Multidisciplinary Management of Ruptured Hepatocellular Carcinoma Andrzej K. Buczkowski, M.D., M.S., F.R.C.S.C., Peter T.W. Kim, M.D., Stephen G. Ho, M.D., F.R.C.P.C., David F. Schaeffer, M.D., Ph.D., Sung I. Lee, M.D., F.R.C.S.C., David A. Owen, M.D., F.R.C.P.C., Alan H. Weiss, M.D., F.R.C.P.C., Stephen W. Chung, M.D., Ph.D., F.R.C.S.C., Charles H. Scudamore, M.D., M.Sc., F.R.C.S.C., F.R.C.S. (Ed) Spontaneous rupture of hepatocellular carcinoma (HCC) is a dramatic presentation of the disease. Most published studies are from Asian centers, and North American experience is limited. This study was under- taken to review the experience of ruptured HCC at a North American multidisciplinary unit. Thirty pa- tients presenting with ruptured HCC at a tertiary care center from 1985 to 2004 were studied retrospectively and analyzed according to the demographics, clinical presentation, tumor characteristics, treatment, and outcome in four treatment groups: emergency resection, delayed resection (resection after angiographic embolization), transcatheter arterial embolization (TAE), and conservative management. Ten, 10, 7, and 3 patients underwent emergency resection, delayed resection, TAE, and conservative treat- ment, respectively. The mean age of all patients was 57 years, and the mean Child-Turcotte-Pugh score was 7 6 2. Cirrhosis was present in 57% of the patients. Seventy percent of tumors were greater than 5 cm in diameter, and 68% of patients had multiple tumors. There was a trend toward higher 30-day mortality in the emergency resection group than in the delayed resection group. One-year survival was significantly bet- ter in the delayed resection group. In selected patients, the multidisciplinary approach of angiographic em- bolization and delayed resection affords better short-term survival than emergency resection. (JGASTROINTEST SURG 2006;10:379–386) Ó 2006 The Society for Surgery of the Alimentary Tract KEY WORDS: Hepatocellular carcinoma, rupture, transcatheter arterial embolization Spontaneous rupture is a dramatic presentation of hepatocellular carcinoma (HCC). Its incidence is as high as 15% in Asia, 1–5 and as low as 3% in the United Kingdom. 6,7 In general, the outcome is poor without active treatment. 8 The clinical presentation may be dramatic but nonspecific, which makes the diagnosis difficult based on history and physical examination alone. Im- aging modalities such as ultrasound and CT are used to confirm the diagnosis. Paracentesis is able to de- tect the presence of bloody ascites but is not routinely used. 9 Because of the high mortality rate of this condi- tion, a number of studies have been conducted in at- tempts to establish a consensus on the optimal method of management. There is a general agree- ment on the principles of management and a trend toward incorporating transcatheter arterial emboli- zation (TAE) in the management algorithm. The principles of management are threefold: resuscita- tion from hypovolemic shock, followed by hemosta- sis, and finally, the treatment of the underlying HCC. Traditionally, various surgical techniques includ- ing emergency hepatic resection, hepatic artery liga- tion, suture plication, and packing have been used to secure hemostasis and to treat the tumor. However, owing to shock and hepatic decompensation in these patients, the mortality rate from emergency surgery has been high. 1,2,4,10–12 As an alternative, a multidis- ciplinary approach including TAE has led to de- creased initial mortality, facilitating selection of the suitable patients for a delayed resection to address the pathology of HCC. 8,13–16 Presented at the 2005 American Hepato-Pancreato-Biliary Association Congress, Hollywood, Florida, April 14–17, 2005. From the Divisions of General Surgery (A.K.B., P.T.W.K., D.F.S., S.I.L., S.W.C., C.H.S.) and Gastroenterology (A.A.W.), Department of Sur- gery, and the Departments of Radiology (S.G.H.) and Pathology (D.A.O.), Vancouver Hospital and Health Sciences Center, Vancouver, British Colombia, Canada. Reprint requests: Andrzej K. Buczkowski, M.D., M.S., F.R.C.S.C., 2nd floor, 855 West 10th Ave., Vancouver, BC, Canada, V5Z 1L7. e-mail: andrzej.buczkowski@vch.ca Ó 2006 The Society for Surgery of the Alimentary Tract Published by Elsevier Inc. 1091-255X/06/$dsee front matter doi:10.1016/j.gassur.2005.10.012 379