Objective: To report the result of hepatectomy for hepatocellular carcinoma (HCC) in Queen Mary Hospital, Hong Kong. Design: A review of data that were collected prospectively. Subjects: 150 consecutive select patients with resectable HCC operated between December 1995 and August 1998 at Queen Mary Hospital, Hong Kong. Main outcome measure: Hospital mortality rate. Results: There was no hospital mortality in the 150 select patients undergoing hepatectomy for HCC. Blood transfusion was not required in 96 (64%) patients. Cirrhosis was present in 70 (47%) patients and chronic hepatitis was present in 56 (37%) patients. Conclusion: Hepatectomy for HCC can be accomplished without hospital mortality with current techniques.published_or_final_versio

Fan, ST

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Title Hepatectomy for hepatocellular carcinoma without hospitalmortalityAuthor(s) Fan, STCitation Hong Kong Practitioner, 1999, v. 21 n. 2, p. 51-54Issued Date 1999URL http://hdl.handle.net/10722/45394Rights Creative Commons: Attribution 3.0 Hong Kong LicenseORIGINAL ARTICLEHepatectomy For Hepatocellular CarcinomaWithout Hospital MortalityS T Fan,* MS, MD, FRCS(Glasgow), FRCS(Edin) ad hoDepartment of SurgeryThe University of Hong KongSummaryObjectiveDesignSubjectsMain outcome measureResultsConclusionKeywords09ttTo report the result of hepatectomy for hepatocellular carcinoma (HCC) in Queen MaryHospital, Hong Kong.A review of data that were collected prospectively.150 consecutive select patients with resectable HCC operated between December 1995 andAugust 1998 at Queen Mary Hospital, Hong Kong.Hospital mortality rate.: There was no hospital mortality in the 150 select patients undergoing hepatectomy for HCC.Blood transfusion was not required in 96 (64%) patients. Cirrhosis was present in 70 (47%)patients and chronic hepatitis was present in 56 (37%) patients.: Hepatectomy for HCC can be accomplished without hospital mortality with currenttechniques. (HK Pract 1999;21:51-54): Hepatectomy, hepatocellular carcinoma, hospital mortalityBm mms mat^ii*! 150(64%)70 £ ( 4 7 % ) 56 -g (37%)IntroductionHepatectomy for hepatocellularc a r c i n o m a (HCC) has been adangerous operation in the pastbecause the liver is often cirrhotica n d t h e l i v e r f u n c t i o n i sunsa t i s f ac to ry . The operat ivemortality rate in cirrhotic patientswas 58% in Foster's survey in 1977.1Many of the deceased pa t ien tssu f fe red f rom mass ive asci tes ,hyperbi l i rubinaemia , sepsis andencephalopathy. Over the last 10years at Queen Mary Hospital, thesurgical techniques and perioperativecare for hepatectomy have graduallyevolved into a standardized protocol.* Address for correspondence: Professor S T Fan, Department of Surgery, The University of Hong Kong, Queen Mary Hospital, 102 Pokfulam Road, Hong Kong.51Hepatocellular Carcinoma without Hospital MortalityORIGINAL ARTICLESince D e c e m b e r 1995, 150consecutive pat ients wi th HCCunderwent hepatectomy w i t h o u thospital mortality. In this report, theperioperative management that led tothe satisfactory short-term result wasreviewed.Patients and methodsBetween December 1995 andAugus t 1998, 150 c o n s e c u t i v epa t i en t s w i t h HCC u n d e r w e n thepa tec tomies a t Queen MaryHospital, Hong Kong. All data werecollected prospectively by a researchassistant.Preoperative managementHepatic functional assessments,including Pugh et al2 modification ofChild's hepatic function classifica-tion and indocyanine green (ICG)clearance test, were performed afterthe tumour was assessed to beresectable by radiological studies.The se lect ion of p a t i e n t s forhepatectomy was based mainly onthe result of ICG clearance test. Avalue of retention of ICG less than14% 15 minutes after injection wasconsidered acceptable for majorhepatectomy.3 Bowel washout wasperformed in the evening beforehepatectomy and antibiotic cover wasgiven at the time of skin incision.Surgical techniqueSurgery was performed througha generous b i l a te ra l subcosta lincision with an addition of thoracicextension when the tumour was largeor located in the r ight posteriorsegment. The aim was to allowadequate exposure of the tumour andto avoid unnecessary manipulation ofthe liver. Intraoperative ultrasono-graphy was performed to detectlesion in the contralateral lobe ofliver and to mark on the liver surfacethe o p t i m u m t r ansec t i on l ine .Dissection and control of ipsilateralhepatic artery and por ta l ve in ,followed by mobilization of the liverlobe b e a r i n g the t u m o u r , andtransection of the liver parenchymaunder inf low vascular control byultrasonic dissector were done. Theipsilateral hepatic duct was dividedduring liver transection, because bythis, the hepatic duct could be ligatedor sutured securely with the hilarplate and the chance of bile leakagewould be reduced. After completionof liver transection, the transectedsurface was inspected carefully forbile leakage. If present, the leakagesite was closed carefully by finesutures. During the operation, carewas exercised to reduce bleeding, topreserve volume of liver remnant andto avoid any hypoxic injury to theliver remnant.Postoperative carePostoperatively, the patients,particularly those with cirrhosis andmajor hepatectomy, were monitoredin the intensive care unit (ICU) witha t t e n t i o n t o f l u i d b a l a n c e ,oxygenation, and tissue perfusion.Mechanical ventilation was given to59 patients. All patients receivedlow-salt albumin for 3 to 5 days.Parenteral nutrition consisting ofbranched-chain amino acid-enrichedsolution, low dose dextrose, medium jcha in t r ig lycer ides was s tarted jimmediately after hepatectomy in all |pa t ients with cirrhosis or major jihepatectomy, and was continued for3 to 7 days until the gastrointestinalfunction returned.4 Once parenteraln u t r i t i o n was started, no otherintravenous fluid was given in orderto avoid fluid retention, elevation ofc e n t r a l v e n o u s p r e s s u r e a n dcongestion of the liver remnant.In this study, hospital mortalitywas defined as death, irrespective ofcause, du r ing hospital izat ion forhepatectomy. Major hepatectomywas defined as resection of 3 or morel i v e r segment s of C o u i n a u d ' snomenclature.5 Minor hepatectomywas defined as resection of 2 orfewer than 2 segments.ResultsThere were 122 male and 28female patients, with the median ageof 52.5 (range 7 - 80). The size ofthe tumours ranged from 1.2 cm to 22cm (median 6.3). Cirrhosis waspresent in 70 (47%) patients, andchronic hepatitis was present in 56(37%) patients. Major hepatectomywas performed in 89 (59%) patients,of whom 25 had underlying cirrhosis(Table 1). Blood transfusion wasg i v e n in 54 ( 3 6 % ) p a t i e n t s .Complications occurred in 58 (39%)patients (Table 2). There was nohospital mortality nor any patientwho returned soon after dischargehad died in the second admission.Those pat ients who developedcomplications were mostly withblood transfusion (Table 3).52Hong Kong Practitioner 21 (2) February 1999ORIGINAL ARTICLETable 1: Types of hepatectomy according to histological statusof liverChronic hepatitis 46Table 2: ComplicationsChest infectionWound infectionWound dehiscenceSubphrenic abscess'Peptic ulcer bleedingNumber12; 24 '224. - : . ' 1 ' ;i: 2 ./ 11 :• • • • • ' 1 .11Infected ascitesIntestinal obstructionBleeding gastrojejunostomy anastomosisAnastomosis leakageincision herniaRenal failurePostoperative bleeding from diaphragmTable 3: Comparison of patients with and without complicationThe distribution of TNM stageswas: stage I-6 patients, stage II -67 patients, stage III - 66 patients,stage IVA - 11 patients.DiscussionIn the p a s t 2 d e c a d e s ,hepatectomy has evolved from arough, hasty, and bloody procedureto a refined, deliberate, and relativelybloodless operation. The hospitalmortality rate of many recent serieswas less than 5%.6-7 This level ofsuccess may become a new standardfor hepatectomy in future.The success of hepatectomy forHCC depends on careful selection ofpatients based on indocyanine greenclearance test, meticulous techniqueto reduce bleeding, preserve livervolume and function, and optimumpostoperative care to preserve oreven enhance l ive r func t ion andregeneration. The good result is theendeavour of a team of surgeons,anaesthetists , and intensive carephys ic i ans . However, the mostBlood loss (L) :Blood transfusion (L)Number of patients without Wood transfusionOperative time (minutes)Fresh frozen plasma replacement (units)Hospital stay (days)Indocyanine green clearance (% at 15 min)Child's AChild's BWith complication(n=58)1.6 (0.2-10)0.15 (0-12.9)430 (135-780)O (0-3)17 (7-66)10.65 (2-48)544Without complication p value. (n=92) . •'• . ': • , • • : • ; • :' . : . ' • 1 (0.1-10) 0 . 0 0 10(0-9) 0.002973% 0.0045390 (105-795) 0.0361O (0-1.3) 0.0710 (5-27) 0,000011.4 (1.6-66.9) 0.837585 0.870577 ' • - .'53Hepatocellular Carcinoma without Hospital MortalityORIGINAL ARTICLE1. Hepatectomy for hepatocellular carcinoma can be performed nowadays without hospital mortality and withminimum blood transfusion.2. Such a result is only possible when meticulous surgical techniques and perioperative care are employed.important aspect is the supervision ofthe senior surgeon who should ensurethat the protocol is fol lowed andthere is no surgical error leading tomassive bleeding and in ju ry to theliver remnant. With technical error,the effort to salvage the patient , nomatter how good and i m m e n s e l yimplemented in the 1CU, is oftenfutile.In the postoperat ive per iod,m e a s u r e s t o i m p r o v e t i s s u eo x y g e n a t i o n and a v o i d a n c e ofcongestion of the l iver remnant arethe p r i m a r y goal . M e c h a n i c a lventilation in the cirrhotic patientscan maintain adequate oxygenationa n d reduce p l e u r a l e f f u s i o n . 8Restriction of intravenous fluid andlowering of central venous pressureto prevent congestion of the liverremnant is necessary. Parenteralnutrition is given immediately aftersurgery, which is the time when thepat ients most r equ i r e metabol icsupport. Parenteral nutrition can alsostimulate liver regeneration, serve asan eff ic ient metabolic vehicle forresolving acute electrolytes and acid-base d i s t u r b a n c e s . H o w e v e r ,p a r e n t e r a l n u t r i t i o n m a y i n d u c eoverloading of circulation. Thus it isimportant to stop all other routes ofintravenous fluid administration onceparenteral nu t r i t ion is given. Theother potential hazard of parenteralnutrition is catheter sepsis. Once itoccurs, all the metabolic gain will becancelled out . To avoid cathetersepsis, it is m a n d a t o r y to use aseparate catheter for administrationof parenteral nutrition inserted underaseptic technique, and to start oralfeeding as soon as the gastrointes-tinal function returns.In conclusion, with adoption ofa standard protocol of surgica ltechnique and perioperative care, az e r o h o s p i t a l m o r t a l i t y o fhepatectomy for HCC is achieved.The next goal in the management ofHCC is to improve the long-termsurvival . •References1. Foster JH, Berman MM. Solid liver tumors.Major Problems in Clinical Surgery 1977;22:89.2. Pugh RNH, Murray-Lyon IM, Dawson JL, etal. Transection of the oesophagus for bleedingvarices. Br J Surg 1973:60:646-649.3. Lau H, Man K, Fan ST, et al. Evaluation ofpreoperative hepatic funct ion in patients withh e p a t o c e l l u l a r c a r c i n o m a u n d e r g o i n ghepatectomy. Br J Surg 1997;84:1255-1259.4. Fan ST, Lo CM, Lai CS, el al. Perioperativen u t r i t i o n a l support in pa t ien ts undergoinghepatectomy for hepatocellular carcinoma. NEngl J Med 1994:331:1547-1552.5 . C o u i n a u d C. E t u d e s a n a t o m i q u e s e tchirurgicales. Paris: Massori; 1957;400-409.6. Tang ZY. Yu YQ, Zhou XD, el al. Threedecades experience in surgery of hepatocellularcarcinoma. Gan To Kagaku Ryoho 1997;1(Suppl 24):126-133.7. Makuuchi M, Miyagawa S, Kakazu T, et al.Results of hepatic resection for hepatocellularcarcinoma. World J Surgery 1995;19:31-34.8. Matsumata T. Kanematsu T, Okudaira Y, et al.Postoperative mechanical ventilation preventingthe occu r r ence of p l e u r a l e f f u s i o n a f te rhepatectomy. Surgery 1987;102:493-497.54

Hepatectomy for hepatocellular carcinoma without hospital mortality

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Hepatectomy for hepatocellular carcinoma without hospital mortality

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