Published online Aug 28, 2015. doi: 10.4254/wjh.v7.i18.2147
Peer-review started: April 30, 2015
First decision: July 25, 2015
Revised: August 10, 2015
Accepted: August 20, 2015
Article in press: August 21, 2015
Published online: August 28, 2015
Hepatocellular carcinoma (HCC) is best treated by liver transplantation, but the applicability of transplantation is greatly limited. Tumor resection in partial hepatectomy is hence resorted to. However, in most parts of the world, only 20%-30% of HCCs are resectable. The main reason for such a low resectability is a future liver remnant too small to be sufficient for the patient. To allow more HCC patients to undergo curative hepatectomy, a variety of ways have been developed to increase the resectability of HCC, mainly ways to increase the future liver remnants in patients through hypertrophy. They include portal vein embolization, sequential transarterial chemoembolization and portal vein embolization, staged hepatectomy, two-staged hepatectomy with portal vein ligation, and Associating Liver Partition and Portal Vein Ligation in Staged Hepatectomy. Herein we review, describe and evaluate these different ways, ways that can be life-saving.
Core tip: There are different ways to increase the resectability of hepatocellular carcinoma by increasing the volume of the future liver remnant (FLR) through hypertrophy. Portal vein embolization features the the embolization of the ipsilateral side of the portal vein which supplies the liver lobe harboring the tumor, either in an open or percutaneous manner. Sequential transarterial chemoembolization and portal vein embolization is a way to augment the effect of portal vein embolization and prevent tumor progression. Staged hepatectomy is mainly for liver tumors with bilobar involvement and colorectal liver metastasis and is often aided by effective adjuvant chemotherapy. Its aim is to strike a balance between complete tumor removal and preservation of the FLR. Two-staged hepatectomy with portal vein ligation is also mainly for liver tumors with bilobar involvement and colorectal liver metastasis. In the first-stage operation, tumor in the liver portion which is designated as the FLR is cleared, and portal vein ligation is performed. The liver parenchyma is transected only in the second-stage operation. Associating Liver Partition and Portal Vein Ligation in Staged Hepatectomy is used to speed up hypertrophy in the hope that the FLR will grow large enough for a safe hepatectomy before tumor progression occurs. It features right portal vein ligation and in-situ splitting of the intended transection surface down to the inferior vena cava. In the first-stage operation, the anterior approach is encouraged and the Pringle maneuver is discouraged, and the hilar plate is left untouched.