Parenchymal sparing anatomical liver resections for hepatocellular carcinoma

The rationale of the performance of anatomic resection (AR) of the liver in case of hepatocellular carcinoma (HCC) is the removal of portal pedicle feeding the tumor because of the tumor’s tendency to invade the portal veins (1). This technical approach is expected to be effective from an oncological perspective for a disease such as HCC, which is associated with a high rate of intrahepatic recurrence (2,3).

In the eighties, Makuuchi et al. proposed the systematic subsegmentectomy (4) reporting excellent results (5), and later some other authors reported new techniques to identify the portal territory of a given HCC and perform a true AR of the liver (5-7). And these techniques have already been shown to be associated with long-term survival (8,9). Briefly, there are two main types of surgical approach for AR: the intrahepatic—transection type, of which the progenitor was in fact the intraoperative ultrasound (IOUS) guided injection of dye as proposed by Makuuchi et al. (4), and the extrahepatic Glissonean pedicle identification and transection as proposed by Takasaki et al. (6).

The logic behind these techniques is double: first, they should be applied to achieve the optimal compromise between the need for the complete tumor removal and the need to spare liver parenchyma to minimize the postoperative risks; second, the sparing of liver parenchyma may allow for the increasing of the resectability, particularly, in those patients with complex tumor such as large or multinodular tumors that might not be considered resectable if the standard traditional surgical approach, consisting in sectionectomy or hemi-hepatectomy, is chosen. Keeping in mind this double logic approach, new parenchymal sparing anatomical resections have been developed, applied and disclosed (10-14) that questioned the standard principles regarding the surgical margin, AR, and tumor exposure when in contact with major intrahepatic vascular structures. Notably, the exposure of HCC was already reported as associated with good oncological outcome (15). Thus, the exposure of a capsulated HCC in contact with major intrahepatic vessels intended to be preserved to save liver volume and liver function should not be considered contraindicated (16). Interestingly, in the surgical community some confusion persists about these issues, which are the surgical margin, AR, and tumor exposure in HCC patients, particularly, about their definitions and their practical applications.

Along this line, we read with interested the article by Wang et al. (17) published in JAMA Surgery that reported the surgical innovation of the performance of AR for HCC based on the extension of the surgical margin with the aim of having 1 cm negative margin. This is what they called “anatomic liver resection based on portal territory with margin priority”. Curiously, Wang et al. (17) did not provide any details concerning the modality used to define the anatomical area to be removed and, consistently, to perform AR. For doing that, the authors suggested the use of the 3D visualization technology that, while is certainly helpful for many different aspects, it cannot be use in real-time to perform AR. In other words, the authors should explain how they transferred the information gathered from the 3D software into the operating room to identify the intrahepatic pedicles and consequently determine the resection area. Surprisingly, there is no mention about the use of IOUS, a golden oldie provider of those techniques for performing parenchyma sparing anatomical resections (18,19). Besides, IOUS would have been useful to achieve the 1 cm margin as claimed by the authors, albeit the use of 1 cm margin rule in HCC surgery is questionable. Previous reports showed the suitability of tumor exposure whenever anatomical resections are performed (15,16). In particular, tumor detachment from major intrahepatic vessel, so-called R1vasc surgery, has proven to be oncologically adequate, factually increasing the resectability of HCC patients. Inversely, facing with a 1 cm margin rule an HCC in contact with major intrahepatic vessel should require vascular resection resulting in major/extended hepatectomies or alternatively demanding complex vascular reconstructions, or ultimately denying resectability. Finally, Wang et al. (15) did not mention their strategy in the management of the hepatic veins when a given HCC is in contact or, as in the example reported in their article, is between two liver sectors drained by two different major hepatic veins. In such case, the 1 cm rule would require the performance of major or extended resection guided by the resection of one or two hepatic veins.

Whether the “anatomic liver resection based on portal territory with margin priority” is an innovative approach is questionable. Certainly, the discussion on techniques for parenchymal sparing anatomical liver resection deserves to be highlighted to make clearer the concepts of AR, tumor margin, and tumor exposure because their comprehension represent the roadmap to safely and efficiently treat HCC patients.

Acknowledgments

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, HepatoBiliary Surgery and Nutrition. The article did not undergo external peer review.

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://hbsn.amegroups.com/article/view/10.21037/hbsn-24-299/coif). G.T. serves as an unpaid editorial board member of HepatoBiliary Surgery and Nutrition. The other author has no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

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