Surgical Strategies for Hepatocellular Carcinoma with Special Reference to Anatomical Hepatic Resection and Intraoperative Contrast-Enhanced Ultrasonography

Abstract

Here we described our strategies to attain a better prognosis for hepatocellular carcinoma (HCC) patients by surgery. Among a variety of attempts conducted to date, we focused on anatomical resection and intraoperative contrast-enhanced ultrasonography. There are still controversies with respect to the significance of anatomical resection. We analyzed the significance of this surgical procedure in 207 patients without macrovascular invasion. These patients underwent either anatomical resection or non-anatomical resection. We found that the patients with anatomical resection had higher recurrence-free survival rate than those with non-anatomical resection. Univariable analysis showed that liver damage, the serum level of α-fetoprotein, tumor number, surgical margin, and type of surgery (anatomical or non-anatomical resection) were significant predictive factors for intrahepatic recurrence. Multivariable analysis revealed that multiple tumors, α-fetoprotein, and non-anatomical resection were independent risk factors for recurrence. We conclude that anatomical resection is a recommendable surgical procedure in patients without macrovascular invasion. A recent innovation is the development of contrast-enhanced ultrasonography. Then we have applied this to liver surgery intraoperatively. We confirm that vascular images contribute to a precise diagnosis and the detection of small portal tumor thrombi, and that Kupffer images are useful to discover the minute tumors. In addition, by clarifying the relationship between tumors and the vascular architecture, real-time 3-dimensional images using Kupffer imaging are a promising guide during the surgical procedures, although further development is needed.

Liver Resection and Transplantation in Hepatocellular Carcinoma

“…Below this size, the risk of dissemination is considered to be negligible with equivalent efficacy of local ablative therapy; beyond this size, majority of patients will already have macroscopic vascular invasion or satellite nodules that lead to a high incidence of recurrence [36]. In the case of central tumors with undefined vascular territory, some authors have found lower recurrence rates and greater survival with 2-cm surgical margins compared with 1-cm margins [37]; however, other authors have found no difference between margins <1 or >1 cm [33,38]. A wide margin up to 2 cm is indeed required.…”

Management of hepatocellular carcinoma: Enlightening the gray zones

“…In fact, perioperative mortality in cirrhotics after HCC resection is about 2%-3%. Moreover, there is a risk of tumor recurrence af-ter surgery of about 70% at 5 years, enclosing both true recurrence and the novo tumours [25][26][27][28][29][30][31][32][33][34][35][36][37][38][39] . Percutaneous local ablation, namely radiofrequency ablation (RFA) and ethanol injection (EI) are the standard of care for BCLC O-A not suitable for surgery.…”

Meta-analysis of anatomic resection versus nonanatomic resection for hepatocellular carcinoma

“…Twenty-two studies have been published comparing AR versus NAR, all between 1996 and 2010, that matched the selection criteria [7][8][9][10][11][12][13][14][15][19][20][21][22][23][24][25][26][27][28][29][30]. Of these studies, one did not provide indications for AR and NAR [7], one focused on comparative data on the different types of hepatic resection [31], one is a nationwide survey report [19]; all three studies were excluded.…”