Surgical outcome after hepatic resection for hepatocellular carcinoma in elderly patients (download tai tailieutuoi com)

SURGICAL OUTCOME AFTER HEPATIC RESECTION FOR HEPATOCELLULAR CARCINOMA IN ELDERLY PATIENTS Le Thanh Son 1 , Ngo Viet Thi 2 SUMMARY Objectives: To evaluate the surgical outcome and p

SURGICAL OUTCOME AFTER HEPATIC RESECTION FOR

HEPATOCELLULAR CARCINOMA IN ELDERLY PATIENTS

Le Thanh Son 1 , Ngo Viet Thi 2

SUMMARY

Objectives: To evaluate the surgical outcome and prognostic factors after hepatic resection

using Takasaki method in elderly people Subjects and methods: Sixty patients over 60 years

old underwent hepatectomy using Takasaki method at Binh Dan Hospital from January 2015 to

January 2019 Results: Takasaki technique for liver resection was applied successfully in all

patients Major hepatectomy (more than 3 liver segments) was performed in 40% of cases The mean blood loss was 427.25 ± 158.4 mL The R0 margin after resection was obtained in 93.4% of cases with low major complications rate (liver failure: 1.7%, post-operative bile leak: 3.3%, ascites: 5%, abdominal infection: 5%, pneumonia: 3.3%, pleural effusion: 3.3%, wound infection: 1.7% The mean overall survival time was 24.4 ± 1.25 months, overall survival rate at

1, 2 and 3 years after hepatectomy were 88.3%, 66.1% and 50.9% respectively Recurrence

rate at 1, 2 and 3 years were 18%, 52% and 60% respectively Conclusion: Hepatectomy using

Takasaki method is an effective and safe procedure in elderly patients with hepatocellular carcinoma

* Keywords: Takasaki technique; Hepatocellular carcinoma; Elderly patients; Anatomic hepatectomy

INTRODUCTION

Elderly people often have many chronic

diseases with impaired organs function

The number of ageing people in the world

has increased rapidly in the last three

decades It is estimated that by 2050

there will be around 2 billion elderly

persons [3] Vietnam is no exception The

rate of Vietnamese elderly people rocketed

recently with the rate of population ageing

in 1989, 1999 and 2009 was 7.2%, 8.3%

and 9.5% respectively [1, 2]

Hepatocellular carcinoma (HCC) ranks

fifth among the most prevalent cancers

worldwide, and is the fourth most common cause of cancer-related death Therefore,

it is a major global health problem Most cases of HCC are attributable to chronic liver disease resulting from chronic hepatitis

B virus (HBV) and hepatitis C virus (HCV) infection Most cases of HCC are estimated

to occur in low resource or middle-resource countries, particularly in Eastern Asia and sub-Saharan Africa The disease incidence is lower in developed countries (Western countries or North America) This is a very common disease with poor outcome, especially in male patients

Corresponding author: Ngo Viet Thi (ngovietthi@yahoo.com)

Date received: 20/11/2020

Date accepted: 22/01/2021

Recently, hepatic resection procedures

were performed based on knowledge of

modern surgical anatomy of the liver and

the surgeon can plan to resect the liver

segments precisely At present, hepatectomy

is a standard treatment of HCC especially

hepatectomy using Takasaki method

Although several studies have reported

on clinical outcomes of hepatic resection

of HCC in elderly patients, feasibility of

the operation, peri-operative risks and the

long-term outcomes remain controversial

Moreover, suitable criteria for the selection

of hepatectomy procedures in elderly

patients have still been under investigation

since HCC being-diagnosed in advanced

stage in this specific group Therefore, in

this study, we aimed to evaluate the

efficacy of hepatectomy for elderly HCC

patients using Takasaki method based on:

- Survival outcome and recurrence rate

after hepatectomy using Takasaki method

in elderly HCC patients

- The complications rate after hepatectomy

using Takasaki method in elderly HCC

patients

SUBJECTS AND METHODS

1 Subjects

The study included 60 patients older

than 60 years who underwent initial

hepatic resection using Takasaki method

for HCC at Binh Dan Hospital from

January 2015 to January 2019

2 Methods

* Treatment procedure:

Pre-operation assessment: Patients’ clinical characteristics were noted (medical history and treatment, chronic conditions, serum AFP, viral hepatitis markers, liver functions, platelet counts HCC was diagnosed by imaging studies with computerized tomography (CT) and/or magnetic resonance imaging (MRI) and liver biopsy if needed based on AASLD guidelines The patients were classified

by AJCC classification and liver resection was indicated based on APASL guidelines

* Surgical treatment: Liver resection

using Takasaki method

* Surgical outcome: Intra and

post-operative, long-term outcome

* Data analysis: Using SPSS 16.0

This study was conducted in accordance with the declaration of Helsinki and the guidelines of the Ethics Committee of Vietnam Military Medical University

RESULTS

1 General characteristics

Patients’ median age was 65.8 ± 4.7 years old More than 75% of patients were under 70 years old

Male/female ratio was 7/3 with the majority of the patients being males (70%)

* Concomitant disease:

Table 1: Concomitant disease

Overall, pre-operative liver function was compensated with Child-Pugh class A (95%), class B (5%) and no patients with Child-Pugh class C were found

Mean serum bilirubin was 16.5 µmol/L (maximum 41.1 µmol/L, minimum 5.1 µmol/L) Etiological factors for HCC in our group were: HBV (58.6%), HCV (26.7%), alcohol (7.8%), other factors (6.9%) All platelet count was over 100.000/mm3

Mean serum AFP pre-operation was 237.5 ng/mL (maximum 2000 ng/mL, minimum 1.83 ng/mL) 81.7% of patients had AFP < 200 ng/mL, 18.3% of patients had AFP > 200 ng/mL

According to ASA classification, ASA II accounted for 70%, ASA I was present in 30%

Table 2: Tumor location

Cardiovascular

Respiratory

Metabolism

Regarding tumor size, tumor less than 5 cm was found in 58.3%, > 5 cm in 41.7%

Tumors differentiation were graded as well, moderate and poor with corresponding rate of 43.4%, 41.7% and 15%

Table 3: Tumor staging by AJCC

Table 4: Intra-operative factors

Mean operative time was 128.6 minutes (range: 60 - 300 minutes, SD: 47.3 minutes)

Mean blood loss: 427.25 ± 158.4 mL (minimum 100 mL, maximum 1,500 mL)

Blood transfusion: 7 cases (11.7%)

Resection margin: R0 was obtained in 93.4% of cases 6.6% of the cases had positive margin

Table 5: Post-operative complications

Related to surgery

* Survival outcome:

The mean observation time was 22.3 ± 8.4 months, maximum 36 months Overall survival time estimated by Kaplan-Meier was 24.4 ± 1.25 months (95%CI: 21.9 to 26.9 months) The overall survival rates at 1, 2 and 3 years were 88.3%, 66.1% and 50.9% respectively

Major hepatectomy

* Recurrence rate after hepatectomy:

Recurrence rate at 1, 2 and 3 years

were 18%, 52% and 60% respectively;

mean recurrence time was 22.1 months

(range: 6 - 36 months)

DICUSSION

1 General characteristics

The mean age of our study group was

65.8 years Many researches show that

HCC is generally diagnosed in

middle-aged and elderly population with the peak

age of from 50 to 60 years old in many

Western and Asia nations [8] The

chronological age of 60 is currently

accepted as a threshold to define an

“elderly” person socially according to

definition of WHO

Most studies showed that HCC is

diagnosed more commonly in men than in

women The male/female ratio in our

study was 7/3 Study by RT Poon had the

same results with 78% of male patients,

equivalent to Anne Adert’s finding (63.6%

male vs 36.4% female) [8] However, in

comparison to younger patients, older

population with HCC is characterized by a

higher prevalence of females The

reasons for the higher proportion of

females in elderly HCC patients are that

the average life expectancy at birth for

females is longer than that of males, and

thus the proportion of females is higher

than that of males in the elderly

population [9]

The concomitant diseases (pulmonary,

cardiovascular, musculoskeletal disorders…)

are the crucial comorbidities in elderly,

especially in post-operative period In our

study, the prevalence of cardiovascular diseases, COPD and diabetes mellitus were 70.5%, 14.7% and 13.1% respectively in which more than half of the patients suffered from hypertension Our result is similar to A Andert’s findings where the prevalence of coronary heart disease, COPD and diabetes mellitus were 75%, 15% and 21% respectively

2 Type of hepatectomy

In this study, we performed major hepatectomy for 24 in a total of 60 cases (40%) Regarding major hepatectomy,

it seems that the degree of liver regeneration at one month after hepatectomy in elderly patients is not significantly different from that in younger patients [10]

3 Operative time

The mean operative time in our study was 128.6 ± 47.3 minutes In one study

to compare outcome of hepatectomy

in super-elderly patients (older than

80 years old) with younger patients, the result showed no difference in operating time between the two groups Other researches gave the same conclusion, even in term of major hepatectomy [11, 12]

4 Intra-operative blood loss and blood transfusion

Many studies showed that intraoperative blood loss and blood transfusion also impacted strongly treatment outcome following liver resection However, the intra-operative blood loss due to hepatectomy of HCC elderly patients is similar to that of younger ones [9]

Mean intraoperative blood loss in our

study was 427.25 ± 158.4 mL which is

similar to the study by Yoon (2017),

Polignano (2008), but less than in study

by Nishikawa (2013), Figueras (2003) and

Kaibori (2009) [9] The difference in

intra-operative blood loss can be explained by

the imperfect technique of liver resection

(the Takasaki method was published in

2007) and many researchers believe that

it will be standardized through time when

the surgeon is more experienced

5 Complications and mortality

The complications rate in our study

was 16.7%, mostly minor complication (1

case with transient post-operative hepatic

failure, 1 case of bile leak, 2 cases of

nosocomial pneumonia, 2 cases of

ascites with small pleural effusion) and all

were treated conservatively We had 2

cases of abdominal infection requiring

aspiration via ultrasound, one of which had bile leakage after hepatectomy There were no deaths related to treatment

or major complications which need to be re-operated during follow-ups Other studies had the same results with overall complication rates being approximately 24% Common complications are mostly wound infection and respiratory failure/ post-operative pneumonia [7]

6 Survival outcome

Mean observation time was 19.2 months in 60 cases of our study The overall survival time was 43.5 ± 2.27 months Overall survival rate at 1, 2 and 3 years were 85.1%, 71% and 64.9%, respectively Other studies also conclude that the long-term outcome, especially in survival time, after hepatectomy for HCC

is almost the same as those of younger patients [9]

Figure 1: The survival rate

7 Recurrence outcome

Recurrence rate at 1, 2 and 3 years after liver resection in our group were 18%, 52% and 60% respectively Mean recurrence time estimated by Kaplan-Meier was 22.1 months (6 - 36 months) Other studies showed that the recurrence rate at 1, 3 and 5 years after hepatectomy for HCC in elderly people vary from 21.9 - 30%, 30 - 50% and

60 - 73.7%, which is similar to our result

Figure 2: Recurrent time

CONCLUSION

Hepatectomy using Takasaki method

to treat HCC elderly patients is a feasible,

safe and effective procedure with good

outcome and low levels of mortality and

morbidity

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