Primary Hepatocellular Carcinoma Associated With Hypersplenism:Surgical Procedures Selection And Prognosis Analysis

BACKGROUNDS:Primary hepatocellular carcinoma(HCC)is the sixth most common neoplastic disease which ranks third according to the mortality,with a mortality rate of 95%and a 5-year survival rate of only 6.9%.As for China,395,000 people are diagnosed with HCC each year with the fatality rate of 35/1000,000.Though many treatment strategies for HCC being developed,surgical resection is still the most important and radical treatment.However,in Asia,about 88.5%of HCC patients are complicated with liver cirrhosis,while in China,this ratio is about 85%-90%.The proportion of patients with splenomegaly in patients with liver cirrhosis varies from 36%to 92%,and hypersplenism caused by liver cirrhosis contributes to secondary thrombocytopenia,hyperbilirubinemia and immunosuppression.In the past,hepatectomy for HCC patients with decompensated cirrhosis is inappropriate and may cause serious consequences.Despite the continuous improvement in surgical techniques and perioperative management,there is still considerable controversy about the choice of surgical methods for these patients.It has been reported that splenectomy can improve postoperative hematologic and hepatic function,promote liver regeneration,improve immune function and reduce the risk of HCC in cirrhotic patients.In addition,for patients with HCC and hypersplenism,splenectomy seems to improve the patient's prognosis and increase the patient's tolerance to major surgery.Therefore,some surgeons advocate the synchronous hepatectomy and splenectomy(HS)for such patients.At the same time,due to the introduction and development of interventional therapy guided by B-ultrasound,some doctors advocate that interventional treatment is recommendable for such patients for its reducing trauma and liver damage.Therefore,this retrospective cohort study was performed to compare the effects of different surgical procedures on patients with HCC and hypersplenism,and to analyze the prognostic risk factors of these patients.METHODS:This study included patients with HCC and hypersplenism who underwent surgical treatment at the General Surgery Department of Qilu Hospital of Shandong University from January 1,2005 to December 31,2015.Included patients were devided into three groups ccording to the surgical method:hepatectomy(HA)group,synchronous hepatectomy and splenectomy(HS)group and radiofrequency ablation(RFA)group.Case information query and telephone follow-up were used to collect indicators information including:general information(gender,age,type of viral hepatitis,smoking history,drinking history,history of diabetes,spleen size,esophageal varices,cirrhosis,Child-Pugh classification,type of.surgery,extent of liver resection,tumor location,number of tumors,invasion of vasculature,margin of resection,preoperative alpha-fetoprotein(AFP)level,preoperative white blood cell(WBC),red blood cell(RBC)and platelet(PLT)counts,preoperative alanine aminotransferase(ALT),Aspartate aminotransferase(AST),serum total bilirubin(T-Bil),and serum albumin(Alb)levels);operation related information(operative time,intraoperative bleeding,whether to transfuse blood,intraoperative blood transfusion volume,whether to conduct hepatic portal occlusion[HPO],HPO time,postoperative complications);postoperative laboratory parameters(WBC,RBC,and PLT counts,and ALT,AST,T-Bil,and Alb levels on the 1st/4th/7th day after surgery;survival data(overall survival time and recurrence-free survival time).Input and statistically analyzed each group of data using SPSS 20.0 software;P values represented two-sided probability,with significance level ? = 0.05,and P<0.05 was considered statistically significant.RESULTS:Sixty-two patients met the inclusion criteria,including 36 in the HA group,16 in the HS group,and 10 in the RFA group.Survival curves showed that the overall survival and recurrence-free survival of HS group were better than the other two groups,while the radiofrequency ablation group had the worst prognosis.The average operation time was(149.17±59.11)min in the HA group,(265.31±93.78)min in the HS group and(24.40±9.09)min in the RFA group.The discrepancy was significant among three groups(p<0.001).There was no significant difference between the HA group and the HS group([270.00±291.03]ml vs[333.33±98.47]ml,p=0.466).The proportion of transfused patients in the HA group was less than that in the HS group(9 patients[25.0%]vs 10 patients[62.5%],p=0.002),and there was no significant difference in intraoperative blood transfusion volume between the two groups([744.44±364.39]ml vs[1020.00±355.28]ml,p=0.114).There were no statistically significant differences among the three groups in the proportion of patients underwent HPO(14[38.9%]vs 2[12.5%]vs 0[0.0%],p=0.064).The HPO time in the HA group was comparable to that in the HS group([22.38112.03]min vs[17.5±3.54]min,p=0.589).As for postoperative complications,there was no significant difference among three groups(14[38.9%]vs 4[25.0%]vs 0[0%],p=0.052).WBC count on the post-operative day(POD)1:there was no significant difference between the HA group and the HS group(p>0.05),while the WBC counts on POD 1 of these two groups were higher than that in the RFA group([12.64±5.41]*109/L vs[15.37±3.84]*109/L vs[8.61±0.71]*109/L,p<0.05);WBC count on POD 4:HS group>HA group>RFA group([12.92±1.99]*109/L vs[8.313.7]*109/L vs[5.02±10.84]*109/L,p<0.05);WBC count on POD 7:HS group>HA group>RFA group([12.82±4.36]*109/L vs[7.26±3]*109/L vs[4.62+0.5]*109/L,p<0.05).There was no significant difference in RBC count among the three groups on POD 1/4/7(p>0.05).There was no significant difference in PLT count between the HA group and the HS group on POD 1([83.09±29.23]*109/L vs[71.63±34.44]*109/L,p=0.228);On POD 4,the PLT count in the HA group was significantly lower than that in the HS group([75.44±23.56]*109/L vs[130.69±45.73]*109/L,p<0.001);the PLT count in the HA group on the POD 7 was significantly lower than that in the HA group([97.84±39.79]*109/L vs[204.75±63.13]*109/L,p<0.001).There was no significant difference in the ALT,AST,and T-Bil levels between the HA group and the HS group on POD 1/4/7(p>0.05).There was no significant difference in Alb level between the HA group and the HS group on POD 1/4(p>0.05).On POD 7,the level of Alb in the HA group was significantly lower than that in the HS group([36.46±4.08]g/L vs[39.43±4.95]g/L,p=0.031).Surgical methods and postoperative complications were risk factors for overall survival and recurrence-free survival,while preoperative Child-pugh classification was a protective factor for overall survival and recurrence-free survival.CONCLUSION:Synchronous hepatectomy and splenectomy can significantly improve the overall survival rate and recurrence-free survival rate of patients with HCC and hypersplenism,improve the general condition of these patients,and not increase postoperative complications and postoperative liver function damage.Therefore,for patients with hepatocellular carcinoma and hypersplenism,synchronous hepatectomy and splenectomy is a safe and effective treatment.