Emergency Versus Delayed Hepatectomy Following Transarterial Embolization in Spontaneously Ruptured Hepatocellular Carcinoma Survivors: a Systematic Review and Meta-analysis

Background: Spontaneous rupture is a life-threatening complication of hepatocellular carcinoma (HCC). Recent trends in surgical treatments avoid emergency hepatectomy (EH) and favor emergency transarterial embolization (TAE) followed by delayed hepatectomy (DH). Still, there is debate on which is the better treatment option and whether delaying hepatectomy increases peritoneal metastasis.

Aim: To provide evidence-based references for the optimal management of patients with spontaneously ruptured HCC by comparing the outcomes of EH and DH.

Methods: Literature on postoperative outcomes of EH and DH in patients with spontaneously ruptured HCC published between the date of the database establishment and May 2022, was identified in the PubMed, EMBASE, and Cochrane Library databases. Revman 5.3 software was used for statistical analyses.

Results: Nine publications were identified, including a total of 681 patients. Of those, 304 underwent EH, and 377 underwent TAE followed by DH. The meta-analysis results indicated that the in-hospital mortality rate in the EH patient group was significantly higher than that in the DH patient group (relative risk (RR) = 2.17, 95% confidence interval (CI) 1.03-4.57, p =0.04). There was no significant differences in the rates of postoperative complications (RR = 1.21, 95% CI 0.77-1.90, p = 0.40), postoperative hospital stay (WMD = - 0.64, 95% CI - 5.61-4.34, p = 0.80), recurrence (RR = 1.09, 95% CI 0.94-1.25, p = 0.27), peritoneal metastasis (RR = 1.06, 95% CI 0.66-1.71, p = 0.80), 1-year survival (RR = 0.91, 95% CI 0.80-1.02, p = 0.11), or 3-year survival (RR = 0.81, 95% CI 0.61-1.09, p = 0.17) in survivors between the two patient groups.

Conclusion: The postoperative outcomes of the spontaneously ruptured HCC survivors who received EH were similar to those who received emergency TAE followed by DH. However, the in-hospital mortality rate was higher in EH patients. Based on the findings, DH with TAE first strategy might be considered over EH as the first line treatment modality. However, these findings await further validation by future high-quality studies.