11

Masatoshi Makuuchi, MD, PhD.

Department of Surgery,University of Tokyo.

Liver Surgery for HCCLiver Surgery for HCC- Present & Future -- Present & Future -

20 20 <<10 10 -- 20 20 5 5 -- 10 10 2 2 -- 5 5 << 2 2

USA USA Spain Spain

UK UK France France

Japan Japan

Taiwan Taiwan

Sweden Sweden

Hong Kong Hong Kong

New New Zealand Zealand

AustraliaAustralia

KoreaKorea ChinaChina

ThailandThailand IsraelIsrael

GreeceGreece ItalyItaly

PolandPoland GermanyGermany

1,000,000/year/world1,000,000/year/world

HCC-incidence in the World

South South AfricaAfrica

HCC-incidence in Japan

40 - /100,00030 - 3925 - 29

- 24

30,000/year/Japan

North

South

Cancer Death in JapanCancer Death in Japan 1 0 0

Stomach

Lung

Liver

Colon Pancreas Esophagus

8 0

1 9 6 5 1 9 7 0 1 9 7 5 1 9 8 0 1 9 8 5 1 9 9 0 1 9 9 5

6 0

4 0

2 0

0

Mor

talit

y/10

0,00

0

32/100,000

2 02 0

4 04 0

6 06 0

8 08 0

1 0 01 0 0

00 11 22 33 44 55 Y rY r

%%

●

●

●

●

　

●

Overall survival in HCCOverall survival in HCCLiver Cancer Study Group of Japan (‘88-’99)Liver Cancer Study Group of Japan (‘88-’99)

Surgery (n=21,711)Surgery (n=21,711)92%92%

69%69%

52%52%

2 02 0

4 04 0

6 06 0

8 08 0

1 0 01 0 0

00 11 22 33 44 55 Y rY r

%%

●

●

●

●

　

●

Overall survival in HCCOverall survival in HCCLiver Cancer Study Group of Japan (‘88-’99)Liver Cancer Study Group of Japan (‘88-’99)

Surgery (n=21,711)Surgery (n=21,711)PEI (n=12,876)PEI (n=12,876)

92%92%

69%69%

52%52%

87%87%

64%64%

40%40%

73%73%

38%38%

21%21%

TAE (n=17,821)TAE (n=17,821)

Liver Cancer Study Group of Japan (’88-’96)Liver Cancer Study Group of Japan (’88-’96)Overall survival / Single, 2cm, LD=A≦Overall survival / Single, 2cm, LD=A≦

00

2020

4040

6060

8080

100100

11 22 33 44 55 66 88

%%

YrYr77

Surgery (n=1,318)Surgery (n=1,318)PEI (n=767)PEI (n=767)72%72%

52%52%

OP vs PEI, p=0.01OP vs PEI, p=0.01

Arii et al. Hepatology 2000; 32: 1224Arii et al. Hepatology 2000; 32: 1224

00

2020

4040

6060

8080

100100

22 33 44 55 66 88

%%

YrYr7711

60%60%

41%41%

Liver Cancer Study Group of Japan (’88-’96)Liver Cancer Study Group of Japan (’88-’96)Overall survival / Single, 2-5cm, LD=AOverall survival / Single, 2-5cm, LD=A

Surgery (n=2,722)Surgery (n=2,722)PEI (n=587)PEI (n=587)

OP vs PEI, p=0.001OP vs PEI, p=0.001


Hepatic resection Hepatic resection vs.vs. Ethanol injection Ethanol injection


OP PEI p OP PEI p

<=2cm, Single 72% 52% 0.01 58% 38% 0.69

<=2cm, 2 tumors 61% 66% 0.58 48% 40% 0.67

2-5cm, Single 60% 41% 0.001 45% 28% 0.001

2-5cm, 2 tumors 42% 37% 0.59 38% 17% 0.007

A BLiver Damage

HCC

Neoplastic Seeding after PEI and RFANeoplastic Seeding after PEI and RFA

RFA for HCCRFA for HCC

Neoplastic seedingNeoplastic seeding 12%12%

Llovet JM.Llovet JM. Hepatology 2001.Hepatology 2001.

MortalityMortality 0.3%0.3%

Livraghi et al.Livraghi et al. Lodi 2002.Lodi 2002.

Recent Advancement in Liver Recent Advancement in Liver SurgerySurgery

No mortality Hx has been realizedNo mortality Hx has been realized..

It should be lass than It should be lass than 1%1%

Increased Safety of Hepatic ResectionIncreased Safety of Hepatic Resection

Operative mortality in HCC PatientsOperative mortality in HCC Patients

~ ‘79~ ‘79

15.8%15.8%

‘‘80~ 8480~ 84 ‘‘85~ 8985~ 89 ~ ‘90~ ‘90

LCSGJLCSGJNCC 1M.NCC 1M.

6M.6M.

Rate of blood tr.Rate of blood tr.

10.1%10.1%31.9%31.9%

>90%>90%

13.2%13.2% 4.2%4.2% 5.4%5.4%

40%40%

6.2%6.2% 1.0%1.0% 2.6%2.6%

25%25%

6.5%6.5% 1.4%1.4% 2.2%2.2%

<10%<10%

LCSGJ:LCSGJ: ’78~79 (44 / 279), ’80~83 (98 / 1506), ’88~89 (66 / 2570), ’78~79 (44 / 279), ’80~83 (98 / 1506), ’88~89 (66 / 2570), ’ ’90~93 (167/1758)90~93 (167/1758)

NCC :NCC : ’79 (7, 22 / 69), ’80~84 (7, 22 / 167), ’88~89 (4, 25 / 402), ’79 (7, 22 / 69), ’80~84 (7, 22 / 167), ’88~89 (4, 25 / 402), ’ ’90~ (12, 56 / 856)90~ (12, 56 / 856)

HepatectomyHepatectomy

Torzilli, MakuuchiTorzilli, Makuuchi

26%26%AuthorsAuthors Dx.Dx. IschemiaIschemiann TransectionTransection MortalityMortality MorbidityMorbidity TransfuseTransfuse

Arch Surg 1999; 134: 984-992.Arch Surg 1999; 134: 984-992.

HCCHCC 107107 Pringle +Pringle +SelectiveSelective

ClampClamp 0%0% 9%9%

FanFan 39%39%Ann Surg 1999; 229: 322-330.Ann Surg 1999; 229: 322-330.

HCCHCC 330330 Pringle +Pringle +No PringleNo Pringle

Clamp +Clamp +CUSACUSA

6%6% >36%>36%

Fong, BlumgartFong, Blumgart 45%45%Ann Surg 1999; 229: 790-800.Ann Surg 1999; 229: 790-800.

HCCHCC 154154 n.d.n.d. n.d.n.d. 5%5% n.d.n.d.

Takenaka, Takenaka, SugimachiSugimachi 50%50%

Arch Surg 1996; 131: 71-76.Arch Surg 1996; 131: 71-76.

HCCHCC 280280 Pringle +Pringle +SelectiveSelective

CUSACUSA 2%2% n.d.n.d.

FusterFuster 46%46%Ann Surg 1996; 223: 297-302.Ann Surg 1996; 223: 297-302.

HCCHCC 4848 PringlePringle ClampClamp 4%4% 25%25%

GozzettiGozzetti 26%26%Br J Surg 1995; 82: 1105-1110.Br J Surg 1995; 82: 1105-1110.

HCC + metaHCC + meta 522522 Pringle +Pringle +No PringleNo Pringle

n.d.n.d. 3%3% 62%62%

SitzmannSitzmann 33%33%Ann Surg 1994; 219: 31-37.Ann Surg 1994; 219: 31-37.

HCC + metaHCC + meta 105105 PringlePringle CUSACUSA 3%3% 75%75%

Hepatectomies in Tokyo University Hepatectomies in Tokyo University (1994.10- 2002.5)(1994.10- 2002.5)

Hepatectomies in Tokyo University Hepatectomies in Tokyo University (1994.10- 2002.5)(1994.10- 2002.5)

Hepatocellular carcinoma: 532Other liver malignancies: 262

(Cholangiocellular carcinoma, Metastatic liver tumors, etc)

Biliary malignancies: 57 (Hilar bile duct cancer, GB cancer) Living donor for liver transplantation: 174Other benign disease: 31

Total 1056

Demographics of 1056 hepatectomiesDemographics of 1056 hepatectomiesDemographics of 1056 hepatectomiesDemographics of 1056 hepatectomiesOperative time * : 　　　　　 420 (75-1495) (min) Blood loss * : 577 (0-8200) (mL)Red blood cell transfusion rate and amount

6.1 (0-3200 mL) (% (range))

Morbidity rate: 38 %Surgical intervention rate: 2.5 %Overall mortality rate (In-hospital & <30 days): 0 %

* Data are expressed as median (range).

For the Safety of HxFor the Safety of Hx

1. Evaluation of hepatic functional reserve1. Evaluation of hepatic functional reserve

2. IOUS2. IOUS

3. Intermittent inflow occlusion3. Intermittent inflow occlusion

4. Volumetric analysis & PVE4. Volumetric analysis & PVE

Makuuchi et al. Seminar in Surg Oncol 1993; 9: 298

Post-op. jaundice is not acceptable.

To achieve no mortality HxTo achieve no mortality Hx

Hepatic surgeon should consider thatoperative indication is not appropriatewhen jaundice followed Hx.

Intraoperative UltrasonographyIntraoperative UltrasonographyLane & GlazerLane & Glazer LancetLancet 2: 334; 19802: 334; 1980Sigel et al.Sigel et al. RadiologyRadiology 137: 531; 1980137: 531; 1980Cook & Lytton.Cook & Lytton. Urol Clin North AmUrol Clin North Am 8: 319; 19818: 319; 1981

Makuuchi et al.Makuuchi et al. Jpn J Clin OncolJpn J Clin Oncol 11: 367; 198111: 367; 1981Plainfosse et al.Plainfosse et al. RadiologyRadiology 147: 829; 1983147: 829; 1983Angelini et al.Angelini et al. Ital J Surg SciItal J Surg Sci 13: 203; 198313: 203; 1983Bismuth et al.Bismuth et al. Presse MedPresse Med 13: 1819; 198413: 1819; 1984Belghiti et al.Belghiti et al. Presse MedPresse Med 13: 1839; 198413: 1839; 1984

Igawa et al.Igawa et al. World J SurgWorld J Surg 8: 772; 19848: 772; 1984Sheu JC et al.Sheu JC et al. SurgerySurgery 97: 97; 198597: 97; 1985Makuuchi et al.Makuuchi et al. Surg Gynecol ObstetSurg Gynecol Obstet 161: 346; 1985161: 346; 1985Gozzetti et al.Gozzetti et al. SurgerySurgery 99: 523; 198699: 523; 1986Makuuchi et al.Makuuchi et al. Surg Gynecol ObstetSurg Gynecol Obstet 164: 68; 1987164: 68; 1987

New Operative Procedures New Operative Procedures Due to Introduction of IOUS Due to Introduction of IOUS

Limited Resection Limited Resection

Subsegmentectomy Subsegmentectomy

IRHV Preserving HxsIRHV Preserving Hxs

Kanematsu et al,Kanematsu et al, Ann Surg, 1981. Ann Surg, 1981.

Makuuchi et al,Makuuchi et al, SGO, 1985. SGO, 1985.

Makuuchi et al,Makuuchi et al, SGO, 1987. SGO, 1987.

Operative Procedure of Systematic SubsegmentectomyOperative Procedure of Systematic Subsegmentectomy

Staining of Subsegment

Marking with Electric Cautery

Tattooing ofParenchyma

HemihepaticBlood Occlusion

Division ofParenchyma

Raw Surfaceafter Segmentectomy

Makuuchi et al. Surg Gynecol Obstet 1985; 161: 346.

MHVMHV MHVMHV

MHVMHV

GBGB

P-S PVP-S PVA-S PVA-S PV

RHVRHV RHVRHV

RHVRHV RHVRHV M + LHVM + LHV




IVCIVC IVCIVC

IVCIVC IVCIVC

Makuuchi et al. Surg Gynecol Obstet 1987; 164: 68.

Inflow Occlusion Technique (1) Inflow Occlusion Technique (1) Inflow Occlusion Technique (1) Inflow Occlusion Technique (1) Pringle

Total inflow occlusion (Pringle’s maneuver) Ann Surg 1908.

Heaney et al. Inflow and outflow occlusion (TVE).

Ann Surg 1966.Makuuchi et al.

Intermittent selective vascular occlusionJ Jpn Surg Soc 1985 (in Japanese)

Makuuchi et al. Intermittent inflow occlusion.

SGO 1987.

Inflow Occlusion Technique (2) Inflow Occlusion Technique (2) Inflow Occlusion Technique (2) Inflow Occlusion Technique (2) Isozaki et al.

Superiority of intermittent to continuous occlusion in rats. Br J Surg 1992.

Belghiti et al. Superiority of Pringle’s maneuver to TVE.

Ann Surg 1996. Belghiti et al.

Superiority of intermittent to continuous occlusion in human. Ann Surg 1999.

Ischemic Preconditioning (1) Ischemic Preconditioning (1) Ischemic Preconditioning (1) Ischemic Preconditioning (1) Murry et al.Murry et al. Dog myocardium. Dog myocardium.

Circulation 1986.Circulation 1986.

Peralta et al.Peralta et al. Rat liver (warm ischemia). Rat liver (warm ischemia). BBRC 1996.BBRC 1996.

Hardy et al.Hardy et al. Rat liver (warm ischemia).Rat liver (warm ischemia).Aust NZ J Surg 1996.Aust NZ J Surg 1996.

Yin, Sankary et al.Yin, Sankary et al. Rat liver transplantationRat liver transplantation (cold ischemia). (cold ischemia).

Transplantation 1998.Transplantation 1998.

Ischemic Preconditioning (2) Ischemic Preconditioning (2) Ischemic Preconditioning (2) Ischemic Preconditioning (2)

Clavien et al. Human liver resection (warm ischemia).

Ann Surg 2000.

Imamura, Makuuchi et al. Human liver transplantation

(living donor). Lancet 2002

LateLate Ichio Honjo Ichio Honjo(1913(1913～～ 1987)1987)

Professor of Kyoto UniversityProfessor of Kyoto UniversityHe did right hepatectomy in March, 1949.He did right hepatectomy in March, 1949.

HonjoHonjo : Shujutu 9: 345, 1950 (in Japanese). : Shujutu 9: 345, 1950 (in Japanese).Honjo and ArakiHonjo and Araki : J Int Surgeons 18: 23, 1955. : J Int Surgeons 18: 23, 1955.

Foster and Berman’s Foster and Berman’s “Solid Liver Tumors”“Solid Liver Tumors”

PV branch ligationPV branch ligation

History of PVEHistory of PVE

Makuuchi et al.Makuuchi et al. NCCHNCCH June June 19821982Okuda et al.Okuda et al. Kurume Univ.Kurume Univ. Jan.Jan. 19831983Inoue et al.Inoue et al. Osaka City Univ.Osaka City Univ. Nov.Nov. 19831983

Makuuchi et alMakuuchi et al. : Nichi Rin Ge Shi 45: 1558, 1984.. : Nichi Rin Ge Shi 45: 1558, 1984.(in Japanese)(in Japanese)

Makuuchi et alMakuuchi et al. : Surgery 107: 521, 1990.. : Surgery 107: 521, 1990.

1. Amount of liver resection exceeds 60% of the whole normal liver.

Indication Criteria of PVEIndication Criteria of PVE

2. Amount of liver resection between 40 and 60% of the liver with ICG retention rate at 15’ between 10 and 20%

Kubota et al. Hepatology 1997;26:1176.

1. Tumor thrombus in HCC.

Recent ChallengesRecent ChallengesIn Surgical Resection for HCCIn Surgical Resection for HCC

2. Multiple HCC.3. Repeated resections.4. Caudate lobe resection.

Dismal Prognosis against any kinds of treatment modalities.

Tumor Thrombus in HCCTumor Thrombus in HCC

We have to find some selectioncriteria for surgical resection.

00

2020

4040

6060

8080

100100

11 22 33 44 55 66 77 88 99 1010

Liver Cancer Study Group of Japan (’88-’99)Liver Cancer Study Group of Japan (’88-’99)%91%91%

74%74%

57%57%

41%41%

29%29%

YrYr

Overall survival in HCC /PVTT* Overall survival in HCC /PVTT*

49%49%

23%23%17%17% 13%13% 12%12%

Vp0Vp0Vp1Vp1Vp2Vp2Vp3Vp3

PVTT*: tumor thrombosis in portal venous branchPVTT*: tumor thrombosis in portal venous branch

Purpose of Preoperative TAE for PVTTPurpose of Preoperative TAE for PVTT

1. Interruption of rapid growth of TT.1. Interruption of rapid growth of TT.

2. Estimation of the other side of the liver.2. Estimation of the other side of the liver.

3. Enhance the atrophy-hypertrophy process.3. Enhance the atrophy-hypertrophy process.

Minagawa et al. Ann Surg 2001; 233: 379.

Relative risk of mortality with Cox’s proportional hazard modeRelative risk of mortality with Cox’s proportional hazard mode

VariableVariable

TherapyTherapy11

# Relative Risk * distribution of primary and daughter nodules # Relative Risk * distribution of primary and daughter nodules

Univariate 95% confidence limitsUnivariate 95% confidence limits Multivariate 95% confidence limitsMultivariate 95% confidence limitsRR#RR# LowerLower UpperUpper p-valuep-value RR#RR# LowerLower UpperUpper p-valuep-value

HepatectomyHepatectomyNon-HepatectomyNon-HepatectomyICG-R15ICG-R15

<20<20>/=20>/=20

Number of Primary NodulesNumber of Primary Nodules1 or 21 or 2>/=3>/=3

Distribution*Distribution*1 or 2 Sectors1 or 2 Sectors>/=3 Section>/=3 Section

PVTTPVTTPortal occlusion (-)Portal occlusion (-)Portal occlusion (+)Portal occlusion (+)

13.313.3

11 2.72.7

11 3.33.3

1.91.9

3.33.3

4.44.4

1.31.3

1.61.6

11

1.71.7

40.240.2

5.55.5

77

3.83.8

7.97.9

<0.0001<0.0001

0.00860.0086

N.S.N.S.

0.00130.0013

0.00120.0012

1110.910.9 3.23.2 3737

<0.0001<0.0001

N.S.N.S.

N.S.N.S.

N.S.N.S.

--

HCC

Repeated resections and challenge to multiple Repeated resections and challenge to multiple tumor resection in both sides of the liver are tumor resection in both sides of the liver are future problems both in HCC and Met.future problems both in HCC and Met.

HBP Surgery, University of Tokyo

Meta

10 nodules 4 times

58 nodules 5 times

Rate of Repeat Hx. For Recurrent HCCRate of Repeat Hx. For Recurrent HCC

Years at 1st Hx.Years at 1st Hx.

Oct. 94~Sep. 96Oct. 94~Sep. 96

Oct 96~Sep. 98Oct 96~Sep. 98

Oct. 98~Dec. 99Oct. 98~Dec. 99

Hepatic Rec.Hepatic Rec.NN 22ndnd Hx. Hx. RateRate

9191

109109

8282

5858

4848

1111

31%31%

33%33%

45%45%

1818

1616

55

HBP Surgery, University of Tokyo

Isolated Subtotal Caudate Lobe ResectionIsolated Subtotal Caudate Lobe Resection

Takayama TTakayama T

High Dorsal Resection High Dorsal Resection

Anterior Transhepatic ApproachAnterior Transhepatic Approach

J Am Coll Surg 1994;179:72-75J Am Coll Surg 1994;179:72-75

Kosuge TKosuge T Arch Surg 1994;129:280-284Arch Surg 1994;129:280-284

AuthorsAuthors NN SingleSingle MultipleMultiple Vas. Inv. Vas. Inv. Rec.(5Y) Rec.(5Y) Survival(5Y)Survival(5Y)

Bismuth 1993Bismuth 1993 < 3cm< 3cm <3, <3cm<3, <3cm absent absent 17% 17% (3Y) (3Y) 83% (3Y) 83% (3Y)Mazzaferro 1996Mazzaferro 1996 4848 < 5cm< 5cm - 3, <3cm- 3, <3cm absent absent 8% 8% 75% (4Y) 75% (4Y)Bismuth 1999Bismuth 1999 4545 < 3cm< 3cm <3, <3cm<3, <3cm absent absent 11% 11% 74% 74%Llovet 1999Llovet 1999 7979 < 5cm< 5cm Solitary Solitary absent absent 4% 4% 74% 74%Iwatsuki 2000 344Iwatsuki 2000 344 any any any any 282 absent282 absent 31% 31% 49% 49%

62 macro(+)62 macro(+)JonasJonas 20012001 120 120 < 5cm< 5cm -3, <3cm-3, <3cm absent absent 16% 16% 71% 71%Yao 2001Yao 2001 7070 <=6.5cm<=6.5cm -3, <=4.5cm-3, <=4.5cm absent absent 75% 75%

<=8cm total<=8cm total

Transplantation for HCCTransplantation for HCC- Selection Criteria -- Selection Criteria -

LDLT for HCCLDLT for HCC

Decreases drop-out rate during waiting timeDecreases drop-out rate during waiting timeTumor growthTumor growthLiver FailureLiver Failure

Enables to challenge for extended indication Enables to challenge for extended indication (i.e. advanced HCC without distant metastases)(i.e. advanced HCC without distant metastases)

In 1993, Shinshu group successfully performed In 1993, Shinshu group successfully performed adult LDLT firstly in the world.adult LDLT firstly in the world.

Which side of the liver should be use as a graft?Which side of the liver should be use as a graft?pros and conspros and cons

Jaundice, Ascites?Jaundice, Ascites?

Low rate of cholestasisLow rate of cholestasisHigher chance of survivalHigher chance of survival

Higher mortality rateHigher mortality rate

Completely safeCompletely safe

RecipientsRecipients

DonorsDonors

To obtain sufficient graftTo obtain sufficient graftwith complete safety of donorwith complete safety of donor

To obtain sufficient graftTo obtain sufficient graftwith complete safety of donorwith complete safety of donor

Donor sideDonor side Recipient sideRecipient side

Remnant liver >30%Remnant liver >30%

(Rt. Liver > 70% (Rt. Liver > 70% L+C < RLS (80%))L+C < RLS (80%))

Demanding >40% Demanding >40% SLV graft SLV graft

To obtain a sufficient graftwith maximum safety of donor

To obtain a sufficient graftwith maximum safety of donor

1. Left Liver Graft with Caudate LobeMiyagawa Transplantation 1998Takayama J Am Coll Surg 1999

2. Right Lateral Sector GraftSugawara Transplantation 2001

3. Right Liver Graft without MHV+ Reconstruction of MHV Tributaries

Lee SG Transplantation 2001Sugawara Ann Surg 2003

1. Left Liver Graft with Caudate LobeMiyagawa Transplantation 1998Takayama J Am Coll Surg 1999

2. Right Lateral Sector GraftSugawara Transplantation 2001

3. Right Liver Graft without MHV+ Reconstruction of MHV Tributaries

Lee SG Transplantation 2001Sugawara Ann Surg 2003

L 38+-6%L 38+-6%L+C 41+-6%L+C 41+-6%Graft volume gain = 8+-2 %Graft volume gain = 8+-2 %

Left Liver Graft with Caudate LobeLeft Liver Graft with Caudate LobeMerit of -10% graft weight gainMerit of -10% graft weight gain

P=0.1P=0.1L 7/14 (50%)L 7/14 (50%)L+C 5/35 (14%)L+C 5/35 (14%)

Risk of cholestasis*Risk of cholestasis*

* Serum total bilirubin levels over 10 mg/dl at the 21 POD* Serum total bilirubin levels over 10 mg/dl at the 21 POD

Sugawara et al. Surgery 2002; 132: 904

Right Lateral Sector GraftRight Lateral Sector Graft Right Lateral Sector GraftRight Lateral Sector Graft

P

R

A

RHV

AP

Donor hepatectomy

Sugawara et al. Transplantation 2002; 73: 111

Venous congestionVenous congestion

Indication for Reconstruction of the Hepatic VeinsIndication for Reconstruction of the Hepatic Veins

1. No regurgitating blood flow in 1. No regurgitating blood flow in occluded hepatic occluded hepatic veinsveins can be seen in the peripheral tributaries.can be seen in the peripheral tributaries.

2. Blood flow of the 2. Blood flow of the relevant portal venous branchesrelevant portal venous branches are are regurgitating.regurgitating.

3. Under 3. Under occlusion of the hepatic arteryocclusion of the hepatic artery discolored area discolored area appears, and when the volume of the area deducts appears, and when the volume of the area deducts from the remnant liver, the remaining liver volume from the remnant liver, the remaining liver volume is smaller than the safe limit of the metabolic is smaller than the safe limit of the metabolic demand.demand.

Sano et al. Ann Surg 2002; 236: 241.

Maema et al. Transplantation 2002; 73: 765-769 Maema et al. Transplantation 2002; 73: 765-769

RHVRHVMHVMHVV8V8

V5V5

Tape Switching Technique Tape Switching Technique

ConclusionConclusion

1. Last 25 years developments in Hx for HCC.1. Last 25 years developments in Hx for HCC.

2. PVE, TACE+Hx, Repeated Hx may 2. PVE, TACE+Hx, Repeated Hx may improve survival.improve survival.

3. Isolated subtotal caudate Hx is established.3. Isolated subtotal caudate Hx is established.

4. New variation of donor Hx enables 4. New variation of donor Hx enables challenging LDLT for advanced HCC.challenging LDLT for advanced HCC.

11

Health & Medicine

Transcript of 11