Impact of Glissonean Pedicle Approach for Centrally Located Hepatocellular Carcinoma in Mongolia

Approaches to surgical resection of centrally located HCC remain controversial. Traditionally, hemi- or extended hepatectomy is suggested. However, it carries a high risk of postoperative complications in patients with cirrhosis. An alternative approach is Glissonean pedicle transection method. This study was conducted to assess the surgical and survival outcomes associated with central liver resection using the Glissonean pedicle transection. Sixty-nine patients with centrally located HCC were studied retrospectively. They were divided into conventional approach group with hemi- or extended hepatectomy, and Glissonean approach group with multisegmental central liver resection using the Glissonean pedicle transection. Glissonean pedicle transection method has comparable or superior surgical and survival outcomes to conventional hemi- or extended hepatectomy with regard to intraoperative bleeding, complications, hospital stay, and postoperative mortality and survival outcomes in patients with centrally located HCC. The 1-, 3-, and 5-year overall survival rates of the conventional approach group were 74%, 64%, and 55% respectively. For the Glissonean approach group, the 1 and 3-year overall survival rates were 86% and 61%, respectively. Glissonean pedicle transection method is a safe and effective surgical procedure in patients with centrally located HCC.Key words: Centrally located HCC, Glissonean approach, Glissonean pedicle transection, Central hepatectomyHepatocellular carcinoma (HCC) is the first leading cause of cancer-related mortality in both men and women in Mongolia, and its incidence is among the highest worldwide.¹ Surgical resection remains the first-line therapeutic strategy for HCC despite recent advancements in treatment modalities.^2-4 However, underlying liver diseases significantly limit the number of HCC patients eligible for surgical resection. This is especially problematic, where the prevalence of chronic hepatitis B and C is over 10% in the general population, and 86.8% of HCC patients have cirrhosis.⁵ Therefore, refining surgical techniques to preserve as much liver parenchyma as possible could potentially improve treatment prospects for cirrhotic HCC patients, particularly in cases when the tumor is centrally located.Traditionally, hemi- or extended hepatectomy is suggested for the treatment of centrally located HCC.⁶ However, such a major hepatic resection sacrifices a large volume of noncancerous liver parenchyma, which carries a high risk of postoperative liver failure in patients with cirrhotic background.^6-8 Preservation of functioning liver parenchyma to a maximum extent possible is crucial to avoid postoperative liver failure in cirrhotic patients. Therefore, Glissonean pedicle transection method is increasingly considered as an effective alternative to hemi- or extended hepatectomies in such cases.^9-16 Nonetheless, multisegmental central liver resection has not been widely used since its introduction for gallbladder cancer in 1972.^17,18 Conventional central liver resection method is technically demanding, and may require prolonged surgical time in order to dissect and confirm each branch of hepatic artery, portal vein, and bile duct to the anterior section.^19,20 This often results in increased risk of bleeding, bile leakage or parenchymal necrosis, and therefore, central liver resection particularly in cirrhotic patients remains controversial.^21,22 The answer to the dilemma could lie with the Glissonean pedicle transection method, which was introduced in the mid-1980s owing to a better understanding of the surgical anatomy of the liver.^20,23 When using this resection method, Glissonean pedicle supplying the target area is ligated and divided at the hepatic hilum prior to resection without exposing the vessels individually.²³ This simplifies hepatic resection, shortens operation time and reduces intraoperative bleeding.²³⁻²⁵ Our previous experience with using this method for hemihepatectomy has resulted in considerable reduction of blood loss during resection, a major determinant of patient outcome.This approach has allowed the ability to adapt the size of resection to the extent of the tumor and to preserve the maximum amount of liver parenchyma, which is crucial for the prevention of postoperative liver failure especially in patients with cirrhotic background. However, it remains unclear whether central liver resection using the Glissonean pedicle transection improves long-term survival. Therefore, the current retrospective study of patients with centrally located HCC, who underwent either hemi- or extended hepatectomy or multisegmental central liver resection, was conducted to assess the perioperative and long-term outcomes associated with central liver resection using the Glissonean pedicle transection.     

Status quo of chronic liver diseases, including hepatocellular carcinoma, in Mongolia

Because Mongolia has much higher liver disease burden than any other regions of the world, it is necessary to provide information on real-time situation of chronic liver disease in Mongolia. In this article, we reviewed studies performed in Mongolia from 2000 to 2011 on seroprevalence of hepatitis B virus (HBV) and hepatitis C virus (HCV) among healthy individuals and patients with chronic liver diseases, and on the practice patterns for the management of liver cirrhosis and hepatocellular carcinoma (HCC). According to previous reports, the seroprevalence of HBV and HCV in general population in Mongolia is very high (11.8% and 15% for HBV and HCV, respectively). Liver cirrhosis is also highly prevalent, and mortality from liver cirrhosis remained high for the past decade (about 30 deaths per 100,000 populations per year). Among patients with cirrhosis, 40% and 39% are positive for HBsAg and anti-HCV, respectively, and 20% are positive for both. The seroprevalence is similar for HCC and more than 90% of HCC patients are positive for either HBV or HCV. The incidence of HCC in Mongolia is currently among the highest in the world. The mortality from HCC is also very high (52.2 deaths per 100,000 persons per year in 2010). Partly due to the lack of established surveillance systems, most cases of HCC are diagnosed at an advanced stage. The mortality from liver cirrhosis and HCC in Mongolia may be reduced by implementation of antiviral therapy program and control of alcohol consumption.