| ObjectiveTo determine the effect of tumor size on perioperative complications and long-term prognosis in hepatocellular carcinoma patients with liver cirrhosis after liver resection.MethodsWe retrospectively analyzed the relevant data of consecutive patients with liver cirrhosis,who received hepatectomy for liver cancer during January 2008 and December2012 in the Southwest Hospital Affiliated to the Third Military Medical University.Based on the preoperative imaging examination and intraoperative focus size,we put the patents with the biggest diameter of<5cm into the small tumor group(ST group),and those with the biggest diameter of≥5cm into the large tumor group(LT group).Student’s t tests or Mann-Whitney U tests was used to compare the clinical data of the two groups,and?~2 test or Fisher’s test was used to compare the categorical variables.The logistic regression model was used for analyzing the risk factors for postoperative complications,and Cox’s proportional hazards regression model for the risk factors for progression free survival(PFS).The Kaplan-Meier method was used for survival analysis,and the Log-Rank Test for testing inter-group differences.The methods mentioned above were used to:1.To investigate the patient distribution of the two groups,including the number and proportion of each group.2.To study the difference in the basic data of each group,including the gender,age,reoperation,hepatitis B serology,Alpha-fetoprotein(AFP),alanine aminotransferase(ALT),aspartate aminotransferase(AST),albumin(Alb),total bilirubin(TBIL),platelet count,prothrombin time,Child-Pugh classification,the number of tumor,tumor embolization,lymph node metastasis,etc.3 To determine the intraoperative and postoperative effect of tumor size,including hepatectomy type,complicated operation,Hilar occlusion,radiofrequency ablation(RFA)assistance,intraoperative blood loss,intraoperative blood transfusion,operation time and hospital stay,etc.4.To understand the difference in postoperative complications and the influencing factors,including the number,type and severity of the complications,and hospital stay,and to conduct univariate and multivariate analysis.5.To understand the effect of tumor size on long-term prognosis after hepatectomy,including progression free survival(PFS)and overall survival(OS),and to conduct univariate and multivariate analysis.ResultsPreoperative characteristics of the patients:Among the 703 patients,there were 638males(90.8%)and 65 females(9.2%);280 patients(39.8%)were in the ST group with the largest tumor diameter of<5 cm,and 423 patients(60.2%)were in the LT group with the largest tumor diameter of≥5 cm.Patients in both the ST and LT group were comparable in terms of gender(male),age,reoperation,and HBV infection(96.0%HBs Ag positive in total).Most clinical characteristics did not differ significantly between patients in each group,including liver biochemistry,including ALT,prothrombin time(PT),total bilirubin and Child-Pugh classification.However,alpha-fetoprotein(AFP≥600 ng/ml,45.4%vs.28.2%,p?0.001),aspartate aminotransferase(AST>40 IU/l,68.8%vs.54.3%,p?0.001),and albumin(Albumin<35 g/l,11.3%vs.6.4%,p=0.029)levels were higher in the LT group,while the platelet counts(PLTs<100×10~9/l,24.8%vs.43.6%,p?0.001)were lower in the LT group.Although Child-Pugh classification and tumor numbers did not differ significantly between groups,more patients in the LT group had tumor embolization(40.2%vs.26.1%,p?0.001)and lymph node metastasis(4.3%vs 1.4%,p=0.035).Intraoperative Condition:The patients from the LT group received a larger range of liver resection than the ST group(40.7%vs.13.9%,p?0.001).The frequency of radiofrequency ablation(RFA)assistance was same in both the groups.However,more patients in the LT group underwent complicated surgeries(13.9%vs.8.9%,P=0.045)including vascular embolectomy,biliary intestinal anastomosis,splenectomy,portal azygous disconnection,gastrointestinal surgery,colon resection,and hepatic portal lymph node dissection,than the ST group.Moreover,more patients in the LT group lost over 500ml of blood during surgery(60.0%vs.38.6%,p?0.001),required Hilar occlusion(66.4%vs54.6%,p=0.002)and intraoperative blood transfusion(35.9%vs.20.7%,p?0.001).As anticipated,patients in the LT group requires longer surgeries than ST group patients(276.6±85.9 vs.237.2±93.5 min,p?0.001).Postoperative condition:Postoperative complications developed in 224 patients(31.9%),and the incidence was higher in the LT group than in the ST group(35.0%vs.27.1%,p=0.029).Among all the patients,bile leakage(40,5.7%),incision infection(33,4.7%),lung infection(51,7.3%),liver failure(39,5.5%),pleural effusion(78,11.1%)and perioperative death(28,4.0%)were the most frequently observed complications.The incidence of bile leakage(7.3%vs.3.2%,p=0.021)and liver failure(7.1%vs.3.2%,p=0.028)was higher in the LT group than the ST group,lung infection(9.6 vs.5.7%,p=0.047)was lower in the LT group.The perioperative death was not significantly higher in the LT group(p=0.102).No significant difference was observed in the overall length of hospital stay between the two groups.The analysis of risk factors for postoperative complications:Univariate analysis suggested that complicated surgery and RFA assistance were common risk factors for both groups.However,multivariate analysis identified,complicated surgery(OR 2.755 95%CI1.196-6.344,p=0.017)as an independent risk factor in the ST group,while albumin levels<35 g/l(OR 4.049 95%CI 2.105-7.752,p?0.001)and surgery>240 min(OR 3.044 95%CI1.912-4.847,p?0.001)were independent risk factors in the LT group.The analysis of postoperative long-term outcomes in the two groups:The progression-free(PFS)and overall survival(OS)of the LT group were shorter than those of the ST group(p?0.001).The median PFS was shorter in the LT group than in the ST group(166 days vs.487 days).similarly,the median OS was shorter in the LT group than in the ST group(562 days vs.865 days).In the ST group,reoperation,HBs Ag positivity and complications were significant risk factors for PFS,and PT>14 sec was independent risk factors for PFS.However in the LT group,tumor embolization,surgeries longer than 240min and PT>14 sec were independent risk factors for PFS,while RFA assistance was protect factor for PFS.In terms of OS,tumor embolization was a common independent risk factor in both groups,while reoperation,Child-Pugh class B,and complicated surgery were independent risk factors for OS in the ST group only,and AST>40 IU/l was independent risk factors for OS in the LT group only.This data suggests that PT>14 sec and tumor embolization were the only common independent risk factors for PFS and OS,respectively.Conclusion1.The HCC patients with tumors<5 cm have better short-and long-term outcomes than those with tumors≥5 cm;2.Hepatectomy for HCC patients with liver cirrhosis should be chosen carefully.It is safer to adopt hepatectomy after the improvement of preoperative levels of albumin or nutritional status;3.For HCC patients with large tumor,bile leakage and liver failure were the major postoperative complications.For patients with small tumor,hepatectomy should be carefully considered if complex surgical treatment is needed,and careful preoperative examinations are necessary to exclude the patients with early metastasis;4.The outcomes of patients with recurrent tumors or multiple tumors are still acceptable after hepatectomy,so hepatectomy is a worthy of recommendation.However,further study based on a large sample is still needed. |
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