A Comparison of Short-Term Outcomes between Laparoscopic and Open Liver Resection in Elderly Patients

Purpose@#The aim of this study was to compare the short-term outcomes between laparoscopic liver resection (LLR) and open liver resection (OLR) in elderly patients with hepatic tumors. @*Methods@#From January 2013 to December 2019, a retrospective study was conducted for a total of 143 patients with over 70 years of age, who underwent liver resection for hepatic tumors. Forty-five patients who received biliary reconstruction at the same time were excluded. According to surgical approaches, 98 patients were classified into LLR and OLR groups. All postoperative complications were classified according to the Clavien-Dindo grading system and the Comprehensive Complication Index (CCI). @*Results@#Incidence of the postoperative complications was not statistically different between LLR and OLR groups. The CCI was significantly lower in the LLR group, with a median of 8.556, and a median of 19.698 in the OLR group (p=0.042). The length of hospital stay in the LLR group was significantly shorter than in the OLR group (p=0.008). @*Conclusion@#LLR is safe and feasible as a treatment for hepatic tumor in elderly patients with potentially less postoperative complications compared to OLR.

A Comparison of Short-Term Outcomes between Laparoscopic and Open Liver Resection in Elderly Patients

Purpose@#The aim of this study was to compare the short-term outcomes between laparoscopic liver resection (LLR) and open liver resection (OLR) in elderly patients with hepatic tumors. @*Methods@#From January 2013 to December 2019, a retrospective study was conducted for a total of 143 patients with over 70 years of age, who underwent liver resection for hepatic tumors. Forty-five patients who received biliary reconstruction at the same time were excluded. According to surgical approaches, 98 patients were classified into LLR and OLR groups. All postoperative complications were classified according to the Clavien-Dindo grading system and the Comprehensive Complication Index (CCI). @*Results@#Incidence of the postoperative complications was not statistically different between LLR and OLR groups. The CCI was significantly lower in the LLR group, with a median of 8.556, and a median of 19.698 in the OLR group (p=0.042). The length of hospital stay in the LLR group was significantly shorter than in the OLR group (p=0.008). @*Conclusion@#LLR is safe and feasible as a treatment for hepatic tumor in elderly patients with potentially less postoperative complications compared to OLR.

Rationale and surgical technique of laparoscopic left lateral sectionectomy using endoscopic staples

PURPOSE: Laparoscopic left lateral sectionectomy (LLLS) has been widely accepted due to benefits of minimally invasive surgery. Some surgeons prefer to isolate glissonian pedicles to segments II and III and to control individual pedicles with surgical clips, whereas opt like to control glissonian pedicles simultaneously using endoscopic stapling devices. The aim of this study was to find the rationale of LLLS using endoscopic staples. METHODS: We retrospectively analyzed and compared the clinical outcomes (operation time, drainage length, transfusion, hospital stay, and complication rate) of 35 patients that underwent LLLS between April 2004 and February 2012. Patients were dichotomized by surgical technique based on whether glissonian pedicles were isolated and controlled (the individual group, n = 21) or controlled using endoscopic staples at once (the batch group, n = 14). RESULTS: Mean operation time was 265.3 +/- 21.3 minutes (mean +/- standard deviation) in the individual group and 170 +/- 22.9 minutes in the batch group. Operation time in the batch group was significantly shorter than the individual group (P = 0.007). Mean drainage length was 4.8 +/- 1.6 and 2.6 +/- 1.5 days in the individual and the batch group. There was significantly shorter in the batch group, also (P = 0.006). No transfusion was required in the batch group, but 4 patients in the individual group needed transfusion. Mean hospital stay was 10.7 +/- 1.1 and 9.4 +/- 0.8 days in the individual and the batch groups (P = 0.460). There were no significant complications or mortality in both groups. CONCLUSION: LLLS using endoscopic staples (batch group) was found to be an easier and safer technique without morbidity or mortality.

Clinical Review and Case Report of Ceftriaxone-associated Gallbladder Pseudolithiasis in Adult / 대한소화기학회지

Although ceftriaxone can be used safely in most instances, it can sometimes induce biliary sludge or stone formation. Most of the patients remain asymptomatic and children are more susceptible to develop this condition, but adults can be affected as well. Because sludge or stones disappear after discontinuing ceftriaxone, this condition is referred to as ceftriaxone-associated pseudolithiasis. A 54-year-old woman was admitted to a local clinic for management of ileus. During admission, she had received ceftriaxone and metronidazole, and had been on nil per os for the past 6 days. She was then referred to our hospital for cholecystectomy due to persistent right upper quadrant pain. Although imaging studies showed gallbladder sludge, pseudolithiasis was suspected because of ceftriaxone administration history and prolonged fasting. After careful watch-and-wait, the condition resolved spontaneously after ceftriaxone discontinuation. Our clear understanding on ceftriaxone-associated gallbladder pseudolithiasis allowed us to avoid an unnecessary cholecystectomy. Herein, we report the case of a 54-year-old woman with ceftriaxone-associated gallbladder pseudolithiasis that was successfully managed by ceftriaxone discontinuation alone.

Systemic metastasis of hepatocellular carcinoma responsive to multidisciplinary treatment including debulking surgery

The lung, followed by regional lymph node and bone, is the most common site for extrahepatic metastasis of hepatocellular carcinoma (HCC). Metastatic skin lesion of HCC is rare, and it is a sign of poor prognosis, indicating the strong possibility of metastases in other regions of the body. We report the case of a 52-year-old male with multiple metastases, including skin metastasis of HCC, which were treated with multidisciplinary therapy.

The comparison of oncologic and clinical outcomes of laparoscopic liver resection for hepatocellular carcinoma

PURPOSE: We evaluate the operative outcome and oncologic outcome of laparoscopic liver resection for hepatocellular carcinoma (HCC), and compare with open liver resection. METHODS: From January 2004 to December 2012, clinical data of 70 patients who underwent laparoscopic liver resection for HCC (laparoscopic liver resection group, lapa-group) were collected and analyzed retrospectively. Control group (open liver resection group, open-group) were retrospectively matched, and compared with lapa-group. RESULTS: Laparoscopic major liver resections were performed in 4 patients. Laparoscopic anatomical resections and nonanatomical resections were performed in 39 patients, and 31 patients, respectively. Mean operative time was shorter in lapa-group (215.5 +/- 121.84 minutes vs. 282.30 +/- 80.34 minutes, P = 0.001), mean intraoperative transfusion rate and total amount were small in lapa-group (24.28%, 148.57 +/- 3,354.98 mL vs. 40.78%, 311.71 +/- 477.01 mL). Open conversion occurred in 6 patients (8.57%) because of bleeding, inadequate resection, invisible mass on intraoperative ultrasonography, and tumor rupture. In lapa-group and open-group, 3-year disease-free survival rates were 58.3% +/- 0.08%, and 62.6% +/- 0.06%, respectively (P = 0.773). In lapa-group and open-group 3-year overall survival rates were 65.3% +/- 0.8%, and 65.7% +/- 0.6%, respectively (P = 0.610). CONCLUSION: Laparoscopic liver resection for HCC is feasible and safe in a large number of patients, with reasonable operative and oncologic results.

The risk factors of early recurrence after hepatectomy in hepatocellular carcinoma

PURPOSE: Early recurrence after hepatectomy is a well-known poor prognostic factor in patients with hepatocellular carcinoma. This study was undertaken to identify the risk factors of early recurrence in patients with hepatocellular carcinoma after hepatectomy. METHODS: One hundred and sixty-seven patients that underwent hepatectomy for hepatocellular carcinoma from January 2005 to December 2010 were enrolled. The numbers of patients with or without early recurrence group were 40 and 127, respectively. Clinico-pathologic factors were retrospectively analyzed. RESULTS: Potential risk factors were classified as host, tumor, or surgical factors. Of the host factors examined, lobular hepatitis activity was found to be a significant risk factor of early recurrence, and of the tumor factors, infiltrative type of gross appearance, level of preoperative AFP and worst Edmondson-Steiner grade were significant. CONCLUSION: The present study shows that an infiltrative gross appearance, a high preoperative AFP level, high lobular hepatitis activity, and a poor Edmondson-Steiner grade are independent risk factors of early recurrence. Accordingly, patients with these risk factors should be followed closely after hepatectomy.

Current Status of Laparoscopic Liver Resection in Korea

Since laparoscopic liver resection was first introduced in 2001, Korean surgeons have chosen a laparoscopic procedure as one of the treatment options for benign or malignant liver disease. We distributed and analyzed a nationwide questionnaire to members of the Korean Laparoscopic Liver Surgery Study Group (KLLSG) in order to evaluate the current status of laparoscopic liver resection in Korea. Questionnaires were sent to 24 centers of KLLSG. The questionnaire consisted of operative procedure, histological diagnosis of liver lesions, indications for resection, causes of conversion to open surgery, and postoperative outcomes. A laparoscopic liver resection was performed in 416 patients from 2001 to 2008. Of 416 patients, 59.6% had malignant tumors, and 40.4% had benign diseases. A total laparoscopic approach was performed in 88.7%. Anatomical laparoscopic liver resection was more commonly performed than non-anatomical resection (59.9% vs 40.1%). The anatomical laparoscopic liver resection procedures consisted of a left lateral sectionectomy (29.3%), left hemihepatectomy (19.2%), right hemihepatectomy (6%), right posterior sectionectomy (4.3%), central bisectionectomy (0.5%), and caudate lobectomy (0.5%). Laparoscopy-related serious complications occurred in 12 (2.8%) patients. The present study findings provide data in terms of indication, type and method of liver resection, and current status of laparoscopic liver resection in Korea.

Single center experience of laparoscopic hepatectomy: the comparison of perioperative outcomes between early and late period

BACKGROUNDS/AIMS: The aim of this study is to clarify the safety and feasibility of laparoscopic hepatectomy, through comparing the early and late periods of perioperative outcomes. METHODS: We retrospectively analyzed 138 patients who underwent laparoscopic hepatectomy from January 2003 to June 2011, at Yeungnam University Hospital. We divided the total patients to early period (from January 2003 to February 2007, n=49) and late period (from March 2007 to June 2011, n=89) groups and compared the perioperative outcomes including the mean operation time, intra-operative blood loss, postoperative hospital stay, intensive care unit (ICU) stay, and duration of liver function test (LFT) normalization. RESULTS: The mean operation time was 308 minutes (range: 140-510) in the early group and 193 minutes (range: 40-350) in the late period group (p<0.001). The mean intraoperative blood loss was 171 ml (range: 50-1,200) in the early and 44 ml (range: 0-400) in the late group (p=0.005). The postoperative hospital stay was 9.7 days (range: 4-31) in the early and 6.8 days (range: 2-9) in the late period (p<0.001). The ICU stay hour was 21.6 hours (range: 0-120) in the early and 2.8 hour (range: 0-24) in the late period (p<0.001). The duration of LFT normalization was 5.7 days (range: 0-39) in the early and 2.1 days (range: 0-20) in the late period (p=0.003). The perioperative outcomes in the late period were better than the early period, which showed a statistically significant difference. CONCLUSIONS: Laparoscopic hepatectomy is feasible and can be safely performed in selected patients but requires a long experience in open liver resection and mastery of laparoscopic surgical skills.

Determination of Malignant and Invasive Predictors in Branch Duct Type Intraductal Papillary Mucinous Neoplasms of the Pancreas: A Suggested Scoring Formula

Prediction of malignancy or invasiveness of branch duct type intraductal papillary mucinous neoplasm (Br-IPMN) is difficult, and proper treatment strategy has not been well established. The authors investigated the characteristics of Br-IPMN and explored its malignancy or invasiveness predicting factors to suggest a scoring formula for predicting pathologic results. From 1994 to 2008, 237 patients who were diagnosed as Br-IPMN at 11 tertiary referral centers in Korea were retrospectively reviewed. The patients' mean age was 63.1 +/- 9.2 yr. One hundred ninty-eight (83.5%) patients had nonmalignant IPMN (81 adenoma, 117 borderline atypia), and 39 (16.5%) had malignant IPMN (13 carcinoma in situ, 26 invasive carcinoma). Cyst size and mural nodule were malignancy determining factors by multivariate analysis. Elevated CEA, cyst size and mural nodule were factors determining invasiveness by multivariate analysis. Using the regression coefficient for significant predictors on multivariate analysis, we constructed a malignancy-predicting scoring formula: 22.4 (mural nodule [0 or 1]) + 0.5 (cyst size [mm]). In invasive IPMN, the formula was expressed as invasiveness-predicting score = 36.6 (mural nodule [0 or 1]) + 32.2 (elevated serum CEA [0 or 1]) + 0.6 (cyst size [mm]). Here we present a scoring formula for prediction of malignancy or invasiveness of Br-IPMN which can be used to determine a proper treatment strategy.

Bioelectrical Impedance May Predict Cell Viability During Ischemia and Reperfusion in Rat Liver

Ischemia and reperfusion (I/R) injury is a major cause of hepatic failure after liver surgery, but no method could monitor or predict it real-time during surgery. We measured bioelectrical impedance (BEI) and cell viability to assess the usefulness of BEI during I/R in rat liver. A 70% partial liver ischemia model was used. BEI was measured at various frequencies. Adenosine triphosphate (ATP) content, and palmitic acid oxidation rate were measured, and histological changes were observed in order to quantify liver cell viability. BEI changed significantly during ischemia at low frequency. In the ischemia group, BEI increased gradually during 60 min of ischemia and had a tendency to plateau thereafter. The ATP content decreased below 20% of the baseline level. In the I/R group, BEI recovered to near baseline level. After 24 hr of reperfusion, the ATP contents decreased to below 50% in 30, 60 and 120 min of ischemia and the palmitic acid metabolic rates decreased to 91%, 78%, and 74%, respectively, compared with normal liver. BEI may be a good tool for monitoring I/R during liver surgery. The liver is relatively tolerant to ischemia, however after reperfusion, liver cells may be damaged depending upon the duration of ischemia.

Impaired Cation Transport May Lead to Bioelectrical Impedance Changes during Hepatic Ischemia

PURPOSE: Ischemia and reperfusion (I/R) injury is a major cause of hepatic failure after liver surgery, but there is no direct method to monitor it in real-time (like an electrocardiogram in heart disease) during surgery. Recently we found the possible role of bioelectrical impedance (BEI) to monitor I/R injury in liver. But the mechanism responsible for ischemia-related BEI changes has not been clearly determined. METHODS: The authors used an LCR meter to quantify BEI changes at 0.12 KHz. Livers were subjected to 70% partial ischemia for 120 minutes, and ATP contents, cation changes in extracellular fluid (ECF; determined using an in vivo intracellular microdialysis technique), hepatocyte sizes, and histological changes were then examined. RESULTS: Liver tissue BEI was found to increase gradually during the first 60 minutes of ischemia and then tended to plateau. During the same period, intracellular ATP contents decreased to below 20% of the baseline level, [Na+] in ECF decreased from 150.4+/-3.8 to 97.8+/-10.6 mmol/L, and [K+] in ECF increased from 7.5+/-0.3 to 34.3+/-5.5 mmol/L during the first 60 minutes of ischemia. Hepatocyte diameter increased by ~20% during the first 60 minutes of ischemia. CONCLUSION: This study suggests that BEI changes during hepatic ischemia are probably caused by sodium and potassium concentration changes in the ECF due to reduced intracellular ATP contents.

Gaining Experience before Establishing a Totally Laparoscopic Left Lateral Sectionectomy as a Standard Procedure

PURPOSE: The aim of this study was to present our experience before establishing laparoscopic left lateral sectionectomy (LLLS) of the liver as a standard procedure, and to show efficacy of a totally LLLS compared to an open left lateral sectionectomy (OLLS). METHODS: We retrospectively analyzed and compared clinical outcomes (operation time, blood loss, hospital stay, complication rate, etc) for 29 patients who underwent LLLS and 27 patients who underwent OLLS between January, 2002 and December, 2009. To see the learning curve for LLLS, we arbitrarily divided the LLLSs we did into an early group (ELLLS) and a late group (LLLLS) based on when they were operated on relative to case number 14. RESULTS: Mean operative times for the ELLLS, LLLLS and OLLS groups were 269.7+/-102.6, 210.0+/-47.9 and 289.1+/-72.8 minutes, respectively. Mean operative time was significantly shorter (p<0.05) in the LLLLS than the OLLS group. Mean intra-operative blood loss was also less in the LLLLS group than the OLLS group (80.00+/-224.2 ml vs. 195.15+/-405.4 ml). Post-operative hospital stay was shorter in the LLLLS group than the OLLS group (9.9+/-4.0 versus 16.9+/-9.1, p=0.071). CONCLUSION: The totally LLLS is a safe, feasible treatment option that can be a standard procedure with better outcomes in selected patients after an initial learning curve.

Prognostic Factors and Clinicopathologic Features after Resection of Small Hepatocellular Carcinoma (< or =2 cm)

PURPOSE: Hepatectomy has been regarded as the first treatment of choice for small hepatocellular carcinoma. However, hepatectomy for treatment of small hepatocellular carcinoma remains a critical issue. This study evaluates the role of treatment regarding the survival rate and clinicopathological features after resection of small hepatocellular carcinoma ((< or =2 cm) METHODS: This retrospective study was based on the medical records of 48 small hepatocellular carcinoma (< or =2 cm) patients who received surgical hepatectomy from 1990 to 2005. Patients who revealed on postoperative pathologic reports were enrolled. The survival rate was analyzed according to clinicopathologic and therapeutic factors and we analyzed the pathologic features of the recurrence group. RESULTS: The presence of liver cirrhosis, ICGR15 (Indocyanine green retension-15) was statistically significant in the univariate analysis. The vascular invasion rate and capsule formation rate was 90, 80% in the recurrence group. CONCLUSION: In the small hepatocellular carcinoma ((< or =2 cm), the presence of liver cirrhosis, ICGR15 (Indocyanine green retension-15) should be checked to predict prognosis. The small hepatocellular carcinoma ((< or =2 cm) is similar to advanced hepatocellular carcinoma so hepatectomy may play an important role in the small hepatocellular carcinoma ((< or =2 cm).

The Prognostic Significance of Anatomical Resection for Small Hepatocellular Carcinoma

PURPOSE: There has been controversy concerning which is the best treatment method for small hepatocellular carcinoma between anatomical resection (AR) and non-anatomical resection (NAR). In this retrospective study, we investigated the outcomes of surgical resection for small hepatocellular carcinoma and the clinical results depending on the type of hepatectomy. METHODS: We performed an analysis of the clinicopathologic factors of forty eight patients who underwent hepatectomy for a small (<2 cm) hepatocellular carcinoma between 1990 and 2005. The AR was defined as the resection based on the segment or lobe, as proposed by Couinaud. NAR was defined as the resection of a lesion without regard to the segmental or lobar anatomy, as proposed by Couinaud. The patients were divided into 2 groups base on the hepatectomy procedure: AR (n=24) and NAR (n=24). RESULTS: There were no significant difference between the two groups for the general characteristics of the patients and the clinicopathologic findings, except for ICG R15. The mean ICG R15 in the AR and NAR groups was 11.8+/-6.9 and 22.4+/-15.6, respectively, The NAR group had significantly higher ICG R15 values. The cumulative 1, 3 and 5 year overall survival rates in the AR and NAR groups were 95.8%, 68.2% and 61.3%, and 76.6%, 59.0% and 52.5%, respectively. The cumulative overall survival rate and the mean 5 year disease free survival rate in the AR group (69.8%) were higher than those of the NAR group (45.8%). However, there was no statistically significant difference. CONCLUSION: Depending on the surgical results of this study, there was no statistically significant difference in the outcomes between the AR and NAR groups.

The Prognostic Significance of Anatomical Resection for Small Hepatocellular Carcinoma

PURPOSE: There has been controversy concerning which is the best treatment method for small hepatocellular carcinoma between anatomical resection (AR) and non-anatomical resection (NAR). In this retrospective study, we investigated the outcomes of surgical resection for small hepatocellular carcinoma and the clinical results depending on the type of hepatectomy. METHODS: We performed an analysis of the clinicopathologic factors of forty eight patients who underwent hepatectomy for a small (<2 cm) hepatocellular carcinoma between 1990 and 2005. The AR was defined as the resection based on the segment or lobe, as proposed by Couinaud. NAR was defined as the resection of a lesion without regard to the segmental or lobar anatomy, as proposed by Couinaud. The patients were divided into 2 groups base on the hepatectomy procedure: AR (n=24) and NAR (n=24). RESULTS: There were no significant difference between the two groups for the general characteristics of the patients and the clinicopathologic findings, except for ICG R15. The mean ICG R15 in the AR and NAR groups was 11.8+/-6.9 and 22.4+/-15.6, respectively, The NAR group had significantly higher ICG R15 values. The cumulative 1, 3 and 5 year overall survival rates in the AR and NAR groups were 95.8%, 68.2% and 61.3%, and 76.6%, 59.0% and 52.5%, respectively. The cumulative overall survival rate and the mean 5 year disease free survival rate in the AR group (69.8%) were higher than those of the NAR group (45.8%). However, there was no statistically significant difference. CONCLUSION: Depending on the surgical results of this study, there was no statistically significant difference in the outcomes between the AR and NAR groups.

Results of Hepatectomy as First Treatment for Hepatocellular Carcinoma within the Milan Criteria with Preserved Liver Function

PURPOSE: Hepatic resection and liver transplantation are surgical therapeutic options for small-sized HCC. But, the therapeutic option for patients meeting the Milan criteria with preserved liver function is facing a dilemma. In this study, we examined the outcomes of surgical resection for HCC patients meeting the Milan criteria with preserved liver function and rationale of hepatic resection as the first treatment for HCC meeting the Milan Criteria. METHODS: Between 1991 and 2006, 248 patients with HCC underwent hepatectomy in 158 primary HCC patients meeting Milan criteria (Group M) and in 90 patients beyond Milan criteria (Group N). Median age was 54.5 years in group M and 52.4 years in group N. RESULTS: The tumor size, mean survival months, E-S grade and vascular invasion rate were significantly different between the two groups. 67 patients in group M and 22 patients in group N had intrahepatic recurrence after primary hepatectomy. The cumulative 1, 3, and 5-year survival rates were 91.9%, 74.5%, and 60.5% in intrahepatic recurrence group M after primary hepatectomy and 100%, 96.0%, and 90.5% in repeated hepatic resection for recurrent treatment in group M, respectively. CONCLUSION: Because of the high survival rate and long-term survival after adequate treatment of recurrence, primary hepatectomy is considered a reasonable option as first-line treatment for HCC meeting Milan criteria with preserved liver function.

Clinical Results of Hepatic Resection for Metastatic Noncolorectal Nonneuroendocrine Tumor

PURPOSE: Hepatic resection has been proven to be an effective therapy for metastatic colorectal carcinoma and it is a beneficial therapy for metastatic neuroendocrine tumors. Yet the role and efficacy of hepatic resection for metastatic noncolorectal nonneuroendocrine (NCNN) carcinoma have not yet been well defined. We evaluated the outcome and the prognostic factors of patients who are undergoing hepatic resection for metastases from NCNN carcinoma. MATERIALS AND METHODS: The records of 46 patients who underwent liver resection for NCNN metastasis from Oct. 1992 to May 2006 were analyzed. Among the 46 patients, 26 patients were excluded due to direct hepatic invasion from stomach cancer. The patient demographics, tumor characteristics, the treatment and the postoperative survival rate were analyzed. RESULTS: The median patient age was 54.9 years (range: 36-69 years) and there were 13 men (85.7%) and 7 women (15.3%). The mean survival time from the date of liver resection was 48+/-7.85 months, and the 5-year survival rate was 33.7%. The primary tumor sites were identified as gastrointestinal in 60% of the patients and non-gastrointestinal in 40% of the patients. Patients with a gastrointestinal primary tumor had a median survival time that was similar to that of patients with non-gastrointestinal primary tumor (48 months versus 42 months, respectively, p=0.847). The number of liver metastases was an independent prognostic factor (p=0.030). CONCLUSIONS: In selected patients with NCNN liver metastasis, hepatic resection is an effective management and it can also prolong survival. Hepatic resection should be considered if lymphatic invasion and metastasis of the other organ are excluded.

A Case Report of a Ciliated Hepatic Foregut Cyst in the Liver

A ciliated hepatic foregut cyst (CHFC) is a rare cystic lesion consisting of a ciliated pseudostratified columnar epithelium, subepithelial connective tissue, a smooth muscle layer, and an outer fibrous capsule. A CHFC is usually unilocular and occurs at a higher frequency in males. A predilection exists at the medial segment located at the left lobe of the liver. We report the first case of a ciliated hepatic foregut cyst mimicking hepatic metastasis on a CT scan of a patient concurrently afflicted with gastric cancer.

Two-Stage Hepatectomy for Bilateral Hepatocellular Carcinoma with Bile Duct Tumor Thrombi

Curative hepatectomy is the most important prognostic factor for hepatic cancer, but also has a high rate of morbidity and mortality. Liver failure due to insufficient liver volume is the main cause of postoperative mortality. Preoperative portal vein embolization can induce hypertrophy of the remnant liver, and a two-stage hepatectomy, with or without portal vein embolization, could be used to treat patients with unresectable liver tumors. We report the case of a successful two-staged hepatectomy for bilateral hepatocellular carcinoma with tumor thrombi.