Indications for Surgery in Cirrhotic Patients

Liver resection (LR) still remains one of the main curative options for hepatocellular carcinoma (HCC). When HCC is diagnosed in the cirrhotic liver, the indication for LR should be carefully established. The assessment of such patients should not consider only tumor burden, but must also necessarily include an accurate evaluation of the preoperative liver function to reduce the risk of the most feared complication following LR, that is, post-hepatectomy liver failure (PHLF). PHLF represents the most important cause of postoperative 90-day mortality and is the most commonly used measure to assess the early postoperative outcome. The evaluation of liver function includes assessment of functional reserve of the cirrhotic liver, presence of portal hypertension, extent of LR, volume of functional remnant liver (FRLV), patient performance status and comorbidities. Furthermore, LR should be carefully evaluated against liver transplantation, when this can be a chance of cure, and other potentially curative therapies such as ablation.