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Conservative Management and Selective Intervention

K. L. Leung, FRCS(Edin); W. Y. Lau, FRCS(Edin), FRACS; P. B. S. Lai, FRCS(Edin); R. Y. C. Yiu, FRCS(Edin); W. C. S. Meng, FRCS(Edin); C. K. Leow, FRCS

Arch Surg. 1999;134:1103-1107.

Hypothesis  A conservative approach using selective intervention is better than an aggressive approach using nonselective intervention for ruptured hepatocellular carcinoma.

Design  Nonrandomized controlled trial.

Setting  A university hospital.

Patients and Interventions  From 1984 to 1990, an aggressive approach was adopted in which 29 and 8 of a total of 40 patients underwent surgical intervention or attempted transarterial embolization (TAE), respectively. From 1991 to 1997, a more conservative approach was used. The initial treatment for 72 patients was conservative with close monitoring. Additional hemostatic procedures consisting of TAE (n=13) or surgical intervention (n=9) were given, depending on the clinical progress, disease status, and liver function of the patients.

Main Outcome Measures  In-hospital mortality, survival.

Results  In-hospital mortality rate was 62% (25 of 40 patients) in the first period and 51% (37 of 72 patients) in the second period. The respective median survival times were 7 and 12 days. If 36 patients with end-stage malignant neoplasms were excluded, the in-hospital mortality rate became 60% (18 of 30 patients) in the first period and 35% (16 of 46 patients) in the second period (P=.03, ² test). The respective median survival times became 8 and 72 days (P=.02, log rank test). In the second period, 7 (54%) of 13 patients who underwent TAE and 1 (11%) of 9 patients who underwent surgical intervention died within the same hospital admission (P=.07, Fisher exact test).

Conclusions  Selective intervention was cost-effective and gave better results than an aggressive approach. When intervention was indicated for hemostasis, surgery seemed better than TAE although the difference was not statistically significant.

From the Department of Surgery, the Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, New Territories, Hong Kong.

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