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

           INTRODUCTION                                       of repeat LLR for the treatment of HCC. [22,23]

           Since  the  first  successful  report  of  laparoscopic   CASE REPORT
           liver wedge resection in 1991,  laparoscopic liver
                                        [1]
           resection (LLR) has been thought to be a “less     A 73-year-old  woman  with hepatitis  C virus (HCV)-
           invasive”  procedure  than  open  liver  resection.  Use   related  liver cirrhosis  (LC) was admitted to our
           of  this  technique  is  especially  beneficial  for  patients   department for treatment of  three lesions in liver
           with concurrent hepatocellular carcinoma (HCC) and   segment 4. These were revealed by contrast-enhanced
           chronic liver disease (CLD). [2-4]  However, accumulated   computed  tomography  (CT) examination  undertaken
           experience  of  this  technique  and  technological   during the follow up to three LLRs that were performed
           developments have facilitated the expansion of the   73, 45, 23 months previously [Figure 1]. The patient
           indications for LLR. [5-7]  It is becoming clear that the   had no history of hepatic  encephalopathy, ascites
           magnified caudal view offered by laparoscopy allows   (except immediately postoperatively) and no specific
           improved visualization, especially for the hilar and   treatment history except that of the liver disease.
           dorsal area of the liver, and is thus beneficial for the
           dissection of hilar Glissonian pedicles and the inferior   The laboratory data showed decreased white blood cell
           vena cava (IVC). [7-9]  LLRs of major hepatectomy   and platelet counts (1,800 and 68,000/µL, respectively)
           and, even, with combined resection of major hepatic   and plasma albumin (3.5 g/dL) and mild elevations in
           veins  are  now  increasingly  reported, [10-12]   despite  the   plasma aspartate transaminase (AST, 76 IU/L)  and
           latter previously being a contraindication. Reports of   alanine transaminase (ALT, 71 IU/L). The prothrombin
           repeated  LLR  procedures [13-16]   are  also  increasing.   time (78%), plasma levels of total bilirubin (0.6 mg/dL) and
           However, these reports have generally included both   prothrombin induced by vitamin K absence-II (PIVKA-
           cases of  HCC with  CLD and of  metastatic  disease   II, 9 mAU/mL) were  within  their normal  ranges, but
           without background liver disease. [17-21]  The  indication   alpha-fetoprotein  (AFP) showed  a mild elevation  (to
           and efficacy of repeated LLR for HCC in a setting of CLD   67.5 ng/mL). The 15-min value during the clearance
           alone has yet to be fully determined. Here we present   rate of indocyanine green loading test (ICG-R15) was
           a case report of a fourth LLR for recurrent HCCs in   24.1%; this had not deteriorated over the 73 months
           cirrhotic liver and review the previously reported cases   since the first LLR [Table 1].


            Table 1: Perioperative clinical variables associated with each LLR
                                        1st                2nd                 3rd                 4th
                  ICG-R15              20.9                27.5                27.0               24.1
                Bleeding (mL)           35                  30                 NC                  50
              Operating time (min)      288                168                 216                 274
                 POHS (days)            11                  9                   9                  8
           LLR: laparoscopic liver resection; ICG-R15: 15 min value during the clearance rate of indocyanine green loading test; 1st: ICG-R15 and
           perioperative course of first LLR; 2nd: ICG-R15 and perioperative course of second LLR; 3rd: ICG-R15 and perioperative course of third LLR; 4th:
           ICG-R15 and perioperative course of fourth LLR; NC: low, unquantifiable; POHS: postoperative hospital stay

            A                               B                                  C













           Figure 1: Contrast-enhanced computed tomography (CT) examination at the first (A), second (B) and third (C) laparoscopic liver resection. (A):
           The patient’s first laparoscopic liver resection [LLR, extended segment 3 (S3) segmentectomy] was performed for two hepatocellular carcinomas
           (HCCs, 18 mm and 12 mm in size) in S3 and at the border of S2-3, 73 months before the fourth LLR. Contrast-enhanced CT examination (venous
           phase) shows two lesions (arrowheads).(B): The patient’s second LLR (partial resection of S5-6) was performed for HCC (30 mm in size) on the
           edge of the border of S5-6, 45 months before the fourth LLR. Contrast-enhanced CT examination (portal phase) shows the lesion (arrowhead). (C):
           The patient’s third LLR (partial resection of S7-1) was performed for a HCC (8 mm) next to the inferior vena cava, 23 months before the fourth
           LLR. Contrast-enhanced CT examination (portal phase) shows the lesion with lipiodol accumulation (arrowhead); this had been previously treated
           by trans-arterial chemo-embolization
            254                                                                                                     Hepatoma Research ¦ Volume 2 ¦ September 19, 2016
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