E-AHPBA-ESSO-ESSR Innsbruck consensus guidelines for preoperative liver function assessment before hepatectomy

Liver metastases from colorectal cancer: A joint ESSO-EAHPBA-UEMS core curriculum collaboration

Colorectal liver metastases (CRLM) are a major indication for liver surgery in Europe, highlighting the need for standardized knowledge and training in surgical oncology. The European Society of Surgical Oncology (ESSO) has updated its core curriculum to provide a structured framework for education. Previous publications have addressed pancreatic, hepatocellular, and biliary tract cancers to support candidates preparing for the European Board of Surgery Qualification (EBSQ) exams in Surgical Oncology and Hepato-Pancreato-Biliary Surgery. However, a dedicated guide for CRLM remains absent. This article aims to fill that gap by offering a structured reference on CRLM, covering epidemiology, staging, genetics, and diagnosis of metastatic colorectal cancer. It also outlines multidisciplinary treatment strategies, including systemic, surgical, interventional, and palliative approaches. A structured literature review was conducted using PubMed to identify the most updated (inter)national management guidelines, prioritizing recent multicentre studies, systematic reviews, and meta-analyses published from January 2020 to January 2025. By bridging the gap between the ESSO core curriculum and detailed subspecialty training, this guide provides an essential resource for hepatobiliary surgeons and surgical oncologists. It serves as a valuable tool for those preparing for board examinations while promoting a standardized approach to CRLM education and management across Europe.

Prognostic role of postoperative persistence of ctDNA molecular signature after liver resection for colorectal liver metastases: Preliminary results from a prospective study

INTRODUCTION

Liver resection represents the cornerstone treatment for Colo-Rectal Liver Metastases (CRLM), but it is still followed by a high recurrence rate. The identification of a valid and reproducible predictor of recurrence can play a key role in correct and timely management of the disease. In this scenario, liquid biopsy may represent an integrative, less invasive, and easily manageable tool to clinically stratify colorectal cancer patients.We aimed to investigate the prognostic role of persistent circulating tumor DNA (ctDNA) signature on CRLM recurrence after liver resection.

METHODS

A series of 51 consecutive patients undergoing liver resection for CRLM were prospectively enrolled between January 2020 and March 2023. Patients underwent liquid biopsy from peripheral blood samples before and after surgery. Other risk factors for disease recurrence were also investigated.

RESULTS

Twenty-nine patients were found to be positive for one of the clinically relevant molecular alterations detected by NGS, at preoperative (T0) ctDNA analysis. At univariate analysis, total tumor size bigger than 60 mm (p = 0.046, HR 2.486) and postoperative persistence of ctDNA molecular signature (p = 0.024, HR 2.831) were significantly associated with recurrence. Multivariable Cox Regression analysis showed that only postoperative persistence of ctDNA molecular signature was associated with recurrence (p = 0.027, HR 2.766). Similarly, 1-3 yr DFS was significantly lower in the subgroup with persistence of molecular signature at liquid biopsy (100-49.5 % vs 57.1-21.4 %, p = 0.018).

CONCLUSION

Postoperative persistence of ctDNA molecular signature could represent a useful tool to predict recurrence after liver resection for CRLM patients.

Biliary tract cancer

BACKGROUND

Biliary tract cancers comprise a heterogeneous collection of malignancies usually described as cholangiocarcinoma of the intra- or extrahepatic bile duct, including perihilar cholangiocarcinoma and gallbladder cancer.

METHODS

A review of pertinent parts of the ESSO core curriculum for the UEMS diploma targets (Fellowships exam, EBSQ), based on updated and available guidelines for diagnosis, surgical treatment and oncological management of cholangiocarcinoma.

RESULTS

Following the outline from the ESSO core curriculum we present the epidemiology and risk factors for cholangiocarcinoma, as well as the rationale for the current diagnosis, staging, (neo-)adjuvant treatment, surgical management, and short- and long-term outcomes. The available guidelines and consensus reports (i.e. NCCN, BGS and ESMO guidelines) are referred to. Recognition of biliary tract cancers as separate entities of the intrahepatic biliary ducts, the perihilar and distal bile duct as well as the gallbladder is important for proper management, as they each provide distinct clinical, molecular and treatment profiles to consider.

CONCLUSION

Core competencies in knowledge to the diagnosis, management and outcomes of biliary tract cancers are presented.

Precision in Liver Surgery: A Comparative Analysis of Volumetry Techniques

BACKGROUND

Future liver remnant volume (FLRV) is a critical determinant of safety for hepatectomy. This study assesses concordance between imaging-based measured FLRV (mFLRV), and body surface area (BSA)-based standardized FLRV (sFLRV), and their association with post-hepatectomy complications.

MATERIALS AND METHODS

All major hepatectomy between 1999 and 2021 were assessed for agreement between mFLRV and sFLRV using concordance correlation coefficient (CCC). Association between each method and major postoperative complications, post-hepatectomy liver failure (PHLF), or grade 4/5 morbidity was compared using logistic regression model and area under the receiver-operating characteristic (AUC) curve to evaluate the discriminatory power of each volumetry method separately.

RESULTS

A total of 1749 patients were included, 49% were female, median age was 60 years, 70.2% had metastatic disease, and 49.7% received preoperative chemotherapy. Median sFLRV (41.3%) was higher than mFLRV (39.4%). Major complications were observed in 5.1% (n = 90). Concordance between mFLRV and sFLRV was moderate, CCC = 0.78 (95% CI 0.75-0.79) but was poor (CCC = 0.39; 95% CI 0.32-0.43) among patients with mFLRV ≤ 35% (n = 528). In this subset, sFLRV overestimated remnant volume in 63% (n = 333) with ≥ 5% overprediction in 145 patients (27.5%). Factors associated with ≥ 5% variation were lower weight (p = 0.003), lower BMI (p = 0.003), and lower BSA (p = 0.004). Both methods performed similarly in predicting major complications with AUC of 0.64 and 0.63 for sFLRV and mFLRV, respectively.

CONCLUSIONS

Imaging- and BSA-based volumetry are moderately correlated, with poor concordance among patients with smaller FLRV where sFLRV overestimated remnant volume. Both techniques can be safely used for volumetric assessment before major hepatectomy.

EORTC consensus recommendations on the optimal management of colorectal cancer liver metastases

Patients with colorectal cancer liver metastases have long represented a unique and thoroughly investigated population. Nevertheless, the optimal management of these is still controversial with a number of open questions which are only partially addressed by available studies and existing guidelines. The European Organisation for Research and Treatment of Cancer (EORTC) Gastrointestinal Tract Cancer Group (GITCG) sought to fill this knowledge gap and promoted the development of a European consensus on this subject. By using the Delphi methodology and leveraging a multidisciplinary team of 43 international experts, including gastrointestinal oncologists, hepatobiliary surgeons, interventional radiologists, radiation oncologists, radiologists, nuclear medicine physicians and pathologists from 12 European countries, 34 practical recommendations and two consensus statements were proposed. These cover varying aspects of the optimal management of colorectal cancer liver metastases such as baseline imaging, selection criteria for liver-directed therapies, treatment strategies, assessment of treatment response, follow-up, care delivery, clinical research and future perspectives. This roadmap document is intended to complement national and international guidelines, and to provide practical guidance for clinicians and multidisciplinary teams, ultimately promoting practice standardisation, optimal management and better patient outcomes across Europe. Also, it provides a unique opportunity to highlight grey areas and unmet needs, and to give a strategic direction to future research in the field by identifying topics where there is no consensus among experts.

An APRI+ALBI-Based Multivariable Model as a Preoperative Predictor for Posthepatectomy Liver Failure

OBJECTIVE AND BACKGROUND

Clinically significant posthepatectomy liver failure (PHLF B+C) remains the main cause of mortality after major hepatic resection. This study aimed to establish an aspartate aminotransferase to platelet ratio combined with an albumin-bilirubin grade (APRI+ALBI), based multivariable model (MVM) to predict PHLF and compare its performance to indocyanine green clearance (ICG-R15 or ICG-PDR) and albumin-ICG evaluation (ALICE).

METHODS

A total of 12,056 patients from the National Surgical Quality Improvement Program database were used to generate a MVM to predict PHLF B+C. The model was determined using stepwise backwards elimination. The performance of the model was tested using receiver operating characteristic curve analysis and validated in an international cohort of 2525 patients. In 620 patients, the APRI+ALBI MVM, trained in the National Surgical Quality Improvement Program cohort, was compared with the MVM's based on other liver function tests (ICG clearance, ALICE) by comparing the areas under the curve (AUC).

RESULTS

A MVM including APRI+ALBI, age, sex, tumor type, and extent of resection was found to predict PHLF B+C with an AUC of 0.77, with comparable performance in the validation cohort (AUC: 0.74). In direct comparison with other MVM's based on more expensive and time-consuming liver function tests (ICG clearance, ALICE), the APRI+ALBI MVM demonstrated equal predictive potential for PHLF B+C. A smartphone application for the calculation of the APRI+ALBI MVM was designed.

CONCLUSION

Risk assessment through the APRI+ALBI MVM for PHLF B+C increases preoperative predictive accuracy and represents a universally available and cost-effective risk assessment before hepatectomy, facilitated by a freely available smartphone app.

Regional Liver Function Assessment Using 99mTc-GSA SPECT/CT Scintigraphy in Malignant Perihilar Biliary Tumor Undergoing Major Liver Resection: A Dual-Center Cohort Study

BACKGROUND

Cholestasis can lead to unreliable results of routine liver function assessment tests in clinical practice and the functional cutoff value of hepatectomy is still unclear. The aim of this study was to determine which 99mTc-GSA scintigraphy functional indicators can predict post-hepatectomy liver failure (PHLF) in patients before major liver resection due to malignant perihilar biliary disease. In addition, it aimed to assess the efficiency of functional future liver remnant (FLR) assessment of 99mTc-GSA scintigraphy indicators.

PATIENTS AND METHODS

A 99mTc-GSA scintigraphy was performed prior to planned surgery in 187 patients, including 81 patients with major liver resection. The 99mTc-GSA scintigraphy parameters including functional liver volume (FLV), ratio of the FLR functional volume to body weight (FLVFLR-BWR), and predictive residual index (PRI) were calculated from radioactive count in regions of FLR and total liver (TOTAL). Morphological liver volume (MLV) was calculated from computed tomography and standardized by standard liver volume (SLV). The efficacy of these parameters in predicting PHLF was compared using generalized linear mixed models and receiver operating characteristic (ROC) curve analysis.

RESULTS

PHLF occurred in 22 patients, who showed lower MLVFLR/SLV, FLVFLR, FLVFLR/FLVTOTAL, FLVFLR-BWR, and PRI and higher resection rate (P < 0.05 for all) than patients without PHLF. After adjusting for clinical parameters, a decreased FLVFLR-BWR (odds ratio, OR 0.17; 95% confidence intervals, CI 0.05-0.53) was found to be an independently significant indicator in the model of GLMM. FLVFLR-BWR (0.835) had the highest ROC among all liver functional indicators.

CONCLUSIONS

The FLR functional parameter preoperatively estimated from preoperative 99mTc-GSA scintigraphy protocol is a promising tool for regional liver function assessment, and it can distinguish high-risk patients who may develop PHLF with malignant perihilar biliary tumor undergoing major liver resection.

Precision surgery for hepatocellular carcinoma

Hepatocellular carcinoma arises in the setting of cirrhosis in most cases, requiring multidisciplinary input to define resectability. In this regard, more precise surgical management considers patient factors and anatomical states, including resection margins, tumour biology, and perioperative therapy. Together with advances in surgical techniques, this integrated approach has resulted in considerable improvements in patient morbidity and oncological outcomes. Despite this, recurrence rates in hepatocellular carcinoma remain high. As the systemic treatment landscape in hepatocellular carcinoma continues to evolve and locoregional options are increasingly used, we review current and future opportunities to individualise the surgical management of patients with hepatocellular carcinoma.

Hepatocellular carcinoma: Revising the surgical approach in light of the concept of multiparametric therapeutic hierarchy

The clinical management of hepatocellular carcinoma (HCC) is strongly influenced by several prognostic factors, mainly tumor stage, patient's health, liver function and specific characteristics of each intervention. The interplay between these factors should be carefully evaluated by a multidisciplinary tumor board. To support this, the novel "multiparametric therapeutic hierarchy" (MTH) concept has been recently proposed. This review will present the main features of available surgical treatments for HCC (liver transplantation, liver resection, ablation). Strengths and weaknesses are reported in the light of clinical decision making and of treatment allocation, with a special focus on the collocation of each treatment in the MTH framework and on how MTH may be useful in supporting clinical decision. Sequential treatments and their role to allow further surgical treatments will also be analyzed.

Soluble TREM2 reflects liver fibrosis status and predicts postoperative liver dysfunction after liver surgery

Background & Aims

Triggering receptor expressed on myeloid cells 2 (TREM2)-expressing macrophages and systemic levels of soluble TREM2 (sTREM2) appear critical in the development of chronic liver disease (CLD) and seem relevant in its detection. The aim of this study was to examine sTREM2 as a marker for early CLD and its potential to predict posthepatectomy liver failure (PHLF) in patients undergoing partial hepatectomy.

Methods

sTREM2 was assessed in the plasma of 108 patients undergoing liver resection. Blood was drawn prior to surgery (preop) and on the first and fifth postoperative day.

Results

Preop sTREM2 levels were similar across different indications for resection (p = 0.091). Higher preop sTREM2 levels were associated with advanced hepatic fibrosis (p = 0.030) and PHLF (p = 0.007). Fibrosis-4 index (FIB-4) (p = 0.619) and model for end-stage liver disease (MELD) (p = 0.590) did not show a difference between patients grouped by their CLD. Comparing the AUC from receiver-operating characteristic analysis, sTREM2 (AUC = 0.708) outperformed FIB-4 (AUC = 0.529), MELD (AUC = 0.587), Child-Pugh grading (AUC = 0.570) and LiMAx (liver maximum capacity test) (AUC = 0.516) in predicting PHLF. Similarly, in uni- and multivariate analysis, only sTREM2 proved predictive for PHLF (p = 0.023). High-risk (p = 0.003) and low-risk (p = 0.011) cut-offs for systemic sTREM2 levels could identify patients at risk for adverse outcomes after surgery. Finally, high sTREM2 was associated with decreased overall survival after liver surgery (p <0.001).

Conclusions

Circulating sTREM2 shows sensitivity for early-stage, asymptomatic liver disease, irrespective of the underlying indication for liver surgery. Assessment of CLD via sTREM2 monitoring could improve early detection of CLD and improve outcomes after liver surgery.

Impact and implications

Soluble TREM2 (sTREM2) has previously been shown to correlate with the degree of chronic liver disease. We found that even in patients undergoing liver resection, who generally do not suffer from end-stage liver disease, sTREM2 reflects liver fibrosis status and predicts postoperative development of liver dysfunction. This is especially relevant for liver surgeons and patients, as postoperative liver dysfunction is the main reason for postoperative mortality. Our findings are also important for hepatologists, as early detection of liver fibrosis and cirrhosis is paramount for overall patient survival and we can show that even in a cohort with a median model for end-stage liver disease score of 6, sTREM2 is able to distinguish patients based on their liver fibrosis status.

Liver function estimation using multiphase hepatic CT: diagnostic performance of iodine-uptake and volumetric parameters

OBJECTIVES

To investigate whether multiphase hepatic CT can predict liver function measured with indocyanine-green-retention test (ICG-R15) and identify patients with severe liver dysfunction contraindicating major hepatectomy, defined as ICG-R15 ≥ 20%, compared to technetium-99m-galactosyl serum albumin (99mTc-GSA) scintigraphy.

MATERIALS AND METHODS

This retrospective study included 118 patients (84 men, mean age, 69.4 ± 11.3 years) who underwent ICG-R15, 99mTc-GSA, and multi-phase CT including early portal-venous-phase and 3-min delayed-phase. CT-derived extracellular volume fraction (ECV), iodine washout rate (IWR), liver and spleen volumes normalized by body-surface-area (LV/BSA and SpV/BSA, respectively), and 99mTc-GSA-derived blood clearance index (HH15) and liver receptor index (LHL15) were quantified. Each parameter was compared between ICG-R15 ≥ 20% (n = 22) and ICG-R15 < 20% (n = 96) groups. Correlations with ICG-R15 were analyzed. The diagnostic performance to predict ICG-R15 ≥ 20% was assessed with areas under the receiver operating characteristic curve (AUC). Multivariable logistic regression analysis was used to identify independent CT predictors, and combined performance was determined.

RESULTS

In the ICG-R15 ≥ 20% group, IWR (p < 0.001), LV/BSA (p = 0.026), LHL15 (p < 0.001) were lower and ECV (p = 0.001), SpV/BSA (p = 0.005), and HH15 (p < 0.001) were higher compared to ICG-R15 < 20% group. ICG-R15 showed positive correlations with ECV (r = 0.355), SpV/BSA (r = 0.248), and HH15 (r = 0.385), while negative correlations with IWR (r = -0.523), LV/BSA (r = -0.123, not statistically significant), and LHL15 (r = -0.504). The AUC of ECV, IWR, LV/BSA, SpV/BSA, HH15, and LHL15 were 0.719, 0.845, 0.653, 0.694, 0.844, and 0.878, respectively. IWR, SpV/BSA, and LV/BSA were independent predictors, with a combined AUC of 0.924.

CONCLUSION

IWR predicted liver function better than ECV and hepatosplenic volumetry. The combined IWR and volumetry yielded an accurate prediction of severe liver dysfunction.

KEY POINTS

Question Despite the widespread use of multiphase CT in patients with hepatobiliary diseases, its potential role in assessing liver function has been scarcely evaluated. Findings Iodine washout rate (IWR), liver volume indexed by body surface area, and spleen volume indexed by body surface area were independent predictors for severe liver dysfunction. Clinical relevance Combined IWR and hepatosplenic volumetry on routine hepatic CT may help assess hepatic function for optimizing treatment strategies and predicting patient prognosis.

Failure to Rescue After Resection of Perhilar Cholangiocarcinoma in an International Multicenter Cohort

BACKGROUND

Failure to rescue (FTR) is defined as the inability to prevent death after the development of a complication. FTR is a parameter in evaluating multidisciplinary postoperative complication management. The aim of this study was to evaluate FTR rates after major liver resection for perihilar cholangiocarcinoma (pCCA) and analyze factors associated with FTR.

PATIENTS AND METHOD

Patients who underwent major liver resection for pCCA at 27 centers were included. FTR was defined as the presence of a Dindo grade III or higher complication followed by death within 90 days after surgery. Liver failure ISGLS grade B/C were scored. Multivariable logistic analysis was performed to identify predictors of FTR and reported using odds ratio and 95% confidence intervals.

RESULTS

In the 2186 included patients, major morbidity rate was 49%, 90-day mortality rate 13%, and FTR occurred in 24% of patients with a grade III or higher complication. Across centers, major complication rate varied from 19 to 87%, 90-day mortality rate from 5 to 33%, and FTR ranged from 11 to 50% across hospitals. Age [1.04 (1.02-1.05) years], ASA 3 or 4 [1.40 (1.01-1.95)], jaundice at presentation [1.79 (1.16-2.76)], right-sided resection [1.45 (1.06-1.98)], and annual hospital volume < 6 [1.44 (1.07-1.94)] were positively associated with FTR. When liver failure is included, the odds ratio for FTR is 9.58 (6.76-13.68).

CONCLUSION

FTR occurred in 24% of patients after resection for pCCA. Liver failure was associated with a nine-fold increase of FTR and hospital volume below six was also associated with an increased risk of FTR.

Future liver remnant volumetry: an E-AHPBA international survey of current practice among liver surgeons

BACKGROUND

Accurate assessment of the future liver remnant (FLR) is crucial for predicting the risk of post-hepatectomy liver failure (PHLF). This survey aims to evaluate the current practices of liver surgeons regarding FLR volumetry and its clinical use.

METHODS

A cross-sectional survey was conducted among 212 liver surgeons to assess their use of FLR volumetry and associated methodologies. The survey consisted of 40 questions distributed in five sections covering multiple aspects of FLR volumetry.

RESULTS

Ninety percent of respondents utilize preoperative FLR volumetry. However, there is significant variability in the methods used for FLR calculation and the thresholds for safe liver resection, which deviate from the proposed 20/30/40 % rule. Before right hepatectomy, 21 % of respondents indicated that they rarely or never utilise volumetry. Extended resections are the surgical procedures in which volumetry is most frequently employed. Furthermore, the kinetic growth rate is not widely adopted in clinical decision making.

CONCLUSION

This survey highlights the widespread use of FLR volumetry, but also reveals substantial variation in its application. This demonstrates a lack of evidence or guidelines regarding the appropriate use of FLR volumetry.

Preoperative setting of functional liver volume enhanced by portal and hepatic vein embolization is key in preventing serious morbidity after hepatectomy with bile duct resection for biliary tract cancer

BACKGROUND

The risk of mortality due to serious complications associated with hepatectomy for biliary tract cancer remains high. We aimed to investigate the significance of preoperative functional liver volume in predicting and preventing serious morbidity following hepatectomy with bile duct resection (BDR).

METHODS

Seventy-one patients who underwent hepatectomy with BDR for biliary tract cancer were included. Functional future remnant liver volume (fFRLV) was calculated using future liver remnant (FLR) volume and functional score measured using EOB-MRI. Patients with unsatisfactory fFRLV values underwent portal or sequential portal/hepatic vein embolization (PVE/HVE). We assessed relationship between variables for liver-related morbidity (LRM), including posthepatectomy liver failure, bile leakage, and persistent ascites. Additionally, we assessed Clavien-Dindo grade IV complications (CD ≥ IV) as indicators of serious morbidity.

RESULTS

LRM and CD ≥ IV occurred in 20 (28.2 %) and 6 (8.5 %) cases, respectively. Preoperative FLR volume (p = 0.021), FLR ratio (p = 0.004), fFRLV (p = 0.008), and ICGK-F (p = 0.023) were associated with LRM. fFRLV (p = 0.017) was predictive for LRM but not independent (AUC:0.704). Preoperative FLR volume (p = 0.005), FLR ratio (p = 0.008), and fFRLV (p < 0.001) were associated with CD ≥ IV. fFRLV (p = 0.017) was an independent predictive factor for CD ≥ IV(AUC:0.914), showing greater predictive power compared to other factors.

CONCLUSION

fFRLV predicts CD ≥ IV in patients undergoing hepatectomy with BDR. A sufficient fFRLV, enhanced by PVE/HVE if necessary, may prevent serious morbidity and mortality.

Initial experience of parenchyma-sparing liver resection with systematic selective hepatic vein reconstruction for colorectal metastases

Objectives

This study aims to assess the feasibility and short-term and intermediate-term technical success rate of the concept of systematic selective hepatic vein (HV) reconstruction for parenchyma-sparing hepatectomies (PSHs) in patients with colorectal liver metastases (CRLM) in accordance with stage 2a of the IDEAL framework.

Design

The prospective case series of patients deemed eligible and operated on according to the concept.

Setting

All patients were treated by a single surgical team in three hospitals in Ukraine from June 2022 to November 2023.

Participants

The study included nine cases of resectable CRLM with at least one lesion located in the hepatocaval confluence with HV(s) invasion, for whom reconstruction of the HV(s) allowed for additional parenchyma preservation, being an alternative to major or extended hepatectomy.

Interventions

Liver resections with different types of HVs reconstruction (primary closure, patching, end-to-end anastomosis with or without grafting) were performed after a thorough evaluation of the future liver remnant volume, volume of potentially additionally preserved parenchyma and possibility of future repeat hepatectomies.

Main outcome measures

Postoperative morbidity, short-term and long-term patency of the reconstructed vessels, and the volume of additionally preserved parenchyma were the focus.

Results

Segmental resection was performed in four cases, two with graft interposition. Patch reconstruction was performed for three HVs and two inferior vena cava resections. Two cases required primary closure. No mortality was observed, while the major morbidity rate was 33%. The short-term and long-term patency of the reconstructed HVs was 88.9% and 66.7%, respectively. HV reconstructions allowed the preservation of additional parenchyma (mean 495.4 mL, 95% CI 350.2 to 640.7). A decision-making algorithm to be used within the described approach is proposed.

Conclusions

Selective HV reconstruction is a feasible approach for PSH for CRLM. Further studies are needed to compare this approach to convenient major hepatectomies.

Dynamic [99mTc]Tc-mebrofenin SPECT/CT in preoperative planning of liver resection: a prospective study

BACKGROUND

At least 20% of the future liver remnant must function properly after liver tumor resection to avoid post-hepatectomy liver failure (PHLF). [99mTc]Tc-mebrofenin scintigraphy and SPECT are unique noninvasive, quantitative methods for evaluating liver function via hepatocellular bilirubin clearance.

AIM

To evaluate the value of dynamic [99mTc]Tc-mebrofenin SPECT/CT parameters for predicting clinically relevant PHLF according to the ISGLS criteria.

METHODS

Thirty-five patients underwent dynamic [99mTc]Tc-mebrofenin SPECT/CT imaging to determine the FLR volumetric rate, functional volume rate, total liver filtration and FLR filtration. On the same day, two-dimensional ultrasound shear wave elastography (2D-SWE) was used to assess parenchymal fibrosis in the FLR. The quantitative dynamic SPECT parameters were compared with the relevant clinical scores and ICG.

RESULTS

The total liver filtration was inversely correlated with the ICG-R15 and MELD-Na score. Twenty-four patients underwent major liver resection due to an adequate FLR rate and did not die within 90 days after the procedure. ROC analysis revealed that the FLR filtration was a significant predictor of PHLF. The best cutoff value for FLR filtration was 2.72%/min/m2.

CONCLUSION

Dynamic [99mTc]Tc-mebrofenin SPECT/CT is an essential tool for selecting patients at risk of clinically relevant PHLF after liver resection.

The assessment of impaired liver function and prognosis in hepatocellular carcinoma

INTRODUCTION

The impairment of liver function strongly limits the therapeutic options for hepatocellular carcinoma (HCC), and the assessment of liver function is key to finding the appropriate therapy for patients suffering from this disease. Furthermore, preexisting liver dysfunction has a negative impact on the prognosis of patients in addition to the malignant potential of HCC. Hence, defining the optimal treatment of patients with HCC requires a comprehensive examination with liver function being a crucial part of it.

AREAS COVERED

This review will provide an overview of the currently existing methods for evaluating the liver function in patients with HCC. Assessment of liver function includes scoring systems but also functional and technical methods. In addition, the role of these tests in different treatment facilities such as liver resection, transplantation, interventional and systemic therapy is summarized.

EXPERT OPINION

A comprehensive pretherapeutic assessment of the liver function includes laboratory-based scoring systems, as well as imaging- and non-imaging-based functional tests. Combining diverse parameters can help to improve the safety and efficacy of HCC therapy particularly in patients with compromised liver function. Future research should focus on optimizing pretherapeutic assessment recommendations for each therapy.

Use of selective internal radiation therapy with yttrium-90 as a bridge to liver resection: a 5-year single-center experience

BACKGROUND

Selective internal radiation therapy (SIRT) with yttrium-90 (Y-90) has been historically reserved for unresectable liver malignancy. Evidence is emerging for the use of SIRT to increase future liver remnant (FLR), allowing for the resection of previously inoperable disease.

METHODS

This was a 5-year retrospective review of all patients undergoing SIRT with Y-90 at a tertiary institute. Patient demographics, clinicopathologic data, surgical details, and postoperative outcomes were reviewed. The primary outcome, safety of liver resection after SIRT, was evaluated with 90-day morbidity and mortality.

RESULTS

A total of 134 SIRT procedures were performed on 113 patients. Post-SIRT complications occurred in 18 patients (15.9%), with a single 30-day mortality. In addition, 17 patients underwent SIRT with the intent to augment FLR for liver resection. After SIRT, mean hepatic mebrofenin extraction and FLR increased from 2.5%/min/m2 and 30.5% to 4.2%/min/m2 and 52.5% (P = .01 and P < .0001, respectively). Ten patients underwent resection, and there were 2 intraoperative complications. The median time from SIRT to resection was 5.2 months. The 90-day postoperative morbidity was 20% (n = 2), and complications were analyzed according to the Clavien-Dindo II classification scale. There was no 30-day or 90-day postoperative mortality.

CONCLUSION

Post-SIRT liver resection is a challenging procedure with low postoperative mortality and morbidity.

Liver venous deprivation (LVD) before extended hepatectomy: a French multicentric retrospective cohort

Background

Post-hepatectomy liver failure (PHLF) is the first cause of death after major hepatectomy, and future liver remnant (FLR) volume is the main factor predicting PHLF. Liver venous deprivation (LVD) via portal and hepatic vein embolization has been suggested to induce a better hypertrophy of the FLR than portal vein embolization. The aim of this retrospective multicentric study was to assess safety, feasibility and efficacity of LVD in a French national multicentric register.

Methods

Between 2016 and 2023, LVD was performed in 7 expert centers, for patients with liver malignancies requiring major hepatectomy with an FLR percentage of total liver volume (FLR%) ≤25% for a healthy liver or <30% for a diseased liver. FLR volumetry was assessed before and 4 weeks after the procedure.

Results

One hundred and ninety-two patients were included in the study. The technical success rate was 100% and severe complication rate post-LVD was 2.6% (5/192). The FLR% increased by 61.7% over an average of 27±9.7 days. Major hepatectomy was performed 40 days after LVD on 161 (83.8%) patients. Hepatectomy was not performed on 31 (16.2%) patients, mostly because of oncological progression. Severe postoperative complications (Clavien-Dindo grade ≥ IIIA) occurred in 21.1% (34/161) of patients. Postoperative mortality rate was 4.3% (7/161).

Conclusions

This study is the largest to confirm that LVD is a safe, reproducible, efficient technique that induces rapid major FLR growth. However, this new technique needs to be standardized and harmonized between centers to ensure uniform results.

Comprehensive Review of Future Liver Remnant (FLR) Assessment and Hypertrophy Techniques Before Major Hepatectomy: How to Assess and Manage the FLR

BACKGROUND

The regenerative capacities of the liver and improvements in surgical techniques have expanded the possibilities of resectability. Liver resection is often the only curative treatment for primary and secondary malignancies, despite the risk of post-hepatectomy liver failure (PHLF). This serious complication (with a 50% mortality rate) can be avoided by better assessment of liver volume and function of the future liver remnant (FLR).

OBJECTIVE

The aim of this review was to understand and assess clinical, biological, and imaging predictors of PHLF risk, as well as the various hypertrophy techniques, to achieve an adequate FLR before hepatectomy.

METHOD

We reviewed the state of the art in liver regeneration and FLR hypertrophy techniques.

RESULTS

The use of new biological scores (such as the aspartate aminotransferase/platelet ratio index + albumin-bilirubin [APRI+ALBI] score), concurrent utilization of 99mTc-mebrofenin scintigraphy (HBS), or dynamic hepatocyte contrast-enhanced MRI (DHCE-MRI) for liver volumetry helps predict the risk of PHLF. Besides portal vein embolization, there are other FLR optimization techniques that have their indications in case of risk of failure (e.g., associating liver partition and portal vein ligation for staged hepatectomy, liver venous deprivation) or in specific situations (transarterial radioembolization).

CONCLUSION

There is a need to standardize volumetry and function measurement techniques, as well as FLR hypertrophy techniques, to limit the risk of PHLF.

Impact of the future liver remnant volume before major hepatectomy

INTRODUCTION

Following major liver resection, posthepatectomy liver failure (PHLF) is associated with a high mortality rate. As there is no therapy for PHLF available, avoidance remains the main goal. A sufficient future liver remnant (FLR) is one of the most important factors to reduce the risk for PHLF; however, it is not known which patients benefit of volumetric assessment prior to major surgery.

METHODS

A retrospective, bi-institutional cohort study was conducted including all patients who underwent major hepatectomy (extended right hepatectomy, right hepatectomy, extended left hepatectomy and left hepatectomy) between 2010 and 2023.

RESULTS

A total of 1511 major hepatectomies were included, with 29.4 % of patients undergoing FLR volume assessment preoperatively. Overall, PHLF B/C occurred in 9.8 % of cases. Multivariate analysis identified diabetes mellitus, extended right hepatectomy, perihilar cholangiocarcinoma (pCCA), gallbladder cancer (GBC) and cirrhosis as significant risk factors for PHLF B/C. High-risk patients (with one or more risk factors) had a 15 % overall incidence of PHLF, increasing to 32 % with a FLR <30 %, and 13 % with an FLR of 30-40 %. Low-risk patients with a FLR <30 % had a PHLF rate of 21 %, which decreased to 8 % and 5 % for FLRs of 30-40 % and >40 %, respectively. For right hepatectomy, the PHLF rate was 23 % in low-risk and 38 % in high-risk patients with FLR <30 %.

CONCLUSION

Patients scheduled for right hepatectomy and extended right hepatectomy should undergo volumetric assessment of the FLR. Volumetry should always be considered before major hepatectomy in patients with risk factors such as diabetes, cirrhosis, GBC and pCCA. In high-risk patients, a FLR cut-off of 30 % may be insufficient to prevent PHLF, and additional liver function assessment should be considered.

Transfemoral hepatic vein access in double vein embolization - initial experience and feasibility

BACKGROUND

Hepatic vein embolization in double vein embolization (DVE) can be performed with transhepatic, transjugular or transfemoral access. This study evaluates the feasibility and technical success of using a transfemoral access for the hepatic vein embolization in patients undergoing preoperative to induce hypertrophy of the future liver remnant (FLR).

MATERIAL AND METHODS

Retrospective analysis of single center cohort including 17 consecutive patients. The baseline standardized FLR was 18.2% (range 14.7-24.9). Portal vein embolization was performed with vascular plugs and glue through an ipsilateral transhepatic access. Hepatic vein embolization was performed using vascular plugs. Access for the hepatic vein was either transhepatic, transjugular or transfemoral. Technical success, number of hepatic veins embolized and complications were registered. In addition, volumetric data including degree of hypertrophy (DH) and kinetic growth rate (KGR), and resection data were registered. R: Seven of the 17 patients had transfemoral hepatic vein embolization, with 100% technical success. No severe complications were registered. In the whole cohort, the median number of hepatic veins embolized was 2 (1-6). DH was 8.6% (3.0-19.4) and KGR was 3.6%/week (1.4-7.4), without significant differences between the patients having transfemoral versus transhepatic /transjugular access (p = 0.48 and 0.54 respectively). Time from DVE to surgery was median 4.8 weeks (2.6-33.9) for the whole cohort, with one patient declining surgery, two having explorative laparotomy and one patient having change of surgical strategy due to insufficient growth.

CONCLUSION

Transfemoral access is a feasible option with a high degree of technical success for hepatic vein embolization in patients with small future liver remnants needing DVE.

Comparison of Complications in Patients with Ductal Cholangiocarcinoma (CCC) and Patients with Colorectal Liver Metastases (CRLMs) After Portal Vein Embolization (PVE): A Matched Cohort Study

PURPOSE

To compare complications in patients with cholangiocarcinoma (CCC) and patients with colorectal liver metastases (CRLMs) after portal vein embolization (PVE) and to identify possible predictive factors.

MATERIAL AND METHODS

Retrospective analysis of consecutive patients, who underwent PVE between July 2011 and March 2020. The study groups were matched for sex and age. Multivariable analysis was performed for the endpoints of complications categorized according for their respective effect on surgical treatment: "Minor" complications had no effect on subsequent surgical treatment, while "intermediate" and "severe" complications delayed or prevented surgery.

RESULTS

A total of 160 patients with either CCC (n = 80) or CRLMs (n = 80) were included: 34/160 experienced complications: 27 (CCC: 21; CRLMs: 6) "minor", 4 (CCC: 3; CRLMs: 1) "intermediate", and 3 (CCC: 2; CRLMs: 1) "severe" complications respectively (p = .01). Patients with CCC received a biliary drainage 5 days on average before PVE. Baseline bilirubin levels were 1.1 mg/dl in CCC patients and 0.55 mg/dl in CRLMs patients (p < .01). Postinterventional infections were more common in CCC patients. The preintervention future liver remnant volume (odds ratio (OR) 0.93; 95% confidence interval (CI) 0.88-0.99; p = .02), body mass index (OR 1.19; 95% CI 1.04-1.36; p = .01), age (OR 0,91; 95% CI 0.84-0.99; p = .01), chemotherapy before PVE (OR 0.03; 95% CI 0.01-0.23; p < .01) and severe liver steatosis (OR 29.52; 95% CI 1.87-467,13; p = .02) were the only significant predictive factors for the occurrence of (minor) complications.

CONCLUSION

PVE can be performed in CCC patients with prior biliary drainage, with similar procedural safety as in patients with CRLMs.

Surgical Considerations in Portal Hypertension

This review provides an in-depth exploration of portal hypertension (PH) and its implications in various surgical procedures. The prevalence of clinically significant PH is 50% to 60% in compensated cirrhosis and 100% in decompensated cirrhosis. The feasibility and safety of hepatic and nonhepatic surgical procedures in patients with PH has been shown. Adequate preoperative risk assessment and optimization of PH are integral parts of patient assessment. The occurrence of adverse outcomes after surgery has decreased over time in this specific population, due to the development of techniques and improved perioperative multidisciplinary care.

Role of liver augmentation prior to hepatic resection - a survey on standards, procedures, and indications in Germany, Switzerland, and Austria

PURPOSE

For primary and secondary liver tumors oncological resection remains a chance of cure. Augmentation of functional liver tissue may be necessary to preserve sufficient future liver remnant (FLR). Clinical decision-making on liver augmentation techniques and indications may differ internationally. Thus, this study aims to identify standards of liver augmentation in hepato-pancreatico-biliary (HPB) centers in Germany, Switzerland, and Austria.

METHODS

Using a web-based survey, 48 hospitals in Germany, Switzerland, and Austria were invited to report their surgical indication, standard procedures, and results of liver augmentation.

RESULTS

Forty (83.3%) of the hospitals invited participated. Most of the hospitals were certified liver centers (55%), performing complex surgeries such as liver transplantation (57.5%) and ALPPS (80%). The standard liver augmentation technique in all countries was portal vein embolization (PVE; 56%), followed by ALPPS (32.1%) in Germany or PVE with hepatic vein embolization (33.3%) in Switzerland and Austria. Standard procedure for liver augmentation did not correlate with certification as liver center, performance of liver transplantation or ALPPS. Surgical indication for PVE varied depending on tumor entity. Most hospitals rated the importance of PVE before resection of cholangiocarcinoma or colorectal metastases as high, while PVE for hepatocellular carcinoma was rated as low.

CONCLUSION

The survey gives an overview of the clinical routine in HPB centers in Germany, Austria, and Switzerland. PVE seems to dominate as standard technique to increase the FLR. However, there is a variety in the main indication for liver augmentation. Further studies are necessary evaluating the differing PVE techniques for liver augmentation.

The Interplay between Perioperative Oxidative Stress and Hepatic Dysfunction after Human Liver Resection: A Prospective Observational Pilot Study

Post-hepatectomy liver failure (PHLF) remains the major contributor to death after liver resection. Oxidative stress is associated with postoperative complications, but its impact on liver function is unclear. This first in-human, prospective, single-center, observational pilot study evaluated perioperative oxidative stress and PHLF according to the ISGLS (International Study Group for Liver Surgery). Serum 8-isoprostane, 4-hydroxynonenal (4-HNE), total antioxidative capacity, vitamins A and E, and intraoperative, sequential hepatic tissue 4-HNE and UCP2 (uncoupling protein 2) immunohistochemistry (IHC) were assessed. The interaction with known risk factors for PHLF and the predictive potential of oxidative stress markers were analyzed. Overall, 52 patients were included (69.2% major liver resection). Thirteen patients (25%) experienced PHLF, a major factor for 90-day mortality (23% vs. 0%; p = 0.013). Post-resection, pro-oxidative 8-isoprostane significantly increased (p = 0.038), while 4-HNE declined immediately (p < 0.001). Antioxidative markers showed patterns of consumption starting post-resection (p < 0.001). Liver tissue oxidative stress increased stepwise from biopsies taken after laparotomy to post-resection in situ liver and resection specimens (all p < 0.001). Cholangiocarcinoma patients demonstrated significantly higher serum and tissue oxidative stress levels at various timepoints, with consistently higher preoperative values in advanced tumor stages. Combining intraoperative, post-resection 4-HNE serum levels and in situ IHC early predicted PHLF with an AUC of 0.855 (63.6% vs. 0%; p < 0.001). This was also associated with grade B/C PHLF (36.4% vs. 0%; p = 0.021) and 90-day mortality (18.2% vs. 0%; p = 0.036). In conclusion, distinct patterns of perioperative oxidative stress levels occur in patients with liver dysfunction. Combining intraoperative serum and liver tissue markers predicts subsequent PHLF. Cholangiocarcinoma patients demonstrated pronounced systemic and hepatic oxidative stress, with increasing levels in advanced tumor stages, thus representing a worthwhile target for future exploratory and therapeutic studies.

Short-term postoperative outcomes of lymphadenectomy for cholangiocarcinoma, hepatocellular carcinoma and colorectal liver metastases in the modern era of liver surgery: Insights from the StuDoQ|Liver registry

INTRODUCTION

The clinical role of lymphadenectomy (LAD) as part of hepatic resection for malignancies of the liver remains unclear. In this study, we aimed to report on the use cases and postoperative outcomes of liver resection and simultaneous LAD for hepatic malignancies (HM).

MATERIALS AND METHODS

Clinicopathological data from patients who underwent surgery at 13 German centers from 2017 to 2022 (n = 3456) was extracted from the StuDoQ|Liver registry of the German Society of General and Visceral Surgery. Propensity-score matching (PSM) was performed to account for the extent of liver resection and patient demographics.

RESULTS

LAD was performed in 545 (16%) cases. The most common indication for LAD was cholangiocarcinoma (CCA), followed by colorectal liver metastases (CRLM) and hepatocellular carcinoma (HCC). N+ status was found in 7 (8%), 59 (35%), and 56 cases (35%) for HCC, CCA, and CRLM, respectively (p < 0.001). The LAD rate was highest for robotic-assisted resections (28%) followed by open (26%) and laparoscopic resections (13%), whereas the number of resected lymph nodes was equivalent between the techniques (p = 0.303). LAD was associated with an increased risk of liver-specific postoperative complications, especially for patients with HCC.

CONCLUSION

In this multicenter registry study, LAD was found to be associated with an increased risk of liver-specific complications. The highest rate of LAD was observed among robotic liver resections.

Comparison of the LiMAx test vs. the APRI+ALBI score for clinical utility in preoperative risk assessment in patients undergoing liver surgery - A European multicenter study

INTRODUCTION

Posthepatectomy liver failure (PHLF) remains the main reason for short-term mortality after liver surgery. APRI+ALBI, aspartate aminotransferase to platelet ratio (APRI) combined with albumin-bilirubin grade (ALBI), score and the liver function maximum capacity test (LiMAx) are both established preoperative (preop) liver function tests. The aim of this study was to compare both tests for their predictive potential for clinically significant PHLF grade B and C (B+C).

MATERIALS AND METHODS

352 patients were included from 4 European centers. Patients had available preop APRI+ALBI scores and LiMAx results. Predictive potential for PHLF, PHLF B+C and 90-day mortality was compared using receiver operating characteristic (ROC) curve analysis and calculation of the area under the curve (AUC). Published cutoffs of ≥ -2.46 for APRI+ALBI and of <315 for LiMAx were assessed using chi-squared test.

RESULTS

APRI+ALBI showed superior predictive potential for PHLF B+C (N = 34; AUC = 0.766), PHLF grade C (N = 20; AUC = 0.782) and 90-day mortality (N = 15; AUC = 0.750). When comparing the established cutoffs of both tests, APRI+ALBI outperformed LiMAx in prediction of PHLF B+C (APRI+ALBI ≥2.46: Positive predictive value (PPV) = 19%, negative predictive value (NPV) = 97%; LiMAx <315: PPV = 3%, NPV = 90%) and 90-day mortality (APRI+ALBI ≥2.46: PPV = 12%, NPV = 99%; LiMAx <315: PPV = 0%, NPV = 94%) CONCLUSION: In our analysis, APRI+ALBI outperformed LiMAx measurement in the preop prediction of PHLF B+C and postoperative mortality, at a fraction of the costs, manual labor and invasiveness.

Extended Right Hepatectomy following Clearance of the Left Liver Lobe and Portal Vein Embolization for Curatively Intended Treatment of Extensive Bilobar Colorectal Liver Metastases: A Single-Center Case Series

BACKGROUND

Two-staged hepatectomy (TSH) including portal vein embolization (PVE) may offer surgical treatment for extensive bilobar colorectal liver metastases (CRLM). This study aimed to investigate the feasibility and outcomes of extended right hepatectomy (ERH) within TSH including PVE for patients with extended CRLM.

METHODS

We retrospectively collected data of patients who underwent TSH for extended CRLM between 2015 and 2021 at our institution. Clearance of the left liver lobe (clear-up, CU) associated with PVE was followed by ERH.

RESULTS

Minimally invasive (n = 12, 46%, MIH) or open hepatectomy (n = 14, 54%, OH) was performed. Postoperative major morbidity and 90-day mortality were 54% and 0%. Three-year overall survival was 95%. Baseline characteristics, postoperative and long-term outcomes were comparable between MIH and OH. However, hospital stay was significantly shorter after MIH (8 vs. 15 days, p = 0.008). Additionally, the need for intraoperative transfusions tended to be lower in the MIH group (17% vs. 50%, p = 0.110).

CONCLUSIONS

ERH following CU and PVE for extended CRLM is feasible and safe in laparoscopic and open approaches. MIH for ERH may result in shorter postoperative hospital stays. Further high-volume, multicenter studies are required to evaluate the potential superiority of MIH.

Hepatocellular Carcinoma: The Role of Surgery in Liver Cirrhosis

Background

Liver surgery is an essential component of hepatocellular carcinoma (HCC) treatment. Advances in surgical techniques and perioperative care have improved outcomes and have helped to expand surgical indications. However, liver fibrosis and cirrhosis still remain major problems for liver surgery due to the relevant impact on liver regeneration of the future liver remnant (FLR) after surgery. Especially in patients with clinically significant portal hypertension due to liver cirrhosis, surgery is limited. Despite recent efforts in developing predictive models, estimating the postoperative hepatic function remains difficult.

Summary

In this review, we focus on the role of surgery in the treatment of HCC in structurally altered livers. The importance of assessing FLR with techniques such as contrast-enhanced CT, e.g., with the help of artificial intelligence is highlighted. Moreover, strategies for increasing the FLR with approaches like portal vein embolization and liver vein deprivation prior to surgery are discussed. Patient selection, minimally invasive liver surgery including robotic techniques, and perioperative concepts like the Enhanced Recovery After Surgery (ERAS) guidelines are identified as crucial parts of avoiding posthepatectomy liver failure.

Key Message

The need for ongoing research to optimize patient selection criteria and perioperative care and to develop innovative biomarkers for outcome prediction is emphasized.

The Impact of Chemotherapy and Transforming Growth Factor-β1 in Liver Regeneration after Hepatectomy among Colorectal Cancer Patients

An ongoing debate surrounds the impact of chemotherapy on post-hepatectomy liver regeneration in patients with colorectal cancer liver metastases (CRLM), with unclear regulatory mechanisms. This study sought to delve into liver regeneration post-resection in CRLM patients, specifically examining the roles of hepatocyte growth factor (HGF) and transforming growth factor β1 (TGF-β1). In this longitudinal observational study, 17 patients undergoing major liver resection for CRLM and 17 with benign indications as controls were enrolled. Liver regeneration within 30 postoperative days was assessed via CT, considering clinicopathological characteristics, liver enzymes, liver stiffness by elastography, and the impact of HGF and TGF-β1 on liver regeneration. The results revealed that the control group exhibited significantly higher mean liver regeneration volume (200 ± 180 mL) within 30 days postoperatively compared to the CRLM group (72 ± 154 mL); p = 0.03. Baseline alkaline phosphatase (AP) and TGF-β1 blood levels were notably higher in the CRLM group. Immunohistochemical analysis indicated a higher proportion of CRLM patients with high TGF-β1 expression in liver tissues compared to the control group (p = 0.034). Correlation analysis showed that resected liver volume, baseline plasma HGF, AP, and albumin levels significantly correlated with liver regeneration volume. However, in multivariable analysis, only resected liver volume (β: 0.31; 95% CI: 0.14-0.47, p = 0.01) remained significant. In conclusion, this study highlights compromised liver regeneration in CRLM patients post-chemotherapy. Additionally, these patients exhibited lower serum TGF-β1 levels and reduced TGF-β1 expression in liver tissue, suggesting TGF-β1 involvement in mechanisms hindering liver regeneration capacity following major resection after chemotherapy.

[The Russian consensus on the treatment of intrahepatic cholangiocarcinoma]

The Russian consensus on the treatment of intrahepatic cholangiocarcinoma was prepared by the group of experts consisting of surgeons, interventional radiologists, radiation therapists and oncologists. The purposes of this consensus are clarification and consolidation of opinions of multidisciplinary team on the following issues of management of patients with intrahepatic cholangiocarcinoma: indications for surgical treatment, features of therapeutic tactics for mechanical jaundice, technical aspects of liver resection, prevention of post-resection liver failure, indications for liver resection using transplantation technologies, laparoscopic and robot-assisted liver resection, perioperative systemic chemotherapy, local non-resection/non-radiotherapy methods of treatment, radiotherapy, follow-up and choice of treatment for recurrence.

Hepatocellular carcinoma

An update on the management of Hepatocellular carcinoma (HCC) is provided in the present article for those interested in the UEMS/EBSQ exam in Surgical Oncology. The most recent publications in HCC, including surveillance, guidelines, and indications for liver resection, liver transplantation, and locoregional or systemic therapies, are summarised. The objective is to yield a set of main points regarding HCC that are required in the core curriculum of hepatobiliary oncological surgery.

A Review of Resection and Surgical Ablation for Primary and Secondary Liver Cancers

The surgical management of primary and secondary liver tumors is constantly evolving. Patient selection, particularly with regard to determining resectability, is vital to the success of programs directed toward invasive treatments of liver tumors. Particular attention should be paid toward determining whether patients are best served with surgical resection or ablative therapies. A multidisciplinary approach is necessary to provide optimal care to patients with liver malignancy.