1. WY Chu, Surgery, Tuen Mun Hospital, NTWC

2.  Initial management as a HST in rupture HCC

3.  Catastrophic event  Initial management is important Stop bleeding Identify potential long term survivors

4. Chan SY, F/43, @ 15.7.2007  Known HBV carrier, L lobe liver mass  Sudden onset RUQ pain with shock  BP 70/45 P110, confused  Bedside USG: FF in Morrison’s pouch  Child’s A, Hb 12 g/dL  CT abdomen with contrast  Hemodynamically unstable

5. Chan SY, F/43, @ 15.7.2008  Laparotomy: 4 cm S2&3 ruptured HCC, cirrhosis, 2L blood with clot  Perihepatic packing & LHA ligation at falciform ligament level  Further resuscitation in ICU  2 nd stage laparotomy 24 hrs later  Left lateral sectionectomy  Discharged post-op D7  Last FU 8.8.2008: well no recurrence

6. TMH series 2004-2007 Survival: 32 months (12-48) Survival: 7 months (3-8)

7. Early diagnosis ? Men ? Younger age ? Trauma hx ? Known HCC ? Cirrhosis ? HBV / HCV ? Shock ? RUQ/ epigastric pain ? Abd distension/ peritonism ?USG : FF

8. Early Resuscitation Correct coagulopathy Blood Transfusion

9. Assessment of patient Independent poor prognostic factors for 30 day mortality Tan et al, ANZJ Surg 2006 Candidate for liver resection Wang et al, ANZJ Surg 2008

10. Early CT scan ? Peripheral location ? Well- defined tumor ? Portal vein thrombosis

11. Early Transarterial embolization TAE  To stop arterial bleeding  Success rate: 83-100%  Liver failure rate: 19-29%  Re-rupture rate: up to 35% Lai et al, Arch Surg 2006

12. Early operation  Open hemostasis  Operable and unstable  Stop the venous bleeding

13. Liver resection  Survival benefit can be observed in patient with curative liver resection. Lai et al, Arch Surg 2006  One stage resection: shorter hospital stay Liu et al, World J Surg 2005  TMH: 2 nd staged operation  24 hours later

14. Summary  Life threatening event  Multidiscriplinary approach  Stop bleeding  Identify the potential candidate who can have long survival after Rx

15. END Thank you