Is functional preservation through wedge resection a viable treatment option for patients with liver tumors, particularly those with early-stage disease and well-preserved liver function?

Wedge Resection for Functional Preservation in Liver Tumors

Yes, non-anatomical wedge resection is a viable and often preferred approach for functional preservation in cirrhotic patients with hepatocellular carcinoma, particularly when liver function is compromised, though anatomical resection remains theoretically superior for tumor clearance. 1

The Anatomical vs. Non-Anatomical Debate

The choice between anatomical resection (AR) and non-anatomical wedge resection (NAR) remains actively debated in hepatobiliary surgery:

• Anatomical resection is theoretically superior for tumor clearance and eradication of micro-metastases through systematic removal of the hepatic segment 1
• However, this approach is rarely feasible in cirrhotic HCC patients, for whom tissue-sparing NAR becomes the procedure of choice 1
• Guidelines recommend anatomical resections when feasible (evidence 3A; recommendation 2C), but acknowledge this must be balanced against preservation of adequate hepatic function 1

When Wedge Resection is Preferred

Non-anatomical wedge resection serves as the primary surgical strategy in specific clinical contexts:

Cirrhotic Patients with Limited Reserve

• Tissue-sparing NAR is the procedure of choice when underlying cirrhosis limits functional reserve 1
• The surgical effort must prioritize preservation of adequate hepatic function over achieving wider anatomical margins 1
• Procedures should be tailored to individual patient characteristics including body size, tumor location (central vs. peripheral), and solitary large HCC 1

Emergency Situations

• Emergency wedge resections are feasible for ruptured HCC in patients with Child-Pugh A or B grade and limited tumor burden 2
• Non-anatomical wedge resections were successfully performed in 5 of 6 emergency cases, with 2 patients disease-free at 24 months 2

Patient Selection Criteria for Resection

Optimal candidates for liver resection (whether anatomical or wedge) must meet strict functional criteria:

• Child-Pugh class A with normal bilirubin AND either hepatic venous pressure gradient ≤10 mmHg OR platelet count ≥100,000 1
• Solitary tumors with very well-preserved liver function represent the first-line indication 1
• Perioperative mortality should be 2-3% in appropriately selected cirrhotic patients 1, 3

Portal Hypertension Assessment is Critical

• HVPG <10 mmHg or absence of surrogates (esophageal varices, splenomegaly with platelet count <100,000/mm³) leads to resectability rates of less than 10% 1
• Carefully selected patients with Child-Pugh B and/or portal hypertension may be candidates for minor surgical resection (evidence level III, recommendation A) 1

Alternative Approaches for Small Tumors

For very small tumors, functional preservation can be achieved through non-surgical methods:

• Radiofrequency ablation (RFA) demonstrates similar outcomes to resection for tumors <2 cm diameter and may be recommended as first-line treatment given lesser invasiveness and morbidity 1
• In early-stage HCC (up to three lesions ≤3 cm), RFA has been adopted as an alternative first-line option irrespective of liver function after demonstrating survival benefit similar to surgery in RCTs 1
• Thermal ablation and resection are equally recommended options for solitary HCC <2 cm in compensated cirrhosis 3

Laparoscopic Approach for Functional Preservation

Minimally invasive techniques enhance functional preservation:

• Laparoscopic liver resection results in reduced intraoperative blood loss and faster postoperative recovery without impairing oncological outcome 1
• LR in cirrhosis should preferably be carried out as laparoscopic resection (evidence level IV, recommendation A) 1

Non-Cirrhotic Patients

The approach differs substantially in patients without cirrhosis:

• Hepatic resection is the treatment of choice for HCC in non-cirrhotic patients, where major resections can be performed with low rates of complications and 5-year survival of 30-50% 1
• In these patients, anatomical resection is more readily achievable without the constraints imposed by underlying liver disease 4

Key Clinical Pitfall

A critical caveat exists regarding the evidence for anatomical resection superiority:

• Retrospective studies linking anatomical resections and better outcome should be interpreted with caution due to propensity of performing wider interventions in patients with well-preserved liver function 1
• The debate between AR and NAR remains unresolved because patients selected for anatomical resection inherently have better baseline liver function, creating selection bias 1

Expected Outcomes

Surgical resection achieves excellent long-term survival in well-selected candidates:

• 5-year survival of 60-80% in well-selected candidates for both resection and transplantation 1
• However, tumor recurrence occurs in 50-70% of cases within 5 years following surgery 1
• Perioperative blood transfusion and postoperative morbidity are independent predictors of survival, emphasizing importance of functional preservation measures 5