Navigating Complex Challenges: Preoperative Assessment and Surgical Strategies for Liver Resection in Patients with Fibrosis or Cirrhosis

Abstract

This review explores the intricacies of evaluating cirrhotic patients for liver resection while exploring how to extend surgical intervention to those typically excluded by the Barcelona Clinic Liver Cancer (BCLC) criteria guidelines by focusing on the need for robust preoperative assessment and innovative surgical strategies. Cirrhosis presents unique challenges and complicates liver resection due to the altered physiology of the liver, portal hypertension, and liver decompensation. The primary objective of this review is to discuss the current approaches in assessing the suitability of cirrhotic patients for liver resection and aims to identify which patients outside of the BCLC criteria can safely undergo liver resection by highlighting emerging strategies that can improve surgical safety and outcomes.

Keywords: cirrhosis; hepatocellular carcinoma; liver resection; portal hypertension; surgical risk assessment.

Figure 1

Barcelona Clinic Liver Cancer (BCLC) staging and treatment strategy algorithm. PS, performance status; TACE, transarterial chemoembolization; OS, overall survival; yr, year; mo, months.

Figure 2

Summary of preoperative optimization and decision-making in patients with resectable HCC and cirrhosis. HCC, hepatocellular carcinoma; LFTs, liver function tests, INR, international normalized ratio; MELD, model for end-stage liver disease; CTP, Child-Turcotte-Pugh; MRS, Mayo risk score; VOCAL-Penn, Veterans outcomes and costs associated with liver disease; FIB-4, Fibrosis-4; ALBI, albumin-bilirubin score; FLR, future liver remnant; CT, computed tomography; MRI, magnetic resonance imaging; ICG-R15, indocyanine green retention rate; ^99mTc-GSA, ^99mTc-labeled galactosyl-human serum albumin scintigraphy; ^99mTc-mebrofenin HBS, ^99mTc-labeled mebrofenin hepatobiliary scintigraphy; PVE, portal vein embolization; HVE, hepatic vein embolization; BCLC, Barcelona Clinic Liver Cancer; PH, portal hypertension; EGD, esophagogastroduodenoscopy; HVPG, hepatic vein portal gradient; TIPS, transjugular intrahepatic portosystemic shunt; kPa, kilopascal; mmHg, millimeter of mercury.