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Fung et al. Hepatocellular carcinoma rupture hepatectomy

presence of haemodynamic stability, non-operative were retrieved from the in-house prospectively
management with close monitoring is gold standard maintained hepatectomy database. The clinical
care. However, when there is haemodynamic data of these patients were collected and analysed
[7]
instability, several treatment options are available. retrospectively. In addition, the hepatectomy
These include non-operative procedures such as histopathology results were reviewed to confirm HCC
transarterial embolisation or absolute alcohol injection, rupture.
and surgical intervention (perihepatic packing, hepatic
artery ligation, suture ligation, radiofrequency ablation Due to the prospective nature of the database, some
or hepatic resection). [8-12] Despite the multiple treatment patients had just undergone hepatectomy and had
options for ruptured HCC, there remains no consensus not had sufficient follow-up period so were excluded
on the optimal approach for these patients. for data analysis. Patients with intra-operative findings
of incidental peri-tumoural haematoma suggestive of
The advantage of one stage emergency liver previously ruptured HCC were excluded. Emergency
resection is the spontaneous control of haemorrhage hepatectomy was defined as liver resection within
with definitive management of the HCC. Emergent 48 h of the clinical or radiological diagnosis of HCC
operation can also reduce the duration of peritoneal rupture. Some patients were referred to our hospital
seeding of ruptured HCC tumour cells by lavage with after haemodynamic stabilisation at the parent hospital
water at operation. [13,14] using TAE. These patients were included in the
emergency hepatectomy group if they proceeded to
However, emergent operative intervention must be liver resection within 48 h of first presentation of HCC
balanced against the high mortality rate of up to 40% [15] rupture.
consequent to the lack of pre-operative objective
assessment of functional liver reserve and extent of TAE was performed by experienced interventional
disease burden, hypovolaemic shock condition and radiologists with selective cannulation and then
coagulopathy. [16] embolisation of the tumour-feeding artery with gel-
foam particles. Surgical intervention was indicated
As a result, the alternative option of staged liver resection when TAE failed to achieve adequate haemostasis. An
after initial haemorrhage control with trans-arterial experienced team of hepato-biliary surgeons performed
embolisation (TAE) is offered in some centres. This hepatectomy. Hepatic parenchymal transection
allows for subsequent assessment of functional liver was undertaken using an ultrasonic dissector and
reserve and operation under elective circumstances. TissueLink (Medtronic, Ireland) radiofrequency
The success of TAE haemostasis is 50-100%, with a dissector. Intermittent Pringle manoeuvre might be
risk of liver failure of up to 33%. Additionally, the 30- applied during hepatectomy. The clinical decision
day mortality after TAE is lower compared to emergent algorithm for ruptured HCC as utilised in the author’s
hepatectomy (0-9% vs. 0-37%). [16] institution is shown in Figure 1.

The survival benefits of two-stage liver resection over Post-operative follow-up of hepatectomy included
emergent hepatectomy remain controversial. Liu et al. ultrasound at 3 months and contrast triphasic
[15]
concluded that survival after two-stage liver resection computed tomography (CT) at 6 months with
post-HCC rupture was inferior compared to patients 3-monthly monitoring of serum alpha-fetoprotein
who did not have this complication, whereas and liver function test for 2 years, then 6-monthly
Yeh et al. [17] found that ruptured HCC had similar thereafter. Supplementary CT was done in the
overall survival rates compared to non-ruptured HCC presence of raised serum alpha-fetoprotein or
but inferior disease-free survival rates. Mizuno et al. [18] suspicion of HCC recurrence on ultrasound. Recurrent
noted that there was no difference in overall survival HCC was diagnosed with radiological imaging (CT
between ruptured and non-ruptured HCC. or positron emission tomography CT) to identify
the location of intra-hepatic recurrence, tumour
In this retrospective single-centre study, the short disease burden and the presence of extra-hepatic
and long term outcomes of patients who underwent disease recurrence. Treatment options for recurrent
emergency and interval hepatectomy for ruptured and HCC included further liver resection, local ablation
resectable HCC were analysed. therapies, transarterial chemo-embolisation (TACE),
external beam radiotherapy, systemic chemotherapy
METHODS or targeted immunotherapy. A multi-disciplinary
team decided on treatment, taking into account the
Patients with a diagnosis of ruptured HCC presenting patients’ liver functional status, recurrence pattern and
between April 2004 and October 2015 to our hospital comorbidities.
Hepatoma Research ¦ Volume 3 ¦ September 08, 2017 197