Surgeon's aspect of an expert consensus-based practical recommendation for surgical treatment of hepatocellular carcinoma.

Recently, Dr. Park and Cho et al. [1] published an interesting article entitled “Surgical treatment of hepatocellular carcinoma: an expert consensus-based practical recommendation from the Korean Liver Cancer Association.” Hepatocellular carcinoma (HCC) is one of the most prevalent cancers in Korea; moreover, the overall 5-year survival rate remains at 39.3%, with only 62.4% for patients with the disease confined to the liver [2]. Liver resection has been shown to be the most effective treatment for HCC [3]; however, current Korean and international clinical guidelines broadly recommend liver resection, requiring practical guidelines that can be standardized across various clinical settings in Korea.
There are many ways to make consensus for treatment, including international consensus conferences [4], expert panel consensus [5], and guideline publication [6], using scientific methods such as the Delphi method [7]. The Korean Liver Cancer Association generated expert panels from the Korean Liver Cancer Association, the Korean Association of Liver Surgery, and the Korean Association of Hepato-Biliary Pancreatic Surgery. They made a set of 27 key questions and 46 statements after vigorously assessing relevant publications, and those statements were consolidated and disseminated to the entire expert panel for voting according to the Delphi methodology. Briefly, consensus agreement, indicating strong agreement on the appropriateness of the proposed recommendation, was met when 70% of the respondents made statements with ratings ≥75, or the median rating was ≥80. Conversely, disagreement agreement, indicating strong disagreement on the appropriateness of the proposed recommendation, was met when 70% of the respondents made statements with ratings ≤25, or the median rating was <20. Statements that reached near agreement or disagreement tended toward consensus; however, there were significant outliers. Statements that did not reach consensus were redistributed in the online survey. The panelists evaluated the two-round survey statements and reached a consensus on several statements. Finally, they made surgery-specific recommendations including when and how to do liver resection and considerations in specific risky situations. They made recommendations for preoperative evaluation, basic principles of hepatic resection, minimally invasive hepatic resection, preoperative and postoperative management, and follow-up, except for the indications for hepatic resection, which will be addressed by other guideline task forces. They focused on the guidelines about “surgery” itself, especially about technical aspects of minimally invasive liver resection and anatomical liver resection from the surgeon’s point of view. Briefly, for fundamental principles of hepatectomy, they made recommendations for optimal surgical margins for HCC, technical strategies to prevent recurrence, maintaining low central venous pressure during hepatectomy, preferred anatomical liver resection, and methods to increase future liver remnant volume. For recent popular minimally invasive liver resection, indications, robotic liver resection, and a difficulty score system were recommended. Recommendations for minimally invasive liver resection were made based on tumor location, tumor size, and the extent of liver resection. They also made recommendations for specific high-risk patient groups, including patients with morbid obesity, patients aged >75 years, those with severe cardiovascular disease, and those with chronic kidney disease.
The treatments for HCC are decided by a multidisciplinary team, and this practical recommendation is useful to communicate with each other and to select optimal treatment for specific patients with HCC. This recommendation also gives some guidance about surgical practice to doctors other than surgeons.
In conclusion, Dr. Park and Cho et al. [1] published “Surgical treatment of hepatocellular carcinoma: an expert consensus-based practical recommendation from the Korean Liver Cancer Association,” which will guide practical recommendations regarding liver resection for surgeons and other clinicians and serve as a model for developing consensus-based recommendations for other diseases.