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presence of ascites, total serum bilirubin levels, and the ICG We have to say that while deciding a surgery for a patient
disappearance rate for deciding the eligibility of the patients with HCC, we use the BCLC and the other algorithms, as
for a resection and the type of the surgical resection. In patients well. To avoid a misunderstanding, we have to highlight
with uncontrolled ascites, bilirubin levels above 2 mg/dL, any that we do not try to create an alternative system to the
type of hepatectomy is contraindicated. The ICG uptake rate well-known systems (such as BCLC and others) to evaluate
in “Makuuchi criteria” is used as objective criteria for deciding the HCC patients. This mnemonic flowchart may only help
the extent of the resection that can be safely performed. in assessing a systematic check of this important clinical
According to the ICG uptake resections, that can be safely decision-making process. Here, we just want to re-read the
performed are classified as, major hepatectomy (ICG < 10%), BCLC and other algorithms from another direction, but more
segmentectomy < 1/3 of liver (10% < ICG < 19%), simply and practically in the daily life. In our clinical practice,
subsegmentectomy < 1/6 of liver (20% < ICG < 29%), and a lots of HCC patients are referred to our department for
limited resection (ICG > 30%) [Figure 4]. [20] the aim of resection from other cities by several clinicians.
We observed that most clinicians (surgeons, but not an
expert on liver surgery, oncologists, gastroenterologists, or
internists) focus only on the size or number of the tumors in
the liver while they were referring their patients. However,
the general condition of the patient (mostly bedridden or
not), bone pains (the possible metastasis), platelet counts,
or presence of esophageal varices, etc., can be overlooked
before the transfers of the patients. Sometimes the simplest
Figure 2: Location may be as important as the number and size of the tumors points are missing in the complex algorithms. “PERISH”
for technical feasibility of surgical resection
flowchart can be used as a simple checklist in the clinical
evaluation of the patients with HCC. This mnemonic
Survival (%)
100 flowchart could be more useful for the clinicians who are not
experts on HCC. We believe that an easy learning method
80 for the selection of the most appropriate candidates for
N portal pressure, Bili < 1
surgical resection can create a charm among the non-expert
60
clinicians on HCC, as well. This mnemonic can make the
↑ Portal pressure, Bili < 1
40 evaluation of the HCC patients more attractive due to its
simplicity.
20
↑ Portal pressure, Bili ≥ 1
0 CONCLUSION
0 12 24 36 48 60 72 84 96
Months
Figure 3: Resection of < 5 cm tumors in Child-Pugh A patients according to the Asking for the patients’ general condition, that is, whether
bilirubin and portal hypertension (adopted from Llovet et al. ) the patient is symptomatic and in bed > 50% of the day,
[18]
should be the first question to select the correct cases for
the resectable HCCs. Following this, asking for suspicious
Makuuchi’s criteria
Ascites metastasis as bone pain and radiological evaluation of
the abdomen and thorax is mandatory. Calculation of the
No or controllable Incontrollable
Child-Pugh score is only the third step of the evaluation. Good
candidates for a surgical resection should be Child-Pugh “A”
Total bilirubin
but a better subgroup “A” with normal bilirubin levels should
be preferred. Technical feasibility of the resection according
to the intra-hepatic distribution of the tumor(s) should be
Normal 1.1-1.9 mg/dL ≥ 2.0 mg/dL
done radiologically, and the patients preferably should
ICG 15’ Limited resection No hepatectomy
not have portal hypertension. If the patient fulfills all the
previous steps, the surgeon can perform the ICG clearance
test, if necessary [Table 3].
Normal 10-19% 20-29% ≥ 30%
Trisegmentectomy Lt hepatectomy Subsegmentectomy Limited resection
Rt hepatectomy Rt segmentectomy As a result, following the “PERISH” flowchart in the treatment
of any HCCs may prevent “perish” of the surgeons while
Figure 4: Makuuchi criteria for safe hepatectomy. ICG: Indo-cyanine Green;
Lt: left; Rt: right deciding the appropriate treatment of HCCs.

Hepatoma Research | Volume 1 | Issue 3 | October 15, 2015 169