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Otsuka et al. Indications and technique for LLR in HCC with liver cirrhosis

(LLR), a minimally invasive treatment for liver cancer, is centers in resecting HCC. In Western countries,
now increasingly performed worldwide. However, few treatment is driven by the Barcelona Clinic Liver Cancer
[11]
studies have investigated LLR for HCC patients with liver algorithm, [22,23] in which evidence of portal hypertension
cirrhosis, and its applicability for this population is thus is a contraindication for surgical resection. Clinically
unclear. This review describes the indications for LLR in relevant portal hypertension is defined as the presence
this patient subgroup and offers guidance on appropriate of esophageal varices or splenomegaly associated with a
surgical technique. platelet count lower than 100 × 10⁹/L. [22]

CURRENT STATUS OF LLR IN THE In East Asian countries, the best candidates for resection
TREATMENT OF HCC are identified by using indocyanine green retention rate
as part of a detailed assessment of preoperative hepatic
LLR was initially described by Reich et al. Subsequent functional reserve. [24,25] Additionally, use of volumetric
[12]
studies showed that it offered minimal invasiveness with computed tomography for assessment of remnant liver
no reduction in safety or disease curability for primary and volume after resection is as important as estimation
[26]
metastatic liver tumors in selected patients. [13,14] However, of hepatic functional reserve. Therefore, patients
because of the technical difficulty of this procedure, with signs of portal hypertension can be candidates
it was not performed until the 1990s. Development for resection if they receive adequate perioperative
of surgical devices and technical refinements in the management, e.g. endoscopic treatment of esophageal
early 2000s increased surgical interest. In the First varices to minimize risk of rupture and pre-hepatectomy
[21]
International Consensus Conference (Louisville or concomitant splenectomy to improve hypersplenism.
Consensus), convened in 2008, LLR was described as Anatomic resection, which can remove the tumor-bearing
a safe and effective surgical approach for management portal territory, is preferred from an oncological perspective
[24]
of liver disease when performed by trained surgeons for radical treatment of HCC. Outcomes of liver resection
with experience in both hepatobiliary and laparoscopic for patients with HCC and cirrhosis has been dramatically
[21]
surgery. In addition, a small number of studies reported improved with parenchyma-preserving technique.
[15]
that LLR was useful for cirrhotic patients. [16,17] With the Percutaneous ablation therapies are another treatment
subsequent uptake of LLR, the Second International of choice for small nodular HCC in patients with
Consensus Conference on LLR, held in 2014, concluded cirrhosis located deep inside the liver; however, such
that minor LLRs, which were performed for left lateral treatment is not suitable for superficially located HCC,
sectionectomies or resections of anterior and lateral because of the increased risk of bleeding, tumor
[27]
segments (Couinaud’s segments II, III, IVb, V, and VI), seeding, and thermal injury to adjacent organs.
[29]
[28]
had become standard practice. Despite encouraging Therefore, surgical resection might be the ideal option
[11]
findings from high-volume centers, [18,19] the efficacy of LLR for superficial small HCCs.
for patients with cirrhosis remains inconclusive because
of the low sample sizes of published studies. The most Patient selection for LLR
recent meta-analysis indicated that the benefits of LLR The selection of candidates for LLR is the most important
would lead to expansion of its indications to include HCC consideration in safely performing LLR. With respect to
with chronic liver disease. [20] host factors, an LLR candidate should have liver function
sufficient for the same procedure performed as open liver
SURGICAL INDICATIONS resection. With respect to tumor factors, the classical
indications for LLR are that the tumor should have a
Resection of HCC in patient with liver cirrhosis diameter less than 5 cm and be located in areas with
In patients with HCC with liver cirrhosis, careful easy technical access to laparoscopy, i.e. in the left lateral
selection of surgical candidates is essential in order section (Couinaud’s segments II and III) or on the surface
to avoid treatment-related complications, e.g. liver of the inferior region of the liver (Couinaud’s segments
failure. Because of differences in the characteristics of IVb, V, and VI).
cirrhosis between Asian and Western countries, there
is considerable variability regarding the indications Partial liver resection or left lateral sectionectomy are the
for HCC resection. Therefore, surgical indications typical procedures for such tumors. With accumulating
for HCC associated with portal hypertension remain experience and technical advancement, LLR has been
controversial. Surgery is contraindicated for patients performed for tumors larger than 5 cm and for lesions
with encephalopathy, uncontrollable ascites, or located in the posterior-to-superior region of the liver
jaundice (serum total bilirubin level > 2.0 mg/dL). [21] (Couinaud’s segments VII, VIII, and IVa), including
advanced non-anatomical and anatomical LLR such
Asian centers have been more aggressive than Western as major hepatectomy (involving the abovementioned
242 Hepatoma Research ¦ Volume 2 ¦ September 19, 2016