Recent Trends in The Surgical Management of Hepatocellular Carcinoma
Mahmoud Talaat Rayan;
Abstract
Hepatocellular carcinomas is considered one of the most common liver and the overall body malignancies. The incidence of hepatocellular carcinoma is rising now adays perhaps due to increase exposure to carcinogens or may be due to advanced screening and diagnostic modalities. With development of a recent surgical techniques the hepatocellular carcinoma had became potentially curable disease.
World wide hepatocellular carcinoma is the third common body malignancies. In Egypt, hepatocellular carcinoma (HCC) is the second most common cancer in men and the 6th most common cancers in women. It has been recognized that the most important clinical risk factor for the development of HCC is cirrhosis. Other risk factors includes HCV, and HBV infection, bilharzial infestation chemicals, aflatoxin, alcholism and smoking.
Most commonly, patients presenting with HCC are men 50 to 60 years of age who complain of right upper quadrant abdominal pain, and weight loss. The tumor may invade the hepatic veins lead to hepatic veins occlusion. Malignant obstructive jaundice is a common presentation of HCC the patient presents with gradual onset, progressive course and short duration of deep jaundice.
Laboratory evaluation of patients with newly diagnosed hepatocellular carcinoma should include testing to determine the severity of the underlying liver disease and to elucidate the etiology of the underlying disease. Laboratory studies should include a complete blood count, electrolytes, liver function tests, coagulation studies, and alpha-fetoprotein determination. Additional study, such as immuno-histochemistry, may be used in routine practice for the diagnosis of HCC.
Cross-sectional imaging with computed tomography (CT) scanning and magnetic resonance imaging (MRI) is most commonly used to detect hepatocellular carcinoma (HCC). Ultrasonography (US) can be sensitive in detecting HCC and, depending on the operator, can detect small lesions. US can evaluate for vascular invasion of the portal and hepatic veins through color Doppler imaging. Nuclear medicine imaging, angiography, and plain films are less useful.
Assesment of hepatic reserve is also important by CT volumetry and other metabolic tests.
Pre-operative screening endoscopy is mandatory to confirm the presence, to determine the size, and to uncover the stigmata of varices in cirrhotic patients, particularly in those with decompensated status.
PVEis indicated when the remnant liver is expected to be less than 40% of the preoperative liver volume in patients with normal liver function, or less than 50% in patients with liver dysfunction. Preoperative correction of anemia and of coagulopathy and chest condition is mandatory.
Liver resection is a potentially curative therapy for patients with early-stage HCC solitary tumor ≤5 cm in size, or ≤3 tumors each ≤3 cm in size and no evidence of gross vascular invasion. The recent development of laparoscopic resection has added new possibilities for the limited removal of peripheral lesions and The avoidance of long sub-costal incisions seems to be associated with reduced morbidity and earlier recovery.
Robotic liver resection is feasible and safe. Robotic-assisted technology appears to improve the precision and ergonomics of single-access surgery while preserving the known benefits of laparoscopic surgery, including cosmosis, minimal morbidity, and faster recovery. Liver transplantation may be the best curative treatment for HCC with the best safety margins. Liver transplantation is also curative for a pre-existing liver condition as cirrhosis or metabolic disorder.
World wide hepatocellular carcinoma is the third common body malignancies. In Egypt, hepatocellular carcinoma (HCC) is the second most common cancer in men and the 6th most common cancers in women. It has been recognized that the most important clinical risk factor for the development of HCC is cirrhosis. Other risk factors includes HCV, and HBV infection, bilharzial infestation chemicals, aflatoxin, alcholism and smoking.
Most commonly, patients presenting with HCC are men 50 to 60 years of age who complain of right upper quadrant abdominal pain, and weight loss. The tumor may invade the hepatic veins lead to hepatic veins occlusion. Malignant obstructive jaundice is a common presentation of HCC the patient presents with gradual onset, progressive course and short duration of deep jaundice.
Laboratory evaluation of patients with newly diagnosed hepatocellular carcinoma should include testing to determine the severity of the underlying liver disease and to elucidate the etiology of the underlying disease. Laboratory studies should include a complete blood count, electrolytes, liver function tests, coagulation studies, and alpha-fetoprotein determination. Additional study, such as immuno-histochemistry, may be used in routine practice for the diagnosis of HCC.
Cross-sectional imaging with computed tomography (CT) scanning and magnetic resonance imaging (MRI) is most commonly used to detect hepatocellular carcinoma (HCC). Ultrasonography (US) can be sensitive in detecting HCC and, depending on the operator, can detect small lesions. US can evaluate for vascular invasion of the portal and hepatic veins through color Doppler imaging. Nuclear medicine imaging, angiography, and plain films are less useful.
Assesment of hepatic reserve is also important by CT volumetry and other metabolic tests.
Pre-operative screening endoscopy is mandatory to confirm the presence, to determine the size, and to uncover the stigmata of varices in cirrhotic patients, particularly in those with decompensated status.
PVEis indicated when the remnant liver is expected to be less than 40% of the preoperative liver volume in patients with normal liver function, or less than 50% in patients with liver dysfunction. Preoperative correction of anemia and of coagulopathy and chest condition is mandatory.
Liver resection is a potentially curative therapy for patients with early-stage HCC solitary tumor ≤5 cm in size, or ≤3 tumors each ≤3 cm in size and no evidence of gross vascular invasion. The recent development of laparoscopic resection has added new possibilities for the limited removal of peripheral lesions and The avoidance of long sub-costal incisions seems to be associated with reduced morbidity and earlier recovery.
Robotic liver resection is feasible and safe. Robotic-assisted technology appears to improve the precision and ergonomics of single-access surgery while preserving the known benefits of laparoscopic surgery, including cosmosis, minimal morbidity, and faster recovery. Liver transplantation may be the best curative treatment for HCC with the best safety margins. Liver transplantation is also curative for a pre-existing liver condition as cirrhosis or metabolic disorder.
Other data
| Title | Recent Trends in The Surgical Management of Hepatocellular Carcinoma | Other Titles | الطرق الجراحية الحديثة في علاج اورام الكبد | Authors | Mahmoud Talaat Rayan | Issue Date | 2015 |
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