**3.1. Hepatic resection**

Hepatic resection is the gold standard in noncirrhotic liver. In western countries, HCC incidence is raising, mostly due to NAFLD and metabolic syndrome [13].

Patients with these pathologic conditions can develop HCC in the absence of cirrhosis or severe fibrosis [14], although hepatic parenchyma shall not be considered healthy since steatosis is determinable in 50% of patients and steatohepatitis (NASH) in 25% [15, 16]. A multicentric study confirmed that HCC patients suffering from metabolic syndrome have higher postoperative hepatic failure, mortality, and morbidity rates [15, 16].

Hepatic surgery obtains excellent results in elderly patients, even if cirrhotic. Advance age

HCC in Elderly Patients. Curative Intraoperative Strategies and Management in Recurrences

http://dx.doi.org/10.5772/intechopen.79748

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However, elderly patients, cirrhotic or not, are often excluded from surgery due to comorbidities that rise ASA score and operative risk. Mini-invasive procedures on the one hand make operative time longer and worsen blood-gases control; on the other hand, they allow to spare hepatic parenchyma and shorten hospitalization and recovery [20]. Therefore, patients treated with mini-invasive surgery vs. open achieve a better outcome, especially if elderly, who often suffer longer hospitalizations either physically (reduced physical activity and nosocomial infection risk) and psychologically (depression, confusion, and

As reported by a recent meta-analysis, even better outcome is achieved with surgery (open or mini-invasive) vs. transarterial chemoembolization (TACE), which is the most used palliative care technique for HCC, whose advantage remains consistent even in advance HCC, even if vascular invasion is present, so up to stage Barcelona Clinic Liver Cancer (BCLC) stageC [17, 21]. Portal hypertension is often associated with hepatic damage. However, several studies proved that hepatic residual functionality and not portal hypertension affects short- and long-time

Patients with mild portal hypertension and preserved hepatic functionality can receive limited resections with morbidity, mortality, and OS similar to patients without portal hypertension [19].

HCC frequently develops and spreads through the portal system and that is why several authors recommend performing anatomical resections; these studies prove a better OS and

More recently, a large Japanese retrospective study (more than 72,000 patients) proved superiority of anatomical resection only for HCC diameter >2 and <5 cm. Superiority is not proven if HCC diameter is <2 cm since portal diffusion risk is very low or >5 cm because other factors

It is also possible to match a parenchyma-sparing surgery with anatomical resection, thanks to subsegmental US-guided resections [27]. This technique with laparoscopic subglissonian or extraglissionan approach is not of common use, due to its technical difficulty and exclusion criteria, that are ascites and moderate to severe portal hypertension. The approach remains interesting and future technical development is possible, especially thanks to robotic surgery. Subsegmental resection shall not be performed for advanced HCC (diameter >2 cm) in order to respect oncologic principles of a radical resection [27]. The procedure allows to spare liver parenchyma, and it

Liver transplantation (LT) is considered the first-line treatment for cirrhotic patients. LT indications are given following the Milan criteria: single HCC nodules (diameter <5 cm) or less

may be really interesting for elderly even if cirrhotics with an early-HCC diagnosis.

than 3 HCC nodules all <3 cm and in any case nonresectable [17].

local disease control for anatomic resection vs. wedge resection [24, 25].

alone is no more a contraindication to surgery.

outcome of hepatic resections [22, 23].

influence prognosis [26].

**3.2. Liver transplantation**

dizziness) [20].

Nevertheless, hepatic resection on metabolic syndrome-liver has excellent oncologic effectiveness and leads to long-time survival [16].

In cirrhotic patients, hepatic resection is the first-line treatment for single HCC nodule and preserved hepatic function, strict indications for hepatic resection are serum-bilirubin <1.5 mg/ dl and Hepatic Portal-Venous Gradient (HPVG) ≤10 mmHg or platelets ≥100,000 [17].

Resection in patients with light portal hypertension and nonenrollable for liver transplant shall be well weighted against locoregional treatments [17].

Cirrhotic liver resection can be a safe practice in well-selected patients with low morbidity and mortality rates [18]. Selection shall be lead through a global, multiparametric evaluation of the patient and shall pass beyond a dogmatic data interpretation.

All guidelines agree that is needed to select cirrhotic patients for hepatic resection thus to achieve the best outcome, but selection criteria are not universally accepted, the ones suggested from several surgical groups are not based on strong evidence. Therefore, it is necessary to develop a multiparametric evidence-based prognostic score to allow to evaluate a "tailored" operative risk and expected survival.

Tailored-risk evaluation is even more important in elderly patients since aging is a strictindividual process, multidimensional evaluation, and CGA score, in particular, are crucial to assess whether advanced in aged patients can be either enrolled or not for surgery with a deep gap in quality of life and overall survival [4].

Child-Pugh class B patients are routinely excluded from surgery; however, in some cases, satisfying outcome was achieved by performing limited hepatic resections in strictly selected patients, with mild serum bilirubin raise (≤2 mg/dl) and without portal hypertension [19] (**Table 2**).

Laparoscopic or robotic approaches could widen indications to Child-Pugh class B patients due to their little invasivity.

In elderly patients, these approaches are extremely interesting.

**Table 2.** Indications to liver resection in HCC patient.

Hepatic surgery obtains excellent results in elderly patients, even if cirrhotic. Advance age alone is no more a contraindication to surgery.

However, elderly patients, cirrhotic or not, are often excluded from surgery due to comorbidities that rise ASA score and operative risk. Mini-invasive procedures on the one hand make operative time longer and worsen blood-gases control; on the other hand, they allow to spare hepatic parenchyma and shorten hospitalization and recovery [20]. Therefore, patients treated with mini-invasive surgery vs. open achieve a better outcome, especially if elderly, who often suffer longer hospitalizations either physically (reduced physical activity and nosocomial infection risk) and psychologically (depression, confusion, and dizziness) [20].

As reported by a recent meta-analysis, even better outcome is achieved with surgery (open or mini-invasive) vs. transarterial chemoembolization (TACE), which is the most used palliative care technique for HCC, whose advantage remains consistent even in advance HCC, even if vascular invasion is present, so up to stage Barcelona Clinic Liver Cancer (BCLC) stageC [17, 21].

Portal hypertension is often associated with hepatic damage. However, several studies proved that hepatic residual functionality and not portal hypertension affects short- and long-time outcome of hepatic resections [22, 23].

Patients with mild portal hypertension and preserved hepatic functionality can receive limited resections with morbidity, mortality, and OS similar to patients without portal hypertension [19].

HCC frequently develops and spreads through the portal system and that is why several authors recommend performing anatomical resections; these studies prove a better OS and local disease control for anatomic resection vs. wedge resection [24, 25].

More recently, a large Japanese retrospective study (more than 72,000 patients) proved superiority of anatomical resection only for HCC diameter >2 and <5 cm. Superiority is not proven if HCC diameter is <2 cm since portal diffusion risk is very low or >5 cm because other factors influence prognosis [26].

It is also possible to match a parenchyma-sparing surgery with anatomical resection, thanks to subsegmental US-guided resections [27]. This technique with laparoscopic subglissonian or extraglissionan approach is not of common use, due to its technical difficulty and exclusion criteria, that are ascites and moderate to severe portal hypertension. The approach remains interesting and future technical development is possible, especially thanks to robotic surgery. Subsegmental resection shall not be performed for advanced HCC (diameter >2 cm) in order to respect oncologic principles of a radical resection [27]. The procedure allows to spare liver parenchyma, and it may be really interesting for elderly even if cirrhotics with an early-HCC diagnosis.
