Risk factors for perioperative morbidity and mortality after extended hepatectomy for hepatocellular carcinoma

BACKGROUND: Extended hepatectomy with resection of more than four segments is a high-risk operation, especially in patients with hepatocellular carcinoma (HCC) associated with chronic liver disease. This study evaluated the risk factors for morbidity and mortality following extended hepatectomy for HCC. METHODS: Preoperative and intraoperative variables of 155 patients who underwent extended hepatectomy for HCC were analysed to identify risk factors for postoperative morbidity and mortality. RESULTS: The overall morbidity rate was 55.5 per cent (n = 86). Most morbidity was due to ascites or pleural effusion. Significant life-threatening complications occurred in 20.0 per cent (n = 31). The perioperative mortality rate was 8.4 per cent (n = 13). Multivariate analysis found that portal clamping (P = 0.023) and perioperative blood transfusion (P < 0.001) were risk factors for morbidity, whereas perioperative blood transfusion (P < 0.001) was the only risk factor for significant morbidity. Co-morbid illness (P = 0.019) and perioperative blood transfusion (P = 0.004) were risk factors for perioperative mortality. CONCLUSION: Meticulous operative techniques to minimize blood loss and transfusion, while avoiding a prolonged Pringle manoeuvre, may help reduce postoperative morbidity. Avoidance of perioperative blood transfusion and careful preoperative selection of patients in terms of overall physiological status are important measures to reduce the postoperative mortality rate.     

Efficacy and safety of radiofrequency ablation for perivascular hepatocellular carcinoma without hepatic inflow occlusion

BACKGROUND: The role of radiofrequency ablation (RFA) for perivascular (up to 5 mm from the major intrahepatic portal vein or hepatic vein branches) hepatocellular carcinoma (HCC) is unclear because of possible incomplete tumour ablation and potential vascular damage. This study aimed to evaluate the safety and efficacy of RFA for perivascular HCC without hepatic inflow occlusion. METHODS: Between May 2001 and November 2003, RFA using an internally cooled electrode was performed on 52 patients with perivascular HCC (group 1) through open (n = 39), percutaneous (n = 9), laparoscopic (n = 2) and thoracoscopic (n = 2) approaches. Hepatic inflow occlusion was not applied during the ablation procedure. The perioperative and postoperative outcomes were compared with those of 90 patients with non-perivascular HCC (group 2) treated by RFA during the same period. RESULTS: The morbidity rate was similar between groups 1 and 2 (25 versus 28 per cent; P = 0.844). One patient in group 1 (2 per cent) and two in group 2 (2 per cent) had developed thrombosis of major intrahepatic blood vessels on follow-up computed tomography scan. There were no significant differences between groups 1 and 2 in mortality rate (2 versus 0 per cent; P = 0.366), complete ablation rate for small HCC (92 versus 98 per cent; P = 0.197), local recurrence rate (11 versus 9 per cent; P = 0.762) and overall survival (1-year: 86 versus 87 per cent; 2-year: 75 versus 75 per cent; P = 0.741). CONCLUSION: RFA without hepatic inflow occlusion is a safe and effective treatment for perivascular HCC.     

Perioperative real-time monitoring of indocyanine green clearance by pulse spectrophotometry predicts remnant liver functional reserve in resection of hepatocellular carcinoma

BACKGROUND: There is no standard method for predicting remnant liver functional reserve after hepatectomy or for monitoring it in real time. METHODS: Indocyanine green (ICG) clearance (K) was measured non-invasively and instantaneously using pulse spectrophotometry before surgery, during inflow occlusion and after hepatectomy in 75 patients who underwent anatomical liver resection for hepatocellular carcinoma (HCC). RESULTS: Eight patients (11 per cent) suffered liver failure and one (1 per cent) died in hospital. An estimated remnant K value of 0.090 per min was the cut-off value for liver failure. In a logistic regression model, the estimated remnant K (0.090 per min; P = 0.022) and age (65 years; P = 0.025) were significant predictors of postoperative liver failure. There was a correlation between the estimated and measured post-hepatectomy K, and between the inflow occlusion K and measured post-hepatectomy K (P < 0.001). The cut-off value of less than 0.090 per min for the estimated remnant K resulted in 88 per cent sensitivity and 82 per cent specificity for predicting liver failure. CONCLUSION: Perioperative real-time monitoring of ICG-K is useful for evaluating the remnant liver functional reserve before, during and after liver resection for HCC. The estimated remnant K is a significant predictor of liver failure.     

Therapeutic value of hepatectomy and transcatheter arterial embolization (TAE) for hepatocellular carcinoma]

Therapeutic value of hepatectomy and TAE was evaluated retrospectively in 150 hepatectomized and 117 non-hepatectomized patients of hepatocellular carcinoma (HCC). Operative death was seen in 5 patients. Cumulative 5 years survival rate and disease free cumulative 5 years survival rate of the 145 hepatectomized patients were 35.4 per cent and 23.6 per cent respectively. These survival rates were significantly affected by tumor size, intrahepatic metastasis (IM) and vascular invasion (Vp). But the influences of tumor margin (TW) and curative resection (relative curative or relative non-curative) were slight. Ninety-two patients (69:dead, 23:alive) had tumor recurrences. TAE was performed in 56 out of 92 patients effectively and 2 years survival rate was 31.5 per cent. Overall cumulative 5 years survival rate of non-hepatectomized patients was 6.6 per cent, but this group showed a more reduced hepatic reserve and more advanced tumor stage. Six patients treated by TAE survived more than 4 years. Hepatectomy is a first option for the treatment of HCC since complete cure may be estimated. However, because of operative risk and higher recurrence rate, use of current multidisciplinary treatment including TAE is necessary for the prognostic improvement of HCC with or without hepatectomy.     

Preoperative estimation of operative risk in liver surgery,with special reference to functional reserve of the remnant liver following major hepatic resection

Hepatic functional reserve was evaluated in 76 patients with known liver, biliary tract or pancreas diseases using kinetic analysis of removal of indocyanine green (ICG) with special reference to maximal removal rate (Rmax). In surgery other than hepatectomy, if ICG Rmax is below 0.4 mg/kg/min the operative risk should be considered high. In hepatic surgery, even if ICG Rmax is above 0.4 mg/kg/min the operative risk was high and it should be required to be above 1.0 mg/kg/min for extended lobectomy or hepatectomy. Furthermore, prior to hepatectomy the functional reserve of the remnant liver was estimated from an effective liver volume rate, calculated from the rate of uptake of radioisotope as measured by on-line computer system, and ICG Rmax. The functional reserve of the remnant liver was compared with the operative results, such as morbidity or mortality for each patient. When ICG Rmax of the remnant liver was below 0.4 mg/kg/min the prognosis was poor in hepatic surgery, because of there were three post-operative death and seven complications such as ascites or liver failure in the ten cases. On the other hand, when above 0.4 mg/kg/min, the prognosis was good without any postoperative death or complications in the twelve cases of hepatic surgery, as the completely same results for general surgery, in which it is as well when ICG Rmax of whole liver is above 0.4 mg/kg/min.     

Clinicopathologic features and postoperative prognosis of multicentric small hepatocellular carcinoma

BACKGROUND: Assessment of clinicopathologic characteristics and postoperative prognoses for patients with multicentric hepatocellular carcinoma (HCC) is important to determine not only a need to operate, but also an appropriate treatment after hepatic resection. STUDY DESIGN: Between May 1990 and April 1998, among 116 patients with an initial hepatectomy for HCC measuring 3 cm or less in maximum diameter, 34 patients had multicentric HCC (MC group), and 82 patients had single nodular HCC (SN group). To clarify the clinicopathologic features of patients in the MC group versus the SN group, we compared both the clinicopathologic parameters and the postoperative prognosis after curative hepatectomy between the two groups. RESULTS: The percentages of patients positive for hepatitis B surface antigen and hepatitis C virus antibody were not significantly different between the two groups. No differences were noted in pathologic characteristics of the main tumor or tumor markers. On the other hand, in the MC group, the percentage of patients evaluated in a Child's classification as either B or C was significantly higher (p < 0.05) than that of patients in the SN group, indicating that patients with multicentric HCC have a poor hepatic functional reserve. Both survival and disease-free survival of patients in the MC group who underwent a curative hepatectomy did not differ statistically from those in the SN group. CONCLUSIONS: Our results indicate that hepatic resection is useful, even for patients with multicentric HCC, if a curative hepatectomy can be performed and liver function can be saved, despite their poor hepatic functional reserve.     

Preoperative estimation of operative risk in liver surgery, with special reference to functional reserve of the remnant liver following major hepatic resection.

Hepatic functional reserve was evaluated in 76 patients with known liver, biliary tract or pancreas diseases using kinetic analysis of removal of indocyanine green (ICG) with special reference to maximal removal rate (Rmax). In surgery other than hepatectomy, if ICG Rmax is below 0.4 mg/kg/min the operative risk should be considered high. In hepatic surgery, even if ICG Rmax is above 0.4 mg/kg/min the operative risk was high and it should be required to be above 1.0 mg/kg/min for extended lobectomy or hepatectomy. Furthermore, prior to hepatectomy the functional reserve of the remnant liver was estimated from an effective liver volume rate, calculated from the rate of uptake of radioisotope as measured by on-line computer system, and ICG Rmax. The functional reserve of the remnant liver was compared with the operative results, such as morbidity or mortality for each patient. When ICG Rmax of the remnant liver was below 0.4 mg/kg/min the prognosis was poor in hepatic surgery, because of there were three postoperative death and seven complications such as ascites or liver failure in the ten cases. On the other hand, when above 0.4 mg/kg/min, the prognosis was good without any postoperative death or complications in the twelve cases of hepatic surgery, as the completely same results for general surgery, in which it is as well when ICG Rmax of whole liver is above 0.4 mg/kg/min.     

术前应用靛氰绿检测联合三维重建成像评估肝门部胆管癌肝脏储备功能

目的探讨肝门部胆管癌患者肝切除术前肝脏储备功能的评估方法及意义。方法单治疗组手术的肝门部胆管癌患者72例。比较通过靛氰绿(ICG)检测、三维成像(3D)重建评估后手术患者并发症发生率。结果 72例患者中,67例患者行ICG检测,56例ICG 15分钟滞留率(R15)10%,11例ICG R1510%。3D重建评估预留肝体积为(860.32±235.41)cm3,预留脏脏体积/全肝体积为38%~75%。32例患者术前采用ICG联合3D重建。术后并发胆漏5例,腹腔积液11例,并发症发生率为22.2%。各组间术后并发症发生率悲剧差异有统计学意义(P0.05)。结论术前ICG检查联合3D重建评估可定量评价患者肝脏储备功能,做出准确手术规划,减少术后并发症。     

Estimation of operative risk in cirrhotic patients, from the aspects of both functional reserve and morphological findings in the liver

In order to evaluate the operative risk in cirrhotic patients, the total risk is measured from the multivariant analyses of 10 useful liver function tests, such as ICG Rmax, LCAT and normotest, etc, and this is very useful on selection of the appropriate operative procedures and on evaluation of the prognosis. In the cases of hepatectomy, however, it is very useful on evaluation of the prognosis, if the functional reserve of the remnant liver could be estimate preoperatively. ICG Rmax of the remnant liver, estimated by our own method using Emission CT, may be the most valuable parameter of the functional reserve of the remnant liver. If ICG Rmax of the remnant liver is over 0.4 mg/kg/min, any types of hepatectomy could be performed with good results. Furthermore, if ICG Rmax of unit liver volume is over 0.8 microgram/kg/min/cm3, the remnant liver regenerates well with good recovering of the functional reserve, following long-term survival. The function of coagulation and reticuloendothelial system, and morphological findings of the liver are also significantly related to the operative results. Therefore, in surgery for cirrhotic patients, especially in hepatectomy, it is necessary to estimate the exact operative risk preoperatively, based on not only hepatic function tests but also coagulation profiles, RES function and morphological findings of the liver, and to select the adequate operative procedures, depending on the operative risk, in order to the excellent operative results.     

Repeat hepatic resection for recurrent colorectal liver metastases is associated with favourable long-term survival

BACKGROUND: The management of patients with recurrent colorectal liver metastases (RCLM) remains controversial. This study aimed to determine whether repeat liver resection for RCLM could be performed with acceptable morbidity, mortality and long-term survival. METHODS: Of 1121 consecutive liver resections performed and prospectively analysed between 1987 and 2005, 852 'curative' resections were performed on patients with colorectal liver metastases. Single liver resection was performed in 718 patients, and 71 repeat hepatic resections for RCLM were performed in 66 patients. RESULTS: There were no postoperative deaths following repeat hepatic resection compared with a postoperative mortality rate of 1.4 per cent after single hepatic resection. Postoperative morbidity was comparable following single and repeat hepatectomy (26.1 versus 18 per cent; P = 0.172), although median blood loss was greater during repeat resection (450 versus 350 ml; P = 0.006). Actuarial 1-, 3- and 5-year survival rates were 94, 68 and 44 per cent after repeat hepatic resection for RCLM, compared with 89.3, 51.7 and 29.5 per cent respectively following single hepatectomy. CONCLUSION: The beneficial outcomes observed after repeat liver resection in selected patients with RCLM confirm the experience of others and support its status as the preferred choice of treatment for such patients.     

Hepatectomy for hepatocellular carcinoma: the surgeon's role in long-term survival.

HYPOTHESIS: The surgeon can contribute substantially to the long-term survival rate of patients undergoing hepatectomy for hepatocellular carcinoma (HCC). DESIGN: The long-term survival rate of patients with HCC undergoing hepatectomy has improved, but the contribution of the surgeon to the improved survival rate is unknown. We surveyed 211 consecutive patients undergoing hepatectomy for HCC. The clinical, operative, and pathological factors were analyzed to identify factors that were important in affecting long-term survival. SETTING: A tertiary referral center. PATIENTS: From April 1989 to December 1995, 211 consecutive patients with HCC underwent 153 major and 58 minor hepatectomies. MAIN OUTCOME MEASURES: Disease-free and overall cumulative survival rate. RESULTS: The 5-year disease-free survival rate was 27%. By Cox regression analysis, blood transfusion (relative risk [RR], 1.21; 95% confidence interval [CI], 1.05-1.40) and TNM stage (RR, 1.90; 95% CI, 1.47-2.47) were shown to be independent prognostic factors in the 5-year disease-free survival rate. The 5-year overall cumulative survival rate was 37%. By Cox regression analysis, the preoperative indocyanine green retention value at 15 minutes after injection (RR, 1.03; 95% CI, 1.01-1.06), blood transfusion (RR, 1.191; 95% CI, 1.078-1.316), tumor rupture (RR, 1.48; 95% CI, 1.08-2.04), and TNM stage (RR, 1.62; 95% CI, 1.27-2.07) were shown to be significant independent factors that influenced cumulative survival rate. CONCLUSIONS: The long-term survival of patients with HCC after hepatectomy depends on tumor staging, preoperative hepatic functional reserve, history of blood transfusion, and rupture of HCC. Preoperative liver function and tumor staging cannot be altered; however, the surgeon can play an important role in improving the prognosis if blood transfusion and iatrogenic tumor rupture can be avoided and if function of the liver remnant can be preserved.     

Preoperative portal vein embolization improves prognosis after right hepatectomy for hepatocellular carcinoma in patients with impaired hepatic function

BACKGROUND: Percutaneous transhepatic portal vein embolization (PTPE) increases the safety of subsequent major hepatectomy. The aim of this study was to determine the effect of PTPE on long-term prognosis after hepatectomy in patients with hepatocellular carcinoma (HCC). METHODS: Seventy-one patients with HCC underwent right hepatectomy between 1984 and 1998. Preoperative PTPE was performed in 33 patients (group 1) and was not used in 38 patients (group 2). Outcome after operation was compared between the groups. The patients were further divided according to the median tumour diameter (cut-off 6 cm) and indocyanine green retention rate at 15 min (ICGR15) (cut-off 13 per cent). RESULTS: The cumulative survival rate was significantly higher in group 1 than in group 2 in patients with an ICGR15 of at least 13 per cent. Tumour-free survival rates were similar in both groups. Of patients with tumour recurrence after right hepatectomy, those in group 1 were more frequently subjected to further treatment. CONCLUSION: Preoperative PTPE improves the prognosis after right hepatectomy for HCC in patients with impaired hepatic function, although it does not prevent tumour recurrence.     

Laparoscopic liver resection

BACKGROUND: This paper describes a 10-year experience of laparoscopic liver surgery, including several major hepatectomies for malignant tumours. METHODS: Of 243 hepatectomies carried out between January 1995 and December 2004, 113 (46.5 per cent) were performed by laparoscopy and 89 were included in this retrospective study. RESULTS: Twenty-four laparoscopic hepatectomies (27 per cent) were for benign disease and 65 (73 per cent) for malignant tumours, including hepatocellular carcinoma (HCC) in 16 patients and colorectal metastasis (CRM) in 41. Minor hepatectomy was performed in 51 patients and major hepatectomy (three or more Couinaud segments) in 38. Conversion to laparotomy was necessary in 12 patients and perioperative blood transfusion in eight. One patient with cirrhosis who underwent right hepatectomy for HCC with conversion to open surgery died 8 days after surgery. Major morbidity occurred in eight patients (16 per cent) having minor hepatectomy and in 11 (29 per cent) of those having a major resection. The 3-year overall and disease-free survival rates for patients with CRM (mean follow-up 30 months) were 87 (11 patients at risk) and 51 (6 patients at risk) per cent respectively. Corresponding values for patients with HCC (mean follow-up 40 months) were 85 (10 patients at risk) and 68 (5 patients at risk) per cent. CONCLUSION: In experienced hands, the results of laparoscopic liver surgery are similar to those for laparotomy.     

三维可视化联合吲哚菁绿清除试验在肝肿瘤合并肝硬化患者手术应用疗效分析

背景与目的:肝脏肿瘤合并肝硬化患者,肝功能储备往往不足,在行肝切除后可易致并发症与肝功能不全的发生,因此术前精准评估患者病情以及术中精确切除范围,对行肝切除术的肝肿瘤合并肝硬化患者的预后至关重要.本研究探讨三维可视化技术(3DVT)联合吲哚菁绿(ICG)清除试验在肝肿瘤合并肝硬化患者手术中应用疗效.方法:回顾性分析20...     

肝癌的外科治疗—香港经验

肝细胞肝癌（ＨＣＣ）在香港是居于第二位的致死恶性肿瘤，肝切除是治疗ＨＣＣ最为常用和有效的方法。香港大学玛丽医院在最近９年来，肝切除术技术和围手术期管理已经逐渐形成了一套自己的常规。为了避免不必要的开腹手术，术前仔细地检查和估计肿瘤扩散的范围及病人的肝功能情况十分重要。超声刀和Ｐｒｉｎｇｌｅ技术的采用能够有效地减少术中失血，术后管理和围手术期营养支持也是重要的确保肝切除术成功的因素。玛丽医院肝切除术     

Liver resection for hepatocellular carcinoma in non-cirrhotic liver without underlying viral hepatitis

BACKGROUND: Hepatocellular carcinoma (HCC) arising in normal liver parenchyma is rare and the outcome after hepatectomy is not well documented. METHODS: Between June 1998 and September 2003, 33 patients without viral hepatitis underwent resection for HCC in a non-cirrhotic, non-fibrotic liver. Data were analysed with regard to operative details, pathological findings including completeness of resection, and outcome as measured by tumour recurrence and survival. RESULTS: Twenty-three major hepatectomies and ten segmentectomies or bisegmentectomies were performed. After potentially curative resection, 19 of 29 patients were alive at a median follow-up of 25 months, with calculated 1- and 3-year survival rates of 87 and 50 per cent respectively. Survival was significantly better after resection of tumours without vascular invasion (3-year survival rate 89 versus 18 per cent; P = 0.024). Disseminated recurrence developed in nine of 29 patients, leading to death within 28 months of operation in all but one of the nine. CONCLUSION: These data justify hepatic resection for HCC arising in non-cirrhotic, non-fibrotic liver without underlying viral hepatitis. Liver transplantation is rarely indicated because the outcome is good after resection of tumours without vascular infiltration, whereas vascular invasion is invariably associated with diffuse extrahepatic recurrence.     

Efficacy of preoperative portal vein embolization prior to major hepatectomy for patients with impaired liver function: A retrospective study

Hepatocellular carcinoma (HCC) is often associated with chronic liver disease, such as hepatitis or cirrhosis, and this association may limit the use of surgery as a therapy, and if surgery is pursued, may give rise to postoperative hepatic failure. We evaluated the outcome in patients with HCC given preoperative portal vein embolization (PVE) before they underwent major hepatectomy. After PVE, portal pressure increased significantly. Two weeks after PVE, both the volume of the non-embolized lobe and the 15-min indocyamine green retention rate (ICG R15) were significantly increased. The prognostic score, calculated on the basis of age, ICG R15, and the resection rate, was significantly decreased. The operative mortality rate was significantly lower in patients who underwent PVE before surgery than in patients who did not receive PVE. The cumulative survival rate of the PVE patients, even those with cirrhosis of the liver, was significantly higher. Prior PVE appears to allow more extensive major hepatectomy and to lessen the risk of this invasive surgery. However, patients in whom the portal pressure immediately after PVE was more than 30cm H₂O and/or whose prognostic score exceeded 50 points developed postoperative hepatic failure. These features should be kept in mind when it is decided whether surgery is indicated. Nevertheless, preoperative PVE appears to be a beneficial procedure for patients undergoing major hepatectomy, particularly those with chronic liver disease.     

Liver resection for hepatocellular carcinoma in patients with cirrhosis

BACKGROUND: Although liver resection is now a safe procedure, its role for hepatocellular carcinoma (HCC) in patients with cirrhosis remains controversial. METHODS: This study compared the results of liver resection for HCC in patients with cirrhosis over two time intervals. One hundred and sixty-one patients had resection during period 1 (1991-1996) and 265 in period 2 (1997-2002). Early and long-term results after liver resection in the two periods were compared, and clinicopathological characteristics that influenced survival were identified. RESULTS: Tumour size was smaller, indocyanine green retention rate was higher, patients were older and a greater proportion of patients were asymptomatic in period 2 than period 1. Operative blood loss, need for blood transfusion, operative mortality rate, postoperative hospital stay and total hospital costs were significantly reduced in period 2. The 5-year disease-free survival rates were 28.2 and 33.9 per cent in periods 1 and 2 respectively (P = 0.042), and 5-year overall survival rates were 45.9 and 61.2 per cent (P < 0.001). Multivariate analysis identified serum alpha-fetoprotein level, need for blood transfusion and Union Internacional Contra la Cancrum tumour node metastasis stage as independent determinants of disease-free and overall survival. CONCLUSION: The results of liver resection for HCC in patients with cirrhosis improved over time. Liver resection remains a good treatment option in selected patients with HCC arising from a cirrhotic liver.     

乙肝相关性肝癌肝脏储备功能评估方案的初步探讨

目的:探讨适合我国乙肝相关性肝癌肝切除患者的肝脏储备功能的评估方案。方法:回顾性分析连续129例因乙肝相关性肝癌行肝部分切除术患者的临床资料,比较3种经典的肝脏储备功能评估方案预测术后肝衰竭发生的特异性与敏感性。结果:全组共有13例(10.1%)患者术后发生肝衰竭(肝衰竭组),其中1例院内死亡;116例术后术后肝功能恢复良好(肝功能恢复良好组)。肝衰竭组患者行大块肝切除比例、术前吲哚青绿15 min滞留率(ICGR15)及年龄明显高于术后肝功能恢复良好组(均P0.05)。ICGR15评估方案与决策树(Decision Tree)评估方案均具有评估价值(均P0.01)。而Decision Tree评估方案预测术后肝衰竭的敏感性、特异性、阳性预测值及阴性预测值分别为95%,84%,64%和98%,均优于ICGR15评估方案。结论:Decision Tree方案适用于乙肝相关性肝癌肝切除患者的肝脏储备功能评估。     

ICG Clearance in Assessing Cirrhotic Patients with Hepatocellular Carcinoma for Major Hepatic Resection

Objective: To deWne the safety of major hepatectomy for hepatocellular carcinoma (HCC) associated with cirrhosis and the selection criteria for surgery in terms of hospital mortality. Design: Major hepatectomy for HCC in the presence of cirrhosis is considered to be contraindicated by many surgeons because the reported mortality rate is high (26% to 50%). Previous workers recommended that only selected patients with Child''s A status or indocyanine green (ICG) retention at 15 minutes of less than 10% undergo major hepatectomy. A survery was made, therefore, of our patients with HCC and cirrhosis undergoing major hepatectomy between 1989 and 1994. Setting: A tertiary referral center. Patients: The preoperative, intraoperative, and post-operative data of 54 patients with cirrhosis who had major hepatectomy were compared with those of 25 patients with underlying chronic active hepatitis and 22 patients with normal livers undergoing major hepatectomy for HCC. The data had been prospectively collected. Intervention: Major hepatectomy, defined as resection of two or more liver segments by Goldsmith and Woodburn nomenclature, was performed on all the patients. Main Outcome Measure: Hospital mortality, which was defined as death within the same hospital admission for the hepatectomy. Results: Preoperative liver function in patients with cirrhosis was worse than in those with normal livers. The intraoperative blood loss was also higher (P=.01), but for patients with cirrhosis, chronic active hepatitis, and normal livers, the hospital mortality rates (13%, 16%, and 14%, respectively) were similar. The hospital mortality rate for patients with cirrhosis in the last 2 years of the study was only 5%. Patients with cirrhosis could tolerate up to 10 L of blood loss and survive the major hepatectomy. By discriminant analysis, an ICG retention of 14% at 15 minutes was cutoff level that could maximally separate the patients with cirrhosis with and without mortality. Conclusion: Major hepatectomy for HCC in the presence of cirrhosis is associated with a mortality rate that is not different from the rate for patients with normal livers. An ICG retention of 14% at 15 minutes would serve as a better selection criterion than the 10% previously used.