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Morise et al.                                                                                                                                                          Repeat LLR for recurrent HCC in cirrhotic liver

           Table 2: Summary of previous reports of repeat laparoscopic hepatectomy that included cases of hepatocellular
           carcinoma
                                             First Hx          Bleeding  Operating  Con.  POHS
           Authors      n Age (year)  Disease        Procedure                                Morbidity Mortality
                                            (open:lap)           (mL)   time (min)  (n)  (days)
                                                      LLS (n = 5),
                 [13]
           Belli et al. *                                      297 ± 134  114.4 ± 11.0   7.4 ± 2.5
           (2009)       12  69 (58-75)  HCC    4:8    Pt (n = 4),   272.2 ± 120  63.9 ± 13.3  1  6.2 ± 3.0  26.6%  0%
                                                      Seg (n = 3)
                                               3:3
           Hu et al. [17]                             LLS (n = 2),
           (2011)       6  49 (46-61)  HCC   (Lap RFA,   Pt (n = 4)  283.3 ± 256.3 140.8 ± 35.7  0  5.67 ± 1.63  16.7%  0%
                                               n = 2)
                                                      LLS (n = 4),
                                   Met (n = 63),
           Shafaee et al. [16]     HCC (n = 3),        Pt, seg
           (2011)       76  61 (29-82)  others   28:44  (n = 53),   300 (0-5000)  180 (80-570)  8  6 (2-42)  26%  0%
                                     (n = 10)         above-seg
                                                       (n = 19)
           Ahn et al. [15]         HCC (n = 3),       LLS (n = 1),
           (2011)       4  57 (54-60)  Met (n =1)  0:4  Pt (n = 3)  481.7 ± 449.5 312.3 ± 158.4  1  10.6 ± 7.4  23.4%  0%
           Tsuchiya et al. [19]
           (2012)       3  73 (52-79)  HCC     0:3            281.3 (mean) 264.6 (mean)  0  8.6 (mean)   0%
           Kanazawa et al. [20]                                                    2
           (2013)       20  70 (46-83)  HCC    15:5      Pt    78 (1-1500)  239 (69-658)  (HALS)  9 (5-22)  5%  0%
                                   HCC (n = 2),                  400
           Shelat et al. [23]  20 57.5 (23-79) Met (n = 16),  0:20  Minor (n = 14)  (IQR 150-  285  3  4 (1-57)  10%  0%
           (2014)                                    Major (n = 6)     (IQR 195-360)
                                   others (n = 2)                200)
                                   HCC (n = 8),       Pt (n = 9),
           Isetani et al. [22]  12  70 (57-81)  Met (n = 2),  8:4  Subseg   50  301 (104-570)  0  12 (9-30)  0%  0%
           (2015)                                               (NC-840)
                                   others (n = 2)      (n = 3)
                                                                                                 [13]
           Data are expressed as median (range) or mean ± standard deviation, unless stated otherwise. *In the paper by Belli et al.,  operating time,
           bleeding and POHS are described separately for patients whose previous hepatectomy was open (upper) or laparoscopic (lower). Con:
           conversion to laparotomy; HALS: hand-assisted laparoscopic surgery; HCC: hepatocellular carcinoma; IQR: interquartile range; LLS: left lateral
           sectorectomy; Met: metastasis; Minor: resection of 2 segments or less; Major: resection of more than 2 segments; NC: low, unquantifiable; POHS:
           postoperative hospital stay; Pt: partial resection; RFA: radiofrequency ablation; Seg: segmentectomy; Subseg: subsegmentectomy

           ICG-R15, and became  HCV-negative,  after taking a   metachronous HCCs within impaired liver and for
           newly developed  oral anti-HCV therapy. The patient   surface HCC in severe LC. [31,32]  The  deterioration
           remained in compensated LC throughout the period in   of liver function should be minimized  with the
           which the four LLRs were performed. As a result, and   reduced  adhesiolysis  and  dissection  required  during
           because of the shortage of cadaver donors in Japan,   a laparoscopic approach. In addition, LLR better
           liver transplantation was not undertaken. During both   prepared patients both physically and psychologically
           the first and fourth LLRs, minor anatomical resections   for a subsequent repeat LR, illustrated by a shortened
           (extended  segment 3 segmentectomy and  4ab        hospital stay for the patient reported here. Thus, LLR
           subsegmentectomy, respectively) were undertaken to   is a powerful localized therapy which can be applied
           remove multiple tumors in the same portal territories,   repeatedly and  may  prolong the  survival of  patients
           because the patient’s liver functional reserve (estimated   with multicentric metachronous HCCs/CLD.
           by ICGR15) was insufficient to support sectionectomy
           or more extended  resection.  Furthermore, ablation   Financial support and sponsorship
           therapy was not performed for the protuberant tumors   None.
           necessitating  the  first  and  second  LLRs  and  for  the
           tumor adjacent to the IVC at the time of third LLR,   Conflicts of interest
           owing to the technical challenges associated. Trans-  There are no conflicts of interest.
           arterial chemo-embolization (TACE) was used prior to
           the third LLR, but the target tumor had regrown six   Patient consent
           months after TACE; therefore, LLR was selected for   Obtained.
           the follow-up treatment.
                                                              Ethics approval
           LLR is highly suitable for repeated laparoscopic partial   The patient was treated within the standards  of our
           or local anatomical LR for the treatment of multicentric   institute and the report was approved.
                           Hepatoma Research ¦ Volume 2 ¦ September 19, 2016                              257
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