"PERISH" flowchart for selection of the patients with resectable hepatocellular carcinoma

Abstract

A selection of patients with hepatocellular carcinoma (HCC) for surgical resection is crucial and algorithms/staging systems help surgeons to decide on a standard treatment for each patient and each HCC stage. However, there are always difficulties in remembering and/or recalling the contents of the algorithms/staging systems. Moreover, most algorithms/staging systems don’t include data about the extent of hepatectomy, intra-hepatic distribution of tumor(s), and technical feasibility of resection, all of which are vital in the surgeons’ decision-making process. Here, we aimed to present a simple and handy mnemonic acronym for selecting resectable HCCs in surgical practice. This was reproduced from the existing well-known staging systems. The designed mnemonic acronym is a phrase “PERISH” and it includes asking for Performance of patient, Extra-hepatic disease, Reserve of liver, Intra-hepatic distribution, Stratifying risk factors, and Hepatectomy size in order. Performance based on whether the patient is mostly bedridden or not, should be the first step of evaluation. Next, asking for suspicious metastasis as bone pain and radiological evaluation of abdomen/thorax is mandatory. The calculation of Child-Pugh score is only the third step. Good candidates for surgical resection should be Child-Pugh “A” with normal bilirubin levels. Technical feasibility of resection according to the intra-hepatic distribution of tumor(s) should be done later and the candidates preferably should not have portal hypertension (no splenomegaly, no thrombocytopenia). If the patient fulfils all the previous steps, the surgeon may perform indo-cyanine green clearance test. Consequently, following the PERISH flowchart may prevent “perish” of the surgeons while selecting the appropriate resectable HCCs.

Keywords

Hepatectomy / hepatocellular carcinoma / surgery / surgical education

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