Liver resection for hepatocellular carcinoma: indications, techniques, complications, and prognostic factors

Although the resectability of hepatocellular carcinoma (HCC) has increased due to recent advances in diagnostic methods, the long-term results are far from satisfactory. Major hepatic resection is indicated in patients with noncirrhotic or mildly cirrhotic liver. Otherwise, limited resection should be carried out. Total or lobar hepatic inflow occlusion appears to decrease blood loss during surgery, and therefore to reduce postoperative morbidity and mortality rates. Total vascular exclusion with or without hypothermia may be indicated in selected patients. Hepatic resection is not necessarily contraindicated for HCC with tumor thrombus in the major portal veins, hepatic veins, inferior vena cava, and bile ducts. There are various postoperative complications, especially in cirrhotic patients, but if hepatic failure occurs, it is usually fatal. To prevent this complication, two factors may be most important: avoiding too great a resection and preventing such trigerring factors as hemorrhagic shock, infection, and gastrointestinal bleeding. Favorable prognostic factors are young age, female sex, and low serum AFP clinically, and small tumor, presence of capsule, absence of vascular invasion and/or daughter nodule, diploid or low proliferative tumor, and negative surgical margin pathologically. Increased necroinflammatory activity of the liver irrespective of viral type and hepatitis C virus-associated liver disease are associated with tumor recurrence in the remnant liver. The significance of adjuvant chemotherapy or interferon therapy remains to be elucidated.