Surgical resection for liver cancer during the COVID-19 outbreak
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LETTER TO THE EDITOR
Surgical resection for liver cancer during the COVID‑19 outbreak Haitham Triki1 · Heithem Jeddou1 · Karim Boudjema1 Received: 30 April 2020 / Accepted: 11 May 2020 © Italian Society of Surgery (SIC) 2020
Abstract During the 2019 novel coronavirus disease (COVID-19) outbreak, therapeutic strategies must be adapted for liver cancer patients balancing the benefit of surgical resection against the risk of contamination incurred by the patient. The impact of COVID-19 in liver cancer patients who undergo surgery is still unclear due to the scarcity of available data. Decisions to postpone scheduled surgery for high risk patients must be made.
Manuscript Since the beginning of 2019 novel coronavirus disease (COVID-19) epidemic in France, caused by severe acute respiratory syndrome coronavirus 2 (SARS-COV-2), hospital capacity, in the most affected regions, has rapidly exceeded. In our department, approximately 250 hepatectomies are performed each year. Decisions to postpone scheduled surgery for liver cancer patients must be made. Since available data are scarce, many questions have arisen vis-à-vis the management of these patients in the context of this pandemic. Zhang C et al. reported a detailed discussion about liver injury in COVID-19 [1]. In fact, 14–53% of COVID-19 patients present abnormal levels of aminotransferases. The degree of liver damage depends on the severity of COVID-19. It seems that cytokine storm syndrome, ischemic hypoxia related to pneumonia and pharmacologic liver injury are the main causes of elevated liver enzymes. However, it has been demonstrated that SARSCOV-2 binds angiotensin converting enzyme 2 (ACE2) receptor to infect the cells. In addition to lung tissue, the ACE2 receptor has also been found in cholangiocytes while the hepatocytes expressed it weakly [1]. Interestingly, it has been shown that ACE2 expression is significantly increased with chronic liver injury and cirrhosis, not only in cholangiocytes but also in hepatocytes [2]. It has been demonstrated in a mouse model after hemi-hepatectomy that ACE2 * Karim Boudjema karim.boudjema@chu‑rennes.fr 1
expression is upregulated during hepatocyte proliferation. Thus, nascent hepatocytes expressing ACE2 receptor could be susceptible to SARS-COV-2 infection [3]. Although it is clear that COVID-19 may cause various degrees of liver damage, many questions remain to be answered about surgery for liver cancer during this pandemic.
Does COVID‑19 increase the risk of morbidity and mortality after liver resection? After hepatectomy, the most life-threatening complication is post-hepatectomy liver failure (PHLF). It is known that sepsis is a major cause of PHLF. It affects Kupffer-cell function and increases the concentration of liver cytokines. leukocyte-Kupffer cell interaction leads to the release of TNFα and IL6 [4]. In a similar way, once the cascade of inflammatory reactions is triggered by SARS-COV-2 or in case of related bacterial infection, COVID-19 could be responsible for the development of PHLF. In addition,
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