Surgical management of hepatic cancer in middle and advanced stage

Abstract

Hepatic cancer is currently the fifth most common malignant neoplasm in the world.Surgical resection is considered as radical treatment.Patients with hepatic cancer in middle or advanced stage according to the Barcelona clinic liver cancer staging system (BCLC) are usually with huge and (or) multinodular lesions and vascular invasion,which are not generally recommended for surgical resection because of high operative mortality,recurrence rate and dismal survival benefit.However,many centers have proved an opposite and encouraging result against the opinions above.With the development of surgical techniques and intensive medical care,the concern of high postoperative mortality for middle or advanced stage hepatic cancer patients is no longer unsolvable.Precise preoperative assessment is essential.The estimation of the liver functional reserve has developed from simple Child-Pugh score to an integrated system including computed tomography evaluation,indocyanine green clearance test,hepatic venous pressure gradient,etc.The estimation of the remnant liver volume after hepatectomy is especially important for surgical treatment for the middle or advanced stage hepatic cancer.Insufficient liver remnant was absolute contraindication for major hepatectomy because of high incidence of postoperative liver failure.In-situ liver transection with one branch of the portal vein ligation has been invented as a novel method to stimulate fast liver regeneration; by this way,a second-stepped radical resection can be performed with a plenty of liver remnant one week later.However,the reliability for hepatic cancer patients with liver cirrhosis is still unknown.Meticulous surgical procedure is another key factor for a safe major hepatectomy.Radical resection is most expected to provide better survival.The development of the technique of liver blood flow occlusion has a markedly influence on partial hepatectomy.Highly selective occlusion and even occlusion-free hepatectomy can reduce warm ischemia injury and improve postoperative survival.Anterior approach is a reasonable maneuver for huge hepatic cancer resection.Cancer thrombosis usually indicates poor prognosis,however,if en-bloc resection or separate thrombectomy can be achieved,surgical resection for the middle and advanced stage hepatic cancer still can provide a better survival benefit to this category of patient than palliative treatment as TACE. Key words: Liver neoplasms ; Vascular occlusion ; Surgical procedure, operative