Laparoscopic RFA with splenectomy for hepatocellular carcinoma

Abstract

BackgroundThe treatment of hepatocellular carcinoma (HCC) is complicated and challenging because of the frequent presence of cirrhosis. Therefore, we propose a novel surgical approach to minimize the invasiveness and risk in patients with HCC, hypersplenism, and esophagogastric varices.MethodsThis was a retrospective study carried out in 25 patients with HCC and hypersplenism and who underwent simultaneous laparoscopic-guided radio-frequency ablation and laparoscopic splenectomy with endoscopic variceal ligation. Tumor size was restricted to a single nodule of <3 cm. Characteristics of the patients (cirrhosis etiology, liver function, tumor size, spleen size), surgery (complications, blood loss, time of stay), and follow-up (recurrence and survival) were examined.ResultsMean operative time was 128 ± 18 min. Mean blood loss was 206 ± 57 mL. Length of stay was 7.0 ± 1.5 days. Mean total costs were 8064 USD. Cytopenia and thrombocytopenia recovered quickly after surgery. No procedure was converted to open surgery. Two patients showed worsening liver function after surgery, three patients showed worsening of ascites, and five patients suffered from portal vein thrombosis. The 1-year tumor-free survival was 78.8 %, and the 21-month tumor-free survival was 61.4 %. According to a literature review, these outcomes were comparable to those of simultaneous open hepatic resection and splenectomy.ConclusionsLaparoscopic-guided radio-frequency ablation with laparoscopic splenectomy and endoscopic variceal ligation could be an available technique for patients with HCC <3 cm, hypersplenism, and esophagogastric varices. This approach may help to minimize the surgical risks and results in a fast increase in platelet counts with an acceptable rate of complications.

Immunological consequences following splenectomy in patients with liver cirrhosis

“…They transiently increase platelet counts for a limited period (42,43), while splenectomy in cirrhotic patients improve hypersplenism, including increase of platelet and white blood cell counts, for a long period (7,8). In addition, splenectomy not only has the clinical benefits, such as improvement of liver function and reduction of portal venous pressure (7)(8)(9)(10)(11), but also may contribute to immunological benefits, based on our study and others (27,28). It would be interesting to examine immune status after treatment with oral thrombopoietin receptor agonists and compare it with that after splenectomy in cirrhotic patients.…”

“…We previously reported that splenectomy in patients with advanced cirrhosis corrected thrombocytopenia, improved liver function, reduced portal venous pressure, and allowed prolonged management of hepatocellular carcinoma (HCC) and hepatitis C virus (HCV) infection (7). Other researchers have also described the clinical benefits of splenectomy in the management of portal hypertension (8,9), HCC (10), and living-donor liver transplantation (11) among patients with liver cirrhosis. In addition, Zhang et al reported that synchronous splenectomy and hepatectomy improved the disease-free survival rate compared with hepatectomy alone (12).…”

Benefits of Splenectomy and Curative Treatments for Patients with Hepatocellular Carcinoma and Portal Hypertension: a Retrospective Study

“…In our study, the proportion of patients with an estimated intraoperative blood loss and an intraoperative transfusion volume were also more significant than previous studies. 16–19 The portion of postoperative transfusion is also very high: as high as 58.6% of all patients received a transfusion. This result was attributed to a high percentage of patients with Child grade B liver function.…”

Improved survival following splenectomy combined with curative treatments for hepatocellular carcinoma in Child B patients: A propensity score matching study

“…7 Unlike most countries in Europe and North America, where HCC and hepatic decompensation is regarded as a contradiction to surgical resection, 2,31 liver resection or local ablation combined with other aggressive surgical procedures, such as splenectomy with or without Hassab's operation, are still carried out in some Asian countries, mainly due to the lack of liver donors and no better alternatives. 13,14,[32][33][34] Splenectomy alone has been reported as a useful measure to extend the surgical indication, as this procedure could improve the liver function within a short time. 22,33 In the past, some surgeons thought that, for patients with HCC complicated with the decompensated liver function, splenectomy should be carried out first, then hepatectomy after the improvement of liver function.…”

“…Follow-up information and long-term outcomes are summarized in Table 3. The median follow-up time was 42 months (IQR, 33-51) in the splenectomy group and 38 months (IQR, [29][30][31][32][33][34][35][36][37][38][39][40][41][42][43][44] in the non-splenectomy group. During the follow-up period, even though there was no significant difference in the number of deaths between the groups, a statistical difference was found in time to recurrence, pattern of recurrence, subsequent treatments, the experience of variceal rebleeding, the cause of death, and liver function change within 1 year after surgery (both P < 0.05).…”