while it was 6 per cent in patients with HCV infection (P < 0.001). CONCLUSION: In the treatment of HCC without cirrhosis, major hepatectomy is advocated to prevent early recurrence. Liver transplantation may be required for patients with HCV infection.     

Surgical Outcomes for the Ruptured Hepatocellular Carcinoma: Multicenter Analysis with a Case-Controlled Study

Background

While spontaneously ruptured hepatocellular carcinoma (HCC) has a poor prognosis, the true impact of a rupture on survival after hepatic resection is unclear.

Methods

Fifty-eight patients with ruptured HCC and 1922 with non-ruptured HCC underwent hepatic resection between 2000 and 2013. To correct the difference in the clinicopathological factors between the two groups, propensity score matching (PSM) was used at a 1:1 ratio, resulting in a comparison of 42 patients/group. We investigated outcomes in all patients with ruptured HCC and compared outcomes between the two matched groups.

Results

Of the 58 patients with ruptured HCC, 7 patients (13 %) died postoperatively. Overall survival (OS) rate at 5 years after hepatic resection was 37 %. Emergency hepatic resection was an independent risk factor for in-hospital death and Child-Pugh class B for unfavorable OS in multivariate analysis. Clinicopathological variables were well-balanced between the two groups after PSM. No significant differences were noted in incidence of in-hospital death (ruptured HCC 12 % vs non-ruptured HCC 2 %, p?=?0.202) or OS rate (5/10-year; 42 %/38 % vs 67 %/30 %, p?=?0.115).

Conclusion

Emergency hepatic resection should be avoided for ruptured HCC in Child-Pugh class B patients. Rupture itself was not a risk for unfavorable surgical outcomes.

     

Radiofrequency ablation for unresectable tumors of the liver

Surgical resection of primary or metastatic tumors of the liver offers patients the best long-term survival. Liver resections may not be appropriate in patients with bilobar metastases, liver dysfunction, or severe comorbidities. Radiofrequency ablation (RFA) is a technique used to destroy unresectable hepatic tumors through thermocoagulation. We retrospectively reviewed a consecutive series of patients undergoing RFA with unresectable hepatic tumors for local recurrence and overall survival. Under an Institutional Review Board-approved protocol, all patients treated with RFA at the University of Alabama at Birmingham from September 1, 1998, to June 15, 2005, were identified. During this time period, 189 lesions in 107 patients were treated with RFA. Patients' charts were retrospectively reviewed. Data is presented as mean +/- SEM. Significance is defined as P < 0.05. Patient demographics revealed 62 per cent males and 38 per cent females with a mean age of 59 (+/- 1) years. Hepatocellular carcinoma (HCC) represented 54 per cent of the tumors treated. Metastatic colorectal cancer represented 22 per cent and the remaining 24 per cent were other metastatic tumors. Overall recurrence rates for all tumors after RFA was 53 per cent. Local recurrence rates for HCC, colorectal cancer, and other metastatic lesions were 27.6 per cent, 29.1 per cent, and 52 per cent, respectively. The morbidity rate for the procedure was 11 per cent. There was one mortality (0.9%) related to RFA. Laparoscopic RFA for HCC in Childs-Pugh Class C cirrhotics (n = 6) resulted in 50 per cent of patients being transplanted with no evidence of disease at a mean follow-up period of 14 months. RFA is a safe and effective way for treating HCC and other unresectable tumors in the liver that are not eligible for hepatic resection. More effective control of systemic recurrence will dictate survival in the majority of patients with metastatic cancers. Local ablation for HCC in cirrhotic patients may be an effective bridge to transplantation. Liver transplantation may still be the most effective long-term treatment for localized HCC.     

Emergency surgery of non-ruptured abdominal aortic aneurysm

BACKGROUND AND AIMS: The pain of an abdominal aortic aneurysm (AAA) is believed to signify rupture, and emergency surgery for symptomatic AAA is a widely accepted practice to prevent rupture. To clarify the benefit of emergency surgery we evaluated the clinical course of emergency treated patients with non-ruptured AAAs. MATERIAL AND METHODS: 110 patients (90 men, mean age 69, range 49-93; 20 women, mean age 75, range 63-89) underwent emergency repair of non-ruptured AAA between 1970 and 1992 at the Department of Thoracic and Cardiovascular Surgery of Helsinki University Central Hospital (HUCH). Survival rates after surgery were analysed using product-limit-survivorship method. The survival rates after age-stratification were compared with those of patients undergone elective surgery (n=599) or emergency surgery because of ruptured AAAs (n=363) during the same period. Risk factors affecting early and late survival rates after operation were analysed by logistic regression analysis and Cox proportional hazard model. RESULTS: Thirty-day operative mortality rates were 18 % (20/110) in the emergency non-ruptured group, compared with 7 % (42/599) in the elective group and 49 % (179/363) in the ruptured group (p<0.05). Thirty day survival rate was not changed among the nonruptured emergency group from 1970 to 1992, whereas the rates of ruptured and elective groups became better during the study period. Late survival rates for 30-day postoperative survivors were clearly reduced among the non-ruptured emergency group, without difference between the emergency operated ruptured and non-ruptured groups. Coronary artery disease was decreasing significantly early and late survival rates after emergency surgery for non-ruptured AAAs (p<0.05, logistic regression and p<0.001 Cox proportional hazard). CONCLUSIONS: Early and late mortality risk is significantly higher (p<0.001) after emergency surgery for haemodynamically stable non-ruptured AAA than after elective surgery, mainly because of coronary artery disease.     

Liver resection for hepatocellular carcinoma in patients without cirrhosis

Background:

Data on liver resection for hepatocellular carcinoma (HCC) without cirrhosis are sparse. The present study was conducted to evaluate the indications and results of liver resection for HCC with regard to safety and efficacy.

Methods:

Data for patients who had liver resection for HCC without cirrhosis between January 1996 and March 2011 were retrieved retrospectively using a prospective database containing information on all patients who underwent hepatectomy for HCC. Patient and tumour characteristics were analysed for influence on overall and disease‐free survival to identify prognostic factors by univariable and multivariable analysis.

Results:

The 1‐, 3‐ and 5‐year overall survival rates after resection with curative intent for HCC without cirrhosis were 84, 66 and 50 per cent respectively. Disease‐free survival rates were 69, 53 and 42 per cent respectively. The 90‐day mortality rate was 4·5 per cent (5 of 110 patients). Surgical radicality and growth pattern of the tumour were independent prognostic factors for overall survival. Disease‐free survival after resection with curative intent was independently affected by growth pattern and by the number and size of tumour nodules.

Conclusion:

Liver resection for HCC without cirrhosis carries a low perioperative risk and excellent long‐term outcome if radical resection is achieved. Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.     

Hepatic Resection and Prognosis for Patients With Hepatocellular Carcinoma Larger Than 10 cm: Two Decades of Experience at Chang Gung Memorial Hospital

Background: Although screening programs in high-risk populations have facilitated the detection of small hepatocellular carcinoma (HCC), some HCC patients continue to present with advanced, large tumors. However, reports of hepatic resection for HCC larger than 10 cm (L-HCC) are limited. This study aims to determine the clinicopathologic factors that influence the prognosis of hepatic resection for L-HCC.Methods: The clinical features of 211 L-HCC patients undergoing hepatic resection were reviewed. Clinical features and factors influencing the outcome of 985 patients with HCC smaller than 10 cm (S-HCC) were used for comparison.Results: Of 1196 surgically resected HCCs, 211 (17.6%) were L-HCC. Multivariate logistic regression analysis showed that the presence of dull abdominal pain, a low indocyanine green retention rate value, a high percentage of alfa fetoprotein (AFP) >400 ng/mL, major hepatectomy, absence of tumor capsule formation, satellite lesions, and vascular invasion were the seven main independent factors differentiating L-HCC from S-HCC patients. Significantly worse overall survival was noted in L-HCC patients, especially those with tumor rupture, satellite lesions, AFP >400 ng/mL, and blood loss of >1 L during surgery.Conclusions: Hepatic resection, when feasible, is safe and is the preferred treatment for L-HCC patients. However, overall and disease-free survival for L-HCC are worse than for S-HCC. Disease-free survival for L-HCC patients undergoing hepatic resection is significantly influenced by a high value of alkaline phosphatase and by AFP. Overall survival for L-HCC patients undergoing hepatic resection is significantly influenced by a high value of AFP, blood loss, tumor rupture, and satellite lesions.     

Impact of Spontaneous Hepatocellular Carcinoma Rupture on Recurrence Pattern and Long-term Surgical Outcomes after Partial Hepatectomy

Background

The clinical significance of spontaneous hepatocellular carcinoma (HCC) rupture association with recurrence pattern and long-term surgical outcomes remains under debate. We investigated the impact of spontaneous HCC rupture on recurrence pattern and long-term surgical outcomes after partial hepatectomy.

Methods

From 2000 to 2012, 119 patients with diagnosed ruptured HCC were reviewed. To compare outcomes between staged hepatectomy in spontaneously ruptured HCC and hepatectomy in non-ruptured HCC, we performed propensity score-matching to adjust for significant differences in patient characteristics. Overall survival, disease-free survival, and recurrence pattern were compared between the matched groups.

Results

Forty-four patients with newly diagnosed ruptured HCC and Child A class were initially treated with transcatheter arterial embolization for hemostasis. Three patients underwent emergency laparotomy, 18 underwent staged hepatectomy, and 23 received transarterial chemoembolization (TACE) alone after transcatheter arterial embolization. Among the 23 patients treated with TACE alone, 10 had resectable tumors. The staged hepatectomy group shows significantly higher overall survival with TACE alone than the resectable tumor group (P < 0.001). After propensity score-matching, overall survival, disease-free survival, and recurrence pattern were not significantly different between the ruptured HCC with staged hepatectomy group and the non-ruptured HCC with hepatectomy group. Peritoneal recurrence rates were similar at 14.3 % versus 10.0 %, respectively (P = 0.632).

Conclusions

Patients with spontaneously ruptured HCC with staged hepatectomy show comparable long-term survival and recurrence pattern as patients with non-ruptured HCC having similar tumor characteristics and liver functional status. Thus, spontaneous HCC rupture may not increase peritoneal recurrence and decrease long-term survival after partial hepatectomy.     

Resection rate and effect of postoperative chemotherapy on survival after surgery for colorectal liver metastases.

BACKGROUND: The purpose of this study was to investigate whether adjuvant therapy can improve survival after curative resection of colorectal liver metastases. METHODS: Some 235 patients had 256 liver resections for metastatic colorectal cancer. There were no predefined criteria for resectability with regard either to the number or size of the tumours or to locoregional invasion, except that resection had potentially to be complete and macroscopically curative. All patients who had curative hepatic resection were advised to start postoperative adjuvant chemotherapy. RESULTS: The resectability rate in screened patients was 91 per cent (235 of 259 patients); the postoperative mortality rate was 4 per cent. In 35 patients resection of the primary tumour was performed simultaneously with partial liver resection. Forty-four patients (19 per cent) developed intra-abdominal recurrence; 14 (6 per cent) underwent reoperation and the recurrent tumour was resected. Adjuvant chemotherapy was given to 99 patients (55 per cent), most treatments being based on 5-fluorouracil with folinic acid. The overall actuarial survival rates at 1, 3 and 5 years were 87, 60 and 36 per cent respectively. In a multivariate analysis, four or more metastases, preoperative carcinoembryonic antigen level higher than 5 ng/ml and a positive resection margin were independent predictors of poor outcome. Adjuvant chemotherapy improved the 5-year survival rate to 53 per cent. CONCLUSION: This study provides some evidence that postoperative chemotherapy is beneficial; however, prospective randomized studies are necessary to define its exact role.     

Ruptured abdominal aortic aneurysm

Between 1974 and 1984, 174 patients with ruptured abdominal aneurysms have been treated by three vascular surgeons. The 11-year period showed a dramatic increase in the number of patients presenting with ruptured aneurysms. The overall operative survival, including patients who died before a graft could be inserted, was 67 per cent with improvement from 60 per cent in the first half of the period to 69 per cent in the second. The overall survival rate for the 162 who had a completed graft was 72 per cent. Reference to data from the Lothian area surgical audit showed that there has been a transfer of responsibility from general to vascular surgeons with an increase in the proportion of patients treated by operation. Concentration of care within a single specialized unit appears to have had a favourable effect on survival.     

Chinese experience with hepatectomy for huge hepatocellular carcinoma

BACKGROUND: The risks and outcome of hepatic resection for huge hepatocellular carcinoma (HCC) are controversial. METHODS: The clinical records of 525 patients who underwent resection of HCC greater than 10 cm in diameter were studied retrospectively. Prognostic factors for long-term survival were evaluated by univariate and multivariate analyses. RESULTS: Postoperative complications were common (26.8 per cent) and five patients (0.9 per cent) required relaparotomy. The 30-day mortality rate was 2.7 per cent. The main causes of postoperative death were liver failure (nine patients) and bleeding (four). The 3-, 5- and 10-year crude survival rates after liver resection were 34.3, 16.8 and 2.9 per cent respectively. CONCLUSION: Prognostic factors for long-term survival mainly reflected the biological behaviour of the tumour. They can be used only as a guide in balancing the risks of operation against the potential benefits of resection in a patient in poor general condition or with poor liver function. They cannot be used alone to exclude patients from liver resection with curative intent. Liver resection for huge HCC was safe and efficacious. It should be used to treat patients with acceptable surgical risks and resectable tumours.     

Malignant tumors of the liver

HCC occurs infrequently in Western countries, with recent increases being reported in California and parts of Europe. Southeast Asia, Japan, and South Africa continue to have a high incidence of this tumor with HBV, cirrhosis, and the ingestion of aflatoxins being identified as probable risk factors. Although the majority of patients present with abdominal pain or mass indicative of extensive tumor, asymptomatic, small HCCs are being detected with increasing frequency. Early detection in high-risk individuals is best accomplished by screening with serum AFP determinations and liver ultrasonography. CT and arteriography are valuable preoperatively in defining anatomy and determining resectability. Five-year survival following resection for cure of HCC ranges from 20 to 40 per cent, with improved survival reported for small asymptomatic tumors. Resection of metastatic liver tumors from colorectal primaries results in 48 per cent 2-year and 24 per cent 5-year survivals, with an additional 5 per cent dying of recurrent cancer after 5 years. Although patients with simultaneous and metachronous metastases do equally well after resection, the presence of four or more individual deposits adversely affects survival. Hepatic artery ligation or embolization can produce a significant palliative reduction in total tumor mass in patients with unresectable liver metastases. Regional chemotherapy using implantable hepatic artery drug infusion pumps is promising, with reports of prolonged survival compared with historical controls. Regional hyperthermia, laser vaporization of tumor, and cryosurgical techniques may prove to have useful roles in the selective treatment of liver cancer in the future. Orthotopic liver transplantation has been successful primarily in those in whom the malignancy is found incidentally in the chronically diseased liver.     

Abdominal pain: a surgical audit of 1190 emergency admissions

In an audit of 1190 emergency admissions with abdominal pain (1166 patients) in a general surgical unit, the diagnosis was non-specific abdominal pain (NSAP) in 415 (35 per cent), acute appendicitis in 200 (17 per cent) and intestinal obstruction in 176 (15 per cent). The largest number of admissions occurred in the age groups 10-29 years (31 per cent) and 60-79 years (29 per cent). Surgical operations were performed in 551 patients (47 per cent) and there was a 16 per cent incidence of unnecessary appendicectomy (22 per cent in the age group 20-29 years). Fifty-one deaths resulted in a 30-day hospital mortality rate of 4.4 per cent and a perioperative mortality rate of 8 per cent. The mortality rate increased significantly in patients aged greater than or equal to 60 years, and patients aged 80-89 years had a perioperative mortality rate of 20 per cent. The causes of perioperative death included laparotomy for inoperable disease (28 per cent), ruptured abdominal aortic aneurysm (23 per cent), perforated peptic ulcer (16 per cent) and colonic resections (14 per cent). The perioperative mortality rates for ruptured aneurysm and perforated ulcer were 71 and 23 per cent respectively. The duration of inpatient stay increased significantly with the age of the patients, including those with NSAP. The results of the study indicate a need to review the methods of management of ruptured aortic aneurysm and perforated peptic ulcer, the methods of diagnosis of appendicitis, particularly in young females, and the factors that determine the duration of stay of patients suffering from NSAP.     

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.     

The surgical experience and a one to sixteen year follow-up of 277 abdominal aortic aneurysms

Between 1960 and 1975, 277 patients with abdominal aortic aneurysms were operated on at the West Virginia University Medical Center. One hundred ninety-three aneurysms were intact lesions and eighty-four were ruptured. Operative mortality for elective resection was 8.8 per cent and for ruptured aneurysms 66.7 per cent. Mortality associated with ruptured abdominal aortic aneurysms was best related to shock and advanced age. Ninety-nine per cent of patients underwent long-term follow-up which ranged from thirteen months to thirteen years and four months (mean, 4 years and 9 months). At present 61 per cent of patients surviving elective resection and 50 per cent of those surviving operation for ruptured aneurysm are alive.     

Liver resection for hepatocellular carcinoma in non-cirrhotic liver without underlying viral hepatitis

BACKGROUND: Hepatocellular carcinoma (HCC) arising in normal liver parenchyma is rare and the outcome after hepatectomy is not well documented. METHODS: Between June 1998 and September 2003, 33 patients without viral hepatitis underwent resection for HCC in a non-cirrhotic, non-fibrotic liver. Data were analysed with regard to operative details, pathological findings including completeness of resection, and outcome as measured by tumour recurrence and survival. RESULTS: Twenty-three major hepatectomies and ten segmentectomies or bisegmentectomies were performed. After potentially curative resection, 19 of 29 patients were alive at a median follow-up of 25 months, with calculated 1- and 3-year survival rates of 87 and 50 per cent respectively. Survival was significantly better after resection of tumours without vascular invasion (3-year survival rate 89 versus 18 per cent; P = 0.024). Disseminated recurrence developed in nine of 29 patients, leading to death within 28 months of operation in all but one of the nine. CONCLUSION: These data justify hepatic resection for HCC arising in non-cirrhotic, non-fibrotic liver without underlying viral hepatitis. Liver transplantation is rarely indicated because the outcome is good after resection of tumours without vascular infiltration, whereas vascular invasion is invariably associated with diffuse extrahepatic recurrence.     

Efficacy of repeat hepatic resection for recurrent hepatocellular carcinomas

Background: This study evaluated the efficacy of repeat hepatic resection for recurrent hepatocellular carcinoma (HCC) and the clinicopathological factors influencing overall survival after resection. Methods: From 1992 to 2005, 231 patients underwent curative hepatic resection for HCC at Yokohama City University, Japan. Of these, 105 patients developed intrahepatic recurrence, and 24 repeat hepatectomies were performed for recurrent HCC. Survival data were analysed, and prognostic factors for repeat hepatic resection were determined. Results: The overall cumulative 1‐, 3‐ and 5‐year survival rates and the median survival time of the patients after initial hepatic resection (n= 231) did not differ from those of the patients after repeat hepatic resection (n= 24), with values of 91.3, 70.2 and 49.1%, and 57 months, versus 91.7, 73.1 and 50.9%, and 61.5 months, respectively (P= 0.875). The operative time and blood loss in patients who underwent repeat hepatic resection did not differ from those who underwent primary resection. Multivariate analysis identified portal invasion at the first hepatic resection and a disease‐free interval of ≤1.5 years after primary hepatic resection as independent risk factors for survival after repeat hepatic resection. The 12 patients who did not show either of the two prognostic factors had 3‐ and 5‐year survival rates of 91.7 and 68.8%, respectively, after repeat hepatic resection. Conclusions: Our findings suggest repeat hepatic resection as the treatment of choice for recurrent HCC patients without portal invasion at the first resection whose recurrence develops after a disease‐free interval of >1.5 years since the previous surgery.     

Curative resection is the single most important factor determining outcome in patients with pancreatic adenocarcinoma

BACKGROUND: Mortality rates associated with pancreatic resection for cancer have steadily decreased with time, but improvements in long-term survival are less clear. This prospective study evaluated risk factors for survival after resection for pancreatic adenocarcinoma. METHODS: Data from 366 consecutive patients recorded prospectively between November 1993 and September 2001 were analysed using univariate and multivariate models. RESULTS: Fifty-eight patients (15.8 per cent) underwent surgical exploration only, 97 patients (26.5 per cent) underwent palliative bypass surgery and 211 patients (57.7 per cent) resection for pancreatic adenocarcinoma. Stage I disease was present in 9.0 per cent, stage II in 18.0 per cent, stage III in 68.7 per cent and stage IV in 4.3 per cent of patients who underwent resection. Resection was curative (R0) in 75.8 per cent of patients. Procedures included pylorus-preserving Whipple resection (41.2 per cent), classical Whipple resection (37.0 per cent), left pancreatic resection (13.7 per cent) and total pancreatectomy (8.1 per cent). The in-hospital mortality and cumulative morbidity rates were 2.8 and 44.1 per cent respectively. The overall actuarial 5-year survival rate was 19.8 per cent after resection. Survival was better after curative resection (R0) (24.2 per cent) and in lymph-node negative patients (31.6 per cent). A Cox proportional hazards survival analysis indicated that curative resection was the most powerful independent predictor of long-term survival. CONCLUSION: Resection for pancreatic adenocarcinoma can be performed safely. The overall survival rate is determined by the radicality of resection. Patients deemed fit for surgery who have no radiological signs of distant metastasis should undergo surgical exploration. Resection should follow if there is a reasonable likelihood that an R0 resection can be obtained.