What are the operation criteria for a patient with hepatocellular carcinoma (HCC), complex medical history, including chemotherapy-induced intestinal edema, recent abdominal surgery, or radiation therapy, and underlying conditions such as diabetes, hypertension, or cardiovascular disease?

Surgical Criteria for Hepatocellular Carcinoma

Surgical resection is the first-line treatment for HCC in patients with Child-Pugh A liver function, no clinically significant portal hypertension, adequate future liver remnant volume (≥20-40%), and good performance status, achieving 5-year survival rates of 50-68% with perioperative mortality <3% in experienced centers. 1, 2

Patient Selection Algorithm for Surgical Intervention

Step 1: Assess Liver Function

• Child-Pugh A patients without portal hypertension are optimal surgical candidates 3
• Child-Pugh B patients may be considered for minor resection only in carefully selected cases 3
• Child-Pugh C patients are absolutely contraindicated for resection due to prohibitive mortality risk 3, 2
• Measure ALBI score within Child-Pugh A patients: ALBI 1 has median survival of 26 months versus 14 months for ALBI 2 3

Step 2: Evaluate Portal Hypertension

• Clinically significant portal hypertension (hepatic-venous pressure gradient >10 mmHg) is a relative contraindication to major resection 3
• Surrogate markers indicating portal hypertension include: esophageal varices on endoscopy, splenomegaly with platelet count <100×10⁹/L, or ascites 3, 2
• Patients with portal hypertension may still undergo minor resection if other criteria are favorable 3

Step 3: Determine Tumor Burden and Resectability

• Single tumors of any size are resectable if adequate liver remnant can be preserved 3, 1
• Two to three nodules within Milan criteria may be eligible for resection based on performance status and liver function 3
• Macrovascular invasion at the main portal vein or hepatic vein level is an absolute contraindication 3, 2
• Segmental or subsegmental portal invasion requires investigation within prospective protocols 3

Step 4: Calculate Future Liver Remnant Volume

• Minimum 20-40% of total liver volume must remain after resection in cirrhotic patients 1, 2
• Non-cirrhotic patients tolerate more extensive resections with lower remnant requirements 3

Step 5: Consider Comorbidities in Context of Complex Medical History

• Diabetes, hypertension, and cardiovascular disease significantly increase perioperative risk, particularly in NAFLD-related HCC where complication rates reach 13-20% 3
• Recent abdominal surgery may preclude laparoscopic approaches but does not eliminate open resection candidacy 3
• Chemotherapy-induced intestinal edema requires assessment of nutritional status and albumin levels before proceeding 3
• Prior radiation therapy to the abdomen necessitates careful evaluation of liver reserve and vascular anatomy 3

Alternative Surgical Option: Liver Transplantation

Liver transplantation should be prioritized over resection for patients meeting Milan criteria (single lesion <5 cm or ≤3 nodules ≤3 cm) with decompensated cirrhosis or Child-Pugh B-C status. 3, 1

• UCSF criteria (single tumor ≤6.5 cm or ≤3 nodules with largest ≤4.5 cm and total diameter ≤8 cm) may also be considered 3
• Living donor liver transplantation achieves 1-, 3-, and 5-year survival rates of 85%, 75%, and 70% respectively 1, 2
• Patients with anticipated waiting time >3-6 months should receive bridging therapy with resection, ablation, or TACE 3

Non-Surgical Alternatives When Surgery is Contraindicated

For Very Early Stage (BCLC 0) or Small Tumors ≤3 cm:

• Radiofrequency ablation or microwave ablation is recommended as first-line treatment for single nodules <2 cm or when resection is not feasible 3, 1
• RFA provides superior local control compared to percutaneous ethanol injection, especially for tumors >2 cm 3
• Laparoscopic approaches can overcome limitations for exophytic tumors or those near the gallbladder or intestine 3

For Intermediate Stage (BCLC B):

• Transarterial chemoembolization is the standard of care for multinodular asymptomatic tumors without macrovascular invasion in patients with Child-Pugh A liver function 3, 4
• DEB-TACE with doxorubicin-eluting beads minimizes systemic chemotherapy side effects 3

For Advanced Stage (BCLC C):

• Sorafenib or atezolizumab plus bevacizumab is indicated for patients with macrovascular invasion, extrahepatic spread, or cancer-related symptoms 3, 4, 5

Critical Contraindications to Avoid

• Never proceed with resection in Child-Pugh C patients—mortality is prohibitive 3, 2
• Do not perform transplantation in patients with macrovascular invasion or extrahepatic disease—outcomes are universally poor 2
• Avoid resection when future liver remnant is inadequate (<20-40% in cirrhosis)—risk of postoperative liver failure is unacceptable 1, 2
• Do not offer major resection to patients with clinically significant portal hypertension unless in the context of clinical trials 3

Surgical Approach Preference

Laparoscopic resection should be performed preferentially over open resection in cirrhotic patients with appropriate tumor location (anterolateral, superficial) and surgeon expertise, as it reduces intraoperative blood loss and accelerates postoperative recovery without compromising oncological outcomes. 3, 2

Postoperative Management

• Adjuvant therapy with atezolizumab plus bevacizumab improves recurrence-free survival after resection, though longer-term data are needed 2
• Neo-adjuvant therapies are not recommended as they have not proven to improve outcomes 3
• Follow-up every 3-4 months in the first year with AFP and dynamic CT/MRI using modified RECIST criteria 3, 1, 4
• Recurrence occurs in 50-70% of cases within 5 years, but curative therapy can still be offered at relapse 3, 1