Surgical management of hepatoma

For the majority patients with HCC, the prognosis is poor. Only a fraction of patients will be resectable at the time of their diagnosis. For the oncologic surgeon caring for such patients, the challenges are multifaceted. First, he or she must have a familiarity with current imaging techniques and reliable support from a radiologist to determine whether a given patient can be technically resectable. We rely most heavily upon the initial diagnostic CT scan followed by the staging CTAP in order to define the resectable patient as clearly as possible. Additionally, the risk of postoperative hepatic failure must be assessed. Careful physical exam, blood chemistries, and volumetric analysis of CT scans demand much judgment on the part of the surgeon. While some patients are clearly capable of undergoing a resection, and others are clearly inoperable due to poor hepatic function, a large group of patients exist in a "gray area" where resection can be entertained but the risk of hepatic failure looms large. In this group the use of the ICG retention test or the 14C-aminopyrine breath test are occasionally useful. Further research into better assessment of hepatic reserve is clearly needed. Once a laparotomy is undertaken, IOUS is a key component of intraoperative staging and the final determinant of resectability. Resection itself must be performed with three goals: Resection of all disease with negative surgical margins, retention of as much hepatic parenchyma as possible in keeping with oncologic principles, and maintenance of hemodynamic stability with minimal transfusion requirements in an effort to minimize the stress of surgery. The combination of vascular control and the porta hepatis (and IVC where necessary), segmental hepatic resection where appropriate, and ultrasonic dissection can accomplish these goals. Intrahepatic recurrence, despite adequate resection, can be expected in many patients, and few will be candidates for a second resection. For this reason, and because most patients are unresectable at presentation, the oncologic surgeon must be familiar with palliative options available for his patients, as well as the surgical management of operable tumors. Close collaboration with one's colleagues in medical oncology, invasive radiology, and gastroenterology are critical to the optimal care of this difficult patient population.