Objective: An evidence-based review to ascertain the operative strategy for oncologic resection of malignant tumors of the liver and an optimal postoperative outcome.
Background: Recommendations for resection of malignant tumors of the liver based on traditional considerations of locoregional control and survival benefit are modified by the functional reserve of the liver remnant.
Methods: Recent publications including prospective randomized trials reporting outcomes with various surgical approaches were reviewed to establish the best current practices.
Results: The goal of hepatectomy for primary or metastatic tumors of the liver is complete resection with evidence that an anatomic resection in hepatocellular carcinoma and hilar cholangiocarcinoma improves survival. For nonanatomic resections the optimal width of the resection margin varies with the pathological type of tumor. Anterior approach to major hepatectomy is a "no-touch" technique that minimizes manipulation of the tumor-bearing liver. Vascular invasion is associated with dismal prognosis and limited major vascular resection is indicated to achieve an R0 (no residual disease) resection for prolongation of survival. Concomitant regional lymphadenectomy is of prognostic value, however it is not performed routinely because its therapeutic value remains unproven. Perioperative blood transfusion and postoperative morbidity are independent predictors of survival emphasizing the importance of measures such as portal vein embolization, hepatic pedicle clamping and preservation of venous drainage of the liver remnant.
Conclusion: The operative strategy for resection of malignant tumors of the liver should address the key components of the extent of hepatectomy including anatomic resection and optimal pathologic margins, use of the anterior approach, necessity for vascular resection, regional lymphadenectomy and measures to minimize blood loss and postoperative morbidity for maximal survival benefit.