肝切除术治疗原发性肝细胞癌自发性破裂(附19例报告)

目的探讨肝切除术治疗原发性肝细胞癌自发性破裂(SRI-ICC)的效果。方法回顾性分析19例肝切除术治疗SRHCC患者的效果。结果肝切除19例，1个月存活率为94．7％，1年、3年及5年存活率分别为63．2％、16．7％及8．3％。平均存活时间为30．8个月(4d～25年零9个月)，最长1例存活超过25年零9个月，目前仍健在。18例肝功能属Child-PughA级患者安全度过围手术期；1例肝功能Child-PughB级者术后4d死于肝功能衰竭。结论SRHCC并非均为晚期病变．对早期肝癌破裂肝功能良好者应采取急诊手术切肝；如患者情况或医疗条件不允许．可行延期或二期手术治疗。     

Prognostic Impact of Fas Ligand on Hepatocellular Carcinoma after Hepatectomy

The expression of Fas ligand on tumor cells may counterattack the hosts immunity and worsen the prognosis. Knowledge of the prognostic impact of Fas ligand on patients with hepatocellular carcinoma (HCC) after hepatectomy is still limited. Fas ligand expression in HCCs was examined in 59 patients who underwent hepatectomy for HCC. The prognosis was analyzed and correlated to the expression of Fas ligand. Expression of Fas ligand was detected by immunohistochemical staining in 27 of the 59 HCCs (45.8%). The Fas ligand was expressed in only a small number of cancer cells. However, even though only a few cancer cells expressed it, the prognosis for patients whose HCCs showed Fas ligand expression was worse than that for patients with an HCC without Fas ligand expression. The mean disease-free survival was only 10.83 ± 1.90 months when HCCs expressed Fas ligand compared with 43.51 ± 7.02 months for those without Fas ligand expression (p = 0.0007). The overall patient survival was 28.34 ± 4.08 months when the HCC expressed Fas ligand compared with 55.31 ± 5.37 months for HCC without Fas ligand expression (p = 0.0003). The expression of Fas ligand did not correlate with the presentation of other prognostic factors. Fas ligand expression is thus an independent prognostic factor for HCC. Thus the HCC expressing Fas ligand has a worse prognosis than the HCC without Fas ligand expression.     

Long-term Outcomes and Prognostic Factors of Elderly Patients with Hepatocellular Carcinoma Undergoing Hepatectomy

Objective  The present study aimed to evaluate the long-term outcomes and prognostic factors of elderly patients with hepatocellular carcinoma (HCC) undergoing hepatectomy. Material and Methods  From January 1983 to December 2006, 2,283 patients with HCC received hepatectomy in Sun Yat-sen University Cancer Center. The clinicopathological data and treatment outcomes of 67 elderly HCC patients (elderly group, ≥70 years of age) and 268 patients (control group, <70 years of age) who were selected randomly from the 2216 younger patients were compared retrospectively. Results  The elderly HCC patients had lower hepatitis B surface antigen-positive rate (P < 0.001), lower rate of marked α-fetoprotein elevation (P = 0.004), higher infection rate of hepatitis C virus (P = 0.010), more preoperative comorbidities (P < 0.001), higher rate of tumor encapsulation (P = 0.040), and better overall survival rate (P = 0.017); whereas there were no significant differences between these two groups in other factors, including gender ratio, liver function, accompanying cirrhosis, pathological tumor–node–metastasis (pTNM) staging, satellite nodules, vascular invasion, tumor rupture, resection margin, intraoperative blood loss, incidence of postoperative complications, hospital mortality, and disease-free survival rate. Multivariate analysis showed that pTNM staging was an independent prognostic factor of long-term survival in elderly patients with HCC. Conclusion  HCC in the elderly was less HBV-associated, less advanced, and less aggressive. Hepatectomy for selected elderly patients with HCC possibly have a better curative effect compared with younger patients. For the elderly patients without preoperative comorbidities or with controlled comorbidities, hepatectomy is a safe and effective treatment. pTNM staging is the only independent predictor of postoperative overall survival in elderly HCC patients.     

Influence of Associated Viral Hepatitis Status on Recurrence of Hepatocellular Carcinoma after Hepatectomy

n = 2), chronic persistent hepatitis (CPH, n = 6), chronic aggressive hepatitis (CAH, n = 31), and liver cirrhosis (LC, n = 29) according to a classification by the European Association for the Study of the Liver. Background data for the groups showed no significant differences. Recurrence was observed in none of the patients in the N and CPH groups, 26 (83.9%) of the patients in the CAH group, and 12 (41.4%) of the patients in the LC group. The cumulative disease-free survival rate of the CAH group was significantly lower than that of the CPH group ( p < 0.05) and LC group ( p < 0.01). This study revealed that the histologic status of the underlying chronic liver disease influenced the recurrence rate in patients with HCC. CAH was considered to be a risk factor for recurrence after resection of HCC.     

肝癌肝移植及肝癌肝切除术后复发特点的比较

目的 了解肝癌患者行肝移植或肝切除两种手术治疗后肿瘤复发的不同特点。方法 复习国内、外文献，比较二者的特点。结果 肝癌肝移植与肝癌肝切除术后复发率、复发时间、常见部位、复发相关因素、机理等方面均有所不同。结论 根据肝癌肝移植或肝切除术后复发的不同特点，针对性地加强肝癌复发的预防，重视复发后的治疗，以延长术后生存，改善生活质量。     

Laparoscopic and Thoracoscopic Partial Hepatectomy for Hepatocellular Carcinoma

Several trials have been reported examining laparoscopic liver resections for the treatment of various kinds of liver tumors. However, there are no detailed reports on the use of laparoscopic (LH) and thoracoscopic (TH) hepatectomy for the treatment of hepatocellular carcinoma (HCC). Eleven laparoscopic and thoracoscopic partial liver resections were attempted for treating HCC. The indications for performing a laparoscopic or thoracoscopic partial hepatectomy were as follows: (1) the tumor was located on the surface of the liver; (2) the tumor was less than 3 cm in diameter; and (3) the tumor was not located adjacent to any large vessels. A TH was performed if the tumor was located in segment 8; an LH was performed if the tumor was located in segment 3, 4, or 5. Hand-assisted operations were performed in two patients. The mean operating time was 186.1 ± 44.0 minutes (range 130–310 minutes). The operative blood loss was 218.3 ± 197.6 ml (range 20–650 ml). The mean postoperative hospital stay was 11.3 ± 5.7 days (range 7–26 days). Two patients experienced postoperative complications (wound infection and ascites). No local recurrences have occurred to date. The overall 5-year survival rate and disease-free 5-year survival rate were 75.0% and 38.2%, respectively. Laparoscopic and thoracoscopic hepatic resections are less invasive than conventional surgical techniques and are useful for treating HCC in select patients.     

Recurrence of Hepatocellular Carcinoma in Noncirrhotic Liver After Hepatectomy

Background

Hepatocellular carcinoma in noncirrhotic liver (HCCNC) is rare. This tumor has a particular epidemiology and presentation, and it requires specific treatment, compared with HCC in cirrhotic liver. The aims of this study were to determine the survival and recurrence rates, prognostic factors, and optimum treatment of HCCNC and to propose a follow-up protocol for patients who have undergone surgery for HCCNC.

Methods

This study included 131 patients who underwent surgical treatment for HCCNC from January 1992 to December 2010. Survival and recurrence rates were evaluated, and the prognostic factors and characteristics of recurrence were analyzed. Pathologic characteristics of the tumors and the nontumoral liver were examined.

Results

The mean survival time was 67.9 months. The 5- and 10-year overall survival rates were 72.9 and 36.7 %, respectively. In all, 54 patients (41.2 %) developed recurrence at a median interval of 30.96 months. Of these recurrences, 31.5 % occurred during the first year, and 24.1 % occurred more than 5 years after surgery. Macro- or microvascular invasion and tumor size >5 cm were significantly associated with a poor survival rate. The predictive factors for recurrence were multiple tumors, tumor diameter >5 cm, and satellite nodules. Patients who underwent surgical treatment for recurrence had a significantly longer survival time than those who did not (p < 0.0292).

Conclusions

Recurrence is the most common cause of death after hepatectomy for HCC, and patients should undergo careful, long-term follow-up. Early detection and treatment of recurrence with curative intent should improve the prognosis of these patients.     

Surgical Outcomes and Clinical Characteristics of Elderly Patients Undergoing Curative Hepatectomy for Hepatocellular Carcinoma

Background

The aim of this study was to investigate the clinical characteristics and outcomes of elderly patients (≥70 years old) undergoing curative hepatectomy for hepatocellular carcinoma (HCC).

Methods

Clinicopathological data and treatment outcomes in 100 elderly patients (≥70 years old) and 120 control patients (≤70 years old) with HCC who underwent curative hepatectomy between 2000 and 2011 were retrospectively collected and compared.

Results

The overall survival rate was similar between the two groups, but the disease-free survival rate was worse in the elderly group when compared with the control group. Prognostic factors for overall and disease-free survival were the same when comparing the two groups. The elderly group had higher rate of females (p?=?0.0230), higher hepatitis C virus infection rate (p?=?0.0090), higher postoperative pulmonary complication rate (p?=?0.0484), lower rate of response to interferon (IFN) therapy (p?=?0.0203) and shorter surgical time (p?=?0.0337) when compared with the control group. The overall recurrence rate was higher in the elderly group than in the control group (p?=?0.0346), but the rate of recurrence within 2 years after the operation was similar when comparing the two groups.

Conclusion

The survival of elderly patients with HCC was similar to that of younger patients. However, the disease-free survival was worse in elderly patients than in younger patients. Aggressive antiviral therapy (e.g. IFN therapy) may be necessary to improve the disease-free survival, even in elderly patients. Additionally, clinicians should be aware of the risk of pulmonary complications in elderly patients after hepatectomy.     

肝癌自发性破裂机理的研究进展

目的 探讨肝癌自发性破裂的机理。方法 采用文献回顾的方法，对肝癌自发性破裂患者的资料加以综述。结果 肝癌自发性破裂的患者体内抗原抗体复合物积聚并沉积在小动脉壁弹力膜上，在其沉积处的小动脉壁存在血管受损现象。结论 乙肝病毒感染所形成的抗原抗体复合物沉积在血管壁导致小动脉脆性病变，可能与肝癌自发性破裂出血有关。     

原发性肝癌自发性破裂的治疗

目的分析原发性肝癌(hepatocellular carcinoma,HCC)自发性破裂的治疗效果。方法26例HCC自发性破裂患者,行一期肝切除9例,一期手术止血4例,二期肝切除11例,另2例行介入治疗。结果二期肝切除和一期肝切除比较,术后并发症发生率分别为27.3%和66.7%,无统计学差异(P=0.175);术后30 d、60 d死亡率分别为0%vs 22.2%,0%vs 44.4%,仅术后60 d死亡率有统计学意义,P=0.026;术后1年、3年生存率比较无统计学意义,分别为90.9%vs 44.4%,3.64%vs 22.2%,P>0.05。结论对于自发性破裂HCC,二期肝切除手术近期效果优于一期肝切除手术,但两者远期生存率并无显著差异。一期切除手术对于部分病人仍可取得较好的效果。     

Short- and Long-term Outcomes after Laparoscopic and Open Hepatectomy for Hepatocellular Carcinoma: A Global Systematic Review and Meta-analysis

Background

Laparoscopic hepatectomy (LH) has been proposed as a safe and feasible treatment option for liver diseases. However, the short- and long-term outcomes of LH versus open hepatectomy (OH) for hepatocellular carcinoma (HCC) have not been adequately assessed. Thus, as another means of surgical therapy for hepatocellular carcinoma (HCC), we assessed the feasibility of performing LH as the standard procedure for disease in the left lateral lobe and peripheral right segments for HCC in selected patients.

Methods

Literature search included PubMed, Embase, Science Citation Index, SpringerLink, and secondary sources, from inception to March 2012, with no restrictions on languages or regions. The fixed-effects and random-effects models were used to measure the pooled estimates. The test of heterogeneity was performed by the Q statistic. Subgroup and sensitivity analyses were performed to explore heterogeneity between studies and to assess the effects of study quality.

Results

A total of 1238 patients (LH 485, OH 753) from 15 studies were included. The pooled odds ratios for postoperative morbidity and incidence of negative surgical margin in LH were found to be 0.37 (95 % confidence interval [CI] 0.27–0.52; P < 0.01) and 1.63 (95 % CI 0.82–3.22; P = 0.16), respectively, compared with OH. Blood loss was significantly decreased in the LH (weighted mean difference ?224.63; 95 % CI ?384.87 to ?64.39; P = 0.006). No significant difference was observed between the both groups for long-term outcomes of overall survival and recurrence-free survival.

Conclusions

In patients with solitary left lateral lobe/right peripheral subcapsular tumors treated with minor resection, this meta-analysis demonstrated that compared to OH, LH may have short-term advantages in terms of blood loss and postoperative morbidity for HCC. Both procedures have similar long-term outcomes. It may be time to consider changing the standard procedures for treatment of HCC in the left lateral lobe and peripheral subcapsular right segments in selected patients.     

肝癌自发性破裂的临床诊断及治疗

目的：探讨、评估肝癌自发性破裂的机理、临床诊断及治疗，为临床医师比较、筛选出有效的诊治方法。方法：采用文献回顾的方法对肝癌自发性破裂患者的临床资料加以综合比较、综述。结果：肝肿瘤破裂可能与肝硬变门脉高压、肿瘤组织坏死、凝血功能障碍、肝癌中的动静脉短路等有关。其临床诊断的误诊率较高，超声波及CT检查的阳性率较高。急诊治疗可采用肝动脉插管栓塞，待患者一般情况好转后采用二期手术疗法可取得最好的治疗效果。结论：肝癌自发性破裂并非肝癌晚期患者所特有，其预后取决于及时诊断及治疗的正确与否。     

肝癌破裂出血的诊断和治疗

目的研究肝癌破裂出血的原因和急性期止血以及止血后Ⅱ期治疗措施。方法对国内、外相关文献进行综述分析。结果肝癌破裂出血的病因目前仍不完全清楚,我国肝癌破裂出血与乙肝病毒感染导致抗原抗体复合物沉积于肿瘤小动脉壁致其损伤继而破裂出血关系密切。治疗方法有保守治疗、手术治疗(肝叶切除、肝动脉结扎术、缝扎填塞)、肝动脉插管栓塞术、其他治疗(无水乙醇瘤内注射、射频消融、生物免疫疗法等)。结论肝动脉插管栓塞术在肝癌破裂出血急性期止血效果良好,可作为Ⅱ期综合治疗的基础。     

Estimating Surgical Outcomes for Hepatocellular Carcinoma

Annals of Surgical Oncology -     

One-stage Liver Resection for Spontaneous Rupture of Hepatocellular Carcinoma

The objective of this study was to evaluate the rationale of a policy of one-stage liver resection for selective cases of spontaneous rupture of hepatocellular carcinoma (HCC). Altogether, 36 patients with spontaneous rupture of an HCC admitted between November 1994 and September 2003 underwent a one-stage laparotomy with a view to curative liver resection; 33 cases underwent liver resection successfully, and 3 cases were found to have lesions unresectable at laparotomy and were treated with other hemostatic procedures. The prognostic value was calculated by Kaplan-Meier survival curve analysis. Effective surgical hemostasis was achieved in all patients, with a postoperative mortality rate of 5.8% (2/36). The estimated survivals at 1, 3, and 5 years for patients who underwent liver resection were 88%, 54%, and 51%, respectively. These results suggest that a one-stage surgical operation offers a feasible, effective treatment for patients with ruptured HCC in whom the tumor is judged likely to be resectable on the computed tomography scan and who have a liver function grade of A or B according to Child-Pugh criteria.     

Impact of Hepatectomy Surgical Complexity on Outcomes and Hospital Quality Rankings

Background

There is substantial variation in the surgical complexity of hepatectomy. Currently, the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) risk adjusts for hospital quality comparisons using only the primary procedure code. Our objectives were to (1) assess the association between secondary procedures and complications; (2) assess model performance with inclusion of surgical complexity adjustment; and (3) examine whether secondary procedures affect hospital quality rankings.

Methods

Using ACS NSQIP (2007–2012), patients undergoing hepatectomy were identified. Secondary procedure codes and total work relative value units (RVUs) were used to approximate procedural complexity. The effect of procedural complexity variables on outcomes and hospital quality rankings were examined using hierarchical models.

Results

Among 11,826 patients who underwent hepatectomy at 261 hospitals, 32.8 % underwent at least one secondary procedure. Serious morbidity occurred in 18.0 % of patients. Seven of nine secondary procedures were significantly associated with death or serious morbidity on multivariable analysis. Model performance improved when secondary procedure categories were included, and secondary procedure categories outperformed total RVUs. The C-statistic for death or serious morbidity was 0.689 in the standard NSQIP model, 0.703 when total RVU was included, and 0.718 when secondary procedure categories were included. Of the 26 hospitals that were poor performers for death or serious morbidity using the standard ACS NSQIP model, three became average performers when secondary procedure categories were included in the model.

Conclusions

Secondary procedures are associated with an increased risk of postoperative complications. Inclusion of secondary procedure code categories in research and risk prediction models should be considered for hepatectomy.     

血管硬化性病变与肝癌自发性破裂的关系

目的 探讨血管壁弹性变化与肝癌自发性破裂的相关关系。方法 选用肝癌破裂及未破裂患者的肝癌组织标本各30例，采用免疫组化ABC法及电子显微镜检测其与血管病变有关的因素：第八因子相关抗原因子(vWF因子)、弹性硬蛋白、弹性蛋白酶(中性粒细胞性)。结果与未破裂组相比，肝癌破裂患者中血管内皮vWF因子表达量明显下降，小动脉壁中弹性蛋白酶分布异常、弹性硬蛋白增生过度、弹力膜断裂。vWF因子为血管受损指标之一，并参与凝血过程。上述病变的结果，导致患者小动脉壁脆性增加及凝血功能下降，稍遇外力的作用即易发生血管破裂，进而可导致肿瘤组织的破裂。结论肝癌患者体内的血管壁硬变可能与肝癌肿瘤破裂有关。     

Appropriate Treatment Strategy for Intrahepatic Recurrence After Curative Hepatectomy for Hepatocellular Carcinoma

Introduction  

The aim of this study is to evaluate the appropriate treatment for intrahepatic recurrence after hepatectomy for hepatocellular carcinoma (HCC).     

Recurrence Patterns After Hepatectomy of Hepatocellular Carcinoma: Implication of Milan Criteria Utilization

Background  Bridge hepatectomy followed by salvage liver transplantation has been proposed for patients with hepatocellular carcinoma (HCC) and preserved liver function. Methods  Data were prospectively collected for 501 consecutive patients who underwent curative primary hepatectomy for HCC between 1990 and 2006. Patient survival, disease-free survival (DFS), recurrence patterns, and risk factors were analyzed in patients classified according to the Milan criteria. Results  Patients were divided into two groups on the basis of whether their disease was within the Milan criteria (group 1, n = 321) or not (group 2, n = 180). Group 1 patient survival and DFS rates were 73.6% and 40.6% at 5 years. Recurrence was observed in 160 group 1 patients (49.8%); in 42 (26.3%) of these 160 patients, the recurrence exceeded the Milan criteria. No recurrence was noted in 145 group 1 patients (45.2%). Group 2 patient survival and DFS rates were 52.2% and 23.2%, respectively, at 5 years. Recurrence was noted in 116 patients (64.4%); recurrence in 58 (50.0%) of these patients was within the Milan criteria. In group 2, no recurrence was noted in 55 patients (30.6%). In group 1, indocyanine green retention rate at 15 minutes of >15%, nonanatomical resection, and multiple tumors were statistically significant risk factors for survival; 10-year patient survival was 78.5% for patients with no risk factors and 64.9% for patients with a single risk factor. Conclusions  The Milan criteria should be used to recommend hepatectomy for patients with HCC; however, it is important to consider the high recurrence rate after hepatectomy and the possible requirement of salvage transplantation.     

Prognosis and Predictors of Surgical Complications in Hepatocellular Carcinoma Patients With or Without Cirrhosis after Hepatectomy

Background

Although poor liver function is associated with a high morbidity rate and poor prognosis in hepatocellular carcinoma (HCC) patients, the exact effects of liver pathology on the surgical outcomes of HCC patients are poorly understood. The purpose of this study was to assess how the liver pathology of HCC patients affects their prognosis and complications rate after liver resection.

Methods

Between January 2006 and November 2010, 149 consecutive hepatocellular carcinoma patients, including 79 noncirrhosis patients and 70 cirrhosis patients, were enrolled in this study.

Results

Among the noncirrhotic patients, operative time, fresh frozen plasma (FFP) transfusion requirement, tumor size, and serum retinol binding protein (RBP) levels were significantly higher in the complications group than in the complications-free groups. On the other hand, in the cirrhotic patients the prothrombin time (PT) and indocyanine green retention value at 15 min (ICGR₁₅) of the complications group were significantly lower and higher, respectively, than those of the complications-free group. In the noncirrhotic patients, recurrence-free survival and overall survival did not differ between the complications and complications-free groups. On the other hand, in the cirrhotic patients, the recurrence-free survival and overall survival of the complications-free group were significantly longer than those of the complications group.

Conclusions

In the noncirrhotic patients, surgical complications had no prognostic effect, whereas they had a significant survival impact in the cirrhotic patients. The surgical strategy for HCC should be based on the patient’s pathological background.