Prognostic criteria for postoperative mortality in 170 patients undergoing major right hepatectomy

BACKGROUND: Postoperative hepatic failure is a dreadful complication after major hepatectomy and carries high morbidity and mortality rates. In this study, we assessed the accuracy of the 50/50 criteria (bilirubin >2.9 mg/dL and international normalized ratio >1.7 on postoperative day 5) and the Mullen criteria (bilirubin peak >7 mg/dL on postoperative days 1-7) in predicting death from hepatic failure in patients undergoing right hepatectomy only. In addition, we identified prognostic factors linked to intra-hospital morbidity and mortality in these patients. METHODS: One hundred seventy consecutive patients underwent major right hepatectomy at a tertiary medical center from 2000 to 2008. Nineteen (11.2%) patients suffered from liver cirrhosis. Univariate and multivariate analyses were performed to identify predictors of intra-hospital mortality, morbidity and death from hepatic failure. RESULTS: The intra-hospital mortality was 6.5% (11/170). Of the six patients who died from hepatic failure, one was positive for the 50/50 criteria, but all six patients were positive for the Mullen criteria. Multivariate analysis showed that male gender, hepatitis C (HCV), hepatocellular carcinoma, postoperative bilirubin >7 mg/dL and ALT<188 U/L on postoperative day 1 were predictive of death from hepatic failure in the postoperative period. Age >65 years, HCV, reoperation, andrenal failure were significant predictors of overall intra-hospital mortality on multivariate analysis. CONCLUSIONS: The Mullen criteria were more accurate than the 50/50 criteria in predicting death from hepatic failure in patients undergoing right hepatectomy. A bilirubin peak >7 mg/dL in the postoperative period, HCV positivity, hepatocellular carcinoma, and an ALT level <188 U/L on postoperative day 1 were associated with death from hepatic failure in our patient population.

Gastrointestinal tract injuries after thermal ablative therapies for hepatocellular carcinoma:A case report and review of the literature

BACKGROUND Radiofrequency ablation(RFA)and microwave ablation(MWA)represent the standard of care for patients with early hepatocellular carcinoma(HCC)who are unfit for surgery.The incidence of reported adverse events is low,ranging from 2.4%to 13.1%for RFA and from 2.6%to 7.5%for MWA.Gastrointestinal tract(GIT)injury is even more infrequent(0.11%),but usually requires surgery with an unfavourable prognosis.Due to its low incidence and the retrospective nature of the studies,the literature reporting this feared complication is heterogeneous and in many cases lacks information on tumour characteristics,comorbidities and treatment approaches.CASE SUMMARY A 77-year-old man who had undergone extended right hepatectomy for HCC was diagnosed with early disease recurrence with a small nodule compatible with HCC in the Sg4b segment of the liver with a subcapsular location.He was treated with percutaneous RFA and a few week later he was urgently admitted to the Surgery ward for abdominal pain and fever.A subcutaneous abscess was diagnosed and treated by percutaneous drainage.A fistulous tract was then documented by the passage of contrast material from the gastric antrum to the abdominal wall.The oesophagogastroduodenoscopy confirmed a circular wall defect at the lesser curvature of gastric antrum, leading directly to the purulentabdominal collection. An over-the-scope clip (OTSC) was used to successfullyclose the defectCONCLUSIONThis is the first reported case of RFA-related GIT injury to have been successfullytreated with an OTSC, which highlights the role of this endoscopic treatment forthe management of this complication.