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Hepatectomy for hepatocellular carcinoma: toward zero hospital deaths
1Department of Surgery, The University of Hong Kong, Queen Mary Hospital, Hong Kong.
Insights
Hepatocellular carcinoma (HCC) hepatectomy can achieve zero hospital mortality with standardized surgical techniques and perioperative care. Further research aims to reduce operation time to decrease postoperative morbidity.
Area of Science:
- Hepatobiliary Surgery
- Surgical Oncology
- Gastroenterology
Background:
- Hepatectomy for hepatocellular carcinoma (HCC) historically has a mortality rate below 10%.
- A zero hospital mortality rate for hepatectomy in a large patient series for HCC has not been previously reported.
- Standardized surgical techniques and perioperative management at Queen Mary Hospital evolved, reducing mortality from 28% (1989) to 0% (1996-1997).
Purpose of the Study:
- To report on surgical techniques and perioperative care protocols yielding zero hospital mortality in 110 consecutive hepatectomies for HCC.
- To analyze hepatectomy outcomes to further reduce postoperative morbidity rates.
Main Methods:
- Surgical techniques focused on minimizing intraoperative blood loss, transfusion needs, and ischemic injury.
- Perioperative care emphasized preserving liver function through adequate oxygenation and specialized nutritional support (branched-chain amino acid-enriched solution, dextrose, medium-chain triglycerides, phosphate).
- Prospective data collection and yearly analysis of pre-, intra-, and postoperative data informed evolving techniques and care.
Main Results:
- No significant changes in patient characteristics over 9 years.
- Significant reductions in intraoperative blood loss and transfusion requirements; 64% of patients from 1994-1997 required no transfusion.
- Potentially fatal complications (sepsis, biliary leakage, hepatic coma) were eliminated; only wound infections persisted. Operation time correlated significantly with postoperative morbidity.
Conclusions:
- Hepatectomy for HCC can be performed without hospital deaths through optimized surgical techniques and perioperative management.
- Preserving the function of the liver remnant is key to achieving zero mortality.
- Strategies to reduce operation time are under investigation to further improve surgical outcomes.
Objective:
The authors report on the surgical techniques and protocol for perioperative care that have yielded a zero hospital mortality rate in 110 consecutive patients undergoing hepatectomy for hepatocellular carcinoma (HCC). The hepatectomy results are analyzed with the aim of further reducing the postoperative morbidity rate.
Summary Background Data:
In recent years, hepatectomy has been performed with a mortality rate of <10% in patients with HCC, but a zero hospital mortality rate in a large patient series has never been reported. At Queen Mary Hospital, Hong Kong, the surgical techniques and perioperative management in hepatectomy for HCC have evolved yearly into a final standardized protocol that reduced the hospital mortality rate from 28% in 1989 to 0% in 1996 and 1997.
Methods:
Surgical techniques were designed to reduce intraoperative blood loss, blood transfusion, and ischemic injury to the liver remnant in hepatectomy. Postoperative care was focused on preservation and promotion of liver function by providing adequate tissue oxygenation and immediate postoperative nutritional support that consisted of branched-chain amino acid-enriched solution, low-dose dextrose, medium-chain triglycerides, and phosphate. The pre-, intra-, and postoperative data were collected prospectively and analyzed each year to assess the influence of the evolving surgical techniques and perioperative care on outcome.
Results:
Of 330 patients undergoing hepatectomy for HCC, underlying cirrhosis and chronic hepatitis were present in 161 (49%) and 108 (33%) patients, respectively. There were no significant changes in the patient characteristics throughout the 9-year period, but there were significant reductions in intraoperative blood loss and blood transfusion requirements. From 1994 to 1997, the median blood transfusion requirement was 0 ml, and 64% of the patients did not require a blood transfusion. The postoperative morbidity rate remained the same throughout the study period. Complications in the patients operated on during 1996 and 1997 were primarily wound infections; the potentially fatal complications seen in the early years, such as subphrenic sepsis, biliary leakage, and hepatic coma, were absent. By univariate analysis, the volume of blood loss, volume of blood transfusions, and operation time were correlated positively with postoperative morbidity rates in 1996 and 1997. Stepwise logistic regression analysis revealed that the operation time was the only parameter that correlated significantly with the postoperative morbidity rate.
Conclusion:
With appropriate surgical techniques and perioperative management to preserve function of the liver remnant, hepatectomy for HCC can be performed without hospital deaths. To improve surgical outcome further, strategies to reduce the operation time are being investigated.