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Kilburn et al. Laparoscopic resection of HCC

Table 1: Baseline characteristics Table 2: Operative characteristics
Baseline characteristics Median (range) or n (%) Operative Total Non- Cirrhotic
Age, years 58 (44-81) characteristics cirrhotic
Female 26 Laparoscopic liver 52 18 34
α-fetoprotein, ng/mL 8.5 (1.7-59,000)* resection
Major hepatectomy,
No cirrhosis 18 (35) n (%)
Cirrhosis 34 (65) Right hepatectomy 4 (8) 4 (22) 0 (0)
Child-Pugh class Left hepatectomy 1 (2) 1 (6) 0 (0)
A 33 Extended right 2 (4) 0 (0) 2 (6)
B 1 hepatectomy
C 0 Left lateral 11 (21) 4 (22) 6 (18)
Known underlying liver disease 37 (71) sectionectomy,
HBV 2 (4) n (%)
HCV 23 (46) Segmentectomy, 24 (46) 7 (39) 17 (50)
Alcohol 3 (6) n (%)
NASH 5 (10) Subsegmental 10 (19) 2 (11) 9 (26)
Unknown (with cirrhosis) 4 (8) resection, n (%)
Posterosuperior 8 (15) 3 (17) 5 (15)
*14.6% of patients had an α-fetoprotein level ≥ 200 ng/mL. HBV: (segments 1, 4a, 7,
hepatitis B virus; HCV: hepatitis C virus; NASH: non-alcoholic 8) resections, n (%)
steatohepatitis Conversion to 5 (9) 2 (11) 3 (9)
laparotomy, n (%)
shears, or the 10 mm laparoscopic Cavitron Ultrasonic Operating time, min, 120 (75-300) 117 (75-240) 120 (90-300)
Surgical Aspirator (Integra Life sciences Corporation, median (range)
NJ, USA), combined with use of locking clips (Hem-o- Blood loss, mL, 300 (20-1,600) 150 (20-600) 350 (30-1,600)
lok, Teleflex Medical, Durham, NC, USA) and staplers. median (range)
Drains were reserved for patients deemed to be high risk increased, from 7 patients during the early period
for bile leak. Postoperatively, patients who underwent (1999-2004), to 18 in the middle period (2005-2010),
major resections (> 3 segments) were admitted to the to 25 in the later period (2011-2015) [Figure 1]. The
intensive care unit (ICU). Patients with minor resections percentage of patients having cirrhosis also increased,
(< 3 segments) were admitted to the general surgical from 57%, to 67%, to 72% respectively. Overall in this
ward. Chemical and mechanical thromboprophylaxis study, 34 patients (65%) had cirrhosis (33 Child-Pugh
were used routinely. Early mobilization and return to a A, 1 Child-Pugh B). Of the patients with cirrhosis, 56%
normal diet was encouraged. had evidence of portal hypertension. The most common
etiology of cirrhosis was hepatitis C (65%) and non-
Postoperative parameters examined included duration alcoholic steatohepatitis (non-alcoholic steatohepatitis,
of ICU and total hospital stay, postoperative morbidity 14%). The baseline characteristics of the patients are
(stratified according to the Clavien-Dindo system of summarized in Table 1.
classification), and 30-day and 90-day mortality. One-, 3-
and 5-year survival and disease-free survival status was Operative characteristics are summarized in Table 2.
recorded and actuarial survivals were estimated using There were 7 (14%) major hepatectomies, including
the Kaplan-Meier method. Mid and long-term follow up 2 extended hemihepatectomies. Seventy-six percent
included clinical, biological and radiological assessment of cirrhotic patients underwent a segmentectomy
1-month post surgery and every subsequent 6-month. or subsegmentectomy, compared with 50% of non-
Survival follow-up was achieved through updated cirrhotic patients (P = 0.068).
medical records and phone calls.
There were 52 operations and of these, 51 were pure
Statistical analyses were performed using R 3.2.0 (R laparoscopic (including 2 involving the addition of
Core Team, 2015). Categorical data were compared intercostal or transthoracic trocars) and 1 was hand-
using Fisher’s exact test; median values from continuous assisted. There were 5 conversions (9%), 3 of which
data were compared using the 2-sample rank test; P- (pure laparoscopic intent) were due an inability to
values of < 0.05 were considered statistically significant. progress as a result of difficult dissections secondary
to intra-abdominal adhesions. One conversion occurred
RESULTS due to uncontrollable hemorrhage in a non-cirrhotic
patient. The final conversion occurred in the hand-
Fifty patients underwent a total of 52 operations. In assisted case of a posterior dome lesion (segment 7/8).
total, 79 HCCs were resected. The annual frequency of This patient had recognised positive margin due to the
laparoscopic resection of HCC in our centers gradually awkward angle and was opened for wider resection.
266 Hepatoma Research ¦ Volume 2 ¦ September 30, 2016