Surgical Resection of Hepatocellular Carcinoma in Compensated Cirrhotic Liver: the Benefits and Selection Criteria

Background: Hepatocellular carcinoma (HCC) represents a fifth of common Malignancies, with an annual diagnosis of 750,000 new cases. It is the third cause of cancer deaths worldwide. The cirrhotic liver is a leading cause of HCC with the annual conversion rate to HCC in the range of 2–6 %. The underlying liver cirrhosis limits certain treatment modalities that potentially further aggravates liver dysfunction. Over the past decade, there were substantial improvements in the HCC resection techniques that has resulted in the reduction of operative mortality. This allowed doing major hepatectomy in cirrhotic patients who are suitable for liver transplantation but lacking availability of cadaveric or living donors. Also, patients who have multi-focal HCC underlying cirrhosis which render them unsuitable for liver transplantation due to its extension beyond Milan criteria. Objective: The objective of this study was to assess the benefits and selection criteria of HCC surgical resection within child–Turcotte–Pugh score (CTP) A and B liver cirrhosis to achieve the best surgical outcomes. Methods: We performed a literature search within English written trials using PubMed and MEDLINE reviews databases from 1986 to 2017. One hundred fifty studies are included in this review evaluating various parameters including HCC and compensated cirrhosis prevalence, pathogenesis, clinical presentation, and diagnostic methods. Furthermore, we have compared oncological hepatic resection with other modalities like transarterial chemoembolization, liver transplantation, embolization of the portal vein, laparoscopic hepatic resection, and ALPPS technique. Principles of surgical hepatectomy and postoperative complications are also presented in this review. Conclusion: This review has demonstrated that hepatic cirrhosis complicated by portal hypertension is not an absolute contraindication for HCC resection. Furthermore, elective surgery must not be directed exclusively to CTP A cirrhosis but it can be applied to highly selected patients who had suffered from advanced hepatic cirrhosis. If multifocal HCC underlying hepatic cirrhosis was unsuitable for liver transplantation, hepatectomy can be carried out to increase the tumor cure chances, prevent it's recurrences, and lead to significant survival rate improvement. The degree of cirrhosis significantly affects the decision of primary hepatic carcinoma treatment and it's prognosis. The interdisciplinary assessment of liver function by surgeons, hepatologists, anesthesiologists, and specialists of critical care are essential for maximum critical stabilization of the patients.   Keywords: Child-Turcotte-Pugh score; hepatocellular carcinoma; hepatectomy; liver cirrhosis; portal hypertensio