Liu CL et al. (2006) Anterior approach versus conventional approach right hepatic resection for large hepatocellular carcinoma: a prospective randomized controlled study. Ann Surg 244: 194–203

Conventional-approach (CA) right hepatic resection for large hepatocellular carcinoma (HCC) can lead to iatrogenic tumor rupture and the spillage of cancer cells into the circulation. An anterior-approach (AA) technique involving complete venous outflow control before right liver mobilization avoids potential tumor cell release.

In a prospective controlled study, 120 patients with large (≥5 cm) liver HCC were randomized to either AA (n = 60) or CA (n = 60) right hepatic resection. Operative and survival outcomes of the two groups were recorded, and levels of plasma albumin mRNA were quantified as evidence of the number of liver cells released into the circulation by each procedure.

The two groups of patients showed similar operative blood loss, morbidity and duration of procedure; however, a higher number of patients in the CA group had major blood loss (≥2 l), resulting in a higher number of blood transfusions in this group. Overall cumulative survival of the AA group was significantly longer than that of the CA group (>68.1 months versus 22.6 months; P = 0.006), a trend that was even stronger in patients with stage II disease (P = 0.0009) or lymphovascular permeation of the tumor (P = 0.034). In addition, patients in the AA group recorded lower plasma albumin mRNA levels at a number of stages of surgery. Multivariate analysis revealed that tumor staging, resection margin, and AA technique were all independent factors affecting overall survival. On the basis of these results, the researchers recommend the AA right hepatic resection technique for large HCC.