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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%
Hepatoma Research ¦ Volume 3 ¦ September 08, 2017 201