Impact of Sarcopenic Obesity on Severe Postoperative Complications in Patients with Gastric Cancer Undergoing Gastrectomy.

INTRODUCTION: Several studies have indicated that sarcopenia affects the short- and long-term outcomes of cancer patients, including those with gastric cancer. In recent years, sarcopenic obesity and its effects have been reported in cancer patients. This study aimed to evaluate the impact of sarcopenic obesity on postoperative complications in patients with gastric cancer undergoing gastrectomy. METHODS: This single-center, retrospective study included 155 patients who underwent curative gastrectomy for gastric cancer from January 2015 to July 2021. Sarcopenia was defined by the psoas muscle index (<6.36 cm2/m2 in men and <3.92 cm2/m2 in women), which measures the iliopsoas muscle area at the lumbar L3 level using computed tomography. Obesity was defined by body mass index (≥25). Patients with both sarcopenia and obesity were defined as the sarcopenic obesity group and others as the non-sarcopenic obesity group. Severe postoperative complications were defined as Clavien-Dindo classification grade IIIa or higher. RESULTS: Of the 155 patients, 26 (16.8%) had sarcopenic obesity. The incidence of severe postoperative complications was significantly higher in the sarcopenic obesity group (30.8% vs. 10.9%; p = 0.014). Multivariate analysis indicated that sarcopenic obesity was an independent risk factor for severe postoperative complications (odds ratio, 3.950; 95% confidence interval, 1.390-11.200; p = 0.010). CONCLUSION: Sarcopenic obesity is an independent risk factor for severe postoperative complications.

Evaluation of Safety-Related Outcomes of One-Segment and More-Than-One-Segment High-Level Hepatectomy in Hepatocellular Carcinoma Based on the Japanese Board Certification System.

BACKGROUND: We evaluated the impact of the Japanese board certification system for expert surgeons (JBCSES) on complications and survival outcomes in hepatectomy for hepatocellular carcinoma. METHODS: The postoperative outcomes of 493 patients who underwent high-level liver surgery involving one-segment (OSeg) hepatectomy and more-than-one-segment (MOSeg) resection were compared before and after JBCSES establishment. After the establishment of the JBCSES, the patients' postoperative outcomes were compared using propensity score matching (PSM) to determine the influence of expert surgeons. RESULTS: The establishment of the JBCSES was associated with a decrease in the overall postoperative complication rates after high-level liver surgery from 50.2 to 38.1% (P = 0.008) and a decrease in Clavien-Dindo class ≥ IIIb complications from 10.2 to 5.0% (P = 0.035). The 90-day mortality rate decreased from 5.1 to 0.7% (P = 0.003), and the 5-year survival rate increased from 51.4 to 63.9% (P = 0.009). Using PSM, a comparison of OSeg hepatectomies that involved expert surgeons (n = 48) and those that did not (n = 48) showed significantly lower intraoperative blood loss in surgeries involving an expert surgeon (mean, 340 vs. 473 mL; P = 0.033). There were no significant differences in complication rates or long-term prognosis between these groups. A comparison of MOSeg hepatectomies that involved expert surgeons (n = 26) and those that did not (n = 26) showed no significant difference in surgical factors, complications, or overall survival between the two groups. CONCLUSIONS: After establishment of the JBCSES, postoperative complication rates and mortality rates decreased and survival rates increased following liver surgery. Expert surgeon participation significantly decreased intraoperative blood loss during OSeg hepatectomies.

Validity of the Algorithm for Liver Resection of Hepatocellular Carcinoma in the Caudate Lobe.

BACKGROUND: We aimed to validate our algorithm for resecting Hepatocellular carcinoma (HCC) in the caudate lobe based on tumor location, tumor size, and indocyanine green clearance rate. METHODS: Patients who underwent curative resections for solitary HCC in the caudate lobe were included. The surgical outcomes of patients with HCC in the caudate lobe were compared with those of patients with HCC in other sites of the liver. RESULTS: After one-to-one matching, the caudate-lobe group (n = 150) had longer operation time, greater amount of bleeding, lower weight of resected specimens, and shorter distance between tumor and resection line than the other-sites group (n = 150), but the complication rates were not different between the groups (38.0% vs. 34.1%, P = 0.719). After a median follow-up period of 3.0 years (range, 0.3-16.2 years), the median overall survivals were 6.5 (95% confidence interval [CI], 5.3-7.9) and 7.5 years (95% CI, 6.3-9.7) in the caudate-lobe and other-site groups, respectively (P = 0.430). Median recurrence-free survivals in the caudate-lobe group (1.9 years; 95% CI, 1.4-2.7) had a tendency to be shorter than those in the other-sites group (2.3 years; 1.7-3.4) (P = 0.052). CONCLUSIONS: Patients' survival and complication rates in the caudate-lobe group were comparable to those in the other-sites group; therefore, our algorithm for resecting HCC in the caudate lobe is of clinical use.

Algorithm for Resecting Hepatocellular Carcinoma in the Caudate Lobe.

OBJECTIVE: To propose an algorithm for resecting hepatocellular carcinoma (HCC) in the caudate lobe. BACKGROUND: Owing to a deep location, resection of HCC originating in the caudate lobe is challenging, but a plausible guideline enabling safe, curable resection remains unknown. METHODS: We developed an algorithm based on sublocation or size of the tumor and liver function to guide the optimal procedure for resecting HCC in the caudate lobe, consisting of 3 portions (Spiegel, process, and caval). Partial resection was prioritized to remove Spiegel or process HCC, while total resection was aimed to remove caval HCC depending on liver function. RESULTS: According to the algorithm, we performed total (n = 43) or partial (n = 158) resections of the caudate lobe for HCC in 174 of 201 patients (compliance rate, 86.6%), with a median blood loss of 400 (10-4530) mL. Postoperative morbidity (Clavien grade ≥III b) and mortality rates were 3.0% and 0%, respectively. After a median follow-up of 2.6 years (range, 0.5-14.3), the 5-year overall and recurrence-free survival rates were 57.3% and 15.3%, respectively. Total and partial resection showed no significant difference in overall survival (71.2% vs 54.0% at 5 yr; P = 0.213), but a significant factor in survival was surgical margin (58.0% vs 45.6%, P = 0.034). The major determinant for survival was vascular invasion (hazard ratio 1.7, 95% CI 1.0-3.1, P = 0.026). CONCLUSIONS: Our algorithm-oriented strategy is appropriate for the resection of HCC originating in the caudate lobe because of the acceptable surgical safety and curability.

Subcuticular Sutures Versus Staples for Wound Closure in Open Liver Resection: A Randomised Clinical Trial.

BACKGROUND: Subcuticular sutures reduce wound complication rates only in clean surgeries. Repeat resection is frequently required in liver surgery, due to the high recurrence rate (30-50%) of liver cancers. The aim of this study is to assess that subcuticular sutures is superior to staples in liver surgery. METHODS: This single-centre, single-blinded, randomised controlled trial was conducted at a university hospital between January 2015 and October 2018. Patients were randomly assigned (1:1) to receive either subcuticular sutures or staples for skin closure. Three risk factors (repeat resection, diabetes mellitus and liver function) were matched preoperatively for equal allocation. The primary endpoint was the wound complication rate, while secondary endpoints were surgical site infection (SSI), duration of postoperative hospitalisation and total medical cost. Subset analyses were performed only for the 3 factors allocated as secondary endpoints. RESULTS: Of the 581 enrolled patients, 281 patients with subcuticular sutures and 283 patients with staples were analysed. As the primary outcome, the wound complication rate with subcuticular sutures (12.5%) did not differ from that with staples [15.9%; odds ratio (OR), 1.33; 95% confidence interval (CI), 0.83-2.15; p = 0.241]. As secondary outcomes, no significant differences were identified between the two procedures in the overall cohort while overall wound complications [7 patients (8.5%) vs. 17 patients (20.0%); OR, 2.68; 95% CI, 1.08-7.29; p = 0.035] with repeat incision were significantly less frequent with subcuticular sutures. CONCLUSION: Subcuticular sutures were not shown to reduce wound complications compared to staples in open liver resection, but appear beneficial for repeat incisions.

Platelet recovery correlates parenchymal volume recovery after liver resection.

AIM: Platelet count seems to assess liver function and predict liver regeneration, but factors associated with liver regeneration remain unclear. This study analyzed the relationship between platelet recovery and postresection liver regeneration. METHODS: Data from 343 candidates from 1245 consecutive patients with liver resection of more than Couinaud's segments were analyzed. Patients were divided into a low-platelet-recovery rate (LPRR) group (lowest 25%) or a control group on the basis of the platelet recovery rate on postoperative day (POD)7. Data were matched before analysis to adjust for operation scale. Trends in liver functional recovery were assessed, and liver volume recovery and remnant ischemic area was calculated using computed tomography volumetry. Factors predicting liver regeneration were analyzed. RESULTS: In 78 matched-pair patients, the all-complications rate (42.3% vs. 26.9%, P = 0.002) and infectious complications rate (21.8% vs. 9.0%, P = 0.027) were significantly higher in the LPRR group than in controls. Trends in liver functional recovery did not differ significantly, whereas significant differences remained for platelet recovery. Parenchyma volume recovery was delayed in the LPRR group from POD7 (84.5% vs. 78.1, P < 0.01) to POD30 (92.5% vs. 85.6, P < 0.01). Platelet recovery rate on POD7 correlated negatively with ischemic liver volume as evaluated on POD2 by computed tomography (r = 0.691). Postoperative ischemic volume on POD2 (5.41 [1.98-11.21], P < 0.001), infectious complications (3.48 [1.44-7.37], P < 0.001), and multiple resection (1.67 [1.10-4.11], P = 0.011) predicted delayed platelet recovery rate on multivariate analysis. CONCLUSION: Platelet recovery correlated with liver volume recovery and occurrence of complications. Large ischemic area might negatively impact regeneration after liver resection.

Favorable outcomes of surgical resection for extrahepatic recurrent hepatocellular carcinoma.

AIM: Repeat resection for intrahepatic recurrent hepatocellular carcinoma (HCC) is effective for the long-term survival of patients; however, little is known about the surgical outcomes of extrahepatic nodules. The aim of this study is to investigate whether resection can contribute to the survival of patients with extrahepatic recurrent HCC. METHODS: Under the conditions that intrahepatic recurrent HCC was absent or controlled by locoregional therapies, patients who had resectable extrahepatic recurrent HCC in the lymph nodes, adrenal gland, peritoneum, lung, or brain were included in this study. The survival of patients who did (Surgical group) and did not (Non-surgical group, underwent other therapies) undergo resection for extrahepatic recurrent HCC was compared. RESULTS: Thirty-eight and 26 patients were included in the Surgical and Non-surgical groups, respectively. No patient had severe postoperative complications. After a median follow-up of 1.2 (range, 0.2-8.8) years, the median cumulative incidence of extrahepatic recurrent HCC was 1.2 years (95% confidence interval [CI], 0.4-3.5) in the Surgical group. The median overall survival was 5.3 (95% CI, 2.5-8.8) and 1.1 (0.8-2.3) years in the Surgical and Non-surgical groups, respectively (P < 0.001). The 5-year rates of survival were 60.5% and 9.1% in the Surgical and Non-surgical groups, respectively. Surgical resection, α-fetoprotein, disease-free interval, and metastasis at the adrenal gland were the independent factors for overall survival. CONCLUSIONS: Due to the favorable surgical outcomes, resection should be considered as one of the therapeutic choices for patients with extrahepatic recurrent HCC if intrahepatic recurrent HCC can be controlled by locoregional therapies.

Liver Resection Versus Embolization for Recurrent Hepatocellular Carcinoma.

BACKGROUND: Despite curative resection, hepatocellular carcinoma (HCC) has a high probability of recurrence. We validated the potential role of liver resection (LR) for recurrent HCC. METHODS: Patients with intrahepatic recurrence with up to three lesions were included. We compared survival times of patients undergoing their first LR to those of patients undergoing repeated LR. Then, survival times of the patients who had undergone LR and transcatheter chemoembolization (TACE) for recurrent HCC after propensity score matching were compared. RESULTS: After a median follow-up period of 3.1 years (range, 0.2-16.3), median overall survival times were 6.5 years (95% CI 6.0-7.0), 5.7 years (5.2-6.2), and 5.1 years (4.9-7.3) for the first LR (n = 1234), second LR (n = 273), and third LR (n = 90) groups, respectively. Severe complications frequently occurred in the first LR group (p = 0.059). Operative times were significantly longer for the third LR group (p = 0.012). After the first recurrence, median survival times after one-to-one pair matching were 5.7 years (95% CI 4.5-6.5) and 3.1 years (2.1-3.8) for the second LR group (n = 146) and TACE group (n = 146), respectively (p < 0.001). The median survival time of the third LR group (n = 41) (6.2 years; 95% CI 3.7-NA) was also longer than that of TACE group (n = 41) (3.4 years; 1.8-4.5; p = 0.010) after the second recurrence. CONCLUSIONS: Repeated LR for recurrent HCC is the procedure of choice if there are three or fewer tumors.

Impact of marginal resection for hepatocellular carcinoma.

PURPOSE: The surgical margin for liver resection to treat hepatocellular carcinoma (HCC) is occasionally < 1 mm. This study determined the impact of a surgical margin < 1 mm [marginal resection (MR)] on the types of recurrence and the prognosis in solitary HCC. METHODS: The data of 454 patients undergoing curative liver resection for solitary HCC in our institution were analyzed. The patients were divided into the MR (n = 90) and non-MR (n = 364) groups. The clinicopathological data and outcomes after liver resection were compared. A case-matching analysis using a propensity scoring method was also performed. RESULTS: The recurrence-free survival was significantly and overall survival was marginally significantly lower in the MR group than in the non-MR group (p = 0.012-0.051, respectively). According to a multivariate analysis, MR was not a significant independent factor for recurrence-free survival (p = 0.056). After propensity score matching, there were no significant differences in the recurrence-free and overall survival between the two groups (p = 0.375-0.496, respectively). Furthermore, there were no significant differences in the intrahepatic recurrence patterns between the two groups before and after matching. CONCLUSION: MR for solitary HCC might be sufficient in patients with a limited liver functional reserve.

Prior hepatitis B virus infection as a co-factor of chronic hepatitis C patient survival after resection of hepatocellular carcinoma.

BACKGROUND: Prior hepatitis B virus infection (PBI) may increase the risk of developing hepatocellular carcinoma (HCC), but the impact of PBI on clinical outcomes following treatment for HCC remains unknown. The aim of this study was to clarify whether PBI affects clinical outcomes after liver resection for hepatitis C virus (HCV)-related HCC by retrospective cohort study. METHODS: PBI patients were defined as those negative for hepatitis B surface antigen and positive for anti-hepatitis B core antibody. Surgical outcomes of HCV-related HCC patients with PBI were compared to those without PBI. Survival of patients with non-B non-C HCC with and without PBI were also compared. RESULTS: In the HCV group, the median overall survival of 165 patients with PBI was 4.7 years (95% confidence interval [CI], 3.9-5.9), and was significantly shorter compared with 263 patients without PBI (6.6 years [5.3-9.8]; p = 0.015). Conversely, there was no significant difference in recurrence-free survival between the two groups (1.8 years [95% CI, 1.4-2.0] vs 2.0 years [1.7-2.3]; p = 0.205). On Cox proportional hazards regression model, independent factors for overall survival were PBI (hazard ratio 1.38 [95% CI, 1.02-1.87]; p = 0.033), multiple tumors (p = 0.007), tumor size (p = 0.002), and liver cirrhosis (p <  0.001). On the other hand, in the non-B non-C HCC group, both the median overall survival (6.5 years [95% CI, 4.8-7.1]) and recurrence-free survival (2.4 years, [95% CI, 1.5-3.3]) in 104 patients with PBI were not significantly different from those (7.5 years [5.5 - NA; p = 0.932]; and 2.2 years [1.7-2.7; p = 0.983]) in 213 patients without PBI. CONCLUSIONS: PBI and HCV in conjunction with each other affect the survival of patients that have undergone resection for HCC.

Liver resection for recurrent hepatocellular carcinoma after radiofrequency ablation therapy.

AIM: Although radiofrequency ablation (RFA) is an effective local treatment of hepatocellular carcinoma (HCC), local recurrence is relatively frequent. We aimed to elucidate the validity of salvage liver resection for recurrent HCC after RFA. METHODS: Patients who underwent liver resection for recurrent HCC after RFA (LR after RFA) and those who underwent second liver resection for recurrent HCC (second LR) were included. The short-term outcomes were compared between the two groups. The survival rates between the two groups were compared after propensity-score matching to adjust for the variables, including patient background, liver function, and tumor status. RESULTS: Major resection was frequently carried out in the LR after RFA group, but there was no significant difference both in operative data and complication rate between LR after RFA (n = 54) and second LR (n = 266) groups. After a median follow-up period of 1.8 years (range, 0.2-10.5), the median overall survival was 4.4 years (95% confidence interval [CI], 2.2 - not applicable) and 5.6 years (95% CI, 4.5-7.3; P = 0.023) in the LR after RFA group (n = 54) and second LR group (n = 54), respectively, and recurrence-free survival was 1.3 years (0.4-2.2) and 1.2 years (0.5-1.8, P = 0.469), respectively. The only independent factor for overall survival of the LR after RFA group was local recurrence (hazard ratio, 2.73; 1.06-9.00). CONCLUSIONS: Salvage liver resection of recurrent HCC after RFA could be recommended due to the safety of the procedure, especially in patients without local tumor progression after RFA.

Liver resection of hepatocellular carcinoma in patients with portal hypertension and multiple tumors.

AIM: Liver resection for hepatocellular carcinoma (HCC) has been recommended only for patients with a single tumor without portal hypertension. We aimed to validate this treatment strategy that is based on by the Barcelona Clinic Liver Cancer staging system. METHODS: Patients undergoing liver resection were divided into two groups: patients with single HCC without portal hypertension (Group 1) and those with at least one factors of portal hypertension and multiple tumors, up to three lesions each ≤3 cm (Group 2). We compared survival and postoperative complications between the two groups. RESULTS: The median overall and recurrence-free survival periods of patients in Group 1 (n = 695) were 8.5 years (95% confidence interval [CI], 6.6-9.0) and 2.4 years (2.2-2.7), respectively, and were significantly longer compared with those of patients in Group 2 (n = 197) (5.6 years [95% CI, 4.8-6.7], P = 0.001, and 1.9 years [1.6-2.1], P < 0.001). On multivariate analysis, the independent factors for overall survival were hepatitis C virus infection (hazard ratio, 1.29 [95% CI, 1.02-1.65], P = 0.032), multiple tumors (1.42 [1.01-1.98], P = 0.040), and vascular invasion (1.66 [1.31-2.10], P < 0.001). Frequency of morbidity (23 [3.3%] patients vs 11 [5.5%] patients, P = 0.143) and mortality (3 [0.4%] patients vs 2 [1.0%] patients, P = 0.305) was not significantly different between the two groups. CONCLUSIONS: Patients with HCC with portal hypertension and/or multiple tumors could be candidates for liver resection due to the safety of the procedure.

Prediction of vascular invasion in hepatocellular carcinoma by next-generation des-r-carboxy prothrombin.

BACKGROUND: In hepatocellular carcinoma (HCC), des-r-carboxy prothrombin (DCP) more accurately reflects the malignant potential than alpha-fetoprotein (AFP). Next-generation DCP (NX-DCP) was created to overcome some of the limitations of conventional DCP. This study assessed the predictive value of NX-DCP for vascular invasion in HCC. METHODS: We prospectively studied 82 consecutive patients who were scheduled to undergo resection for HCC. Patients were divided into two groups according to the presence or absence of pathological vascular invasion. The predictive powers of AFP, conventional DCP, and NX-DCP for vascular invasion were compared by receiver operating characteristic curve analysis, and correlations with tumour markers and the presence of vascular invasion were assessed. RESULTS: Vascular invasion was pathologically confirmed in 21 patients (positive group) and absent in 61 patients (negative group). The NX-DCP level was significantly higher in the positive group than in the negative group (510.0 mAU ml(-1) (10-98 450) vs 34.0 mAU ml(-1) (12-541), P<0.0001), while the AFP level did not differ significantly between the groups (9.7 ng ml(-1) (1.6-43 960.0) vs 11.0 ng ml(-1) (1.6-1650.0), P=0.49). The area under the curve (AUC) of NX-DCP (AUC=0.813, sensitivity=71.4%, 1-specificity=13.1%) had good sensitivity for the prediction of vascular invasion, while the AUC of AFP was 0.550 (sensitivity=28.6%, 1-specificity=1.60%). The suitable cutoff value for identifying pathological vascular invasion in HCC was 33 mm (AUC: 0.783, sensitivity=71.43%, 1-specificity=11.48%). CONCLUSIONS: The NX-DCP level can be used to predict the presence of vascular invasion in HCC.

Clinical score to predict the risk of bile leakage after liver resection.

BACKGROUND: In liver resection, bile leakage remains the most common cause of operative morbidity. In order to predict the risk of this complication on the basis of various factors, we developed a clinical score system to predict the potential risk of bile leakage after liver resection. METHODS: We analyzed the postoperative course in 518 patients who underwent liver resection for malignancy to identify independent predictors of bile leakage, which was defined as "a drain fluid bilirubin concentration at least three times the serum bilirubin concentration on or after postoperative day 3," as proposed by the International Study Group of Liver Surgery. To confirm the robustness of the risk score system for bile leakage, we analyzed the independent series of 289 patients undergoing liver resection for malignancy. RESULTS: Among 81 (15.6 %) patients with bile leakage, 76 had grade A bile leakage, and five had grade C leakage and underwent reoperation. The median postoperative hospital stay was significantly longer in patients with bile leakage (median, 14 days; range, 8 to 34) than in those without bile leakage (11 days; 5 to 62; P = 0.001). There was no hepatic insufficiency or in-hospital death. The risk score model was based on the four independent predictors of postoperative bile leakage: non-anatomical resection (odds ratio, 3.16; 95 % confidence interval [CI], 1.72 to 6.07; P < 0.001), indocyanine green clearance rate (2.43; 1.32 to 7.76; P = 0.004), albumin level (2.29; 1.23 to 4.22; P = 0.01), and weight of resected specimen (1.97; 1.11 to 3.51; P = 0.02). When this risk score system was used to assign patients to low-, middle-, and high-risk groups, the frequency of bile leakage in the high-risk group was 2.64 (95 % CI, 1.12 to 6.41; P = 0.04) than that in the low-risk group. Among the independent series for validation, 4 (5.7 %), 16 (10.0 %), and 10 (16.6 %) patients in low-, middle, and high-risk groups were given a diagnosis of bile leakage after operation, respectively (P = 0.144). CONCLUSIONS: Our risk score model can be used to predict the risk of bile leakage after liver resection.

Surgical outcomes in patients with hepatocellular carcinoma associated with metabolic syndrome.

BACKGROUND: Only a few papers have focused on the surgical outcomes of patients with hepatocellular carcinoma (HCC) associated with the metabolic syndrome. We compared the outcomes of patients with metabolic HCC with those of patients with non-B, non-C HCC associated with other etiologies. METHODS: Metabolic HCC was defined as HCC arising in patients with at least three of the following metabolic disorders: central obesity, dyslipidemia, hypertension, and diabetes mellitus. A total of 246 patients with non-B, non-C HCC were divided into three groups: metabolic HCC (n = 35), alcoholic HCC (n = 114), and cryptogenic HCC (n = 97). Clinical characteristics, surgical data, and survival were compared among the three groups. RESULTS: Metabolic HCC was diagnosed at a significantly higher age than alcoholic (75 vs. 68 years, P = 0.004) and cryptogenic HCCs (75 vs. 71 years, P = 0.027). Postoperative complications occurred significantly higher in patients with metabolic HCC compared with those with cryptogenic HCC (40.0 vs. 22.7 %, P = 0.049). Especially, pulmonary complications were significant in metabolic HCC compared with cryptogenic HCC (22.9 vs. 8.2 %, P = 0.023). The overall survival rates in the metabolic, alcoholic, and cryptogenic HCC groups were 96.7 % (95 % CI, 90.5-100), 96.3 % (95 % CI, 92.8-99.9), and 95.6 % (95 % CI, 91.5-99.9) at 1 year, respectively, and 87.2 % (95 % CI, 74.5-100), 82.9 % (95 % CI, 74.6-92.2), and 84.5 % (95 % CI, 75.7-94.3) at 3 years, respectively (P = 0.84). The disease-free survival rates in each group were 74.4 % (95 % CI, 60.5-91.5), 76.9 % (95 % CI, 69.2-85.5), and 74.3 % (95 % CI, 65.0-84.8) at 1 year, respectively, and 29.3 % (95 % CI, 16.6-51.8), 39.0 % (95 % CI, 29.7-51.2), and 41.1 % (95 % CI, 29.7-56.8) at 3 years, respectively, (P = 0.90). CONCLUSIONS: Metabolic HCC patients have specific risks of postoperative complication related to the metabolic syndrome.

Marginal survival benefit in the treatment of early hepatocellular carcinoma.

BACKGROUND & AIMS: Early treatment has been recommended for hepatocellular carcinoma (HCC) due to its high cure rate. However, the reported survival benefits of treating early HCC may be affected by lead time. METHODS: Early HCC was defined as a well-differentiated cancer containing Glisson's triad (carcinoma in situ). We applied the concept of lead time to chronic liver disease, which is originally the length of time between screen-detected and symptom-detected disease. To evaluate prolongation of survival with treatment of early HCC, survivals of patients with early and overt HCCs smaller than 2.0 cm treated with liver resection were compared. To calculate lead time and survival benefit of liver resection, survivals of untreated early and overt HCC patients were compared. RESULTS: After liver resection, median overall survival of 46 patients with early HCC (8.8 years; 95% CI, 7.2-11.2) was significantly longer than that of the 202 with overt HCC (6.8 years; 95% CI, 6.2-8.3, p = 0.0257). The prolongation in survival time with liver resection for early HCC was 34.7 (95% CI, 22.1-46.5) months. On the other hand, comparing liver resection and natural history, the survival benefits of surgery for 12 patients with early and 16 with overt HCC were 74.7 (95% CI, 51.9-97.4) and 73.4 (95% CI, 57.9-88.9) months, respectively. Consequently, the lead time and survival benefit with resection for early HCC were estimated as 33.4 (95% CI, 18.9-47.8) and 1.3 (95% CI, -22.1-24.7) months, respectively. CONCLUSIONS: Survival benefit of resection for early HCC is marginal because of a long lead time, and early HCC is therefore not a target lesion for surgery.

Good candidates for a third liver resection of colorectal metastasis.

BACKGROUND: Having three liver resections for colorectal metastases has long been considered to be associated with a high risk of postoperative complications. The present study was designed to assess the feasibility and survival benefits of three liver resections. METHODS: Between 2004 and 2011, data for 273 consecutive patients with colorectal metastases were analyzed. The patient characteristics, tumor status, operation-related variables, degree of liver steatosis, and short- and long-term outcomes were compared according to the number of liver resections. RESULTS: The history of preoperative chemotherapy was higher for patients who had had three liver resections as compared with other resections: i.e., one resection 41.0 %, versus two resections 56.8 %, versus three resections 81.8 %; p = 0.04. Patients receiving three liver resections had a high rate of liver steatosis (17.9 vs. 32.4 vs. 59.1 %; p = 0.03). The median operative time for three resections was significantly longer than for the other resections (359 min [range: 115-579 min] vs. 395 min [range: 178-740 min], vs. 482 min [range: 195-616 min]; p = 0.04). However, the complication rate and the postoperative hospital stay did not differ among the three groups. The 1-, 3- and 5-year survival rates did not differ significantly among the three groups (83.3, 57.5, and 44.6 % for one resection vs. 92.3, 52.1, and 35.7 % for two resections vs. 93.3, 49.0, and 34.1 % for three resections). Patients who had <5 tumors at a third liver resection and a recurrence interval of ≥ 500 days from the second resection were good candidates for three resections. CONCLUSIONS: Undergoing three resections of colorectal metastasis is feasible and provides a similar survival benefit as one or two resections, without increasing morbidity or mortality.

Complete remission by transarterial infusion with cisplatin for recurrent bile duct tumor thrombus of hepatocellular carcinoma: report of a case.

Bile duct tumor thrombus (BDTT) of a hepatocellular carcinoma (HCC) is a rare entity which was found microscopically in 1 to 9.2% of the resected specimen.A 54-year-old male was found to have a 65-mm hepatocellular carcinoma in segment VI of the liver with a huge intrahepatic bile duct tumor thrombus. As the main trunk of the posterior segment branched from the left bile duct, the BDTT of the posterior branch extended to the common bile duct via the left bile duct. When the posterior segment was resected along with the left lobe, the estimated remnant liver volume was less than 30%. Therefore, the patient underwent extended posterior segmentectomy with choledochotomy and all of the BDTT was removed via the common bile duct.Three months later, his serum bilirubin (6.63 mg/dL) and des-gamma-carboxy prothrombin (410 ng/mL) were re-elevated due to recurrent BDTT. A well-enhanced BDTT was observed by computed tomography (CT) at the left bile duct. Transarterial chemotherapy with cisplatin was scheduled, followed by endoscopic retrograde bile duct drainage. After four sessions of this chemotherapy, the BDTT had vanished and the tumor marker was decreased to within the normal range. The patient was stably treated with this regimen and has remained recurrence-free for five years.

Postoperative outcomes of patients with hepatocellular carcinoma negative for all virus-related markers.

PURPOSE: The outcomes of patients with resectable hepatocellular carcinoma (HCC) negative for all virus-related markers have not yet been characterized. This study investigated the outcomes of such patients in comparison to those who had virus-related resectable HCC. METHODS: A total of 398 patients with HCC were divided into 2 groups, comprising patients in which all virus-related markers (HBs-Ag, HBs-Ab, HBe-Ag, HBe-Ab, HBc-Ab, HCV-Ab) were negative (all-negative group, n = 63) and those with at least 1 positive virus-related marker (virus-related group, n = 335). The clinical characteristics, surgical data, and survival rates were compared between the groups. RESULTS: The serum AST (30 vs. 45 IU/l, P < 0.0001) and ALT (21 vs. 42 IU/l, P < 0.0001) levels were significantly lower in the all-negative group than in the virus-related group. The tumor size (4.3 vs. 3.1 cm, P < 0.0001), the prevalence of DM (46.8 vs. 25.4 %, P = 0.001), and BMI (24.8 vs. 22.9, P = 0.0023) were significantly higher in the all-negative group than in the virus-related group. HCC arose from a cirrhotic liver in a significantly higher proportion of patients in the virus-related group than in the all-negative group (20.6 vs. 44.8 %, P = 0.0002). The survival outcomes were not significantly different in the 2 groups (all-negative vs. virus-related: 5-year overall survival rate, 58.2 vs. 55.2 %, P = 0.27), despite such differences in the patients' characteristics. CONCLUSIONS: The postoperative outcomes of patients with HCC are independent of the presence or absence of hepatitis viral infection.

Effect of blood product transfusion on the prognosis of patients undergoing hepatectomy for hepatocellular carcinoma: a propensity score matching analysis.

BACKGROUND: Hepatectomy, the most common treatment for hepatocellular carcinoma, is associated with greater intraoperative blood loss than is resection of other malignancies. The effect of blood product transfusion (red blood cell [RBC], platelet, fresh frozen plasma [FFP], 5 and 25% albumin) on prognosis remains unclear. This study examined effects of blood product transfusion on prognoses of patients who underwent hepatectomy for hepatocellular carcinoma. METHODS: We included 2015 patients with pathologically confirmed hepatocellular carcinoma who underwent hepatectomy at our institution during 1990-2019. Patients (n = 534) who underwent repeat hepatectomy, non-curative hepatectomy, those with synchronous cancer in other organs, those who died within 1 month of surgery, and those with missing data were excluded. Finally, 1481 patients (1142 males, 339 females; median age: 68 years) with curability A or B were included. RESULTS: Intraoperative blood loss (> 500 mL) was an independent predictor of RBC transfusion (odds ratio, 8.482; P < 0.001). All transfusion groups had poorer recurrence-free survival (RFS) and overall survival (OS) than non-transfusion groups. After propensity score matching, the 5 year RFS rate was 13.4 and 16.3% in the RBC and no-RBC groups, respectively (P = 0.020). The RBC group had a significantly lower 5 year OS rate than the no-RBC group (42.1 vs. 48.8%, respectively; P = 0.035) and the FFP group (57.0%) than the no-FFP group (63.9%) (p = 0.047). No significant between-subgroup differences were found for other blood transfusion types. CONCLUSIONS: RBC transfusion promotes hepatocellular carcinoma recurrence and RBC/FFP transfusions reduced long-term survival and RFS and OS in patients who underwent radical liver resection of HCC.