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Page 2 of 10 Yamaguchi et al. Hepatoma Res 2018;4:50 I http://dx.doi.org/10.20517/2394-5079.2018.68

EVALUATION OF PREOPERATIVE HEPATIC RESERVE
Liver carcinoma is often caused by viral hepatitis, alcoholic hepatitis, or non-alcoholic steatohepatitis
(NASH), and when hepatectomy is performed it is necessary to pay attention to postoperative decrease in
residual liver function as well as curability of the cancer.

The Child-Pugh score is used worldwide to assess preoperative hepatic reserve. The EASL-EORTC clinical
[3]
practice guidelines usually exclude Child-Pugh B and C patients and even Child-Pugh A patients with
[2]
increased portal blood pressure or high levels of bilirubin from indications for hepatectomy. The Japanese
guidelines also recommend a treatment decision based on the Child-Pugh score, and hepatectomy in Child-
Pugh A and B patients and liver transplant in Child-Pugh C patients have shown favorable results .
[4,5]
Importantly, an indication for liver transplant in Child-Pugh C patients is because liver transplants performed
in Japan are usually living-donor liver transplantation due to the scarcity of brain-dead donors, and patients
undergoing liver transplantation have developed liver cancer mostly caused by decompensated cirrhosis.

The evaluation scale often used in Japan for hepatectomy is assessment of liver damage under the general
rules for the clinical and pathological study of primary liver cancer calculated by an indocyanine green
retention rate after 15 min (ICG15), ascites, serum bilirubin level, serum albumin level, and prothrombin
activity . Actually, many reports showed that the ICG load test was a significant predictor of postoperative
[6]
death , and the Makuuchi criteria for safe hepatic resection, which are used as a reference for hepatectomy
[7,8]
[9]
in many institutions, also base the advisability of hepatectomy on bilirubin level, ICG15, and ascites as well
as the resectable limits. There was little mortality in patients undergoing hepatectomy in compliance with
these criteria. Based on what was mentioned above, the ICG load test is considered likely to be important for
decision-making concerning indications for hepatectomy.

Some reports showed that technetium-99m-galactosyl human serum albumin (99mTc-GSA) liver scintigraphy
was more useful than ICG15 retention rate in the assessment of histological hepatic damage [10,11] and more
effective in the prediction of complications and operative death in patients with hepatic disorders .
[12]
However, 99mTc-GSA scintigraphy using nuclides is performed only at a limited number of institutions and
is not common worldwide.

INDICATIONS FOR HEPATECTOMY
Indicators for surgery other than hepatic reserve include tumor diameter, the number of tumors, presence
of vascular invasion and extrahepatic metastasis. Looking at the stage classification, the EASL-EORTC-
guidelines recommend hepatectomy as a treatment option for HCC patients at Barcelona Clinic Liver
[2]
Cancer (BCLC) stage 0 or BCLC stage A and with normal portal blood pressure and bilirubin level.
Transarterial chemoembolization (TACE) is recommended as a treatment for the patients at BCLC stage B
[Figure 1]. However, studies showed the 5-year survival rate and perioperative mortality rate in HCC patients
at BCLC stage B and undergoing hepatectomy were 30% to 57% and 2.6% to 5.4% respectively [13-16] , and the
prognosis of the patients with solitary hepatocellular carcinoma and undergoing hepatectomy was much
more favorable than those undergoing TACE. There are many surgeons/clinicians who believe that not all
HCC patients at BCLC stage B should be excluded from an indication for hepatectomy.

In terms of the number of HCC tumors, a better prognosis was reported in patients with a solitary tumor than
in patients with multiple tumors . Hepatectomy was more useful than local ethanol injection treatment in
[17]
patients with liver damage A or B under the general rules for the clinical and pathological study of primary
liver cancer. The treatment plan may change depending on if the HCC tumor size is larger or smaller than
3 cm. Hasegawa et al. reported that hepatectomy showed more favorable outcomes than radiofrequency
[18]
ablation (RFA) in patients with a solitary tumor smaller than 3 cm. As written above, hepatectomy is
recommended as the first treatment option for patients with solitary HCC, and RFA is reported for patients
with HCC smaller than 3 cm as the second treatment option equivalent to hepatectomy [Figure 2].