World Journal of Surgery

, Volume 36, Issue 11, pp 2670–2676 | Cite as

Management of Spontaneously Ruptured Hepatocellular Carcinoma and Hemoperitoneum Manifested as Acute Abdomen in the Emergency Room

  • Kuan-Chun Hsueh
  • Hsiu-Lung Fan
  • Teng-Wei Chen
  • De-Chuan Chan
  • Jyh-Cherng Yu
  • Shung-Sheng Tsou
  • Tzu-Ming Chang
  • Chung-Bao Hsieh
Article

Abstract

Background

Spontaneously ruptured hepatocellular carcinoma (HCC) with hemoperitoneum has a poor prognosis, especially in cases of cirrhosis. Patients usually present to emergency rooms (ERs) with acute abdomen. The aim of the present study was to determine the factors affecting mortality and to compare the prognosis of conservative treatment, transcatheter arterial embolization (TAE), or hepatectomy in these situations.

Methods

Fifty-four patients with spontaneously ruptured HCC diagnosed between January 2004 and August 2010 were enrolled in this retrospective review of clinical data. Grouping by survival or mortality, univariate and multivariate analyses of factors affecting 30-day mortality, and long-term survival were conducted. The outcomes of the various treatments were analyzed.

Results

After primary fluid resuscitation in the ER, 6 of 54 patients underwent conservative treatment. Emergency hepatectomy was performed on 19 patients; TAE was used for 29 patients, 18 of whom received staged hepatectomy thereafter. Poor liver function, prolonged international normalized ratio (INR), and conservative treatment were associated with increased 30-day mortality. Logistic regression analysis of cumulative survival revealed that INR ≥ 1.4, multiple intrahepatic HCC, and conservative treatment were related to poorer long-term survival. The patients who received hepatectomy, either immediate or staged after TAE, had higher survival rates of 85.2 % at 30 days and 62.2 % at 1 year.

Conclusions

The treatment of ruptured HCC should be tailored to the individual case. Prolonged survival is possible in patients with preserved liver function through curative liver resection. Emergency physicians, radiologists, and surgeons play essential roles in managing these patients.

References

  1. 1.
    Chen MF, Hwang TL, Jeng LB et al (1995) Clinical experience with hepatic resection for ruptured hepatocellular carcinoma. Hepatogastroenterology 42:166–168PubMedGoogle Scholar
  2. 2.
    Vergara V, Muratore A, Bouzari H et al (2000) Spontaneous rupture of hepatocellular carcinoma: surgical resection and long-term survival. Eur J Surg Oncol 26:770–772PubMedCrossRefGoogle Scholar
  3. 3.
    Liu CL, Fan ST, Lo CM et al (2001) Management of spontaneous rupture of hepatocellular carcinoma: single-center experience. J Clin Oncol 19:3725–3732PubMedGoogle Scholar
  4. 4.
    Bassi N, Caratozzolo E, Bonariol L et al (2010) Management of ruptured hepatocellular carcinoma: implications for therapy. World J Gastroenterol 16:1221–1225PubMedCrossRefGoogle Scholar
  5. 5.
    Chen CY, Lin XZ, Shin JS et al (1995) Spontaneous rupture of hepatocellular carcinoma. A review of 141 Taiwanese cases and comparison with nonrupture cases. J Clin Gastroenterol 21:238–242PubMedCrossRefGoogle Scholar
  6. 6.
    Lai EC, Lau WY (2006) Spontaneous rupture of hepatocellular carcinoma: a systematic review. Arch Surg 141:191–198PubMedCrossRefGoogle Scholar
  7. 7.
    Chen WK, Chang YT, Chung YT et al (2005) Outcomes of emergency treatment in ruptured hepatocellular carcinoma in the ED. Am J Emerg Med 23:730–736PubMedCrossRefGoogle Scholar
  8. 8.
    Tan FL, Tan YM, Chung AY et al (2006) Factors affecting early mortality in spontaneous rupture of hepatocellular carcinoma. ANZ J Surg 76:448–452PubMedCrossRefGoogle Scholar
  9. 9.
    Choi BG, Park SH, Byun JY et al (2001) The findings of ruptured hepatocellular carcinoma on helical CT. Br J Radiol 74:142–146PubMedGoogle Scholar
  10. 10.
    Pombo F, Arrojo L, Perez-Fontan J (1991) Haemoperitoneum secondary to spontaneous rupture of hepatocellular carcinoma: CT diagnosis. Clin Radiol 43:321–322PubMedCrossRefGoogle Scholar
  11. 11.
    Kirikoshi H, Saito S, Yoneda M et al (2009) Outcomes and factors influencing survival in cirrhotic cases with spontaneous rupture of hepatocellular carcinoma: a multicenter study. BMC Gastroenterol 9:29PubMedCrossRefGoogle Scholar
  12. 12.
    Li WH, Cheuk EC, Kowk PC et al (2009) Survival after transarterial embolization for spontaneous ruptured hepatocellular carcinoma. J Hepatobiliary Pancreat Surg 16:508–512PubMedCrossRefGoogle Scholar
  13. 13.
    Kung CT, Liu BM, Ng SH et al (2008) Transcatheter arterial embolization in the emergency department for hemodynamic instability due to ruptured hepatocellular carcinoma: analysis of 167 cases. AJR Am J Roentgenol Rad Ther 191:231–239CrossRefGoogle Scholar
  14. 14.
    Yeh CN, Lee WC, Jeng LB et al (2002) Spontaneous tumour rupture and prognosis in patients with hepatocellular carcinoma. Br J Surg 89:1125–1129PubMedCrossRefGoogle Scholar
  15. 15.
    Tanaka A, Takeda R, Mukaihara S et al (2001) Treatment of ruptured hepatocellular carcinoma. Int J Clin Oncol 6:291–295PubMedCrossRefGoogle Scholar
  16. 16.
    Lai EC, Wu KM, Choi TK et al (1989) Spontaneous ruptured hepatocellular carcinoma. An appraisal of surgical treatment. Ann Surg 210:24–28PubMedCrossRefGoogle Scholar
  17. 17.
    Cherqui D, Panis Y, Rotman N et al (1993) Emergency liver resection for spontaneous rupture of hepatocellular carcinoma complicating cirrhosis. Br J Surg 80:747–749PubMedCrossRefGoogle Scholar
  18. 18.
    Chiappa A, Zbar A, Audisio RA et al (1999) Emergency liver resection for ruptured hepatocellular carcinoma complicating cirrhosis. Hepatogastroenterology 46:1145–1150PubMedGoogle Scholar
  19. 19.
    Chen ZY, Qi QH, Dong ZL (2002) Etiology and management of hemmorrhage in spontaneous liver rupture: a report of 70 cases. World J Gastroenterol 8:1063–1066PubMedGoogle Scholar
  20. 20.
    Hsieh JS, Huang CJ, Huang YS et al (1987) Intraperitoneal hemorrhage due to spontaneous rupture of hepatocellular carcinoma: treatment by hepatic artery embolization. AJR Am J Roentgenol Rad Ther 149:715–717Google Scholar
  21. 21.
    Tarantino L, Sordelli I, Calise F et al (2011) Prognosis of patients with spontaneous rupture of hepatocellular carcinoma in cirrhosis. Updates Surg 63:25–30PubMedCrossRefGoogle Scholar
  22. 22.
    Miyamoto M, Sudo T, Kuyama T (1991) Spontaneous rupture of hepatocellular carcinoma: a review of 172 Japanese cases. Am J Gastroenterol 86:67–71PubMedGoogle Scholar
  23. 23.
    Battula N, Madanur M, Priest O et al (2009) Spontaneous rupture of hepatocellular carcinoma: a Western experience. Am J Surg 197:164–167PubMedCrossRefGoogle Scholar
  24. 24.
    Lin CS, Chang CS, Yang SS et al (2008) Retrospective evaluation of serum markers APRI and AST/ALT for assessing liver fibrosis and cirrhosis in chronic hepatitis B and C patients with hepatocellular carcinoma. Intern Med 47:569–575PubMedCrossRefGoogle Scholar
  25. 25.
    Ichikawa T, Uenishi T, Takemura S et al (2009) A simple, noninvasively determined index predicting hepatic failure following liver resection for hepatocellular carcinoma. J Hepatobiliary Pancreat Surg 16:42–48PubMedCrossRefGoogle Scholar
  26. 26.
    Sonoda T, Kanematsu T, Takenaka K et al (1989) Ruptured hepatocellular carcinoma evokes risk of implanted metastases. J Surg Oncol 41:183–186PubMedCrossRefGoogle Scholar
  27. 27.
    Miyoshi A, Kitahara K, Kohya N et al (2011) Outcomes of patients with spontaneous rupture of hepatocellular carcinoma. Hepatogastroenterology 58:99–102PubMedGoogle Scholar
  28. 28.
    Castells L, Moreiras M, Quiroga S et al (2001) Hemoperitoneum as a first manifestation of hepatocellular carcinoma in Western patients with liver cirrhosis: effectiveness of emergency treatment with transcatheter arterial embolization. Dig Dis Sci 46:555–562PubMedCrossRefGoogle Scholar
  29. 29.
    Shimada R, Imamura H, Makuuchi M et al (1998) Staged hepatectomy after emergency transcatheter arterial embolization for ruptured hepatocellular carcinoma. Surgery 124:526–535PubMedCrossRefGoogle Scholar

Copyright information

© Société Internationale de Chirurgie 2012

Authors and Affiliations

  • Kuan-Chun Hsueh
    • 1
  • Hsiu-Lung Fan
    • 2
  • Teng-Wei Chen
    • 2
  • De-Chuan Chan
    • 2
  • Jyh-Cherng Yu
    • 2
  • Shung-Sheng Tsou
    • 1
  • Tzu-Ming Chang
    • 1
  • Chung-Bao Hsieh
    • 2
  1. 1.Division of General Surgery, Department of SurgeryTungs’ Taichung MetroHarbour HospitalTaichungTaiwan, ROC
  2. 2.Division of General Surgery, Department of Surgery, Tri-Service General HospitalNational Defense Medical CenterTaipeiTaiwan, ROC

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