Central hepatectomy: the golden mean for treating central liver tumors?

The treatment of patients with central liver tumors involving segments 4, 5 and 8 is a difficult clinical problem. These tumors often straddle Cantlie's line and involve parts of both lobes of the liver. The traditional management of such tumors is to perform either an extended right or an extended left hepatectomy. However, extended hepatectomies are associated with greater morbidity and mortality, mainly due to increased risk of postoperative liver failure. Central hepatectomy (or mesohepatectomy) may be superior to extended hepatectomy, because it conserves more liver parenchyma. However, the operation can be tedious and may result in increased blood loss, and was therefore infrequently used. Recommendations for its application for centrally located tumors are not clear. The aim of our study is to evaluate the evidence supporting central hepatectomy as a safe procedure for the management of central hepatic tumors, and to describe the effectiveness of central hepatectomy compared to extended hepatectomy. We present herein two patients who underwent central hepatectomy and systematically review the English literature until December 2006. We found 13 studies of multisegmental (> or = 2 segments) central liver resection that included at least four patients. Only three retrospective non-randomized studies have looked at central hepatectomy in comparison to lobar or extended hepatectomy, and no clear consensus emerges. To date, there is insufficient evidence to categorically state that central hepatectomy is superior to extended hepatectomy, thus the use of all approaches can be justified. However, if central hepatectomy can be performed without excessive blood loss, then it should be preferred, as it is less extensive and results in greater functional remnant liver. Additionally, it would clearly be superior in patients with cirrhosis.