<b><i>Background:</i></b> Frail patients are likely to suffer from postoperative complication, but this assumption has not been well confirmed. <b><i>Objectives:</i></b> This study aims to clarify the importance of frailty in patients undergoing hepatectomy for predicting severe postoperative complications. <b><i>Method:</i></b> One hundred and forty-three patients aged >65 years undergoing hepatectomy between 2011 and 2016 were enrolled in this study. The relevance of frailty versus sarcopenia for postoperative outcome was assessed. We defined clinical frailty (CF) as a CF scale >4. Sarcopenia was defined by the total muscle area at the level of the third lumbar vertebra measured on computed tomography. <b><i>Results:</i></b> There were 16 patients (11%) with CF and 80 patients (56%) with sarcopenia. CF was associated with high age (<i>p</i> < 0.0001), severe postoperative complications (Clavien-Dindo classification ≥3) (<i>p</i> = 0.0059), and postoperative in-hospital stay (<i>p</i> = 0.0013). On the other hand, sarcopenia was not associated with postoperative outcome. Logistic regression analysis revealed that only CF was an independent predictor of severe postoperative complication (risk ratio of 4.2; <i>p</i> = 0.017). The occurrence of organ/space surgical site infection was significantly higher in the frailty group than in the non-frailty group. <b><i>Conclusion:</i></b> CF, but not sarcopenia, is a robust predictor of severe postoperative complications for patients undergoing hepatectomy.
The resectability of hepatocellular carcinoma (HCC) has been assessed based on the liver functional test, the liver volume of the future liver remnant (FLR), and, more recently, the functional liver volume of FLR. Liver volume is estimated via multi-detector computed tomography and three-dimensional image visualization technologies, and functional liver volume is investigated via 99m Tc-galactosyl human serum albumin scintigraphy, 99m Tc-mebrofenin hepatobiliary scintigraphy, and gadoxetic acid-enhanced magnetic resonance imaging. Several special techniques have been developed to promote FLR hypertrophy, thus allowing for safe hepatectomy. As an interventional technique, portal vein embolization (PVE) is essential, and, along with transarterial chemoembolization or hepatic vein embolization, this is beneficial in promoting a much larger FLR. Dual embolization is recommended for patients with very small FLR or with PVE failure. Radioembolization by Yttrium-90 microspheres (i.e., radiation lobectomy) can help in achieving FLR hypertrophy and has an anticancer effect on HCC. Transarterial chemoembolization on PVE has a similar anticancer effect. Surgical procedures, such as two-stage hepatectomy as well as associated liver partition and portal vein ligation for staged hepatectomy, are somewhat invasive. Therefore, they should be applied as a salvage procedure for patients with HCC who had inadequate response to the interventional approach. However, the best approach should be selected mainly based on the functional volume of FLR and the patients' condition; in addition, the resources of each facility should be considered.
Background: Lenvatinib, a newly developed oral multi-tyrosine kinase inhibitor, has amazing potential in the multidisciplinary treatment of advanced or metastatic hepatocellular carcinoma. Thrombocytopenia is a serious adverse event that causes drug dose reduction or withdrawal. Partial splenic embolization is currently being used as a non-surgical treatment for thrombocytopenia caused by various pharmacotherapies. Case Report: Partial splenic embolization was performed for three patients with hepatocellular carcinoma receiving lenvatinib therapy with/without transarterial chemoembolization. Partial splenic embolization was advantageous for various situations, including the induction of lenvatinib for patients with thrombocytopenia, application of lenvatinib after multiple transarterial chemoembolization using cisplatin and radiotherapy, and re-administration of lenvatinib after lenvatinib therapy-induced thrombocytopenia. In all cases, lenvatinib therapy was completed without need for cessation due to thrombocytopenia. Conclusion: We strongly recommend the new concept of combining partial splenic embolization and lenvatinib therapy for hepatocellular carcinoma.Multidisciplinary treatment, including molecular targeted therapy, is recommended for advanced or metastatic hepatocellular carcinoma (HCC) (1-4). Lenvatinib is a newly developed oral multi-tyrosine kinase inhibitor that can provide greater tumor regression and tumor necrosis compared to sorafenib (5-7). Since March 2018, lenvatinib has become available for use in the treatment of HCC in Japan and its use has been spreading globally (8-10). Lenvatinib is generally indicated for patients with good liver functional reserve, i.e. those with Child-Pugh score of 5 or 6 points (5, 6). Nonetheless, even for patients with advanced HCC who have chronic liver disease, lenvatinib was reported to have an acceptable safety profile (4, 9, 10). The phase III REFLECT trial comparing lenvatinib and sorafenib demonstrated different adverse events profiles. Accordingly, more than 5% patients in the lenvatinib group developed several grade three or more adverse events, including hypertension (23%), reduced appetite (5%), reduced weight (8%), protein urine (6%), reduced platelet count (5%), elevated aspartate aminotransferase (5%), and increased blood bilirubin (7%). ( 6) The lenvatinib group had fewer instances of palmar-plantar erythrodysesthesia (27%) than the sorafenib group (52%). Moreover, a systematic review and meta-analysis for lenvatinib cancer therapy demonstrated that thrombocytopenia (25.4%), hypertension (17.7%), and peripheral edema (15.5%) were the most frequent adverse events (grade ≥3) (11).Partial splenic embolization (PSE) has been developed as a non-surgical treatment for alterations in blood cell count, especially platelet count (12-14). However, hypersplenism due to liver cirrhosis has remained the main reason for application of PSE. Recently, indications for PSE have expanded to include coexisting hypersplenism in chemotherapy patients, pretreatment for...
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