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Fung et al.                                                                                                                                                            Hepatocellular carcinoma rupture hepatectomy

           presence of haemodynamic  stability,  non-operative   were  retrieved  from  the  in-house prospectively
           management with close monitoring is gold standard   maintained hepatectomy database.  The clinical
           care.  However, when  there is haemodynamic        data of these patients were collected and analysed
                [7]
           instability,  several treatment options are available.   retrospectively.  In  addition,  the  hepatectomy
           These include non-operative  procedures such as    histopathology results were reviewed to confirm HCC
           transarterial embolisation or absolute alcohol injection,   rupture.
           and surgical intervention (perihepatic packing, hepatic
           artery ligation, suture ligation, radiofrequency ablation   Due to the prospective nature of the database, some
           or hepatic resection). [8-12]  Despite the multiple treatment   patients had just undergone  hepatectomy and had
           options for ruptured HCC, there remains no consensus   not had sufficient follow-up period so were excluded
           on the optimal approach for these patients.        for data analysis. Patients with intra-operative findings
                                                              of incidental peri-tumoural haematoma suggestive of
           The advantage of one stage emergency liver         previously ruptured HCC were excluded. Emergency
           resection is the spontaneous control of haemorrhage   hepatectomy  was  defined  as  liver  resection  within
           with  definitive  management  of  the  HCC.  Emergent   48 h of the clinical  or radiological diagnosis  of HCC
           operation can also reduce the duration of  peritoneal   rupture. Some patients  were referred  to our hospital
           seeding of ruptured HCC tumour cells by lavage with   after haemodynamic stabilisation at the parent hospital
           water at operation. [13,14]                        using  TAE.  These  patients  were  included  in  the
                                                              emergency  hepatectomy group if they proceeded  to
           However,  emergent operative intervention must  be   liver resection within 48 h of first presentation of HCC
           balanced against the high mortality rate of up to 40% [15]   rupture.
           consequent to  the lack of  pre-operative objective
           assessment of functional  liver reserve and extent of   TAE  was  performed  by  experienced  interventional
           disease burden, hypovolaemic  shock  condition and   radiologists  with selective  cannulation  and  then
           coagulopathy. [16]                                 embolisation  of  the  tumour-feeding artery  with gel-
                                                              foam particles. Surgical  intervention  was indicated
           As a result, the alternative option of staged liver resection   when TAE failed to achieve adequate haemostasis. An
           after  initial haemorrhage control with trans-arterial   experienced team of hepato-biliary surgeons performed
           embolisation  (TAE)  is  offered  in  some  centres.  This   hepatectomy.  Hepatic  parenchymal  transection
           allows for subsequent assessment of functional liver   was undertaken using an ultrasonic dissector and
           reserve and operation under elective circumstances.   TissueLink  (Medtronic,  Ireland)  radiofrequency
           The success of TAE haemostasis is 50-100%, with a   dissector.  Intermittent Pringle manoeuvre  might be
           risk of liver failure of up to 33%. Additionally, the 30-  applied  during hepatectomy.  The clinical  decision
           day mortality after TAE is lower compared to emergent   algorithm for ruptured HCC as utilised in the author’s
           hepatectomy (0-9% vs. 0-37%). [16]                 institution is shown in Figure 1.

           The  survival  benefits  of  two-stage  liver  resection  over   Post-operative follow-up of hepatectomy included
           emergent hepatectomy remain controversial. Liu et al.    ultrasound  at  3  months  and  contrast  triphasic
                                                         [15]
           concluded that survival after two-stage liver resection   computed tomography (CT) at 6 months with
           post-HCC rupture was inferior compared to patients   3-monthly  monitoring  of  serum  alpha-fetoprotein
           who did not have this complication,  whereas       and liver function test for 2 years, then 6-monthly
           Yeh  et al. [17]  found that ruptured HCC had similar   thereafter. Supplementary CT was done in the
           overall survival rates compared to non-ruptured HCC   presence of raised serum alpha-fetoprotein or
           but inferior disease-free survival rates. Mizuno et al. [18]   suspicion of HCC recurrence on ultrasound. Recurrent
           noted that there was no difference in overall survival   HCC  was  diagnosed  with  radiological  imaging  (CT
           between ruptured and non-ruptured HCC.             or positron emission tomography CT) to identify
                                                              the location of intra-hepatic recurrence, tumour
           In this retrospective single-centre study, the short   disease burden and the presence of extra-hepatic
           and long term outcomes of patients who underwent   disease recurrence.  Treatment options for recurrent
           emergency and interval hepatectomy for ruptured and   HCC included further liver resection, local ablation
           resectable HCC were analysed.                      therapies,  transarterial  chemo-embolisation  (TACE),
                                                              external beam radiotherapy, systemic chemotherapy
           METHODS                                            or  targeted  immunotherapy.  A  multi-disciplinary
                                                              team  decided  on  treatment,  taking  into  account  the
           Patients with a diagnosis of ruptured HCC presenting   patients’ liver functional status, recurrence pattern and
           between April 2004 and October 2015 to our hospital   comorbidities.
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