Central hepatectomy for centrally located malignant liver tumors: A systematic review

Table 1 Characteristics and results of studies on central hepatectomy (1983-2013) n (%)

Ref.	Year	n	Diagnosis	Operative time (min)	Vascular control	Blood loss (mL)	Morbidity	Mortality	Survival outcome
Hasegawa et al[27]	1989	16	HCC, CRM	300-660	Pedicle occlusion	600-7500	7 (50)	1 (6)	Median OS 34 mo
Makuuchi et al[28]	1993	17	HCC, CCA, CRM	412	NA	1482	7 (41.1)	1 (5.8)	NA
Nagino et al[29]	1998	15	Hilar CCA	NA	NA	NA	NA	NA	NA
Wu et al[17]	1999	15	HCC	474	Pringle’s maneuver or pedicle occlusion	2450	3 (20)	0 (0)	1-yr OS 67%	1-yr DFS 53%
									3-yr OS 44%	3-yr DFS 31%
									6-yr OS 30%	5-yr DFS 21%
Scudamore et al[19]	2000	18	HCC, CRM, GBC	238	Pringle’s maneuver	914	11 (61.1)	0 (0)	NA	NA
Yamashita et al[30]	2001	16	HCC, CCA, metastases, hemangioma, others	NA	NA	NA	NA	NA	NA	NA
3Jarnagin et al[3]	2002	15	Benign and malignant lesions	NA	NA	NA	NA	NA	NA	NA
Wu et al[22]	2002	58	HCC, CCA, metastases	409	Total hepatic flow clamping (28 patients)	1685	8 (8.5)	0 (0)	NA	NA
				399	Selective clamping of ipsilateral blood flow (30 patients)	1159	10 (33.3)	0 (0)	NA	NA
Hu et al[23]	2003	52	HCC	265	NA	1030	9 (17)	0 (0)	Median OS 51 mo	Median DFS 23 mo
Chouillard et al[25]	2003	19	HCC, metastases, CCA, benign tumor	280	Pringle’s maneuver ± hepatic vein clamping	NA	NA	0 (0)	NA	NA
1Chen et al[18]	2006	118	HCC	128	Pringle’s maneuver ± IVC occlusion	592	36 (30.5)	1 (0.8)	NA	NA
Kim et al[31]	2006	35	HCC, CCA, hepatic sarcoma	331	Extraglissonian approach and parenchymal Kelly crushing	516	2 (5.7)	1 (2.8)	1-yr OS 94%	NA
									2-yr OS 72%
									5-yr OS 62%
Giuliante et al[32]	2007	18	HCC, metastases	448	Intermittent pedicle clamping	NA	6 (33.3)	0 (0)	NA	NA
1Chen et al[33]	2007	246	HCC	177 (with preoperative TACE)	Pringle’s maneuver ± IVC control	790	31 (34.8)	3 (3.4)	1-yr OS 87.1%	1-yr DFS 75%
									3-yr OS 62.9%	3-yr DFS 46.2%
									5-yr OS 46.2%	5-yr DFS 31.8%
				115 (without)		420	38 (24.2)	1 (0.6)	1-yr OS 82.2%	1-yr DFS 69.6%
									3-yr OS 54.4%	3-yr DFS 38%
									5-yr OS 31.7%	5-yr DFS 16.5%
1Chen et al[7]	2008	256	HCC	174	Pringle’s maneuver ± IVC control	750 (Pringle only); 380 (Pringle with IVC control)	72 (28.1)	1 (0.4)	1-yr OS 77.0%	1-yr DFS 59.1%
									3-yr OS 49.8%	3-yr DFS 28.8%
									5-yr OS 35.1%	5-yr DFS 17.0%
Mehrabi et al[34]	2008	48	HCC, metastases, CCA, GBC, hemangioma, other	238	Pringle’s maneuver in 9 patients	1120	13 (27.1)	1 (2)	NA	3-yr DFS 47.9%
Lee et al[20]	2008	27	HCC	330	Pedicle ligation	1400	12 (44.4)	2 (7.9)	NA	NA
Arkadopoulos et al[35]	2012	36	HCC, metastases	180	Selective hepatic vascular exclusion/Pringle’s maneuver (16 patients)	650	6 (37.5)	0 (0)	NA	NA
				150	Sequential hemihepatic vascular control (20 patients)	400	9 (45)	0 (0)	NA	NA
Gallagher et al[36]	2013	21	HCC	627	Intermittent Pringle’s maneuver	1590	4 (19)	1 (4.8)	1-yr OS 90.5%	1-yr DFS 65%
									3-yr OS 66.8%	3-yr DFS 34.8%
									5-yr OS 66.8%	5-yr DFS 34.8%
Cheng et al[8]	2012	63	HCC	230	Pringle’s maneuver	500	8 (12.7)	5 (7.9)	1-yr OS 87.5%	1-yr DFS 50%
									5-yr OS 53.1%	5-yr DFS 15%
3Yang et al[37]	2013	150	HCC	NA	Pringle maneuver	NA	NA	NA	NA
Total number		8952	range	115-627		380-2450	Overall morbidity: 27.5%	Overall mortality: 2.3%
							(range: 12.7%-61.1%)	(range: 0%-7.1 %)

¹Indicates multiple studies with overlapping study periods from a single institution;

²Total number calculated after excluding studies with repeat patients;

³Limited data available as CH patients were a subset of a larger group of patients undergoing various types of hepatic resections. Overall morbidity and mortality was calculated by considering the number of events as a percentage of the total number of patients in included studies. HCC: Hepatocellular carcinoma; CRM: Colorectal metastases; CCA: Cholangiocarcinoma; GBC: Gallbladder carcinoma; IVC: Inferior vena cava; NA: Not available; OS: Overall survival; DFS: Disease-free survival; TACE: Transarterial chemoembolization; CH: Central hepatectomy.

Table 2 Summary of case-control studies comparing central hepatectomies and lobar/extended hepatectomies n (%)

Ref.	Year	Resection type	n	Operative time (min)	Blood loss (mL)	Mortality	Morbidity	Complications (n)
Wu et al[17]	1999	Central hepatectomy	15	474	2450	0 (0)	3 (20)	Bile leak (1), pleural effusion (1), ascites (1)
		Extended hepatectomy	25	348	1863	1 (4)	6 (24)	Bile Leak (2), pleural effusion (1), ascites (1), prolonged jaundice (2), intra-abdominal abscess (2), wound infection (1)
			P value	0.09	0.23	0.43	0.99	-
Scudamore et al[19]	2000	Central hepatectomy	18	238	914	0 (0)	1intra (5.5)	Intraoperative bleeding (1), pneumonia (2), intra-abdominal fluid collection (2), fever longer than 48 hours (2), transient fever (2), bile leak (1), late intra-abdominal fluid collection (1)
		Lobar hepatectomy	71	222	1025	1 (1.4)	9early (50)	NA
							1late (5.6)
							6intra (8.5)
							29early (40.8)
							3late (4.2)
		Extended hepatectomy	43	304	1628	0 (0)	2intra (4.7)	NA
							21early (48.9)
							9late (20.9)
			P value	< 0.001	0.009 for extended vs central	-	0.05 for late complications	-
Hu et al[23]	2003	Central hepatectomy	52	265	NA	0 (0)	9 (17)	Bile leak (3), pleural effusion (3), 1 postoperative massive ascites (1), subphrenic abscess (1)
		Conventional or extended hepatectomy	63	264	NA	2 (3.1)	12 (19)	Bile leak (2), wound infection (4), pneumonia (2), liver failure (2), subphrenic abscess (1), pleural effusion (1)
			P value	0.953		0.408	0.491	-
Cheng et al[8]	2012	Central hepatectomy	63	230	500	5 (7.9)	8 (12.7)	Liver failure (2), bile leak (1)1
		Hemi-/extended hepatectomies	41	316	750	3 (7.3)	6 (14.6)	Liver failure (2), bile leak (1)
			P value	< 0.001	0.004	1.000	0.777	-
Total		Central hepatectomy	148	Mean 268	Mean 882	3.4% (0%-7.9%)	20.90% (range: 20%-66.7%)
		Hemi-/extended hepatectomies	243	Mean 299	Mean 1352	2.9% (0%-7.3%)	38.70% (range: 14.6%-74.4% )

¹Other complications described included gastrointestinal bleeding, intra-abdominal hematoma, abscess, intra-abdominal bleeding, pneumonia, wound infection, but did not specify the treatment group in which it occurred. Weighted means were calculated for operative time and blood loss. NA: Not available.

Table 3 Type and frequency of complications reported following central hepatectomy

Type of complication1	Number reported (n = 200)	Frequency (%)
Surgical complications
Bile leakage/biloma	36	18
Intra-abdominal abscess	16	8
Wound infection	7	3.5
Bleeding	4	2
Intestinal perforation	1	0.5
Medical complications
Pleural effusion/empyema	62	31
Ascites	29	14.5
Pneumonia/pulmonary infection	13	6.5
Pulmonary edema	6	3
Fever	4	2
Upper gastrointestinal bleeding	3	1.5
Urinary tract infection	3	1.5
Transient hepatic dysfunction/ prolonged jaundice	3	1.5
Hepatic necrosis/liver failure	3	1.5
Acute renal failure	2	1
Stroke	1	0.5
Arrhythmia	1	0.5
Deep vein thrombosis	1	0.5
Other (not specified)	4	2

¹Calculated out of a total of 200 events.