Anterior approach versus conventional approach right hepatic resection for large hepatocellular carcinoma: a prospective randomized controlled study

Abstract

Objective: To evaluate whether major right hepatectomy using the anterior approach technique for large hepatocellular carcinoma (HCC) results in better operative and long-term survival outcomes when compared with the conventional approach technique.

Summary background data: The anterior approach technique has been advocated recently for large right liver tumors. However, its beneficial effects on the operative and survival outcomes of the patients have not been evaluated prospectively.

Methods: A prospective randomized controlled study was performed on 120 patients who had large (> or =5 cm) right liver HCC and underwent curative major right hepatic resection during a 57-month period. The patients were randomized to undergo resection of the tumor using the anterior approach technique (AA group, n = 60) or the conventional approach technique (CA group, n = 60). The anterior approach technique involved initial vascular inflow control, completion of parenchymal transection, and complete venous outflow control before the right liver was mobilized. Operative and long-term survival outcomes of the two groups were analyzed. Quantitative assessments of markers of circulating tumor cells at various stages of surgery of the two techniques were also assessed by plasma albumin-mRNA.

Results: The overall operative blood loss, morbidity, and duration of hospital stay were comparable in both groups. Major operative blood loss of > or =2 L occurred less frequently in the AA group (8.3% vs. 28.3%, P = 0.005). As a result, blood transfusion requirement and number of patients requiring blood transfusion were significantly lower in the AA group. Hospital mortality occurred in 1 patient in the AA group and 6 patients in the CA group (P = 0.114). Median disease-free survival was 15.5 months in the AA group and 13.9 months in the CA group (P = 0.882). Overall survival was significantly better in the AA group (median >68.1 months) than in the CA group (median = 22.6 months, P = 0.006). The survival benefit appeared more obvious in patients with stage II disease and patients with lymphovascular permeation of the tumor. The anterior approach was also found to associate with significantly lower plasma albumin-mRNA levels at various stages of surgery compared with the CA technique. On multivariate analysis, tumor staging, anterior approach hepatic resection, and resection margin involved by the tumor were independent factors affecting overall survival.

Conclusion: The anterior approach results in better operative and survival outcomes compared with the conventional approach. It is the preferred technique for major right hepatic resection for large HCC.

Figures

FIGURE 1. Flow chart and randomization of patients with large HCC (≥5 cm), which was considered suitable for major right hepatectomy.

FIGURE 2. Cumulative disease-free survival (A) and overall survival (B) of patients who underwent major right hepatectomy using anterior approach (60 patients) and conventional approach (60 patients).

FIGURE 3. Cumulative disease-free survival (A) and overall survival (B) of patients with stage II disease in the anterior approach group (18 patients) and the conventional approach group (25 patients).

FIGURE 4. Cumulative disease-free survival (A) and overall survival (B) of patients with lymphovascular permeation of tumor in the anterior approach group (37 patients) and the conventional approach group (39 patients).

FIGURE 5. Cell-free circulating albumin-mRNA level was significantly lower in the anterior approach group compared with the conventional approach group, (A) before parenchymal transection (P = 0.034) and (B) at the end of surgery after delivery of the tumor (P = 0.040).