Hepatocellular carcinoma (HCC) is one of the most common malignant tumors, and hepatectomy is still the standard treatment for HCC, and about 90% of HCC in China is combined with cirrhosis of different degrees. In China, about 90% of HCC is combined with varying degrees of cirrhosis, and post- resectional liver failure (PLF) must be prevented in cases of cirrhosis. In the last decade or so, techniques related to liver resection have made great progress, such as 3D imaging, methods of liver reserve function assessment, surgical techniques, artificial liver techniques, anesthesia and ICU, etc. The mortality rate of liver resection has decreased from 10% in the 1980s to less than 5% today, and some teams, including ours, even reported zero mortality [1,2]. In this paper, we focus on the prevention and treatment of PLF based on our experience combined with the literature. DATA AND METHODS 1. GENERAL DATA: A total of 1000 cases of surgically resected and pathologically confirmed HCC were performed in our hospital from July 2000 to June 2008. There were 922 males and 78 females, aged 21-89 years, with a mean age of 54.5 years. 725 cases (72.5%) had AFP (+) and 857 cases (85.7%) had HBsA g positivity. There were 910 cases (91%) with varying degrees of cirrhosis. There were 201 cases (20.1%) with combined portal hypertension, splenomegaly, and moderate and severe varices of esophageal veins. The size of tumors ranged from 1.1-495 px, with an average of 140 px. The number of tumors ranged from 1-6, with an average of 2.5. Tumor sites: 270 cases in the left lobe, 580 cases in the right lobe, 91 cases in the caudal lobe, and 59 cases in the others. Preoperative radiofrequency ablation treatment was performed in 131 cases, and TACE was performed in 142 cases. The preoperative liver function grade A, B, and C were 71.1%, 28.9%, and 0%, respectively, and those with liver function grade B were treated with liver preservation therapy before surgery. Preoperative pulsatile pigment concentration measurement (PDD) was performed to detect indocyanine green retention (ICGR) in 344 cases. Preoperative liver tissue biopsy was performed in 76 cases. Preoperative 3D CT and MRI revascularization of the liver was performed in 134 cases. Morphological evaluation and residual liver volume calculation were performed in 235 cases. 2. Surgery: 62 cases of left outer lobectomy, 33 cases of left inner lobectomy, 101 cases of left lobectomy, and 59 cases of enlarged left hemicolectomy. Right anterior lobe resection was performed in 102 cases, right posterior lobe resection in 168 cases, right lobe resection in 188 cases, and enlarged right hemihepatectomy in 32 cases. There were 129 cases of middle hepatectomy, 91 cases of caudal lobe resection, and 35 cases of others. Blood flow blocking method: 401 cases of intermittent blocking method of the first hepatic portal at room temperature, blocking time 5-38 minutes, average time 16 minutes. There were 334 cases of hemihepatic (into the liver) blood flow block, 139 cases of complete (in and out of the liver) hemihepatic blood flow block, and 126 cases of no blood flow block, including 98 cases of Belghiti pre-positioned sling method. 3. Results: The liver function was Child B grade, and the liver function was changed to Child A grade after preoperative hepatoprotective treatment. The preoperative PDD method detected ICG clearance test in 344 cases, ICGR15 6-25%, mean 15.5%. Preoperative liver tissue biopsy for liver fibrosis degree Metavir score was performed in 76 cases, the most severe cirrhosis (F4) in 4 cases, severe fibrosis (F3) in 21 cases, moderate fibrosis (F2) in 41 cases, and mild fibrosis (F1) in 10 cases. Preoperative 3D CT and MRI revascularization of the liver was performed for morphological evaluation and residual liver volume calculation in 235 cases, with 35.5-52% residual liver volume and a mean residual liver volume of 43.3%. Intraoperative bleeding volume was 200-2500ml , average 600ml, including >1000ml in 186 cases. Blood transfusion was 0-3000 ml, average 500 ml, including >1000 ml in 176 cases. The operative time was 40 minutes-7.5 hours, with an average of 2.8 hours. The vast majority of patients (95.3%) had varying degrees of ascites after surgery, of which 22% had massive ascites. There were 31 cases of postoperative bleeding, and 19 cases of hemostasis by secondary surgery. There were 88 cases of postoperative bile leak, 31 cases of nasobiliary drainage under ERC, and 12 cases of secondary surgery. There were 18 cases of postoperative liver failure, with an incidence of 1.8%. 13 of the 18 cases of PLF were elderly patients (>65 years old), 15 cases of liver function ChildB to ChildA, 9 cases of right lobe resection, 7 cases of enlarged left/right lobe resection, 14 cases of intraoperative bleeding >1000 ml, 13 cases of intraoperative blood transfusion >1000 ml, 14 cases of ICGR15 >20% (16 cases ICGR test in progress), hepatoportal block >20 minutes 7 cases (10 cases in progress). The degree of liver fibrosis Metavir score F4/F3 6 cases (in 7 cases of liver biopsy). Hepatic residual liver volume < 40 % 9 cases (out of 12 cases with hepatic residual liver volume assessment). 18 cases of PLF were cured after aggressive treatment with hepatoprotection, support and promotion of hepatocyte regeneration, artificial liver and liver transplantation. The perioperative mortality rate of the whole group of 1000 cases was 0%, and the 1-, 3- and 5-year survival rates were 74.5%, 59.4% and 43.8%, respectively. The definition of PLF has not been unified, and it is generally considered that elevated serum bilirubin, low white egg reduction, prolonged PT, ascites and different degrees of hepatic encephalopathy occur after hepatectomy. The more widely accepted definition abroad is the so-called 50C50 criterion: PT index <50% (i.e., international standardized ratio >1.7%) and serum bilirubin >450 mmol/L (2.9 mg/dL) within five days postoperatively [3,4]. We, along with other centers in China, mostly use liver failure treatment guidelines as criteria, i.e., patients presenting with postoperative hepatic encephalopathy of grade II or higher with impaired coagulation mechanisms and progressive worsening of xanthogranuloma. The incidence of PLF has been reported in the literature to be in the range of 0-32%, generally in the range of 0.7-9.1%, and the mortality rate of hepatic resection has been reduced to 0-5% in the last decade, with PLF accounting for 18-75% of the total deaths after hepatectomy [5]. The incidence of PLF in our center in the last decade was 1.8% and the mortality rate of hepatic resection was 0%. The more recognized independent risk factors for the occurrence of PLF are small residual liver volume, excessive intraoperative blood loss and transfusion, severe preoperative hypoproteinemia, significantly prolonged PT, and male elderly patients [6]. These factors were more than half of the 18 cases of PLF in our group. Hepatectomy in patients with HCC with cirrhosis requires a rigorous evaluation, including tumor staging, morphology and liver reserve function. Morphological assessment is mainly based on various imaging techniques including abdominal ultrasound, 3D CT and MRI of the liver. imaging examinations can obtain tumor size, accurate localization, relationship with blood vessels, degree of vascular invasion and satellite foci, as well as volume calculation and even simulation of liver resection. Most scholars believe that liver resection is only feasible for cirrhotic patients with liver function Child-Pugh grade A. In our group, 289 patients with Child B liver function were treated with preoperative hepatoprotective therapy before surgery to convert liver function to Child A. However, some patients with Child-Pugh grade A cirrhosis underwent hepatectomy, and despite the small extent of resection, severe liver failure could occur after surgery, showing the limitations of Child-Pugh grade assessment. ICGR15) <15% can tolerate a larger volume of hepatectomy, and above 20% can tolerate only a small localized volume of hepatectomy. We have reported the use of the pdd method for icg clearance test to detect icgr15 in hcc patients, and the results showed that the pdd method is an ideal method to perform icg clearance test to detect liver reserve function; r15 can well reflect the liver reserve function of primary liver cancer patients [7]. In our group, 344 cases were tested by icg clearance test, and icgr15 plf="" icgr15="">20%. Therefore care should be taken to prevent PLF when hepatic resection is performed for icgr15 > 20%. preoperative liver tissue biopsy allows for Metavir scoring (F0-F4) of the degree of liver fibrosis. The postoperative risk level is F4, F3, F2, F1 in order, and the risk level of F1 liver resection is close to that of normal liver resection. In our group, liver biopsy liver fibrosis degree score was performed in 7 of 18 PLF cases, and F4/F3 in 6 cases, indicating that liver fibrosis degree is closely related to PLF. Other liver fibrosis examination methods (e.g., fibrosis test, elastometry) also have some reference value. The residual volume of the liver was assessed preoperatively by imaging techniques to evaluate the various parts of the liver, resected liver and tumor tissue volumes for precise analysis. The percentage of resected tissue to the whole liver volume ([resected liver volume – tumor volume]/volume of the whole liver) and, more informatively, the percentage of residual effective functional liver (residual liver volume/[whole liver volume – tumor volume]) were calculated. In our group, 12 of the 18 PLF cases were evaluated for residual liver volume, and 9 of them had <40% residual liver volume; therefore, it is generally considered that liver resection for < p="">hepatic sclerosis should not exceed 40%. there are three main issues when performing liver resection for HCC: the choice of anatomic/non-anatomic liver resection, the protection of functional liver tissue, and the prevention of bleeding. Anatomic hepatectomy helps to reduce bleeding during hepatectomy and reduce complications in the residual liver section. However, anatomical hepatectomy removes more non-tumoral functional liver tissue, which will inevitably affect the functional compensation of the residual liver. Non-anatomic hepatectomy whose resection area only includes the tumor and surrounding liver tissue does not coincide with the distribution of liver segments and lobes to protect as much non-tumor functional liver tissue as possible, and generally requires the cutting edge to be at least 25px from the tumor margin [8]. Recent retrospective studies have focused on the role of anatomical hepatectomy in improving overall survival and tumor-free survival.Hasegawa et al. reported that the overall 5-year survival and tumor-free survival in the anatomical hepatectomy group were 66% and 35%, respectively, while the overall 5-year survival and tumor-free survival in the non-anatomical hepatectomy group were 34% and 16%, respectively, with significant differences between the two groups (P < 0.01) [9 ]. We had a randomized control to observe the safety of 38 anatomical and non-anatomical (15 vs 23) hepatectomies for HCC. The results showed that there were no operative deaths in either group, and there were no significant differences in intraoperative bleeding, complication rates, or length of hospital stay. The rate of recent recurrence was significantly lower in the anatomical hepatectomy specimen, and the one-year tumor-free survival rate was higher than that of non-anatomical hepatectomy. This suggests that anatomic hepatectomy is a safe and effective procedure for the treatment of HCC, and should be used whenever possible in cases for which it is indicated, with the hope of achieving better outcomes [10,11]. However, it has also been shown that this advantage of anatomical hepatectomy over non-anatomical resection treatment cannot yet be established [12]. Therefore, when the patient's liver function reserve function is at a critical level, at this time, the preservation of functional liver parenchyma is more important than anatomical resection. Since the 1970s, non-anatomic hepatic resection has been the main procedure for HCC in China, and it has become the country with the highest number of cases and the most experience in this procedure, with a significant reduction in mortality and the emergence of a large number of long-term survival cases, which is remarkable to the world. Therefore, according to our national situation, non-anatomic resection is still an effective treatment for HCC and should be tailored to local conditions. Many studies have shown that bleeding and transfusion during hepatectomy for hepatocellular carcinoma are significantly associated with prognosis, and bleeding and transfusion can increase the frequency of complications and mortality and tumor recurrence during hepatectomy [13,14]. The author's study in the 1990s showed that intraoperative bleeding during hepatectomy was significantly associated with postoperative survival and tumor-free survival, and the idea that preferring to prolong the block time and minimize bleeding could significantly reduce complications and mortality of hepatectomy surgery was proposed earlier in China [15,16]. More than 80% of the 18 PLF cases in our group had bleeding/transfusion >1000 ml during surgery, again showing that intraoperative bleeding and transfusion were significantly associated with prognosis. Methods of hepatic resection to control bleeding include blood flow blocking techniques, low central venous pressure anesthesia, anterior approach for large tumors and appropriate modality of liver parenchymal transection. The cirrhotic liver is less tolerant of local ischemia than the normal liver, and intermittent blockade (15 minutes of blockage followed by 5 minutes of release) is appropriate. Bloodless hepatectomy has undergone more than 30 years of development, and there have been successive surgical methods such as whole liver flow block at room temperature, whole liver flow block with low temperature perfusion, and selective flow block. In the 1980s, I was the first to advocate the use of a modified normothermic total hepatic flow block technique (i.e., hepatectomy with normothermic total hepatic flow block without blocking the abdominal aorta) in China. This method greatly improves the surgical resection rate, simplifies the surgical approach, and likewise achieves the goal of bloodless hepatectomy [16]. Hypothermic perfusion may improve tolerance to ischemia. However, this technique is complicated by the long duration of complete blockage of hepatic blood flow and can cause significant hemodynamic and some biochemical alterations, especially in coagulation mechanisms. Therefore, this technique is less commonly used. Selective (hemihepatic/hepatic segmental) flow blocking techniques allow for precise anatomical localization of the tumor to be resected and for precise hepatic resection. In addition to the flow block technique, another important way to reduce bleeding is to limit intraoperative fluid intake as much as possible during hepatic resection and maintain low central venous pressure. This requires an experienced anesthesia team and excellent cooperation between the surgical and anesthesia teams. Some authors have reported that intermittent hilar block combined with low central venous pressure avoids all major bleeding and allows 80% of patients to be operated without blood transfusion [17]. Anterior approach hepatectomy reduces the risk of tumor rupture and liver bleeding and reduces the number of tumor cells shed into the circulatory system. belghiti reported that the pre-positioned sling method can help guide the cross-section and reduce bleeding, making the anterior approach easier]. Isolated/semi-isolated hepatectomy improves resection rates for tumors that are occult posterior to the liver, invade the posterior inferior hepatic vena cava and the main hepatic quiet and are not routinely resectable. We were the first in the world to successfully apply semi-isolated hepatectomy technique clinically in 1992, breaking through the forbidden zone of liver surgery[18] . In recent years, with the increasing maturity of liver transplantation, it has made isolated/semi-isolated hepatectomy easier, safer and more precise. In today’s scarcity of donor liver, the isolated/semi-isolated hepatectomy technique is still valuable for the treatment of hepatocellular carcinoma that is difficult to be managed by conventional hepatectomy. The main complication after liver resection for hepatocellular carcinoma is postoperative liver failure. Postoperative liver failure is characterized by jaundice, coagulation factor deficiency (prolonged prothrombin time or increased internationalization ratio), ascites and hepatic encephalopathy. The treatment of PLF has not been reported in a large number of cases, and most centers, including ours, mostly refer to the treatment of acute liver failure. The basic medical treatment includes: discontinuation or reduction of hepatotoxic drug products, necessary basic life support measures, maintenance of water-electrolyte and acid-base balance, application of drugs to protect liver function and promote hepatocyte regeneration, and prevention of complications such as stress ulcers. The maintenance of vital organs is important in PLF treatment not only because the deterioration of these organs directly leads to the death of the patient, but also because the improvement of vital organs allows the patient to pass the risk period, which in turn increases the success rate of artificial liver support or liver transplantation, and reduces the incidence of serious complications. Artificial liver support systems (ALSS) is a device and method to replace the failing liver function of patients with severe liver disease with artificial methods to provide supportive treatment. In our center, we have been trying to explore a new treatment model of artificial liver combined with liver transplantation for acute liver failure since 1998 [19]. All 18 PLF cases underwent 42 non-biological artificial liver, 4 biological artificial liver, and 2 artificial liver combined with liver transplantation in addition to basic medical treatment. The biologic artificial liver method included plasma exchange, Biologic-DT, CVVH, MARS, etc. The biologic artificial liver was constructed by self-built new BAL (BIOLIV A3A Reactor) using polysulfone membrane fiber tubes, and none of the 18 cases died, and 2 cases were successfully transitioned to liver transplantation by artificial liver treatment. Therefore, ALSS or combined liver transplantation has an extremely important role in the treatment of PLF.