EASL–EORTC Clinical Practice Guidelines (CPG) on the management of hepatocellular carcinoma (HCC) define the use of surveillance, diagnosis, and therapeutic strategies recommended for patients with this type of cancer. This is the first European joint effort by the European Association for the Study of the Liver (EASL) and the European Organization for Research and Treatment of Cancer (EORTC) to provide common guidelines for the management of hepatocellular carcinoma. These guidelines update the recommendations reported by the EASL panel of experts in HCC published in 2001 [1]. Several clinical and scientific advances have occurred during the past decade and, thus, a modern version of the document is urgently needed. The purpose of this document is to assist physicians, patients, health-care providers, and health-policy makers from Europe and worldwide in the decision-making process according to evidencebased data. Users of these guidelines should be aware that the recommendations are intended to guide clinical practice in circumstances where all possible resources and therapies are available. Thus, they should adapt the recommendations to their local regulations and/or team capacities, infrastructure, and cost– benefit strategies. Finally, this document sets out some recommendations that should be instrumental in advancing the research and knowledge of this disease and ultimately contribute to improve patient care. The EASL–EORTC CPG on the management of hepatocellular carcinoma provide recommendations based on the level of evidence and the strength of the data (the classification of evidence is adapted from National Cancer Institute [2]) (Table 1A) and the strength of recommendations following previously reported systems (GRADE systems) (Table 1B).

http://www.bclc.cat/download/easl-guidelines.pdf

EASL-EORTC Clinical Practice Guidelines: Management of hepatocellular carcinoma European Association for the Study of the Liver ⇑ , European Organisation for Research and Treatment of Cancer

/pdf/nccn-clinical-practice-guidelines-in-oncology-hepatobiliary-1kpacqqvi8.pdf

NCCN clinical practice guidelines in oncology: hepatobiliary cancers.

Posthepatectomy liver failure: A definition and grading by the International Study Group of Liver Surgery (ISGLS)

Objective
To assess the nature of changes in the field of hepatic resectional surgery and their impact on perioperative outcome.

Improvement in Perioperative Outcome After Hepatic Resection: Analysis of 1,803 Consecutive Cases Over the Past Decade

Purpose Chemotherapy before resection of hepatic colorectal metastases (CRM) may cause hepatic injury and affect postoperative outcome. Patients and Methods Four hundred six patients underwent hepatic resection of CRM between 1992 and 2005. Pathologic review of the nontumorous liver was performed using established criteria for steatosis, steatohepatitis, and sinusoidal injury. The effect of chemotherapy and liver injury on perioperative outcome was analyzed. Results One hundred fifty-eight patients (38.9%) received no preoperative chemotherapy, whereas 248 patients (61.1%) did. The median duration of chemotherapy was 16 weeks (range, 2 to 70 weeks). Chemotherapy consisted of fluoropyrimidine-based regimens (fluorouracil [FU] alone, 15.5%; irinotecan plus FU, 23.1%; and oxaliplatin plus FU, 19.5%) and other therapy (3.0%). On pathologic analysis, 36 patients (8.9%) had steatosis, 34 (8.4%) had steatohepatitis, and 22 (5.4%) had sinusoidal dilation. Oxaliplatin was associated with sinusoidal dilation compared with no chemotherapy (18.9% v 1.9%, respectively; P .001; odds ratio [OR] 8.3; 95% CI, 2.9 to 23.6). In contrast, irinotecan was associated with steatohepatitis compared with no chemotherapy (20.2% v 4.4%, respectively; P .001; OR 5.4; 95% CI, 2.2 to 13.5). Patients with steatohepatitis had an increased 90-day mortality compared with patients who did not have steatohepatitis (14.7% v 1.6%, respectively; P .001; OR 10.5; 95% CI, 2.0 to 36.4). Conclusion Steatohepatitis is associated with an increased 90-day mortality after hepatic surgery. In patients with hepatic CRM, the chemotherapy regimen should be carefully considered because the risk of hepatotoxicity is significant.

https://ascopubs.org/doi/pdf/10.1200/JCO.2005.05.3074

Chemotherapy regimen predicts steatohepatitis and an increase in 90-day mortality after surgery for hepatic colorectal metastases

Background: Recent reports highlighting reduced mortality rates to less than 1% after hepatic resections have evaluated the management of selected patients. The current risk of liver resection in unselected patients needs to be more clearly defined to appreciate the actual risk of new indications. Study Design: From 1990 to 1997, 747 consecutive patients, including 16 operated in emergency, underwent hepatic resection. Resection was indicated for malignancy in 473 patients (63%). Major resections were performed in 333 patients (45%). An underlying liver disease, including cirrhosis (n = 239) and obstructive jaundice (n = 4), was present in 253 patients (35%). Multivariate analysis of the risk factors for postoperative mortality, morbidity, and transfusion after stratifying patients for the circumstance of the operation and the pathological changes of the remnant liver was performed. Results: There was no intraoperative death and the overall mortality rate was 4.4%. This rate was 25% after emergency liver resection and 3.9% after elective liver resection (p Conclusions: The 1% basic risk of elective liver resection on normal liver suggests that indications of resection for malignancy could be extended, unless an associated extrahepatic procedure is needed. Because of this low basic risk, future studies evaluating resection on normal liver should not consider in-hospital mortality as the only end point. (J Am Coll Surg 2000;191:38-46. © 2000 by the American College of Surgeons)

Seven hundred forty-seven hepatectomies in the 1990s: an update to evaluate the actual risk of liver resection.

Background: As the impact of obesity on surgical outcomes after colorectal resection is not well known, this study was designed to compare the results of colorectal resection in obese and nonobese patients.

Methods: From 1990 to 1997, 584 consecutive patients underwent elective colorectal resection in our department. Of these, 158 (27%) were obese (body mass index >27). Obese and nonobese patients were well matched for demographic data and surgical procedures.

Results: After right or left colectomy, no difference was noted between obese and nonobese patients for overall mortality, morbidity, or leakage rates. However, after left colectomy, postoperative intra-abdominal collections requiring treatment were significantly more frequent in obese than in nonobese patients (10% versus 2%; P 2 (P 60 years (P 2 (P <0.05) were significant risk factors for perioperative blood transfusions.

Conclusions: Our study suggested that, for obese patients, (1) right colectomy can be performed in the same manner as for nonobese patients; (2) after left colectomy, abdominal drainage may be indicated, and (3) after proctectomy, a defunctioning stoma should be recommended when diabetes mellitus or ASA status >2 is present, and an autologous blood transfusion could be discussed for patients >60 years old or with ASA status >2.

Impact of obesity on surgical outcomes after colorectal resection.

Background:

The aim of this case-matched study was to determine the best treatment strategy for patients with asymptomatic colorectal cancer and irresectable synchronous liver metastases.



Methods:

Between 1997 and 2002, 27 patients with asymptomatic colorectal cancer and irresectable synchronous liver metastases were treated by chemotherapy without initial primary resection (chemotherapy group). These 27 patients were compared with 32 patients matched for age, sex, performance status, primary tumour location, number of liver metastases, nature of irresectable disease and type of chemotherapy, but who were treated initially by resection of primary tumour (resection group).



Results:

The 2-year actuarial survival rate was 41 per cent in the chemotherapy group and 44 per cent in the resection group (P = 0·753). In the latter group, the mortality and morbidity rates for primary resection were 0 and 19 per cent (six of 32 patients) respectively. In the chemotherapy group, intestinal obstruction related to the primary tumour occurred in four of 27 patients. The mean overall hospital stay was 11 days in the chemotherapy group and 22 days in the resection group (P = 0·003).



Conclusion:

Systemic chemotherapy without resection of the bowel cancer is the option of choice because, for most patients, it is associated with a shorter hospital stay and avoids surgery without a detrimental effect on survival. Copyright © 2005 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

Treatment strategy for patients with colorectal cancer and synchronous irresectable liver metastases.

Background: The role of preoperative biliary drainage (PBD) before liver resection in the presence of obstructive jaundice remains controversial. Our patients with proximal duct carcinoma undergo noninvasive assessment followed by rapid laparotomy without PBD if the lesion is deemed resectable. Hypothesis: Our aim was to report operative outcome of these patients and to analyze their specific features by comparison with patients without biliary obstruction who underwent major liver resection. Design: A case-comparison study. Setting: A tertiary care university hospital in a metropolitan area. Patients: Twenty consecutive jaundiced patients underwent major liver resection without PBD. The jaundiced patients were matched with 27 nonjaundiced patients with normal underlying liver selected from a computer bank of 261 patients undergoing liver resections and identical for age, tumor size, type of liver resection, and vascular occlusion. Main Outcome Measure: Postoperative course including mortality, morbidity, transfusion rates, and results of liver function tests. Results: Seventeen jaundiced patients (85%) and 13 nonjaundiced patients (48%) received blood transfusions (P = .03). Morbidity was 50% in jaundiced and 15% in nonjaundiced patients (P = .006), mainly resulting from subphrenic collections and bile leaks occurring only in jaundiced patients. In contrast, there were no significant differences for mortality (5% vs 0%) and liver failure (5% vs 0%). Postoperative changes in liver function test results were comparable between groups. Conclusions: Major liver resections without PBD are safe in most patients with obstructive jaundice. Recovery of hepatic synthetic function is identical to that of nonjaundiced patients. Transfusion requirements and incidence of postoperative complications, especially bile leaks and subphrenic collections, are higher in jaundiced patients. Whether PBD could improve these results remains to be determined. Arch Surg. 2000;135:302-308

https://jamanetwork.com/journals/jamasurgery/articlepdf/390540/soa9089.pdf

Major liver resection for carcinoma in jaundiced patients without preoperative biliary drainage.

background
The surgical management of gallbladder carcinoma is controversial, especially as regards the indications for radical resection. The aim of this study was to evaluate the results of surgical treatment for gallbladder carcinoma with special reference to the extent of its histological spread.

Stéphane Benoist

Papers

Seven hundred forty-seven hepatectomies in the 1990s: an update to evaluate the actual risk of liver resection.

Impact of obesity on surgical outcomes after colorectal resection.

Treatment strategy for patients with colorectal cancer and synchronous irresectable liver metastases.

Major liver resection for carcinoma in jaundiced patients without preoperative biliary drainage.

Long-term results after curative resection for carcinoma of the gallbladder