Tse-Jia Liu

Factors Influencing Postoperative Morbidity, Mortality, and Survival After Resection for Hilar Cholangiocarcinoma

UNLABELLED OBJECTIVE; Morbidity and mortality involved in the resection of hilar cholangiocarcinoma were reviewed retrospectively. The clinicopathologic and laboratory parameters that might influence the patients survival also were re-evaluated. SUMMARY BACKGROUND DATA Although much progress has been made in the diagnosis and management of hilar cholangiocarcinoma, long-term outlook for most patients remains poor. Surgical resection is usually prohibited because of its local invasiveness, and most patients can only be managed by palliative drainage. Recently, many surgeons have adopted a more aggressive resection with varying degrees of success. Several prognostic factors in bile duct carcinoma have been proposed; however, no reports have specifically focused on resected hilar cholangiocarcinoma and its prognostic survival factors using multivariate analysis. METHODS The clinical records and pathologic slides of 49 cases with resected hilar cholangiocarcinoma were reviewed retrospectively. Twenty clinical and laboratory parameters were evaluated for their correlation with postoperative morbidity and mortality, whereas 31 variables were evaluated for their significance with postoperative survival. Variables showing statistical significance in the first univariate analysis were included in the following multivariate analysis using stepwise logistic regression test for factors affecting morbidity and mortality and Cox stepwise proportional hazard model for factors influencing survival. RESULTS There were 5 in-hospital deaths, and the cumulative 5-year survival rate in 44 patients who survived was 14.9%, with a median survival of 14.0 months. Multivariate analysis disclosed that co-existent hepatolithiasis and lower serum asparate aminotransferase levels (<90 U/L) had a significant low incidence of postoperative morbidity, whereas a serum albumin of less than 3 g/dL was the only significant factor affecting mortality. Regarding survival, univariate analysis identified eight significant factors: 1) total bilirubin > or = 10 mg/dL, 2) curative resection, 3) histologic type, 4) perineural invasion, 5) liver invasion, 6) depth of cancer invasion, 7) positive proximal resected margin, and 8) positive surgical margin. However, multivariate analysis disclosed total bilirubin > or = 10 mg/dL, curative resection, and histologic type as the three most significant independent variables. CONCLUSIONS Surgical resection provides the best survival for hilar cholangiocarcinoma. An adequate nutritional support to increase serum albumin over 3 g/dL is the most important factor to decrease postoperative mortality. Moreover, preoperative biliary drainage to decrease jaundice and a curative resection with adequate surgical margin are recommended if longer survival is anticipated. Patients with well-differentiated adenocarcinoma seem to survive longer compared to those with moderately or poorly differentiated tumors.

Hepatic resection of hepatocellular carcinoma in cirrhotic livers : Is it unjustified in impaired liver function ?

BACKGROUND Resection for hepatocellular carcinoma in patients with cirrhosis and impaired liver function is usually unjustified because of higher surgical risks and poorer long-term prognosis. METHODS A retrospective comparison of the background and resectional results of patients with cirrhosis and hepatocellular carcinoma was carried out between those with preoperative indocyanine green 15-minute retention rate of 20% or greater (group A, impaired function group, n = 36) and those with indocyanine green 15-minute retention rate of 10% or less (group B, normal function group, n = 34). RESULTS The group A patients had significantly lower serum albumin level and higher serum bilirubin level, longer prothrombin time, higher incidence of associated esophageal varices, and poorer Childs classifications for cirrhosis. Although the tumor diameter in both groups was similar (A, 6.9 versus B, 7.1 cm; p = 0.94), the resected liver amount in group B was greater (227.4 versus 473.2 gm; p = 0.038) because of a greater extent of liver resection (p < 0.001) and a wider surgical margin (0.34 versus 1.85 cm; p < 0.0001). The amount of operative blood loss and blood transfusion, operative morbidity, and operative mortality were not different between the two groups. The pathologic characteristics and staging were also comparable. The 5-year disease-free and actuarial survival rates of groups A and B were 30.9% and 29.6% (p = 0.16) and 45.2% and 33.4% (p = 0.11), respectively. CONCLUSIONS If the amount of resected nontumorous liver parenchyma could be reduced, resection of hepatocellular carcinoma in selected patients with cirrhosis and impaired liver function is still justified in spite of a narrow surgical margin.

Liver resection for hepatocellular carcinoma in octogenarians.

BACKGROUND Liver resection is risky in patients aged > or = 80 years. Because of short life expectancies and improved nonoperative modalities, the role of liver resection in octogenarians with hepatocellular carcinoma (HCC) is unclear. METHODS A retrospective review of the operative results of 260 patients with HCC between 1991 and 1997 was performed. According to the age at the time of operation, these patients were divided into 2 groups. Group 1 comprised 21 patients aged > or = 80 years, and group 2 comprised the other 239 younger patients. The backgrounds, pathologic features of the tumor, and operative results of the patients were compared. RESULTS Octogenarians had a higher incidence of associated medical diseases, a higher incidence of negative serum hepatitis B surface antigen, a lower alpha-fetoprotein level, and a higher indocyanine green retention rate. Although octogenarians had a longer postoperative hospital stay, there were no significant differences between the 2 groups regarding operative morbidity and mortality. The 5-year disease-free and actuarial survival rates for octogenarians and younger patients were 50.6% and 35.3% (P = .15) and 40.9% and 59.3% (P = .46), respectively. CONCLUSION Under meticulous preoperative assessments and postoperative care, liver resection for HCC is justified in selected octogenarians, with short- and long-term results comparable to those of younger patients.

Mesohepatectomy for centrally located hepatocellular carcinoma: an appraisal of a rare procedure

BACKGROUND For centrally located hepatocellular carcinoma (HCC), extended major hepatectomy is usually recommended, but the risk of postoperative liver failure is high when liver function is not sound. Mesohepatectomy (en bloc resection of Goldsmith and Woodburnes left medial and right anterior segments or Couinauds segments IV, V, and VIII) is a rare procedure, so its role in treating HCC is unclear. STUDY DESIGN We retrospectively reviewed 364 patients who underwent a curative resection for HCC. Among them, 15 patients were treated by mesohepatectomy. Their nontumorous liver revealed cirrhosis in 11 and chronic hepatitis in 4. The mean tumor diameter was 12.8 cm. In 10 of the 15 patients, HCC also invaded adjacent organs. The operative results of another 25 patients with different disease extent who underwent extended major hepatectomy were compared. RESULTS The hepatic inflow occlusion time for mesohepatectomy was longer than for extended hepatectomy (p = 0.01). The mean operative blood loss, amount of blood transfusion, operating time, and postoperative hospital stay in the mesohepatectomy group were 2,450 mL, 1,100 mL, 7.9 hours, and 14.9 days, respectively. In the extended-hepatectomy group, the values were 1,863mL, 768mL, 5.8 hours, and 16.8 days, respectively (all p>0.05 compared with mesohepatectomy). No patient died after mesohepatectomy, but after extended hepatectomy there was one death from liver failure. The Union Internationale contre le cancer (UICC) TNM stages of patients who underwent mesohepatectomy were as follows: stage II in 1, stage III in 4, and stage IVA in 10. All patients who underwent extended hepatectomy presented with stage IVA disease. The 6-year disease-free and actuarial survival rates after mesohepatectomy were 21% and 30%, respectively. The 6-year disease-free survival rate after extended hepatectomy was 9% (p = 0.11 compared with mesohepatectomy). CONCLUSION Although mesohepatectomy is time-consuming, it is justified for selected patients with centrally located large HCC in a diseased liver.

Hepatic resection for bilobar multicentric hepatocellular carcinoma: Is it justified?

BACKGROUND Hepatic resection for multiple hepatocellular carcinomas (HCCs) involving both lobes of the liver is rarely recommended because of high operative risks and low radicality. Thus the justification of hepatic resection for bilobar multicentric HCC remains undefined. METHODS Two hundred eleven patients with HCC, who underwent curative hepatic resection, were studied retrospectively. The patients were divided into two groups. Group A consisted of 39 patients with bilobar (both sides of Cantlies line) multicentric HCCs. Group B consisted of 172 patients with HCC with solitary or unilobar lesions. The backgrounds and resectional results of patients in groups A and B were compared. RESULTS Patients in group A usually required multiple separate liver resections and a longer operative time. However, the operative blood loss, amount of blood transfused, and operative morbidity and mortality rates were not significantly different. Patients in group A showed higher incidences of associated satellite nodules, microscopic vascular invasion, and a lack of capsules. The 6-year disease-free and actuarial survival rates of patients in groups A and B were 30.5% and 41.8% (p = 0.17) and 42.9% and 51.4% (p = 0.12), respectively. For patients in group A the presence of satellite nodules in any resected tumor was the only independent unfavorable feature that influenced the actuarial survival rate after multivariate analysis. CONCLUSIONS Liver resection is justified for bilobar multicentric HCCs in selected patients, if the tumors can be totally resected. Postoperative adjuvant therapies should be considered when satellite nodules are present in any resected tumor.

Bacterial translocation after cirrhotic liver resection: a clinical investigation of 181 patients

BACKGROUND Cirrhotic patients are usually associated with a high susceptibility to infection. Although bacterial translocation from gut mucosa to mesenteric lymph node (MLN) and systemic circulation is a well-known phenomenon after hepatectomy, its role in cirrhotic patients remains unclear. MATERIALS AND METHODS MLN was harvested for bacterial culture before and after liver resection in 181 cirrhotic patients. The characteristics and postoperative courses of patients with positive and negative bacterial culture for MLN after hepatectomy were compared. Postoperative systemic antibiotics were administered if infectious complications occurred. RESULTS No bacteria were cultured in MLN before hepatectomy. Bacterial translocation (BT) to MLN after hepatectomy occurred in 36 patients (BT group). After multivariate analysis, intraoperative blood transfusion was the only independent factor that influenced bacterial translocation rates after cirrhotic liver resection. BT group patients also had higher infectious and overall complication rates, with a longer postoperative hospital stay. Among the cultured bacteriae from infected sites in BT group patients with infectious complications, only 2 patients (12.5%) had totally different bacterial species to those cultured from MLNs. CONCLUSIONS Bacterial translocation more often occurred after liver resection in cirrhotic patients who received intraoperative blood transfusion. Such patients had higher postoperative infectious and overall complication rates. Thus, avoidance of intraoperative blood transfusion is mandatory for cirrhotic liver resection.

Large Cell Neuroendocrine Carcinoma of the Ampulla of Vater : Report of a Case

Large cell neuroendocrine carcinoma in the ampulla of Vater is rare and very different from the common ampullary adenocarcinoma. A 59-year-old man was admitted with obstructive jaundice. Gastroendoscopy showed a swollen ampulla of Vater and pathological examination of an ampullary biopsy revealed findings of a carcinoid tumor. After endoscopic biliary drainage, he underwent pancreaticoduodenectomy. A diagnosis of large cell neuroendocrine carcinoma was confirmed by immunohistochemical examination of the resected specimen. Despite adjuvant chemotherapy with cyclophosphamide and cisplatin, liver and peritoneal metastasis developed within 5 months and he survived for only 10 months after the operation. Thus, further investigations are needed to find a more effective postoperative adjuvant chemotherapy agent to treat patients with this aggressive tumor.

Hepatocellular carcinoma with adjacent organ extension: the enhancement of preoperative transcatheter arterial embolization and the results of surgical resection.

A review was conducted on 93 patients with hepato-cellular carcinoma (HCC) who underwent a collective total of 98 resections. A total of 24 hepatic resections were performed on 22 patients who had a serosa-exposed tumor (group A), for which combined resection of the adjacent organs was also required due to gross tumor invasion. The tumors of the group A patients were larger, had a higher incidence of intrahepatic vascular involvement, and were in a more advanced stage than those of the other patients (group B). Nevertheless, there were no differences in operative morbidity and mortality between the two groups. Only ten of the group A patients, who each underwent one operation, had concomitantly resected adjacent organs histologically invaded by HCC, while histological examination revealed adhesions in the remaining surgical specimens of concomitantly resected adjacent organs. More of the group A patients had undergone a preoperative transcatheter arterial embolization (TAE), which may enhance the histological invasion of HCC to the adjacent organs. The median survival times of the group A and B patients were 15.3 months and 40.1 months, respectively (P < 0.05), although whether the concomitantly resected organs were truly invaded by HCC did not influence the prognosis. Thus, en bloc combined resection of HCC-invaded adjacent organs is still advocated even for recurrent tumors; however, for serosa-exposed HCC after TAE, earlier resection is recommended whenever possible to avoid invasion of the adjacent organs.

The necessity of hepatic vein reconstruction after resection of cranial part of the liver and major hepatic veins in cirrhotic patients

BACKGROUND The necessity of hepatic vein reconstruction (HVR) after resection of cranial part of the liver and major hepatic vein(s) in cirrhotic patients when residual liver is insufficient for a major hepatectomy remains unclear. METHODS Fifty-two cirrhotic patients who underwent resection of cranial part of the liver and hepatic vein(s) for liver neoplasms were divided retrospectively into 3 groups based on the volume of the congestive area of the remnant liver after hepatectomy: group A, 28 patients, the volume of the congestive area was ≤20% of the residual liver volume and underwent no HVR; group B, 7 patients, the volume of the congestive area was >20% of residual liver volume and underwent no HVR; and group C, 17 patients, in whom HVR was performed (the volume of the congestive area was >20% of residual liver volume in 16 and <20% in 1). Background characteristics and postoperative results were compared between the groups. RESULTS Although group C patients had a significantly longer operative time, their postoperative courses were similar to group A patients. Group B patients had a significantly longer postoperative hospital stay and a greater postoperative morbidity and 90-day mortality. No 90-day mortality ensued in the group A and C patients. CONCLUSION In selected cirrhotic patients whose remnant liver is insufficient for major hepatectomy, HVR appears to be safe and desirable after resection of the cranial part of liver and hepatic vein when the volume of congestive area of liver remnant exceeds 20% of future residual liver volume.

SELECTIVE SENTINEL LYMPH NODE DISSECTION IN BREAST CANCER: Experiences from Taiwan

The significance of the sentinel lymph node (SLN) was examined in 58 Chinese breast cancer patients. The method of technetium-99m sulfur colloid injection and the intraoperative gamma probe was found to be very useful for identifying the SLN. The positive predictive value was 64.5%, and the negative predictive value was 93.2%. Findings suggest that lymph node dissection is not necessary in breast cancer patients with a negative SLN.