Outcomes of major liver resection for children with hepatoblastoma weighing less than 10 kg: avoiding liver transplantation with extended or extreme resection.
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BACKGROUND: Hepatoblastoma is a rare disease and major hepatectomy in small children is technically challenging surgery due to small size of blood vessels, bile ducts, small liver volume, and the challenge of intraoperative monitoring. Detailed information about surgical outcomes of major liver resection in children with HB weighing < 10 kg are limited. The threshold of the future liver remnant (FLR) in children remains controversial and is not defined. We aim to report our institutional experience of major liver resection in children with HB weighing < 10 Kg. METHODS: A single center retrospective analytic study of pediatric patients diagnosed with HB undergoing major liver resection from January 2010 to March 2024 at a tertiary referral hospital and transplant center. Demographic variables, tumor variables, radiographic data, surgical details, postoperative outcomes were collected. The patients were divided into < 10 kg and ≥ 10 kg and compared. The patients who underwent extended or extreme liver resection were subgroup analyzed. RESULTS: Forty-three patients were included, 26 (60%) < 10 kg and 17 (40%) ≥ 10 Kg. Median age at surgery of < 10 kg group was 9 months and of ≥ 10 kg group was 19 months (p = 0.04). Median weight of < 10 kg group was 8.2 kg [IQR 7.12–9]. The majority of < 10 kg patients had POSTTEXT 2 (62%) and 3 (31%). Patient weighing < 10 kg had slightly higher median operative time (240 vs. 220 min, p = 0.55) and higher median blood loss (107 vs. 80 ml, p = 0.63). There were also no significant differences in rate of blood transfusion, length of hospital, and ICU stays between two groups. There were no significant differences in overall survival and disease-free survival between < 10 kg and ≥ 10 kg (90% vs. 68%, p = 0.2, and 80% vs. 61%, p = 0.22, respectively). Eleven (26%) patients underwent extended or extreme liver resection; 10/11 weighed < 10 kg with minimum body weight at 6.8 Kg. FLR to body weight (BW) ratio (FLV/BW) was between 1.4 and 2.9% and 11.9–41% of FLR/total liver volume (TLV). CONCLUSIONS: Surgical outcomes of major liver resection and surgical complications in children with HB weighing < 10 kg were comparable to ≥ 10 kg children. There was no incidence of mortality rate related to surgical complication or biliary complication in our cohort. Our study also highlighted that extended or extreme liver resection was feasible and safe to perform in < 10 kg children with HB. FLR/BW ratio between 1.4 and 2.9% was not associated with PHLF in children < 10 Kg; however, a further larger study is required. LEVEL OF EVIDENCE: Level 3 retrospective study.