Skip to main content
NCBI home page
Annals of Surgery logoLink to Annals of Surgery
. 1999 Mar;229(3):322–330. doi: 10.1097/00000658-199903000-00004

Hepatectomy for hepatocellular carcinoma: toward zero hospital deaths.

S T Fan 1, C M Lo 1, C L Liu 1, C M Lam 1, W K Yuen 1, C Yeung 1, J Wong 1
PMCID: PMC1191696  PMID: 10077043

Abstract

OBJECTIVE: The authors report on the surgical techniques and protocol for perioperative care that have yielded a zero hospital mortality rate in 110 consecutive patients undergoing hepatectomy for hepatocellular carcinoma (HCC). The hepatectomy results are analyzed with the aim of further reducing the postoperative morbidity rate. SUMMARY BACKGROUND DATA: In recent years, hepatectomy has been performed with a mortality rate of <10% in patients with HCC, but a zero hospital mortality rate in a large patient series has never been reported. At Queen Mary Hospital, Hong Kong, the surgical techniques and perioperative management in hepatectomy for HCC have evolved yearly into a final standardized protocol that reduced the hospital mortality rate from 28% in 1989 to 0% in 1996 and 1997. METHODS: Surgical techniques were designed to reduce intraoperative blood loss, blood transfusion, and ischemic injury to the liver remnant in hepatectomy. Postoperative care was focused on preservation and promotion of liver function by providing adequate tissue oxygenation and immediate postoperative nutritional support that consisted of branched-chain amino acid-enriched solution, low-dose dextrose, medium-chain triglycerides, and phosphate. The pre-, intra-, and postoperative data were collected prospectively and analyzed each year to assess the influence of the evolving surgical techniques and perioperative care on outcome. RESULTS: Of 330 patients undergoing hepatectomy for HCC, underlying cirrhosis and chronic hepatitis were present in 161 (49%) and 108 (33%) patients, respectively. There were no significant changes in the patient characteristics throughout the 9-year period, but there were significant reductions in intraoperative blood loss and blood transfusion requirements. From 1994 to 1997, the median blood transfusion requirement was 0 ml, and 64% of the patients did not require a blood transfusion. The postoperative morbidity rate remained the same throughout the study period. Complications in the patients operated on during 1996 and 1997 were primarily wound infections; the potentially fatal complications seen in the early years, such as subphrenic sepsis, biliary leakage, and hepatic coma, were absent. By univariate analysis, the volume of blood loss, volume of blood transfusions, and operation time were correlated positively with postoperative morbidity rates in 1996 and 1997. Stepwise logistic regression analysis revealed that the operation time was the only parameter that correlated significantly with the postoperative morbidity rate. CONCLUSION: With appropriate surgical techniques and perioperative management to preserve function of the liver remnant, hepatectomy for HCC can be performed without hospital deaths. To improve surgical outcome further, strategies to reduce the operation time are being investigated.

Full text

PDF
322

Images in this article

324Figure 1.
on p.324
324Figure 2.
on p.324
324Figure 3.
on p.324
324Figure 4.
on p.324

Selected References

These references are in PubMed. This may not be the complete list of references from this article.

  1. Belghiti J., Di Carlo I., Sauvanet A., Uribe M., Fekete F. A ten-year experience with hepatic resection in 338 patients: evolutions in indications and of operative mortality. Eur J Surg. 1994 May;160(5):277–282. [PubMed] [Google Scholar]
  2. Chiba T., Kawai K., Ikenaka K., Nakamura H., Okamoto M., Harada N., Tanaka H., Shirasaka T., Fujii S. Effect of an exogenous energy source and amino acids on DNA synthesis in regenerating rat liver. Biochim Biophys Acta. 1983 Feb 22;755(3):420–427. doi: 10.1016/0304-4165(83)90245-3. [DOI] [PubMed] [Google Scholar]
  3. Choti M. A., Bowman H. M., Pitt H. A., Sosa J. A., Sitzmann J. V., Cameron J. L., Gordon T. A. Should hepatic resections be performed at high-volume referral centers? J Gastrointest Surg. 1998 Jan-Feb;2(1):11–20. doi: 10.1016/s1091-255x(98)80098-x. [DOI] [PubMed] [Google Scholar]
  4. Driscoll D. F., Palombo J. D., Bistrian B. R. Nutritional and metabolic considerations of the adult liver transplant candidate and organ donor. Nutrition. 1995 May-Jun;11(3):255–263. [PubMed] [Google Scholar]
  5. Emond J. C., Polastri R. Anatomical hepatectomy for resection or transplantation. Am J Surg. 1996 Jul;172(1):29–34. doi: 10.1016/S0002-9610(96)00069-4. [DOI] [PubMed] [Google Scholar]
  6. Fan S. T., Lai E. C., Lo C. M., Chu K. M., Liu C. L., Wong J. Hepatectomy with an ultrasonic dissector for hepatocellular carcinoma. Br J Surg. 1996 Jan;83(1):117–120. doi: 10.1002/bjs.1800830138. [DOI] [PubMed] [Google Scholar]
  7. Fan S. T., Lai E. C., Lo C. M., Ng I. O., Wong J. Hospital mortality of major hepatectomy for hepatocellular carcinoma associated with cirrhosis. Arch Surg. 1995 Feb;130(2):198–203. doi: 10.1001/archsurg.1995.01430020088017. [DOI] [PubMed] [Google Scholar]
  8. Fan S. T., Lo C. M., Lai E. C., Chu K. M., Liu C. L., Wong J. Perioperative nutritional support in patients undergoing hepatectomy for hepatocellular carcinoma. N Engl J Med. 1994 Dec 8;331(23):1547–1552. doi: 10.1056/NEJM199412083312303. [DOI] [PubMed] [Google Scholar]
  9. Fan S. T., Wong J. Metabolic clearance of a fat emulsion containing medium-chain triglycerides in cirrhotic patients. JPEN J Parenter Enteral Nutr. 1992 May-Jun;16(3):279–283. doi: 10.1177/0148607192016003279. [DOI] [PubMed] [Google Scholar]
  10. George R., Shiu M. H. Hypophosphatemia after major hepatic resection. Surgery. 1992 Mar;111(3):281–286. [PubMed] [Google Scholar]
  11. Haley R. W., Culver D. H., Morgan W. M., White J. W., Emori T. G., Hooton T. M. Identifying patients at high risk of surgical wound infection. A simple multivariate index of patient susceptibility and wound contamination. Am J Epidemiol. 1985 Feb;121(2):206–215. doi: 10.1093/oxfordjournals.aje.a113991. [DOI] [PubMed] [Google Scholar]
  12. Johnson M., Mannar R., Wu A. V. Correlation between blood loss and inferior vena caval pressure during liver resection. Br J Surg. 1998 Feb;85(2):188–190. doi: 10.1046/j.1365-2168.1998.00570.x. [DOI] [PubMed] [Google Scholar]
  13. Kameoka N., Nimura Y., Sato T., Kato M., Yasui A., Kondo S. Postprandial responses of liver blood flow prior to and following hepatectomy in conscious dogs. J Surg Res. 1996 Mar;61(2):437–443. doi: 10.1006/jsre.1996.0142. [DOI] [PubMed] [Google Scholar]
  14. Kim S. T., Kim K. P. Hepatic resections for primary liver cancer. Cancer Chemother Pharmacol. 1994;33 (Suppl):S18–S23. doi: 10.1007/BF00686662. [DOI] [PubMed] [Google Scholar]
  15. Ko S., Nakajima Y., Kanehiro H., Aomatsu Y., Yoshimura A., Taki J., Kin T., Yagura K., Ohashi K., Nakano H. Transthoracic transdiaphragmatic approach for hepatectomy of Couinaud's segments VII and VIII. World J Surg. 1997 Jan;21(1):86–90. doi: 10.1007/s002689900198. [DOI] [PubMed] [Google Scholar]
  16. Kubota K., Makuuchi M., Kusaka K., Kobayashi T., Miki K., Hasegawa K., Harihara Y., Takayama T. Measurement of liver volume and hepatic functional reserve as a guide to decision-making in resectional surgery for hepatic tumors. Hepatology. 1997 Nov;26(5):1176–1181. doi: 10.1053/jhep.1997.v26.pm0009362359. [DOI] [PubMed] [Google Scholar]
  17. Lai E. C., Fan S. T., Lo C. M., Chu K. M., Liu C. L. Anterior approach for difficult major right hepatectomy. World J Surg. 1996 Mar-Apr;20(3):314–318. doi: 10.1007/s002689900050. [DOI] [PubMed] [Google Scholar]
  18. Lau H., Law S., Wong J. Prospective evaluation of vacuum pleural drainage after thoracotomy in patients with esophageal carcinoma. Arch Surg. 1997 Jul;132(7):749–752. doi: 10.1001/archsurg.1997.01430310063012. [DOI] [PubMed] [Google Scholar]
  19. Lau H., Man K., Fan S. T., Yu W. C., Lo C. M., Wong J. Evaluation of preoperative hepatic function in patients with hepatocellular carcinoma undergoing hepatectomy. Br J Surg. 1997 Sep;84(9):1255–1259. [PubMed] [Google Scholar]
  20. Lee C. S., Chao C. C., Lin T. Y. Partial hepatectomy on cirrhotic liver with a right lateral tumor. Surgery. 1985 Nov;98(5):942–948. [PubMed] [Google Scholar]
  21. Makuuchi M., Takayama T., Gunvén P., Kosuge T., Yamazaki S., Hasegawa H. Restrictive versus liberal blood transfusion policy for hepatectomies in cirrhotic patients. World J Surg. 1989 Sep-Oct;13(5):644–648. doi: 10.1007/BF01658893. [DOI] [PubMed] [Google Scholar]
  22. Man K., Fan S. T., Ng I. O., Lo C. M., Liu C. L., Wong J. Prospective evaluation of Pringle maneuver in hepatectomy for liver tumors by a randomized study. Ann Surg. 1997 Dec;226(6):704–713. doi: 10.1097/00000658-199712000-00007. [DOI] [PMC free article] [PubMed] [Google Scholar]
  23. Marchesini G., Zoli M., Dondi C., Bianchi G., Cirulli M., Pisi E. Anticatabolic effect of branched-chain amino acid-enriched solutions in patients with liver cirrhosis. Hepatology. 1982 Jul-Aug;2(4):420–425. doi: 10.1002/hep.1840020405. [DOI] [PubMed] [Google Scholar]
  24. Matsumata T., Kanematsu T., Okudaira Y., Sugimachi K., Zaitsu A., Hirabayashi M. Postoperative mechanical ventilation preventing the occurrence of pleural effusion after hepatectomy. Surgery. 1987 Sep;102(3):493–497. [PubMed] [Google Scholar]
  25. Michelson A. D., MacGregor H., Barnard M. R., Kestin A. S., Rohrer M. J., Valeri C. R. Reversible inhibition of human platelet activation by hypothermia in vivo and in vitro. Thromb Haemost. 1994 May;71(5):633–640. [PubMed] [Google Scholar]
  26. Miyagawa S., Makuuchi M., Kawasaki S., Kakazu T. Criteria for safe hepatic resection. Am J Surg. 1995 Jun;169(6):589–594. doi: 10.1016/s0002-9610(99)80227-x. [DOI] [PubMed] [Google Scholar]
  27. Nagao T., Inoue S., Goto S., Mizuta T., Omori Y., Kawano N., Morioka Y. Hepatic resection for hepatocellular carcinoma. Clinical features and long-term prognosis. Ann Surg. 1987 Jan;205(1):33–40. doi: 10.1097/00000658-198701000-00006. [DOI] [PMC free article] [PubMed] [Google Scholar]
  28. Nagasue N., Kohno H., Chang Y. C., Taniura H., Yamanoi A., Uchida M., Kimoto T., Takemoto Y., Nakamura T., Yukaya H. Liver resection for hepatocellular carcinoma. Results of 229 consecutive patients during 11 years. Ann Surg. 1993 Apr;217(4):375–384. doi: 10.1097/00000658-199304000-00009. [DOI] [PMC free article] [PubMed] [Google Scholar]
  29. Noun R., Jagot P., Farges O., Sauvanet A., Belghiti J. High preoperative serum alanine transferase levels: effect on the risk of liver resection in Child grade A cirrhotic patients. World J Surg. 1997 May;21(4):390–395. doi: 10.1007/pl00012259. [DOI] [PubMed] [Google Scholar]
  30. O'Keefe S. J., El-Zayadi A. R., Carraher T. E., Davis M., Williams R. Malnutrition and immuno-incompetence in patients with liver disease. Lancet. 1980 Sep 20;2(8195 Pt 1):615–617. doi: 10.1016/s0140-6736(80)90284-6. [DOI] [PubMed] [Google Scholar]
  31. Ozawa K. Hepatic function and liver resection. J Gastroenterol Hepatol. 1990 May-Jun;5(3):296–309. doi: 10.1111/j.1440-1746.1990.tb01632.x. [DOI] [PubMed] [Google Scholar]
  32. Pugh R. N., Murray-Lyon I. M., Dawson J. L., Pietroni M. C., Williams R. Transection of the oesophagus for bleeding oesophageal varices. Br J Surg. 1973 Aug;60(8):646–649. doi: 10.1002/bjs.1800600817. [DOI] [PubMed] [Google Scholar]
  33. Rigotti P., Peters J. C., Tranberg K. G., Fischer J. E. Effects of amino acid infusions on liver regeneration after partial hepatectomy in the rat. JPEN J Parenter Enteral Nutr. 1986 Jan-Feb;10(1):17–20. doi: 10.1177/014860718601000117. [DOI] [PubMed] [Google Scholar]
  34. Rohrer M. J., Natale A. M. Effect of hypothermia on the coagulation cascade. Crit Care Med. 1992 Oct;20(10):1402–1405. doi: 10.1097/00003246-199210000-00007. [DOI] [PubMed] [Google Scholar]
  35. Segawa T., Tsuchiya R., Furui J., Izawa K., Tsunoda T., Kanematsu T. Operative results in 143 patients with hepatocellular carcinoma. World J Surg. 1993 Sep-Oct;17(5):663–668. doi: 10.1007/BF01659138. [DOI] [PubMed] [Google Scholar]
  36. Sheen P. C., Lee K. T., Chen H. Y., Chen J. S., Ker C. G. Conservative hepatic resection for hepatocellular carcinoma of cirrhotic patients. Int Surg. 1996 Jul-Sep;81(3):280–283. [PubMed] [Google Scholar]
  37. Shimada M., Takenaka K., Fujiwara Y., Gion T., Shirabe K., Yanaga K., Sugimachi K. Risk factors linked to postoperative morbidity in patients with hepatocellular carcinoma. Br J Surg. 1998 Feb;85(2):195–198. doi: 10.1046/j.1365-2168.1998.00567.x. [DOI] [PubMed] [Google Scholar]
  38. Ueno S., Tanabe G., Yamada H., Kusano C., Yoshidome S., Nuruki K., Yamamoto S., Aikou T. Response of patients with cirrhosis who have undergone partial hepatectomy to treatment aimed at achieving supranormal oxygen delivery and consumption. Surgery. 1998 Mar;123(3):278–286. [PubMed] [Google Scholar]
  39. Vauthey J. N., Klimstra D., Franceschi D., Tao Y., Fortner J., Blumgart L., Brennan M. Factors affecting long-term outcome after hepatic resection for hepatocellular carcinoma. Am J Surg. 1995 Jan;169(1):28–35. doi: 10.1016/s0002-9610(99)80106-8. [DOI] [PubMed] [Google Scholar]
  40. Yamanaka N., Okamoto E., Toyosaka A., Mitunobu M., Fujihara S., Kato T., Fujimoto J., Oriyama T., Furukawa K., Kawamura E. Prognostic factors after hepatectomy for hepatocellular carcinomas. A univariate and multivariate analysis. Cancer. 1990 Mar 1;65(5):1104–1110. doi: 10.1002/1097-0142(19900301)65:5<1104::aid-cncr2820650511>3.0.co;2-g. [DOI] [PubMed] [Google Scholar]

Articles from Annals of Surgery are provided here courtesy of Lippincott, Williams, and Wilkins

RESOURCES