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Hepatocellular carcinoma (HCC) related to metabolic syndrome (MS) as unique risk factor is gradually overpassing the more common viral and alcohol etiology, becoming a global health issue. Liver surgery for metabolic syndrome-related HCC in this frail subset of patients constitute a challenge, due to high morbidity and mortality rate reported in literature, and contrasting results in term of oncologic outcome. The present multicentric prospective study aims to ascertain if the combination of sleeve gastrectomy and liver surgery in the same surgical procedure may have benefit in terms of reduced perioperative morbidity and prolonged Overall Survival and Recurrence Free Survival. Secondary outcome will be the evaluation of the consequences induced by sleeve gastrectomy on liver disease, in particular liver fibrosis evaluated in term of NFS score (Non-Alcoholic Fatty Liver Disease Fibrosis score), FIB-4 (Fibrosis-4 Index for Liver Fibrosis) score and Fibroscan transient elastography.
Obesity is a worldwide epidemic, with more than 2 billion people currently overweight and an additional 1.12 billion projected to be overweight by 2030. HCC (hepatocellular carcinoma) associated to obesity and its comorbidity is overcoming Hepatitis C Virus (HCV) related cancer and is already the leading cause of liver transplant in USA. HCC remains the sixth most common cancer in the world and the third cause of cancer-related death. Considering these epidemiological evidence, the incidence of MS-HCC (metabolic syndrome-related hepatocellular carcinoma) is expected to increase with huge cost efforts for the global healthcare system. The impaired performance status of patients with HCC and metabolic syndrome seems to explain high perioperative morbidity rate reported in literature. Literature reports several experiences of bariatric surgery combined to liver transplant for chronic liver disease related induced by non alcoholic steatohepatitis (NASH), performed before or after liver surgery, or even at the same time. Even if evidences are weak, outcomes reported seem to be promising. Since sleeve gastrectomy is not only a mere restrictive bariatric procedure, but it produces hormonal and metabolic changes, with the present study the investigators want to ascertain if sleeve gastrectomy at time of liver resection for MS-HCC (metabolic syndrome-related hepatocellular carcinoma) can modify short perioperative outcomes and long-term oncologic results.
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| Label | Type | Description | Intervention Names |
|---|---|---|---|
| Patients affected by HCC induced by metabolic syndrome as unique risk factor | Experimental | Patients aged 18 years old and older, affected by HCC with MS (metabolic syndrome) as unique risk factor who comply with the criteria for bariatric surgery, will undergo liver resection and sleeve gastrectomy with minimally-invasive technique in the same surgical procedure |
|
| Patients with HCC related to metabolic syndrome as unique risk factor | Active Comparator | Patients aged 18 years old and older, affected by HCC (hepatocellular carcinoma) with MS (metabolic syndrome) as unique risk factor who will undergo liver resection only |
|
| Name | Type | Description | Arm Group Labels | Other Names |
|---|---|---|---|---|
| Liver resection and simultaneous sleeve gastrectomy for HCC induced by metabolic syndrome | Procedure | Patients in the experimental arm will undergo liver resection for HCC and sleeve gastrectomy for MS during the same surgical procedure. |
| Measure | Description | Time Frame |
|---|---|---|
| Overall Survival | Calculated from the date of diagnosis to the date of death from any cause | 1 year, 3 years, 5 years |
| Recurrence-free Survival | Calculated from the date of surgery to the date of recurrence | 1 year, 3 years, 5 years |
| 90-day mortality | Mortality from any cause | 90 post-operative days |
| Comprehensive Complication Index | Any deviation from the normal postoperative course measured on a scale from 0 (no complication) to 100 (death) | 90 post-operative days |
| Measure | Description | Time Frame |
|---|---|---|
| Fibrosis-4 Index for Liver Fibrosis score | Fibrosis-4 Index for Liver Fibrosis score (FIB-4 score) will be calculated using the following formula: FIB-4 score= Age (years)× aspartate aminotransferase (AST) (U/L)/[platelet count (109/L)×√alanine aminotransferase (ALT) (U/L)] | After 6 months, up to 5 years |
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Inclusion Criteria:
Be willing and able to provide written informed consent/assent for the trial
Be ≥ 18 years of age on day of signing informed consent.
Have hepatocellular carcinoma with metabolic syndrome as unique risk factor
Have an overall Child-Pugh score = A
Be eligible for liver resection with laparoscopic or robotic technique
Be eligible for bariatric surgery as defined below
Exclusion Criteria:
Have hepatocellular carcinoma related to other etiology, even in case of coexisting metabolic syndrome
Denial of the patient to undergo bariatric procedure
Have BMI < 30
Have negative opinion of psychologic consultant
Have an overall Child-Pugh score > 7
Evidence of clinical significant portal hypertension as followed:
Of note: 1) Conversion to open surgery for any reason does not represent a reason of data exclusion from the analysis; 2) any type of hepatic resection, according to Brisbane classification, is included, also major hepatectomy requiring preoperative intervention to achieve adequate volume remnant
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| Name | Role | Phone | Extension | |
|---|---|---|---|---|
| Annarita Libia | Contact | 0039 0833335284 | libiamd@me.com | |
| Annarita Libia | Contact | 0039 0833335285 | libiamd@me.com |
| Name | Affiliation | Role |
|---|---|---|
| Annarita Libia | Ospedale Vito Fazzi, Lecce | Principal Investigator |
| Facility | Status | City | State | ZIP | Country | Contacts |
|---|---|---|---|---|---|---|
| Ospedale Vito Fazzi | Lecce | 73100 | Italy |
| PubMed Identifier | Type | Citation | Retractions |
|---|---|---|---|
| 30617773 | Background | Yang T, Hu LY, Li ZL, Liu K, Wu H, Xing H, Lau WY, Pawlik TM, Zeng YY, Zhou YH, Gu WM, Wang H, Chen TH, Han J, Li C, Wang MD, Wu MC, Shen F. Liver Resection for Hepatocellular Carcinoma in Non-alcoholic Fatty Liver Disease: a Multicenter Propensity Matching Analysis with HBV-HCC. J Gastrointest Surg. 2020 Feb;24(2):320-329. doi: 10.1007/s11605-018-04071-2. Epub 2019 Jan 7. | |
| 23147992 |
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Patients 18 years old and older, affected by hepatocellular carcinoma (HCC) with metabolic syndrome (MS) as unique risk factor, with compensated liver function (Child A) who are deemed suitable for liver resection and comply with the criteria for bariatric surgery, will undergo liver resection of HCC and simultaneous sleeve gastrectomy for morbid obesity during the same surgical procedure.
Patients affected by HCC related to metabolic syndrome who fall within exclusion criteria, will undergo liver resection for HCC without sleeve gastrectomy.
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| Liver resection for HCC induced by metabolic syndrome | Procedure | Patients in the active comparator arm will undergo liver resection for HCC |
|
| Non-Alcoholic Fatty Liver Disease Fibrosis Score |
Non-Alcoholic Fatty Liver Disease Fibrosis Score (NFS score) will be calculated using the following formula: NFS = -1.675 + 0.037 - age (years) + 0.094 - BMI (kg/m2) + 1.13 × impaired fasting glucose/diabetes (yes = 1, no = 0) + 0.99 × aspartate aminotransferase/ alanine aminotransferase (AST/ALT) ratio - 0.013 × platelet count (×109/l) - 0.66 × albumin (g/dl). |
| After 6 months, up to 5 years |
| Fibroscan stiffness | The Fibroscan stiffness measurement relies on the propagation of elastic waves to assess the stiffness of the liver: the faster elastic waves propagates within the liver, the stiffer the organ is. The final liver stiffness value is the median of individual liver stiffness values using the valid measurements and is expressed in kilo Pascal (kPa). | After 6 months, up to 5 years |
| Body Mass Index | Body Mass Index (BMI) is combination of bodyweight and body height and presented as kg/m^2 | After 3 months, up to 5 years |
| Weight loss | Weight loss expressed in Kg | After 3 months, up to 5 years |
| Percent excess weight loss | Percent excess weight loss (%EWL) is calculated as follows: [(initial weight - current weight) / (initial weight - ideal weight)] × 100 | After 3 months, up to 5 years |
| Control of obesity-induced hypertension | Change of antihypertensive therapy assessed by medical history questionnaire | After 3 months, up to 5 years |
| Control of obesity-induced comorbidities | change of insulin therapy or oral hypoglycemics assessed by medical history questionnaire | After 3 months, up to 5 years |
| Background |
| Cauchy F, Zalinski S, Dokmak S, Fuks D, Farges O, Castera L, Paradis V, Belghiti J. Surgical treatment of hepatocellular carcinoma associated with the metabolic syndrome. Br J Surg. 2013 Jan;100(1):113-21. doi: 10.1002/bjs.8963. Epub 2012 Nov 12. |
| 34118015 | Background | de Barros F, Cardoso Faleiro Uba PH. Liver transplantation and bariatric surgery: a new surgical reality: a systematic review of the best time for bariatric surgery. Updates Surg. 2021 Oct;73(5):1615-1622. doi: 10.1007/s13304-021-01106-3. Epub 2021 Jun 12. |
| 31866269 | Background | Hobeika C, Ronot M, Beaufrere A, Paradis V, Soubrane O, Cauchy F. Metabolic syndrome and hepatic surgery. J Visc Surg. 2020 Jun;157(3):231-238. doi: 10.1016/j.jviscsurg.2019.11.004. Epub 2019 Dec 19. |
| ID | Term |
|---|---|
| D006528 | Carcinoma, Hepatocellular |
| D024821 | Metabolic Syndrome |
| D009767 | Obesity, Morbid |
| ID | Term |
|---|---|
| D000230 | Adenocarcinoma |
| D002277 | Carcinoma |
| D009375 | Neoplasms, Glandular and Epithelial |
| D009370 | Neoplasms by Histologic Type |
| D009369 | Neoplasms |
| D008113 | Liver Neoplasms |
| D004067 | Digestive System Neoplasms |
| D009371 | Neoplasms by Site |
| D004066 | Digestive System Diseases |
| D008107 | Liver Diseases |
| D007333 | Insulin Resistance |
| D006946 | Hyperinsulinism |
| D044882 | Glucose Metabolism Disorders |
| D008659 | Metabolic Diseases |
| D009750 | Nutritional and Metabolic Diseases |
| D009765 | Obesity |
| D050177 | Overweight |
| D044343 | Overnutrition |
| D009748 | Nutrition Disorders |
| D001835 | Body Weight |
| D012816 | Signs and Symptoms |
| D013568 | Pathological Conditions, Signs and Symptoms |
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| ID | Term |
|---|---|
| D006498 | Hepatectomy |
| ID | Term |
|---|---|
| D013505 | Digestive System Surgical Procedures |
| D013514 | Surgical Procedures, Operative |
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