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Limited liver resection with limited mobilization:

A preferred surgical technique in cirrhotic patients with hepatocellular carcinoma

Fouad A. Fouad M.D ., Tarek k.Saber M.D

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INTRODUCTION

• Hepatocellular carcinoma (HCC) is the fifth most common cancer.

• The third leading cause of cancer death worldwide.

• Surgical treatment is an effective treatment for HCC.

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THE AIM OF THE THIS STUDY

• We aimed to evaluate if • Limited hepatic ligaments dissection and • Limited hepatic volume resection

Decreased risk of operative and post operative morbidity , mortality and hospital stay.

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METHODS

• Data of twenty nine patients with HCC on a background of cirrhosis were studied during the period from January 2002, to December 2009.

• Patients were operated upon in the department of surgical oncology in the National Cancer Institute Cairo University.

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METHODS

• Group (A) included sixteen patients in whom wide anatomical hepatic resection of more than one hepatic segments done and needed hepatic mobilization.

• Group (B) included thirteen patients who underwent limited hepatic resection inform of resection of the lesion regardless of segmental or lobar anatomy and did not need hepatic mobilization.

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• ELIGIBILITY CRITERIA for patient inclusion in the study were: Patients selected with a single tumor 5 cm or smaller and two tumors each 3 cm or less.

• EXCLUSION CRITERIA :Extra hepatic metastases, and inferior vena cava or main portal vein tumor thrombus precluded curative hepatic resection.

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TECHNIQUE

• Anatomical resection: was defined as the systematic removal of a hepatic segment confined by cancer-bearing portal tributaries and needed hepatic mobilization in which resection of more than one Couinaud segments.

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COUINAUD SEGMENTS

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TECHNIQUE

• Limited non anatomical resection was defined as the resection of a lesion regardless of segmental or lobar anatomy without hepatic mobilization.

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 Clinicopathological and

surgical data for 29 HCC patients

Variable Group(A)Anatomical resection+ hepatic mobilization(NO.=16)

Group(B)Limited non-anatomical resection(NO.=13)

P value

Age Years (mean±SD)

56±13 61±11 0.2802

Sex(M:F) 11:5 9:4 0.312Hepatitis c virus 100% 100%

Child-Pugh score 5.7±o.5 6.1 ±o.4 0.1271

Liver cirrhosis Present/absent

16/0 13/0 1.000

Tumor size cm (mean ± SD)

5.1 ± 0.9 4.7 ± 1.1 0.2906

a-fetoprotein (ng/ml) ± SD

590±150 630±o213 0.5771

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Operative data of hepatic resection for 29 HCC patients

Variable Group(A)Anatomical resection+ hepatic mobilization(NO.=16)

Group(B)Limited non-anatomical resection(NO.=13)

P value

Operative time (min.)

113.3±38.4 107.8±31.7 0.6504

Blood loss (mean ± SD) ml

253±87.3 145.1±25 0.0002

Hepatic ligaments cutting (yes/no)%

(16/16)% 1/130.005

Surgical margin mm (mean ± SD)

8.3 ± 5.9 7.4 ± 5.4 0.6748

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 Post operative mortality and

morbidity for 29 HCC patientsVariable Group(A)

Anatomical resection+ hepatic mobilization(NO.=16)

Group(B)Limited non-anatomical resection(NO.=13)

P value

Mean hospital stay(days) 7±6.3 3±2.4 0.0399

Operative mortality (one month death)

1/16(6.5%) 0/13% 0.567

Postoperative Morbidity(total)

10/16(62.5%) 1/13(7.5%) 0.036

Bleeding Jaundice

1/161/16

0 /130/13

Ascites Mild Moderate Severe Encysted ascites

8/164/162/161/61/16

1/131/130/130/130/13

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Kaplan-Meier survival curve for 29 patients with HCC

0 10 20 30 40 50 60 70

0

20

40

60

80

100

Time

Surviv

al probability (

%)

GROUPAB

15

P = 0.9291

The overall survival 3-years and 5-years survival in: group A patients was 68% ;39% and in group B was 65%; 33%.

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CONCLUSIONS• Surgical treatment of HCCs, the balance

between curability and hepatic function preservation is important.

• Limited liver resection with limited mobilization is the preferred technique for HCC in cirrhotic patients.

• Anatomical resection with hepatic mobilization did not improve the overall survival compared with limited hepatic resection.

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CONCLUSIONS

• Increased risk of operative morbidity were identified in patients who had, resection of :

• A large volume of functioning liver parenchyma • Extensive hepatic mobilization and dissection of the

hepatic ligaments increase post operative morbidity especially ascites due to increase lymphatic transudation ; increase portal hypertension.

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