الفهرس 
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Abstract
This retrospective study was conducted on all Child-Pugh class A cirrhotic patients with HCC who underwent resection. In total, 120
patients with HCC who underwent liver resection surgery from 2010 to
2017 were included in this study. These patients were recruited from
hepatology and gastoenterology department and surgery department at
National Liver Institute, Menoufia University. Patients with liver tumors
other than HCC, those who underwent combined resection and
radiofrequency ablation and those with evidence of extra-hepatic spread
of the tumor were excluded from this study. Our aim was to assess the
predictors of the hepatic decompensation, recurrence and survival in
cirrhotic patients with HCC after surgical resection.
It was found that:
• The mean age of the studied patients was 59.23پ}6.52 years old.
Patients were mostly males (76.7%). The cause of liver disease was
chronic HCV infection in 105 (87.5%) patients and chronic HBV
infection in 15 (12.5%) patients.
• Forty-seven (39.2%) patients received antiviral treatment for HCV
infection, 41 of them received direct acting antivirals (34.2%).
• Patients were mostly Child A5 cirrhotic patients (75%) with a
preoperative MELD score less than 10 in the majority of patients
(75%). Preoperative MELD score was 8.54پ}1.78. The tumor was
classified as BCLC stage 0, A and B in 12 (10%), 72 (60%) and 36
(30%) patients, respectively.
• Prior to surgery, forty-two (35%) patients had clinically significant
portal hypertension as indicted by the presence of gastroesophageal
varices on upper endoscopy.
• On imaging, the mean diameter of the largest tumor was 4.57پ}2.03
cm; the tumor was single in most of the patients (93.3%), affecting
mainly the right lobe of the liver (48.3%). Additionally, the tumor
diameter was less than 5 cm in 86 patients (71.7%).
• Patients had a mean preoperative serum bilirubin of 0.87پ}0.34 mg/dL,
a mean preoperative serum albumin of 3.78پ}0.48 g/dL, a mean
preoperative INR of 1.16پ}0.1 and a mean preoperative serum AFP
level of 193.37پ}343.37 ng/mL. Notably, serum AFP level was less
than 20 ng/mL in the majority of patients (51.7%). In sixty-four
(53.3%) patients, platelets count was less than 150,000/mm3.
• Regarding the liver resection operation, the approach was open in
most of the patients (55%) and the resection was anatomical in 22
(18.3%) patients; only one segment (wedge resection) was resected in
the majority of the patients (48.3%).
• Intraoperative bleeding was reported in 50 (41.7%) patients.
Following surgery, blood and plasma transfusion were required in 47
(39.2%) and 55 (45.8%) patients, respectively.
• In fifty-eight (48.3%) patients, the tumor was grade 1 or 2 while grade
3 or 4 was present in 38 (31.7%) patients. Lymphovascular invasion
was present in 44 (36.7%) patients.
• After resection, patients had a mean serum bilirubin of 1.5پ}0.64
mg/dL, a mean serum albumin of 3.21پ}0.41 g/dL, a mean INR of
1.25پ}0.14 and a mean serum AFP level of 2109.7پ}10795.17 ng/mL.
Postoperative hospital stay was 8.9پ}5.05 days with a mean ICU stay
of 4.28پ}4.19 days.
• Patients had a mean of Child-Pugh score of 6.62پ}1.54 and 6.51پ}1.1
on discharge and three months post-operatively, respectively.
• Postoperative MELD score was ≤10 in 68 (56.7%) patients with a
mean score of 10.63پ}2.27. The 50-50 criteria were fulfilled in four
(3.3%) patients. Post-hepatectomy liver failure (PHLF) developed in
44 (36.7%) patients; PHLF was classified as grade A, B and C in 16
(13.3%), 22 (18.3%) and 6 (5%) patients, respectively.
• Postoperative complications included hemorrhage, bile leak, wound
infection and chest infection in 4 (3.3%), 2 (1.7%), 4 (3.3%) and 14
(11.7%) patients, respectively.
• Follow-up of the studied patients after the liver resection surgery
demonstrated HCC recurrence in 34 (28.3%) of the patients. Fifty
(41.7%) patients developed hepatic decompensation after surgery.
Peri-operative mortality rate was 4/120 (3.3%). Fifty (41.7%) patients
died over a median follow-up of 34.4 months.
• Preoperative factors significantly associated with hepatic
decompensation after the liver resection surgery were identified on
univariate analyses. These included the lack of anti-viral therapy for
HCV prior to surgery (p<0.001), presence of clinically significant
portal hypertension (p=0.006), advanced BCLC stage (p<0.001),
preoperative MELD scores of 10-20 (p<0.001). Preoperative MELD
scores were significantly higher in patients who developed hepatic
decompensation after resection (p=0.001).
• On univariate analyses, tumor characteristics that were significantly
associated with hepatic decompensation after the liver resection
surgery included tumors with diameter greater than five centimeters
(p<0.001), multiple tumor foci (p=0.027), extension of the tumor
beyond Milan criteria (p<0.001) and the presence of lymphovascular
invasion (p=0.003). Additionally, the tumor diameter was significantly
higher in patients who developed hepatic decompensation after
resection (p<0.001), compared to those who did not decompensate.
• Operative factors that were significantly associated with hepatic
decompensation after the liver resection surgery on univariate analysis
included open resection (p<0.001) and ICU admission (p=0.004).
Moreover, longer ICU (p=0.016) and hospital stays (p<0.001) were
significantly associated with postoperative hepatic decompensation.
• Post-operative factors that were significantly associated with hepatic
decompensation after the liver resection surgery on univariate analyses
included the development of wound infection (p=0.028), chest
infection (p<0.001), advanced grades of PHLF (p<0.001) and the
fulfillment of the 50-50 criteria (p=0.028). Furthermore, higher
postoperative bilirubin levels (p<0.001) and higher Child-Pugh scores
(p<0.001) were significantly associated with postoperative hepatic
decompensation.
• On multivariate analysis, preoperative MELD score (OR=2.7, 95% CI:
1.2-5.7, p=0.013), tumor diameter (OR=5.4, 95% CI: 2-14.8, p=0.001)
and the duration of hospital stay (OR=2.5, 95% CI: 1.5-4.2, p=0.001)
were independent predictors of hepatic decompensation after the liver
resection surgery for HCC.
• On univariate analysis, predictive factors of recurrence after the liver
resection surgery included age >60 years (p=0.027), preoperative CTP
score (p=0.002), preoperative AFP levels (p<0.001), and the presence
of lymphovascular invasion (p<0.001)
• On multivariate analysis, preoperative MELD score (OR=1.9, 95% CI:
1.2-3.2, p=0.011), preoperative AFP levels (OR=1.01, 95% CI: 1.002-
1.01, p=0.001), the presence of lymphovascular invasion (OR=54.5,
95% CI: 4.1-726.7, p=0.002) and postoperative serum bilirubin levels
(OR=5.1, 95% CI: 1.3-20.7, p=0.023) were independent predictors of
recurrence after the liver resection surgery
• The perioperative mortality rate after liver resection (within 30-days
after the operation) was 4/120 (3.3%).
• The 1-year, 2-year, 3-year, 4-year, and 5-year survival rates after the
liver resection surgery for HCC were 72%, 63%. 60%, 58%, and 58%,
respectively.
• Kaplan-Meier statistics demonstrated that clinically significant portal
hypertension was not significantly associated with poor survival.
• On the other hand, preoperative AFP levels >400 ng/mL (p=0.003),
pre-operative MELD scores of 10-20 (p<0.001), BCLC stage
(p<0.001), the development of post-hepatectomy liver failure
(p=0.004) and its advanced grade (p<0.001), fulfillment of the 50-50
criteria after surgery (p<0.001), postoperative MELD scores >10
(p<0.001), the development of postoperative decompensation
(p<0.001) and HCC recurrence after surgery (p<0.001) were
significantly associated with poor survival after liver resection.
• On multivariate cox regression analysis, preoperative MELD score
(HR=1.37, 95% CI: 1.16-1.62, p<0.001), different grades of PHLF
(Grade A: HR=2.33, 95% CI [0.59-9.24]; Grade B: HR=3.15, 95% CI
[1.11-8.95]; Grade C: HR=373.41, 95% CI [66.23-2105.43]; p<0.001)
and development of HCC recurrence after resection (HR=11.67, 95%
CI: 4.19-32.52, p<0.001) were independent prognostic factors for the
survival.
• In conclusion, fifty patients (41.7%) of our studied patients developed
hepatic decompensation after liver resection surgery for HCC and 34
(28.3%) patients developed HCC recurrence.
• Preoperative MELD score, tumor diameter and the duration of
hospital stay were independent predictors of hepatic decompensation
after liver resection.
• Factors that proved to independently predict HCC recurrence after
surgery included preoperative MELD score, preoperative AFP levels,
the presence of lymphovascular invasion and postoperative serum
bilirubin levels.
• Looking at the survival after HCC resection, fifty (41.7%) patients
died over a median follow-up of 34.4 months.
• Furthermore, preoperative MELD score, different grades of PHLF and
the development of HCC recurrence after resection were significant
independent prognostic factors for the survival of patients after the
liver resection surgery.