一般外科 case presentation. By intern 楊容欣 指導老師 :Dr. 魏昌國

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1 一般外科 case presentation By intern 楊容欣 指導老師 :Dr. 魏昌國

2 Patient profile Name 王琴祿 Age:64 years old Gender: male ID:E Date of admission:

3 Chief complain HCC s/p 3 PEI, AFP elevating during recent months, ask for second opinion

4 Brief history 64 y/o male with DM under regular medical control Liver tumor was noted during healthy examination in March 2004, in Seg 5 < 2Cm

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6 Brief history Lost of contact PEI was performed in 高雄長庚 HCC rupture, and emergent TACE was performed Repeated PEI for 2 times Back to our hospital for second opinion. liver function, CT were arranged.

7 Brief history Since liver function was borderline normal, and PEI was ineffective Surgical treatment was considered Spontaneous rupture, elevating AFP uncontrolled tumor size The patient was admitted to GS ward for further evaluation and management.

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16 Lab 5/10 TBI: 0.5 DBI: 0.2 GOT/GPT: 37/40 BUN:11 Cre:0.8 Alb:3.8 PT : 11.5 sec HBsAg 17215/120 Posit AFP ng/ml Anti HCV Negative.

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18 Review of system Respiratory System: Chest pain(-), Cough(-), Sputum(-), Dyspnea(-), Asthma(-), Hemoptysis(-), Tachypnea(-) Cardio-vascular System: Palpitation(-), Orthopnea(-), Short of breath(-), Edema(-), Exertional Dyspnea(-) Gastro-intestinal System: Nausea(-), Vomiting(-), Hematemesis(-), Constipation(-), Diarrhea(-), Jaundice(-), Melena(-), Bloody stool(-), Tenesmus(-), Abdominal pain(-) Poor appetite(-), BWL(-)

19 Physical examination HHENT: pink conjuctiva, Chest and lung: clear BS Heart: regular-regular heart beats Abdomen: soft, falt, no tenderness,liver,spleen: not palpable Ext: no pitting edema

20 Operation on 5/18 Procedure: 1 extend lobectomy seg 4,5,8 2 cholecystectomy OP finding: 1.mild cirrhosis 2.a 8x8x8 cm tumor at seg 4,5,8 3. unreasonable hyoptention noted after total vascular exclusion

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22 Lab 5/19 GPT/ALT 453 IU/L GOT/AST 452 IU/L APTT 27.1 sec PT 12.3 sec ALB 2.9 g/dl DBI 0.6 mg/dl TBI 1.5 mg/dl

23 Brief history Weaning and transferred to GS ward on 5/20

24 Discussion surgical management of HCC with liver cirrhosis

25 Background localized unresectable HCC,cytoreduction &sequential resection 是一種治療選擇 經由 regional cancer multimodality combination therapy,72/663 surgically verified unresectable HCC 變成 resectable, median tumor diameter 由 10 公分減為 5 公分,surgical mortality 1.4%for sequential resection, 5-yr survival rate 為 62.1%

26 Multimodality combination therapy for cytoeduction 包括 regional fractionated radiotherapy (R/T), radioimmunotherapy,tace,pei, PAI, 而且經由 triple or double combination therapy 可有 much higher sequential resection rates as compared to single therapy

27 而日本 Harada 的報告, 對於 stage IVa HCC, 採用 hepatectomy+tace+ PEI 可致 47.7% 的 5-yr survival rate, 比 hepatectomy+tace or conservative treatment 好 其中 interval between the first TACE&sequential resection 為 6.5 months.

28 TACE 方面, 它是 unresectable HCC 的 first choice,transcatheter oily chemoemboli-zation (TOCE) 比 nonoily TACE 有效,lipiodol uptake 比例與 survival rate 有關

29 TACE followed by resection 的 survival rate 比 TACE alone 好 (59%vs 13.7%) 肝功能良好及有良好 collateral circulation 者, 雖有 main PV thrombosis 仍可作 TACE

30 Bronowick 比較 Okuda stage I HCC resection (30 例 ), liver transplantation (17 例 ) 及 TOCE (42 例 ), 結束顯示 5-yr survival rate,toce 與 resection,transplantation 相當 Tanaka 報告提及 large HCC (483 例 ),combined TAE& PEI,5-yr-survival rate 仍有 35% 但 TAE 之後可能產生兩個 major problems, 即 increased risk of pulmonary metastasis 及 acute hepatic failure 12.1%in 369 pts Lygidakis 的報告,hepatic a 及 splenic a 的 locolregional immumo chemotherapy 比單獨由 hepatic a 治療好, mean survival 分別為 22.3 vs 10.2 月

31 PEI PEI 已被證實能很有效地治療 samll HCC Livraghi 報告 746 cirrhotic pts with HCC(<5 cm),5-yr-survival 在 child A 有 47%,29% (Child,s B),0% (Child,s C) acetic acid injection (PAI) 的結果,Ohiniishi 的報告 91 例 small HCC (<3 cm),5-yr survival rate 為 49%; percutaneous microwave therapy 也是一種 approach as regional cancer therapy

32 如何預防 recurrence? 目前認為 preop. resectable HCC<8cm 則不應作 TACE,but indicated for HCC>8cm resection 後,postop chemoimmunotherapy 對於 survival 延長有益, 另外 postop TACE 則可減少 intrahepatic recurrence,dr. Uchino 的報告可看出 postop TACE vs oral C/T vs placebo,3-yr survival rate 分別違 86%,50% 及 15% oral 5-FU 對於 mild liver dysfunction 的 case 可益於 prevent recurrence, 但 severe liver dysfunction 則不然

33 Background Spontaneous rupture is a lifethreatening complication of HCC, occurring in % of cases.

34 Method and material January 1994 to December 2000, 11 patients (7 males and 4 female, mean age 66.2 (11.86 years) were treated for ruptured HCC, in 10 cases involving a cirrhotic liver

35 7( child A~B): minor resection 4 patients died 3, 4, 6 and 62 months after surgery; 3 patients are actually alive 22, 25, and 89 months after surgery 4:TAE due to poor liver function all patients died within 6 months.

36 conclusion When ruptured HCC is suspected, preserved liver function (Child A-B7) and a resectable hepatic tumour are considered clear indications to surgery. Emergency liver resection achieved good early and long-term results

37 Ischemic preconditioning protects liver from hepatectomy under hepatic inflow occlusion for hepatocellular carcinoma patients with cirrhosis World J Gastroenterol 2004;10(17):

38 warm ischemia for cirrhotic liver should not exceed 30 min

39 Ischemic preconditioning (IPC) giving a short period of ischemia and reperfusion and subsequently sustaining a prolonged ischemic insult Clavien PA. Protective effects of ischemic preconditioning for liver resection performed under inflow occlusion in humans. Ann Surg 2000; 232:

40 (1) The general condition of the patients was good. (2) The tumor did not extend beyond half of the liver and had no distant metastasis. (3) Liver function belonged to Child A or B and liver function reserve was type P1 (7.3 μmol/l) or P2 according to OGTT Zhonghua Waike Zazhi 1993; 31:

41 IPC with 5 min of ischemia and 5 min of reperfusion produced the best protection on cirrhotic rat liver I/R model Zhongguo Bingli Shengli Zazhi 2002; 18: 55-58

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46 Total Vascular Exclusion of the Liver During Hepatic Surgery: Selective Use, Extensive Use, or Abuse? Volume 132(10) October 1997 pp

47 indication close relationship of the lesion to be resected with the inferior vena cava (IVC) Lesion closed to hepatic veins at their confluence into the IVC or between the portal bifurcation and the IVC. retrohepatic IVC was infiltrated by a tumor that could not be removed with a conventional hepatic resection.

48 722 patients November 1, 1981, to March 31, 1996, 19 (2.6%) required total vascular exclusion hepatic lesions closely adherent to or infiltrating the retrohepatic vena cava or centrally located in the liver, strictly in contact with the hepatic vein convergence.

49 6 had tumoral infiltration of the retrohepatic vena cava in 4 cases the venous wall was partially resected, 2 it was completely removed no operative deaths

50 TVE procedure accomplished with low rates of morbidity and mortality when performed in specialized surgical liver units. After resections under TVE, most of our patients achieved acceptable survival, comparable to that of patients with similar tumors.

51 comment 沒有 borderilne liver function 要用操 child A Focus 的點太多這個病人主要是 unresectable liver tumor Post TACE 沒有討論到這個病人的特點