Prediction of the risk of hepatic failure in patients with portal vein invasion hepatoma after hepatic resection

The Role of the Multiparametric MRI LiverMultiScanTM in the Quantitative Assessment of the Liver and Its Predicted Clinical Applications in Patients Undergoing Major Hepatic Resection for Colorectal Liver Metastasis

Liver biopsy remains the gold standard for the histological assessment of the liver. With clear disadvantages and the rise in the incidences of liver disease, the role of neoadjuvant chemotherapy in colorectal liver metastasis (CRLM) and an explosion of surgical management options available, non-invasive serological and imaging markers of liver histopathology have never been more pertinent in order to assess liver health and stratify patients considered for surgical intervention. Liver MRI is a leading modality in the assessment of hepatic malignancy. Recent technological advancements in multiparametric MRI software such as the LiverMultiScanTM offers an attractive non-invasive assay of anatomy and histopathology in the pre-operative setting, especially in the context of CRLM. This narrative review examines the evidence for the LiverMultiScanTM in the assessment of hepatic fibrosis, steatosis/steatohepatitis, and potential applications for chemotherapy-associated hepatic changes. We postulate its future role and the hurdles it must surpass in order to be implemented in the pre-operative management of patients undergoing hepatic resection for colorectal liver metastasis. Such a role likely extends to other hepatic malignancies planned for resection.

Liver Function-How to Screen and to Diagnose: Insights from Personal Experiences, Controlled Clinical Studies and Future Perspectives

Acute and chronic liver disease is a relevant problem worldwide. Liver function plays a crucial role in the course of liver diseases not only in estimating prognosis but also with regard to therapeutic interventions. Within this review, we discuss and evaluate different tools from screening to diagnosis and give insights from personal experiences, controlled clinical studies and future perspectives. Finally, we offer our novel diagnostic algorithm to screen patients with presumptive acute or chronic liver disease in the daily clinical routine.

The role of imaging in prediction of post-hepatectomy liver failure

Post-hepatectomy liver failure (PHLF) is not only a leading cause of mortality but also a leading cause of life-threatening complications in patients undergoing liver resection. The ability to accurately detect the emergence of PHLF represents a crucially important step. Currently, PHLF can be predicted by a comprehensive evaluation of biological, clinical, and anatomical parameters. With the development of new technologies, imaging methods including elastography, diffusion-weighted magnetic resonance imaging, and gadolinium ethoxybenzyl diethylenetriaminepentaacetic acid-enhanced MRI play a more significant role in the pre-operative prediction and assessment of PHLF. In this review, we summarize the mainstream studies, with the aim of evaluating the role of imaging and improving the clinical value of existing scoring systems for predicting PHLF.

Hepatic resection or transarterial chemoembolization for hepatocellular carcinoma within Milan criteria: A propensity score matching analysis

This study aimed to compare the long-term survival of patients with hepatocellular carcinoma (HCC) within the Milan criteria who underwent hepatic resection (HR) or transarterial chemoembolization (TACE).Medical records were retrospectively analyzed for HCC patients within the Milan criteria treated at Affiliated Tumor Hospital of Guangxi Medical University between March 2003 and March 2008, 159 of whom underwent HR and 42 of whom underwent TACE. Long-term overall survival (OS) was evaluated using the Kaplan-Meier method before and after propensity score matching. Cox proportional hazard modeling was used to identify possible predictors of OS.Propensity score matching was used to generate 32 pairs of patients, for which OS was significantly higher after HR than TACE at 1 year, 96.6% versus 84.4%; 3 years, 75.4% versus 53.1%; 5 years, 48.8% versus 29.7%, respectively (P = .038). Among all patients with multinodular HCC (2-3 tumors ≤3 cm), HR was also associated with significantly higher OS than TACE at 1 year, 95.2% versus 72.7%; 3 years, 71.4% versus 9.1%; 5 years, 35.1% versus 0%, respectively (P < .001). By contrast, among all patients with a single HCC tumor ≤5 cm, HR and TACE were associated with similar OS at 1 year, 85.9% versus 90.3%; 3 years, 62.0% versus 61.3%; 5 years, 42.1% versus 33.2%, respectively (P = .332).HR provides survival benefit over TACE in HCC patients within the Milan criteria, especially patients with multinodular HCC involving 2 to 3 tumors ≤3 cm. However, HR and TACE appear to be similarly effective for patients with single-tumor HCC ≤5 cm.

Prognostic nomogram for hepatocellular carcinoma in adolescent and young adult patients after hepatectomy

Background

Hepatocellular carcinoma (HCC) was rarely discussed in adolescent and young adult (AYA) patients. This study aimed to discuss the character of AYA HCC patients and establish an effective prognostic nomogram for patients after hepatectomy.

Results

For all of the patients, the median OS was 57 months with 5-year OS rate 60.4%, and DFS was 48 months with 5-year DFS rate 51.4%. The tumor size, vascular invasion status and the pathological differentiation were the independent predictors for both OS and DFS. Except for that, gender, Neutrophil-lymphocyte ratio, HbeAg, and α-Fetoprotein were the predictors for OS. The c-index for OS prognostic nomogram was 0.75 (95% CI, 0.71 to 0.79), and c-index was 0.70 (95% CI, 0.66 to 0.74) for DFS prognostic nomogram, which was better than American Joint Commission on Cancer 2002 and 2010, Okuda staging system, the Japanese Integrated Staging system, and Tokyo staging system.

Materials And Methods

This study was based on 423 AYA HCC patients (younger than 40 years old) undergoing hepatectomy in West China Hospital between 2008 to 2014. Based on the multivariate risk factors, the nomogram was constructed for predict the possibility for overall survival (OS) and disease-free survival (DFS) rate. Harrel’s concordance index (c-index) was used to compare the predictive accuracy and discriminative ability between the nomogram and eight contemporary staging systems.

Conclusions

Our prognostic nomogram could accurately and preciously provide individual prediction for AYA HCC patients in OS and DFS after hepatectomy.

Potential use of metabolic breath tests to assess liver disease and prognosis: has the time arrived for routine use in the clinic?

The progression of liver disease may be unique among organ system diseases in that progressive fibrosis compromises not only the sufficiency of hepatocyte mass but also impairs blood flow to the liver, resulting in porto-systemic shunting. Although liver biopsy as an assessment of fibrosis has become the key biomarker of and target for new therapies, it is invasive and subject to sampling error, and cannot quantify metabolic function or porto-systemic shunting. Measurement of the hepatic venous pressure gradient accommodates some of the deficiencies of biopsy but requires expertise not widely available and misses minor changes in hepatocellular mass and thereby information about metabolic function. Thus, an unmet need in clinical hepatology remains unfulfilled: a noninvasive biomarker which quantitates both the hepatocellular insufficiency and porto-systemic shunting inherent in progressive hepatic fibrosis. Ideally, such a biomarker should correlate with clinical endpoints including liver-related survival and cirrhotic complications, be performed at the point-of-care, and be affordable and easy to use. This review, an expert opinion, summarizes background and recent data suggesting that metabolic breath tests may now meet these requirements and have a valid place in clinical hepatology to supplant the time-honoured assessment of hepatic fibrosis.

Hepatic resection versus transarterial chemoembolization for patients with Barcelona Clinic Liver Cancer intermediate stage Child-Pugh A hepatocellular carcinoma

The present study aimed to compare the overall and recurrence-free survival rates following hepatic resection (HR) and transcatheter arterial chemoembolization (TACE) in patients with Barcelona Clinic Liver Cancer (BCLC) classified intermediate-stage Child-Pugh A hepatocellular carcinoma (HCC). A total of 443 patients were examined, among whom 274 underwent HR, whereas 169 received TACE. The overall survival, recurrence-free survival between groups and subgroups, and risk factors with respect to mortality and recurrence, were analyzed. The 1-, 3- and 5-year overall and recurrence-free survival rates were 70, 46 and 37% and 73, 52, and 37%, respectively after HR, compared with 38, 15, and 12% and 44, 25 and 16%, respectively after TACE. Overall and recurrence-free survival rates were significantly increased following HR compared with TACE. Subgroup analysis in the multi-nodule group showed that the 1-, 3- and 5-year overall survival rates were 68, 38 and 30% after HR, compared with 36, 10 and 0% following TACE. In the solitary tumor group, 1-, 3- and 5-year overall survival rates were 71, 50 and 38% after HR, and 41, 22 and 15% after TACE. The overall survival rate after HR was significantly increased compared with that after TACE in the solitary tumor and multi-nodule groups. The risk factors for mortality include solitary tumor diameter >10 cm, multi-nodules, serum albumin level ≥35 g/l, prothrombin time >13 sec, alphafetoprotein levels >400 ng/ml, and patients with hepatitis B virus. Solitary tumor diameter >10 cm, multi-nodules, and hepatitis B virus (P<0.001) were found to be associated with higher recurrence of HCC. Overall and recurrence-free survival rates were improved after HR compared with those after TACE in BCLC stage B, Child-Pugh A, HCC patients.

Obesity Does Not Influence Outcomes in Hepatocellular Carcinoma Patients following Curative Hepatectomy

BACKGROUND

Whether obesity affects surgical outcomes in patients with hepatocellular carcinoma (HCC) is controversial. Here we retrospectively evaluated the impact of obesity on outcomes in HCC patients after curative hepatectomy.

METHODS

Patients with Child-Pugh A liver function who underwent curative hepatectomy between 2006 and 2010 were categorized as obese (BMI ≥25 kg/m2, n = 68) and non-obese (<25 kg/m2, n = 242). To reduce interference from baseline differences between the two groups, propensity score-matched analysis was performed in the ratio 1:2 using a caliper width of 0.1. Surgical outcomes were compared for 61 obese and 115 non-obese patients.

RESULTS

Obese patients had higher levels of albumin and aspartate aminotransferase, and more solitary tumors compared to the non-obese patients (all P<0.05). In the propensity-matched cohort, baseline characteristics did not differ between the two groups (all P>0.05). Obese and non-obese patients had comparable 30-day mortality (1.6% vs. 2.6%, P = 1.000), 90-day mortality (3.3% vs. 4.3%, P = 1.000), and incidence of postoperative complications (19.7% vs. 18.3%, P = 0.819). Overall survival at 1, 3, and 5 years was similar for obese patients (83.6%, 63.6%, 41.6%) as for non-obese patients (80.9%, 65.9%, 49.1%; P = 0.358). Disease-free survival at 1, 3, and 5 years was also similar for obese patients (71.5%, 36.3%, 24.3%) as for non-obese ones (60.2%, 43.7%, 27.7%; P = 0.969).

CONCLUSION

Our propensity score-matched analysis strengthens the case that obesity does not adversely affect surgical outcomes of HCC patients undergoing curative hepatectomy.

Comparison of long-term survival of patients with solitary large hepatocellular carcinoma of BCLC stage A after liver resection or transarterial chemoembolization: a propensity score analysis

BACKGROUND

The aim of this study was to compare the long-term outcome of patients with a solitary large (> 5 cm) hepatocellular carcinoma (HCC) in Barcelona Clinic Liver Cancer (BCLC) stage A who received liver resection (LR) or transarterial chemoembolization (TACE).

METHODS

Our study examined 128 patients treated by LR and 90 treated by TACE. To reduce bias in patient selection, we conducted propensity score analysis in the present study and 54 pairs of patients after propensity score matching were generated, their long-term survival was compared using the Kaplan-Meier method. Independent predictors of survival were identified by multivariate analysis.

RESULTS

Long-term survival was significantly better for the LR group by log-rank test (P < 0.001). In multivariate analysis, tumor size, serum ALT level and TACE independently predicted survival. Despite similar baseline characteristics after propensity score matching, LR group still had significantly better survival (1 year, 68.5 vs. 55.0%; 3 years, 47.6 vs. 21.2%; 5 years, 41.3 vs. 18.5%; P = 0.007) than TACE group. The LR and TACE groups had comparable 30- and 90-day post-treatment mortality. Multivariate analysis showed that serum ALT level, serum AFP level and TACE independently predicted survival by multivariate analysis after propensity score matching.

CONCLUSION

Our propensity-score-matched study suggested that LR provided significantly better long-term survival than TACE for a solitary large HCC of the BCLC stage A, regardless of tumor size.

Comparison of long-term survival of patients with solitary large hepatocellular carcinoma of BCLC stage A after liver resection or transarterial chemoembolization: a propensity score analysis

BACKGROUND

The aim of this study was to compare the long-term outcome of patients with a solitary large (> 5 cm) hepatocellular carcinoma (HCC) in Barcelona Clinic Liver Cancer (BCLC) stage A who received liver resection (LR) or transarterial chemoembolization (TACE).

METHODS

Our study examined 128 patients treated by LR and 90 treated by TACE. To reduce bias in patient selection, we conducted propensity score analysis in the present study and 54 pairs of patients after propensity score matching were generated, their long-term survival was compared using the Kaplan-Meier method. Independent predictors of survival were identified by multivariate analysis.

RESULTS

Long-term survival was significantly better for the LR group by log-rank test (P < 0.001). In multivariate analysis, tumor size, serum ALT level and TACE independently predicted survival. Despite similar baseline characteristics after propensity score matching, LR group still had significantly better survival (1 year, 68.5 vs. 55.0%; 3 years, 47.6 vs. 21.2%; 5 years, 41.3 vs. 18.5%; P = 0.007) than TACE group. The LR and TACE groups had comparable 30- and 90-day post-treatment mortality. Multivariate analysis showed that serum ALT level, serum AFP level and TACE independently predicted survival by multivariate analysis after propensity score matching.

CONCLUSION

Our propensity-score-matched study suggested that LR provided significantly better long-term survival than TACE for a solitary large HCC of the BCLC stage A, regardless of tumor size.

Comparison of survival of patients with BCLC stage A hepatocellular carcinoma after hepatic resection or transarterial chemoembolization: a propensity score-based analysis

BACKGROUND

It is unclear whether hepatic resection (HR) or transarterial chemoembolization (TACE) is associated with better outcomes for patients with hepatocellular carcinoma (HCC) in Barcelona Clinic Liver Cancer (BCLC) stage A. The present study compared survival for patients with BCLC stage A HCC treated by HR or TACE.

METHODS

Our study examined 360 patients treated by HR and 221 treated by TACE. To reduce bias in patient selection, 152 pairs of propensity-score-matched patients were generated, and their long-term survival was compared using the Kaplan-Meier method. Independent predictors of survival were identified using the Cox proportional hazards model.

RESULTS

Among propensity-score-matched pairs of patients with Child-Pugh A liver function who were treated by HR or TACE, the 1-, 3-, and 5-year overall survival rates were 75.5, 44.8, and 30.2 % after HR and 64.5, 24.1, and 13.7 % after TACE (P < 0.001). Serum AST level, serum AFP level, tumor size, and TACE independently predicted survival in Cox regression analysis.

CONCLUSIONS

Our propensity-score-matched study confirmed that HR was associated with higher survival rates than was TACE in patients with BCLC stage A HCC.

Hepatic resection associated with good survival for selected patients with intermediate and advanced-stage hepatocellular carcinoma

OBJECTIVE

The efficacy and safety of hepatic resection (HR) to treat patients with Barcelona Clinic Liver Cancer (BCLC) stage B and C hepatocellular carcinoma (HCC) was retrospectively assessed.

BACKGROUND

Although guidelines from the European Association for the Study of Liver Disease and the American Association for the Study of Liver Disease do not recommend HR for treating BCLC stage B/C HCC, several Asian and European studies have come to the opposite conclusions.

METHODS

A consecutive sample of 1259 patients with BCLC stage B/C HCC who underwent HR (n = 908) or transarterial chemoembolization (TACE, n = 351) were included. Moreover, propensity score-matched patients were analyzed to adjust for any baseline differences. In parallel with this retrospective clinical study, the MEDLINE database was searched for studies evaluating the efficacy and safety of HR for BCLC stage B/C HCC.

RESULTS

Among our patient sample, the 90-day mortality rate in the HR group was 3.1%. HR provided a survival benefit over TACE at 1, 3, and 5 years (88% vs 81%, 62% vs 33%, and 39% vs 16%, respectively; all P < 0.001). Propensity scoring and subgroup analyses based on tumor size, tumor number, presence or absence of macrovascular invasion, and portal hypertension (PHT) also showed that HR was associated with better long-term survival than TACE. All 36 studies identified in our literature search reported that HR is associated with good long-term survival and low morbidity. Multivariate analyses revealed that alpha-fetoprotein more than or equal to 400 ng/mL, diabetes mellitus, macrovascular invasion, and PHT are independent predictors of poor prognosis in patients with BCLC stage B/C HCC.

CONCLUSIONS

Our clinical and literature analyses suggest that in patients with HCC with preserved liver function, the presence of large, solitary tumors, multinodular tumors, macrovascular invasion, or PHT are not contraindications for HR.

Advanced age is not a contraindication for liver resection in cases of large hepatocellular carcinoma

BACKGROUND

The role of surgery in the management of large hepatocellular carcinomas (HCCs) is controversial. Advanced age and comorbidities are taken into account when major surgery is considered.

PURPOSE

To compare the outcomes of liver resection (LR) and transarterial chemoembolization (TACE) for resectable HCC in patients aged 70 years or older.

PATIENTS AND MATERIALS

This study included 70 patients aged 70 years or older treated for large HCCs (≥5 cm) between January 2007 and December 2012: 37 underwent LR and 33 underwent TACE. The outcomes of these patients were retrospectively analyzed. Univariate and multivariate Cox proportional hazard models were established. Kaplan-Meier survival curves were generated, and survival data were compared using the log-rank test.

RESULTS

Hospital stay was significantly longer in the LR group than in the TACE group (10 days vs 8.5 days; P = 0.003). Treatment-related complications were more frequent in the TACE group, but this difference was not statistically significant. LR was associated with a better disease-free survival rate, median survival rate and cumulative overall survival rate.

CONCLUSION

Our results showed that LR could be a safe and effective treatment option for HCC tumors ≥5 cm in patiets aged 70 years or older.

Comparison of long-term survival of patients with BCLC stage B hepatocellular carcinoma after liver resection or transarterial chemoembolization

BACKGROUND AND AIMS

Treatment of patients with Barcelona Clinic Liver Cancer Stage B hepatocellular carcinoma (BCLC-B HCC) is controversial. This study compared the long-term survival of patients with BCLC-B HCC who received liver resection (LR) or transarterial chemoembolization (TACE).

METHODS

A total of 257 and 135 BCLC-B HCC patients undergoing LR and TACE, respectively, were retrospectively evaluated. Kaplan-Meier method was used for long-term survival analysis. Independent prognostic predictors were determined by the Cox proportional hazards model.

RESULTS

The hospital mortality rate was similar between groups (3.1% vs. 3.7%; P = 0.76). However, the LR group showed a significantly higher postoperative complication rate than the TACE group (28 vs. 18.5%; P = 0.04). At the same time, the LR group showed significantly higher overall survival rates (1 year, 84 vs. 69%; 3 years, 59 vs. 29%; 5 years, 37 vs. 14%; P<0.001). Moreover, similar results were observed in the propensity score model. Three independent prognostic factors were associated with worse overall survival: serum AFP level (≥400 ng/ml), serum ALT level, and TACE.

CONCLUSIONS

LR appears to be as safe as TACE for patients with BCLC-B HCC, and it provides better long-term overall survival. However, prospective studies are needed to disclose if LR may be regarded as the preferred treatment for these patients as long as liver function is preserved.

Comparison of long-term survival of patients with BCLC stage B hepatocellular carcinoma after liver resection or transarterial chemoembolization

BACKGROUND AND AIMS

Treatment of patients with Barcelona Clinic Liver Cancer Stage B hepatocellular carcinoma (BCLC-B HCC) is controversial. This study compared the long-term survival of patients with BCLC-B HCC who received liver resection (LR) or transarterial chemoembolization (TACE).

METHODS

A total of 257 and 135 BCLC-B HCC patients undergoing LR and TACE, respectively, were retrospectively evaluated. Kaplan-Meier method was used for long-term survival analysis. Independent prognostic predictors were determined by the Cox proportional hazards model.

RESULTS

The hospital mortality rate was similar between groups (3.1% vs. 3.7%; P = 0.76). However, the LR group showed a significantly higher postoperative complication rate than the TACE group (28 vs. 18.5%; P = 0.04). At the same time, the LR group showed significantly higher overall survival rates (1 year, 84 vs. 69%; 3 years, 59 vs. 29%; 5 years, 37 vs. 14%; P<0.001). Moreover, similar results were observed in the propensity score model. Three independent prognostic factors were associated with worse overall survival: serum AFP level (≥400 ng/ml), serum ALT level, and TACE.

CONCLUSIONS

LR appears to be as safe as TACE for patients with BCLC-B HCC, and it provides better long-term overall survival. However, prospective studies are needed to disclose if LR may be regarded as the preferred treatment for these patients as long as liver function is preserved.

¹³C-methacetin breath test in the evaluation of disease severity in patients with liver cirrhosis

AIMS

The non-invasive (13)C-methacetin ((13)C-MBT) breath test has been proposed as a measure of metabolic liver function that improves the diagnostic efficacy of serologic and biochemical tests in assessing hepatic functional capacity and liver disease severity, The goal of this study was to establish the clinical utility of this test in quantifying hepatic metabolic function in patients with liver cirrhosis of varying severity and to compare (13)C-MBT measurements with the AST/ALT ratio, APRI score, and other routine liver tests.

METHODS

Routine liver function tests including serum bilirubin, aspartate aminotransferase activity (AST), alanine aminotransferase (ALT), AST/ALT ratio, the APRI score, the percentage of dose rate (PDR) and cumulative percentage of dose rate (CPDR) of the (13)C-MBT were evaluated in 52 cirrhotic patients of alcohol etiology (Child-Pugh A/B/C 10/28/14) and 37 healthy controls.

RESULTS

The (13)C-MBT differed significantly between healthy controls and cirrhotic patients at all time intervals measured. It also proved the ability to differentiate patients with liver cirrhosis based on severity of hepatic impairment corresponding to the Child-Pugh classification A vs. B vs. C. The ROC curve analysis suggested that the best prediction is provided by time intervals between the 10th - 20th or 10th - 40th minute of PDR.

CONCLUSIONS

The (13)C-MBT offers a reliable means for quantification of hepatic metabolic function over the complete range of functional liver impairment. It is non-invasive, easy to perform and completely safe.

Appropriate liver resection type for patients with the American joint committee on cancer classification T1 and T2 hepatocellular carcinoma

SYNOPSIS

Major liver resection prevents intrahepatic tumor recurrence in T2 hepatocellular carcinoma patients with microvascular invasion or daughter nodules.

BACKGROUND AND OBJECTIVES

There is no consensus on whether major or minor hepatectomy is better for hepatocellular carcinoma (HCC) patients. We investigated the outcomes of liver resection type in resectable HCC patients.

METHODS

Two hundred sixty-three HCC patients with Child-Pugh class A liver function who underwent curative hepatectomy were enrolled. Among them, 186 patients had pathologic stage T1 HCC and 77 had stage T2 HCC. Patients were also classed according to the type of resection (major or minor). Clinicopathologic characteristics and outcomes were compared.

RESULTS

Patients with T1 HCC who underwent major resection had a higher rate of blood transfusion than those who underwent minor resection (P < 0.001). The disease-free survival rate of T2 patients who underwent major resection was better than that of patients who underwent minor resection (P = 0.004). The overall survival rates of T1 and T2 HCC patients did not differ significantly between those with major or minor resection.

CONCLUSIONS

Major liver resection is recommended for T2 HCC patients with adequate remnant liver function because it results in a better disease-free survival rate than does minor resection in these patients. Minor liver resection is suggested for T1 HCC patients, except for those with a tumor sitting close to vessels, because it is associated with a low incidence of blood transfusion and a good survival rate.

Superselective transarterial chemoembolization vs hepatic resection for resectable early-stage hepatocellular carcinoma in patients with Child-Pugh class a liver function

PURPOSE

In contrast to hepatic resection (HR) for resectable early-stage HCC, the efficacy of transarterial chemoembolization (TACE) is controversial. This study is designed to compare the long-term outcome of TACE using superselective technique with hepatic resection for the treating resectable early-stage HCC and Child-Pugh class A liver function.

METHODS

In total, 185 consecutive patients with resectable early-stage HCC and Child-Pugh class A liver function were included: 73 patients received superselective TACE (group I) and 112 patients underwent HR (group II). We evaluated the therapy-related recurrence and long-term outcome and in both groups. The risk factors of recurrence and mortality were assessed by Cox's model.

RESULTS

The mean survival time of group 1 patient was similar to that of group 2 patient (40.8±19.8 vs 46.7±24.6 months respectively, p=0.91). The 1-, 3-, and 5-year overall survival rates after TACE (group I)and HR (group II) were 91%, 66%, and 52% and 93%, 71%, and 57%, respectively (p=0.239). The 1-, 3-, and 5-year recurrence-free survival rates in groups 1 and 2 were 68%, 28%, and 17% and 78%, 55%, and 35%, respectively (p<0.0001). Serum albumin, tumour size, tumour number and recurrence interval were independent risk factors for mortality. Serum albumin level, tumour size, tumour number, and treatment modality of TACE or HR could predict HCC recurrence.

CONCLUSION

TACE is an efficient and safe treatment for resectable early-stage HCC with overall survival rates similar to that of HR. Thus, TACE is indicated in selected patients with resectable early-stage HCC.

Comparing hepatic resection and transarterial chemoembolization for Barcelona Clinic Liver Cancer (BCLC) stage B hepatocellular carcinoma: change for treatment of choice?

BACKGROUND

Compared to transarterial chemoembolization (TACE) for patients with hepatocellular carcinoma (HCC), stage B in the Barcelona Clinic Liver Cancer (BCLC) classification, the role of hepatic resection remains unclear. The present study compared the long-term outcome of hepatic resection with TACE in the treatment of BCLC stage B HCC.

METHODS

A total of 171 patients with BCLC stage B, Child's classification A (Child A), HCC were included in this retrospective study. Of these, 93 patients underwent hepatic resection (group I) and 73 patients received TACE (group II). We evaluated the long-term outcome and therapy-related mortality in both groups. The risk factors of mortality were assessed. The survival curve was analyzed by the Kaplan-Meier method.

RESULTS

The 1-, 2-, and 3-year overall survival rates for the two groups after hepatic resection and TACE were 83%, 62%, 49% and 39%, 5%, 2%, respectively (P < 0.0001). We did not observe significant differences in the therapy-related mortality between the two groups (P = 0.78). Treatment modality and serum albumin level were independent risk factors for survival by Cox regression analysis.

CONCLUSIONS

Our study demonstrated that hepatic resection for BCLC stage B, Child A HCC patients had better survival rates than TACE group. Thus, hepatic resection is indicated in selected patients with BCLC stage B.

A fourth dimension in decision making in hepatology

Today, the assessment of liver function in patients suffering from acute or chronic liver disease is based on liver biopsy and blood tests including synthetic function, liver enzymes and viral load, most of which provide only circumstantial evidence as to the degree of hepatic impairment. Most of these tests lack the degree of sensitivity to be useful for follow-up of these patients at the frequency that is needed for decision making in clinical hepatology. Accurate assessment of liver function is essential to determine both short- and long-term prognosis, and for making decisions about liver and non-liver surgery, TIPS, chemoembolization or radiofrequency ablation in patients with chronic liver disease. Liver function tests can serve as the basis for accurate decision-making regarding the need for liver transplantation in the setting of acute failure or in patients with chronic liver disease. The liver metabolic breath test relies on measuring exhaled (13) C tagged methacetin, which is metabolized only by the liver. Measuring this liver-specific substrate by means of molecular correlation spectroscopy is a rapid, non-invasive method for assessing liver function at the point-of-care. The (13) C methacetin breath test (MBT) is a powerful tool to aid clinical hepatologists in bedside decision-making. Our recent findings regarding the ability of point-of-care (13) C MBT to assess the hepatic functional reserve in patients with acute and chronic liver disease are reviewed along with suggested treatment algorithms for common liver disorders.

A review of factors predicting perioperative death and early outcome in hepatopancreaticobiliary cancer surgery

OBJECTIVES

In the context of comparisons of surgical outcomes, risk adjustment is the retrospective adjustment of a provider's or a surgeon's results for case mix and/or hospital volume. It allows accurate, meaningful inter-provider comparison. It is therefore an essential component of any audit and quality improvement process. The aim of this study was to review the literature to identify those factors known to affect prognosis in hepatobiliary and pancreatic cancer surgery.

METHODS

PubMed was used to identify studies assessing risk in patients undergoing resection surgery, rather than bypass surgery, for hepatobiliary and pancreatic cancer.

RESULTS

In total, 63 and 68 papers, pertaining to 24 609 and 63 654 patients who underwent hepatic or pancreatic resection for malignancy, respectively, were identified. Overall, 22 generic preoperative factors predicting outcome on multivariate analysis, including demographics, blood results, preoperative biliary drainage and co-morbidities, were identified, with tumour characteristics proving disease-specific factors. Operative duration, transfusion, operative extent, vascular resection and additional intra-abdominal procedures were also found to be predictive of early outcome.

CONCLUSIONS

The development of a risk adjustment model will allow for the identification of those factors with most influence on early outcome and will thus identify potential targets for preoperative optimization and allow for the development of a multicentre risk prediction model.

Volumetric analysis of the liver after right portal vein embolization: mid-term follow-up based on embolization score

AIM

To evaluate liver volume alterations and liver function after right portal vein embolization (PVE) during mid-term follow-up based on embolization score.

MATERIALS AND METHODS

Computed tomography (CT) images and liver function profiles were obtained before PVE, and at short-term (7-45 days), and mid-term follow-up (106-380 days) after PVE in all 30 patients. The patients were divided into group A (PVE score >or=3, n=20) and group B (PVE score <3, n=10). High score indicates more complete embolization.

RESULTS

Left liver volume (LLV) and percentage future liver remnant (%FLR) increased significantly between pre-PVE and short-term follow-up and between short-term and mid-term follow-up in group A. Increase in FLR volume was significantly higher at the mid-term follow-up than at the short-term follow-up in group A. The ratio of embolized to total liver volume (RETLV) on short-term follow-up was significantly higher in group A than in group B. Aspartate transaminase (AST) and alanine transaminase (ALT) were elevated on short-term follow-up, whereas at mid-term follow-up in group A, they had significantly returned to the baselines.

CONCLUSION

PVE resulted in continued compensatory hypertrophy of the unembolized liver during the 6-month follow-up. Compensatory hypertrophy in the unembolized liver was proportional to the ratio of embolization and to the embolized liver volume.

Point-of-care continuous 13C-methacetin breath test improves decision making in acute liver disease: Results of a pilot clinical trial

AIM: To assess the role of the ¹³C-methacetin breath test (MBT) in patients with acute liver disease.

METHODS: Fifteen patients with severe acute liver disease from diverse etiologies were followed-up with ¹³C-MBT during the acute phase of their illnesses (range 3-116 d after treatment). Patients fasted for 8 h and ingested 75 mg of methacetin prior to the MBT. We compared results from standard clinical assessment, serum liver enzymes, synthetic function, and breath test scores.

RESULTS: Thirteen patients recovered and two patients died. In patients that recovered, MBT parameters improved in parallel with improvements in lab results. Evidence of consistent improvement began on day 3 for MBT parameters and between days 7 and 9 for blood tests. Later convergence to normality occurred at an average of 9 d for MBT parameters and from 13 to 28 d for blood tests. In both patients that died, MBT parameters remained low despite fluctuating laboratory values.

CONCLUSION: The ¹³C-MBT provides a rapid, non-invasive assessment of liver function in acute severe liver disease of diverse etiologies. The results of this pilot clinical trial suggest that the MBT may offer greater sensitivity than standard clinical tests for managing patients with severe acute liver disease.

Quantitative assessment of hepatic function and its relevance to the liver surgeon

BACKGROUND

Standard evaluation of patients undergoing hepatic surgery has been through radiological and quantitative determination of liver function. As more complex and extensive surgery is now being performed, often in the presence of cirrhosis/fibrosis or following administration of chemotherapy, it is questioned whether additional assessment may be required prior to embarking on such surgery. The aim of this review was to determine the current knowledge base in relation to the performance of quantitative assessment of hepatic function both pre- and post-operatively in patients undergoing hepatic resectional surgery and liver transplantation.

METHODS

An electronic search was performed of the medical literature using the MEDLINE database to identify relevant articles with cross-referencing of all identified papers to ensure full literature capture.

RESULTS AND CONCLUSIONS

The review has identified a number of different methods of dynamically assessing hepatic function, the most frequently performed being through the use of indocyanine green clearance. With the recent and further anticipated developments in hepatic resectional surgery, it is likely that quantitative assessment will become more widely practiced in order to reduce post-operative hepatic failure and improve outcome.

A new measure to assess the difficulty of liver resection

BACKGROUND

There is no valid measure to assess surgical difficulty and feasibility of a planned liver resection. It is the objective of this study to evaluate a mathematical measure from a 3D graphical analysis.

METHODS

Eleven different 3D models of hepatic tumours were evaluated by experts for resectability and analysed with Amira graphic software taking into consideration the portal and hepatic venous vascular relationships. Virtual resection volumes with increasing resection margins from 1 to 30 mm were determined separately for portal veins, hepatic veins, their intersections and volume unions. The integral of the increasing resection volumes was defined as risk coefficient. The risk coefficients from this volumetric analysis were compared with the expert opinion.

RESULTS

The risk coefficient based on the integral of portal venous and hepatic venous volume unions reproduced the expert opinion highly significantly (correlation coefficient 0.9, p<0.05) and more accurately than volumetric analysis of the planned resection margin.

CONCLUSION

With automated volumetric analysis, anatomically problematic situations in liver surgery can be reproduced and scaled. The risk coefficient obtained is a suitable objective measure for defining risk areas in liver surgery.

[Evaluation of liver function before living donor liver transplantation and liver resection]

Liver resection is the curative therapeutic option for hepatocellular carcinoma, biliary tumors, metastases of colorectal and other extrahepatic tumors, living donor liver transplantation and other benign liver diseases.

AIM OF STUDY

To summarize the evaluation methods of liver function before living donor liver transplantation and liver resection.

METHOD

We summarize the literature about the evaluation of liver function.

RESULTS

Perioperative mortality is determined mostly by the extent of preoperative evaluation focused on the liver. After resection the remnant liver parenchyma must cope with the challenge caused by increased metabolism, portal overflow, decreased vascular bed and biliary tract and oxidative stress following the operation. If the remnant liver is unable to grow up to this challenge, acute liver failure occurs. This maintains the necessity of determining the hepatic functional reserve and the hepatic remnant volume. Child-Pugh classification is widely spread to predict outcome. Dynamic functional tests such as indocyanine green retention test, galactosyl human serum albumin scintigraphy and aminopyrine breath tests can be used to evaluate hepatic reserve. To determine remnant liver volume modern imaging processes such as CT volumetry and hepatobiliary scintigraphy are available.

CONCLUSION

After the detailed evaluation resection can be limited to an extent which is oncologically radical enough (1% remnant liver tissue/kg) and spares parenchyma which can ensure survival yet. With careful preoperative examination mortality can be reduced even to reach zero.

Review article: the assessment of liver function using breath tests

BACKGROUND

Hepatologists have long sought to develop a test for assessing liver function, but this aim has been stalled by the complexity of the liver and its diverse functions. Results of metabolic tests, including breath tests, correlate with clinical and histological parameters of patients with liver disorders; however, these tests tend to be cumbersome and impractical for everyday use. The recent development of a real-time, point-of-care liver function breath test has made it straightforward to assess the metabolic function of the liver.

AIM

To review the available data on the use of breath tests for assessing liver reserve in various conditions and their application in various clinical hepatology settings.

RESULTS

The (13)C-methacetin breath test enables accurate follow-up of patients with acute or chronic liver damage, where overall hepatic function is significantly suppressed by known causes of liver disorders, including acute, sub-acute or chronic conditions. The metabolic breath test can detect both gradual and spontaneous improvements in liver function and the effects of treatment.

CONCLUSIONS

Breath testing that provides continuous quantification of methacetin metabolism may be a sensitive tool for the diagnosis and follow-up of patients with liver disorders.