Hepatectomy for hepatocellular carcinoma: Toward zero hospital deaths

Objective The authors report on the surgical techniques and protocol for perioperativ e care that have yielded a zero hospital mortality rate in 110 consecutive patients undergoing hepatectomy for hepatocellular carcinoma (HCC). The hep atectomy results are analyzed with the aim of further reducing the postoper ative morbidity rate. Summary Background Data In recent years, hepatectomy has been performed with a mortality rate of <1 0% in patients with HCC, but a zero hospital mortality rate in a large pati ent series has never been reported. At Queen Mary Hospital, Hong Kong, the surgical techniques and perioperative management in hepatectomy for HCC hav e evolved yearly into a final standardized protocol that reduced the hospit al mortality rate from 28% in 1989 to 0% in 1996 and 1999. Methods Surgical techniques were designed to reduce intraoperative blood loss, bloo d transfusion, and ischemic injury to the liver remnant in hepatectomy. Pos toperative care was focused on preservation and promotion of liver function by providing adequate tissue oxygenation and immediate postoperative nutri tional support that consisted of branched-chain amino acid-enriched solutio n, low-dose dextrose, medium-chain triglycerides, and phosphate. The pre-, intra-, and postoperative data were collected prospectively and analyzed ea ch year to assess the influence of the evolving surgical techniques and per ioperative care on outcome. Results Of 330 patients undergoing hepatectomy for HCC, underlying cirrhosis and ch ronic hepatitis were present in 161 (49%) and 108 (33%) patients, respectiv ely, There were no significant changes in the patient characteristics throu ghout the 9-year period, but there were significant reductions in intraoper ative 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 operat ed on during 1996 and 1997 were primarily wound infections; the potentially fatal complications seen in the early years, such as subphrenic sepsis, bi liary leakage, and hepatic coma, were absent. By univariate analysis, the v olume 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 mor bidity rate. Conclusion With appropriate surgical techniques and perioperative management to preser ve function of the liver remnant, hepatectomy for HCC can be performed with out hospital deaths. To improve surgical outcome further, strategies to red uce the operation time are being investigated.