2012 EDUCATIONAL BOOK - American Society of Clinical Oncology

SURGICAL MANAGEMENT OF HCC
quality of preoperative imaging, new lesions are detected in
up to 30% of cases by intraoperative ultrasound, of which
one-third will turn out to be malignant, underscoring the
importance of this diagnostic tool. 13 Historically, resection of
the right liver has involved mobilization of the right liver
with extreme left displacement to expose the retrohepatic
inferior vena cava followed by extrahepatic control of the
right hepatic vein. Potential deleterious consequences of this
approach are iatrogenic rupture of the tumor and hemodynamic
compromise of the left lobe. The so-called anterior
approach entails initial vascular inflow control and parenchymal
transection before mobilization of the right liver.
This technique minimizes manipulation of the tumorbearing
liver and spillage of tumor cells. Results from a
prospective randomized controlled study of anterior compared
with a conventional approach for patients with HCC
measuring 5 cm or more demonstrated significantly less
major operative blood loss of2Lormore (28.3% vs. 8.3%, p �
0.005) and superior overall survival (median 68.1 months vs.
22.6 months, p � 0.006) with the anterior approach. 14
The liver-hanging maneuver originally described by Belighiti
and colleagues 15 consists of passing a tape in the
avascular retrohepatic, precaval space to suspend the liver
during parenchymal transaction. Elevation of the tape compresses
the liver and reduces bleeding of the deeper parenchymal
plane while simultaneously guiding the plane of the
parenchymal transection. The hanging maneuver approach,
which greatly facilitates the anterior approach described
above, has been modified based on the three Glisson’s
pedicles and hepatic veins facilitating right and left anatomic
liver resections. 16
The best technique of parenchymal transection remains a
matter of debate. A Cochrane Collaborative meta-analysis of
seven trials evaluated 556 randomly selected patients who
had undergone liver resection using the most common liver
parenchymal transection devices available today. 17 The
comparisons include cavitron ultrasound surgical aspirator
(CUSA) compared with the clamp-crush technique (two
trials); radiofrequency dissecting sealer (RFDS) compared
with the clamp-crush technique (two trials); sharp dissection
compared with the clamp-crush technique (one trial); and
hydrojet compared with CUSA (one trial). 15 The clampcrush
technique is a liver parenchymal transsection technique
that involves crushing the liver parenchyma with a
clamp, which leaves blood vessels and bile ducts behind.
Those structures can subsequently be ligated or clipped. One
trial compared CUSA, RFDS, hydrojet, and the clamp-crush
technique. The report found that the clamp-crush technique
was 2 to 6 times less expensive than the other methods
depending on the number of surgeries performed each
year and therefore was favored by the authors. An additional
technique that is now commonly used for parenchymal
liver transection is stapling with a vascular stapler.
Currently, there is an open prospective trial comparing
the clamp-crush technique to vascular stapler hepatectomy
for parenchymal transection in elective hepatic resection
(CRUNSH, NCT01049607). Weber and colleagues reported
on liver tumor resections using radiofrequency energy in 15
patients between January 2000 and June 2001. 18 The device
creates zones of necrosis that are subsequently transected
with a scalpel, thereby rendering this approach suitable for
laparoscopic liver resections. 19
A growing body of literature has confirmed the safety and
good long-term outcome of laparoscopic liver resection. The
largest series of laparoscopic liver resection for HCC was a
recent multicenter European trial in which 163 laparoscopic
liver resections were performed in a population of 74%
cirrhotics. 20 Inclusion criteria were predefined and included
patients with compensated cirrhosis, esophageal varices of
grade 1 or less, a platelet count of at least 80,000/mm 3 ,
tumors less than 10 cm in size, an absence of major vascular
invasion, and an American Society of Anesthesiologists
(ASA) score of 3 or less, as well as those without evidence of
cirrhosis. Median follow-up was 30.4 months after resection
with 1- and 3-year overall survival rates of 93% and 69%,
respectively. Since this series was reported, operative time,
blood loss, number of transfused packed red blood cells, and
open conversion rates have continued to decline, suggesting
a learning curve of this relatively novel technique. 21 A small
study has suggested patients who had previously undergone
laparoscopic resection compared with those who had undergone
open surgery for HCC had decreased morbidity following
salvage liver transplantation. 22 In this study, 24 total
patients underwent salvage liver transplant after either
prior laparoscopic (12 patients) or open resection (12 patients).
The laparoscopy group demonstrated shorter resection
and total operative time, less blood loss, and reduced
need for blood transfusions. However, the most important
question in comparing open resection with laparoscopic
resection is whether oncologic outcomes are the same. A
recent meta-analysis evaluated 10 nonrandomized controlled
studies with 494 subjects, of whom 213 underwent
laparoscopic and 281 underwent open resection for HCC. In
addition to the improved morbidity among patients undergoing
laparoscopic compared with open resection, there was
no difference between the groups with respect to surgical
margins, overall survival rates, and disease-free survival
rates. 23 These findings were similar to those observed in a
recent meta-analysis of 10 studies looking at 627 patients
from China. 24 Despite the absence of higher-level evidence,
laparoscopic liver resection for HCC is rapidly becoming
preferable to open resection in well-selected patients.
Outcomes and Prognostic Factors
Hepatic resection for HCC has become a safer operation,
with a reported in-hospital mortality rate of around 2% and
a 90-day mortality rate of 5%, largely due to advances in
surgical technique and improved patient selection, as demonstrated
in a recent series of 129 patients with HCC from
Toronto. 25 These marked improvements in outcomes can, in
part, be attributed to increased utilization of segmental and
parenchymal-sparing resections and decreased intraoperative
blood loss. Nevertheless, morbidity for liver resections
rates remain high at 20% to 50% and include complications
such as pleural effusion (9%), perihepatic abscess (6%), ileus
(6%), sterile perihepatic fluid collections (5%), wound infection
(5%), urinary tract infection (4%), bile leak/biloma (3%),
pneumonia (3%), and deep venous thrombosis (2%), as
reported in a series of 1,803 patients consisting of 21%
patients with HCC. 26 Expected 1-, 3-, 5-, and 10-year survival
rates following HCC resection are 85%, 64%, 45%, and
21%, respectively, as reported by the Liver Cancer Study
Group in Japan. These data are derived from the largest
report to date, which includes 6,785 patients with cirrhosis
operated on between 1988 and 1999. 27 Patients without
significant portal hypertension and normal bilirubin achieve
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