BACKGROUND: The effectiveness of surveillance for hepatocellular carcinoma (HCC) using ultrasound (US) in North America has been questioned due to the predominance of patients of Caucasian ethnicity and larger body habitus.OBJECTIVE: To determine the effectiveness of US surveillance for HCC in a Canadian hepatobiliary centre and to identify independent variables associated with early detection of tumour(s).METHODS: A retrospective review of patients with first HCC in a US surveillance population at the authors’ hospital yielded 201 patients (over a 10.5-year period). Patients were categorized into three groups: regular surveillance (frequency of surveillance ≤12 months [n=109]); irregular surveillance (frequency of surveillance >12 months [n=38]); or first surveillance (tumour detected on first scan [n=54]). The Milan criteria for transplantation and Barcelona Clinic Liver Cancer (BCLC) staging system were used as outcome measures. Effective surveillance was defined as tumour detection within Milan criteria or curative BCLC stages 0 and A; its association with multiple patient- and disease-related variables was tested.RESULTS: When using the Milan criteria as outcome, 84 of 109 (77%) regular surveillance patients, 23 of 38 (61%) irregular surveillance patients and 40 of 54 (74%) first surveillance patients had tumours meeting the transplantation criteria. The difference between regular and irregular surveillance was statistically significant (P=0.03). When using the BCLC staging system, 87 of 109 (80%) regular surveillance patients, 26 of 38 (68%) irregular surveillance patients and 41 of 54 (76%) first surveillance patients had their tumours detected in BCLC curative stages (0 and A; P=0.11). Regular surveillance was the only variable significantly associated with detection of tumour(s) within the Milan criteria (OR 2.76 [95% CI 1.10 to 6.88]). Tumours detected more recently were more likely to be <2 cm in size (BCLC stage 0; OR 2.38 [95% CI 1.07 to 5.31]).CONCLUSION: A high rate of HCC surveillance success was achieved using US alone when performed regularly in a specialized hepatobiliary centre.