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Fung et al.                                                                                                                                                            Hepatocellular carcinoma rupture hepatectomy


              No ongoing haemorrhage (no                    Diagnosis of
               active contrast extravastion               ruptured HCC on
                   on contrast CT)                          contrast CT


                                                     Ongoing haemorrhage (active
                                                       contrast extravastion on
                                                           contrast CT)



                   Conservation       Haemodynamically stable            Haemodynamically
                    management           Patent portal vein                  unstable
                                                                                           Surgically resectable HCC
                                                                                           Patient fit for emergency
                                                                                                 operation
                                       Transarterial angiogram           Emergency surgical
                                         and embolisation of                intervention
                                           ruptured HCC     Failed TAE
                                                           haemostasis

                                         Work-up for interval
                                           hepatectomy

           Figure 1: Algorithm for the management of ruptured HCC. HCC: hepatocellular carcinoma; TAE: trans-arterial embolisation; CT: computed
           tomography


           Statistical analysis was performed with independent t   differences in pre-operative international  normalized
           test for continuous variables and chi-square test was   ratio and bilirubin levels between the two groups.
           used  to compare  discrete  variables.  Kaplan-Meier
           analysis was used to estimate overall survival between   Eight (89%) and 18 (90%) patients in the emergency
           emergency and interval hepatectomy groups. Overall   and interval hepatectomy groups were hepatitis B
           survival  was  defined  as  the  time  from  hepatectomy   virus positive, respectively (P = 0.66). There was more
           until death from any cause, or until the observation   severe liver dysfunction in the emergency hepatectomy
           period  was completed.  Survival  data were  censored   group, with higher pre-operative Child-Pugh grade (P =
           on  November  7th,  2015.  Statistical  significance  was   0.04, Table 1).
           defined as a P value < 0.05 and statistical calculations
           were performed on SPSS 22 software (IBM).          Five  (56%)  patients  underwent  pre-operative  TAE  in
                                                              the emergency hepatectomy group compared  to 10
           RESULTS                                            patients (48%) in the interval hepatectomy group (P =
                                                              0.5). Two patients in the emergency group had failed
           Preoperative demographics                          embolisation due to small collateral vessels, whereas
                                                              4 patients had unresponsive shock despite adequate
           Thirty patients underwent  hepatectomy for ruptured   fluid  resuscitation  and  proceeded  to  emergency
           resectable HCC. Nine (30%) patients underwent      hepatectomy without prior TAE.
           emergency hepatectomy with a median time
           to operation  of 0 days (range  0-2). For interval   Operative characteristics
           hepatectomy,  median time to operation  was 19     In the emergency hepatectomy group, all patients
           days (range 3-49). The median age for patients who   underwent anatomical resection (5 left  lateral
           underwent  emergency  hepatectomy was 56 years     sectionectomies,  2 left hepatectomies  and 2 right
           compared  to 54 years in the interval  hepatectomy   hepatectomies)  compared  to 15 (76%)  in the
           group (P = 0.13). There was a similar distribution of   interval  group  (3 left lateral sectionectomies,  2 left
           male patients in both groups (89% vs. 90%, P = 0.66).   hepatectomies, 9 right hepatectomies and 1 caudate
           The pre-operative haemoglobin  (10.1  vs. 12.0,  P =   lobectomy)  (P = 0.07).  The mean  HCC  tumour size
           0.07) and platelet count (171 vs. 220, P = 0.11) were   was larger (10.5 vs. 8.3 cm, P = 0.17) in the emergency
           lower and creatinine was worse (102 vs. 87, P = 0.32)   hepatectomy group.
           in the emergency hepatectomy group but this did not
           reach statistical significance. There were no significant   The  mean operative time  for  liver resection in the

            198                                                                                                     Hepatoma Research ¦ Volume 3 ¦ September 08, 2017
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