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Fung et al.                                                                                                                                                            Hepatocellular carcinoma rupture hepatectomy

           Li et al. [25]  identified tumours located in segments II, III   post-operative outcomes might be related to the short
           and VI to be associated with its rupture. Furthermore,   operation time (mean 146 min), small transection area
           tumour rupture can occur in both large  and small   (mean 35 cm ) and no pre-operative angiogram and
                                                                          2
           HCCs.  Chan et al. [26]  found that ruptured HCC was   embolisation.
                 [8]
           associated  with more aggressive  disease  compared
           to non-ruptured HCC as evidenced by higher tumour   The main objective of ruptured HCC treatment is
           marker titres, higher rates of micro-vascular invasion   haemorrhage  control whilst preserving as much
           and tumour multifocality. Zhu et al.  found that tumour   functional liver tissue as possible. [6,28,29]  The
                                          [5]
           size > 5 cm,  hypertension,  liver cirrhosis, vascular   management  of ruptured HCC is challenging  and
           thrombus and extra-hepatic invasion  were predictive   multiple  treatment options  are available,  dependent
           of spontaneous HCC rupture on multivariate analysis.  on the clinical  condition  and haemodynamic  stability
                                                              of the patient. [7]
           In the present  study, emergency  hepatectomy  was
           defined as liver resection within 48 h of the clinical or   TAE  is  the  preferred  method  for  non-operative
           radiological diagnosis of HCC rupture. In the published   haemostasis of ruptured HCC. [20,30]  TAE can function
           literature, there are no guidelines on the optimal time   as  definitive  palliative  therapy  or  act  as  a  bridge  to
           for emergency operative intervention for ruptured HCC.   interval hepatectomy. [23,27,31]  However, whilst TAE may
           Whilst an arbitrary method to distinguish hepatectomy   achieve  haemostasis  of the tumour haemorrhage,
           into same admission liver resection (emergency     there are risks of re-bleeding, liver abscess and this
           group), and hepatectomy during second hospitalization   intervention cannot treat  the  tumour cells that  have
           (elective) is valid and clinically practical, we undertook   seeded  the peritoneal  cavity. [32]  Surgical  intervention
           this subgroup analysis and found that the there was   for ruptured HCC is indicated when haemostasis with
           considerable overlap between emergency and interval   TAE has been unsuccessful. [16]
           hepatectomy groups in terms of the time interval from
           onset of  ruptured HCC to  liver resection (data not   Yang et al. [33]  reviewed the outcomes of 132 patients
           shown). However, the use of the 48-h time interval   with ruptured HCC, of which 17 patients underwent
           resulted in eliminated this overlap.               emergency  hepatectomy  and  11  patients  had  TAE
                                                              then interval hepatectomy.  There were no 30-day
           The   indications  for  emergency    hepatectomy   mortality and 1-year survival rates were 56.3% and
           comprised  of  patients  with  CT  confirmed  ruptured   63.6% respectively. The median overall survival was
           HCC that presented with hypovolaemic shock, which   13.0 and 14.6 months. In the present series, 1-year
           was  refractory  to  adequate  fluid  resuscitation  and   survival  was 78%  and  85%,  with overall  median
           with failed trans-arterial angiogram  and embolization   survival of 29 months in the emergency hepatectomy
           of  the ruptured HCC. Patients who remained        group compared to 15.7 months in the interval group
           haemodynamically  unstable for angiogram  were     (P = 0.25).
           transferred to the operating room. The liver function and
           CT were assessed for feasibility of safe and curative   Zhang  et al. [29]  reported  on the impact of interval
           hepatectomy prior to proceeding  with emergency    hepatectomy or repeat TACE after successful TACE for
           operation.                                         ruptured HCC. One hundred and twenty-six cases of
                                                              ruptured HCC underwent TAE for haemostasis of which
           The patients who underwent emergency hepatectomy   74 had interval hepatectomy. The 90-day mortality rate
           had worse preoperative Child-Pugh grade, larger tumour   was 6.8% in the hepatectomy group and 7.7% in the
           size, greater operative blood loss and blood transfusion   TACE group (P = 0.84), all of whom died from tumour
           requirements and higher rates of anatomical resection   recurrence.  The 1-, 3-, 5-year survival rates were
           but shorter operative times compared to the elective   85.1%, 63.5% and 37.8% in  the hepatectomy group
           hepatectomy group. In the post-operative period, the   compared  to  69.2%,  46.2%  and  17.3%  in  the TACE
           complication rate was higher in the emergency group   group (P = 0.004).
           (44%  vs.  38%) but there were no 30-day mortality
           or requirement for re-operative  intervention  in both   Dissemination of ruptured HCC tumour cells into the
           groups. Emergency hepatectomy for ruptured HCC in   peritoneal  cavity is one argument  for proponents
           patients with Child-Pugh C cirrhosis is associated with   of emergency hepatectomy for ruptured HCC. [34,35]
           significant peri-operative mortality as reported in other   Zhang et al. [29]  reported an 11.8% incidence of peritoneal
           case series, [20,23,27]  but in this present study, 2 patients   disease in their series of ruptured HCCs. In the present
           with Child-Pugh  C cirrhosis  underwent  emergency   study, there was an 11% peritoneal recurrence rate in
           hepatectomy without 30-day mortality. The favourable   the emergency hepatectomy group compared to 29%
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