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“PERISH” fl owchart for selection of the patients with resectable fl owchart for selection of the patients with resectable
“PERISH”
hepatocellular carcinoma
hepatocellular carcinoma

Cuneyt Kayaalp, H. Kerem Tolan, Mehmet Caglikulekci
Liver Transplantation Institute, Inonu University, 44315 Malatya, Turkey

ABSTRACT
A selection of patients with hepatocellular carcinoma (HCC) for surgical resection is crucial and algorithms/staging systems
help surgeons to decide on a standard treatment for each patient and each HCC stage. However, there are always diffi culties
in remembering and/or recalling the contents of the algorithms/staging systems. Moreover, most algorithms/staging systems
do not include data about the extent of hepatectomy, intra-hepatic distribution of tumor(s), and technical feasibility of
resection, all of which are vital in the surgeons’ decision-making process. Here, we aimed to present a simple and handy
mnemonic acronym for selecting resectable HCCs in surgical practice. This was reproduced from the existing well-known
staging systems. The designed mnemonic acronym is a phrase “PERISH” and it includes asking for Performance of patient,
Extra-hepatic disease, Reserve of the liver, Intra-hepatic distribution, Stratifying risk factors, and Hepatectomy size in order.
Performance based on whether the patient is mostly bedridden or not should be the fi rst step of evaluation. Next, asking
for suspicious metastasis as bone pain and radiological evaluation of abdomen/thorax is mandatory. The calculation of
Child-Pugh score is only the third step. Good candidates for surgical resection should be Child-Pugh “A” with normal bilirubin
levels. Technical feasibility of resection, according to the intra-hepatic distribution of tumor(s) should be done later, and the
candidates preferably should not have portal hypertension (no splenomegaly, no thrombocytopenia). If the patient fulfi lls
all the previous steps, the surgeon may perform indo-cyanine green clearance test. Consequently, following the PERISH
fl owchart may prevent “perish” of the surgeons while selecting the appropriate resectable HCCs.

Key words: Hepatectomy; hepatocellular carcinoma; surgery; surgical education

Address for correspondence:
Prof. Cuneyt Kayaalp, Liver Transplantation Institute, Inonu University, 44315 Malatya, Turkey. E-mail: cuneytkayaalp@hotmail.com
Received: 02-03-2015, Accepted: 14-06-2015

INTRODUCTION damage are the most common predisposing etiological
factors for HCCs. HBV is the main etiology responsible
[2]
Hepatocellular carcinoma (HCC) is the primary malignancy for most of the HCC cases observed in Africa and the Asian
of the hepatocytes accounting for nearly 90% of all the liver parts of the world due to its high prevalence. However,
cancers, which is the fifth most common cancer around due to the global utilization of vaccination programs
the world. HCCs are most common in damaged liver the HBV-associated HCC incidences are getting lower.
[1]
[3]
parenchyma. Chronic hepatitis B virus (HBV) and hepatitis One-third of the cirrhotic population develops an HCC
C virus, alcohol and steatohepatitis-induced hepatocyte throughout their lives, with an annual incidence of 3-5%. [3]

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DOI: How to cite this article: Kayaalp C, Tolan HK, Caglikulekci M. "PERISH"
10.4103/2394-5079.161329 flowchart for selection of the patients with resectable hepatocellular
carcinoma. Hepatoma Res 2015;1:165-70.

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