Limited hepatic resection for selected cirrhotic patients with hepatocellular or cholangiocellular carcinoma: A prospective study

Abstract

From 1 January 1983 to 1 January 1989 123 cirrhotic patients with hepatocellular cancer (n = 122) or cholangiocarcinoma (n = 1) were screened using liver function tests, alpha-fetoprotein determination, ultrasonography with biopsy (and in selected cases computed tomography or nuclear magnetic resonance), laparoscopy and angiography, Child-Pugh classification and urea-nitrogen synthesis rate. Twenty-three patients were selected for surgical resection because the tumour was smaller than 5 cm, not centrally located and at least 1 cm away from main structures; there was no evidence of multicentricity or metastatic disease; and the Child-Pugh classification was A or B and the urea-nitrogen synthesis rate at least 6 g/day. Upper gastrointestinal endoscopy was used routinely to identify oesophageal varices which were present in 17 cases; ten patients with a history of variceal haemorrhage (43 per cent) had preoperative endoscopic sclerotherapy. In cases with recurrent haemorrhage, surgery was used to prevent intraoperative and postoperative bleeding. Tumour resection was carried out using controlled hypotension and hepatoduodenal ligament clamping. Twelve bisegmentectomies, ten segmentectomies and one atypical resection were performed. The operative mortality rate was 13 per cent with liver failure and sepsis as the causes of death. The 'recurrence rate' was 26 per cent and the late mortality rate for the whole group up to 1 January 1990 was 30 per cent; 13 patients were still alive. The 12-month survival rate was 77 per cent and after 5 years it was 49 per cent. Thus, surgical resection of small liver tumours is the treatment of choice in this selected group of patients.

Techniques of Hepatectomy for Hepatocellular Carcinoma

“…Nevertheless, how long the cirrhotic liver can tolerate warm ischemia was not known until 1984 when we first reported our experi ence on this subject [6]. Our finding that the cirrhotic liver can tolerate normothermic ischemia for at least 30 min during limited resection was later confirmed by other investigative groups [7,8]. For segmental or subsegmental resection of the cirrhotic liver in which injury to intrahepatic major branches of the hepatic vein is anticipated, we occlude the hepatic vein simultaneously with the Pringle's maneuver as shown in figure 1.…”

“…were carried out with the old concept that human livers are not able to tolerate normothermic ischemia for longer than 15-20 min. Thereafter, it has been elucidated that warm ischemia of the normal liver for at least 60 min is safe even at the time of major hepatic resection [5] and that limited resection of the cirrhotic liver can be safely performed under normothermic conditions for at least 30 min [6][7][8][9], It can probably be agreed nowadays that hypothermia is not necessary in most cases of hepatic resection provided that the resection is to be performed by expert teams.…”

Usefulness of Intraoperative Measurement of Portal Venous Pressure for Confirming the Most Appropriate Hepatectomy in Patients with Borderline Hepatic Functional Reserve

“…Several preoperative criteria have been reported for determining the limit of liver resection 2,[6][7][8] . The Makuuchi and Takasaki criteria are well-known liver volume-based criteria 2,7) .…”

Evacuation of the Pleural Cavity With an InfantFeeding Catheter Following en Bloc Resectionof Hepatocellular Carcinoma and InvolvedDiaphragm–an Institutional Experience

“…With better case selection, more refined surgical technique [3,4] and optimal postoperative care [4,5], the previously high mortality and morbidity of elective liver resection have given way to a more acceptably low level with satisfactory functional outcome. This, coupled with the grave prognosis of inoperable disease [2], makes hepatobiliary surgeons to adopt an aggressive attitude towards the choice of treatment options for hepatocellular carcinoma.…”