Post hepatectomy liver failure (PHLF) - Recent advances in prevention and clinical management

EGFR-mediated crosstalk between vascular endothelial cells and hepatocytes promotes Piezo1-dependent liver regeneration

Hepatocyte proliferation is essential for recovering liver function after injury. In liver surgery, the mechanical stimulation induced by hemodynamic changes triggers vascular endothelial cells (VECs) to secrete large amounts of cytokines that enhance hepatocyte proliferation and play a pivotal role in liver regeneration (LR). Piezo1, a critical mechanosensory ion channel, can detect and convert mechanical forces into chemical signals, importing external stimuli into cells and triggering downstream biological effects. However, the precise role of Piezo1 in VECs, especially in terms of mediating LR, remains unclear. Here, we report on a potential mechanism by which early changes in hepatic portal hemodynamics activate Piezo1 in VECs to promote hepatocyte proliferation during the process of LR induced by portal vein ligation in rats. In this LR model, hepatocyte proliferation is mainly distributed in zone 1 and zone 2 of liver lobules at 24-48 h after surgery, while only a small number of Ki67-positive hepatocytes were observed in zone 3. Activation of Piezo1 promotes increased secretion of epiregulin and amphiregulin from VECs via the PKC/ERK1/2 axis, further activating epidermal growth factor receptor (EGFR) and ERK1/2 signals in hepatocytes and promoting proliferation. In the liver lobules, the expression of EGFR in hepatocytes of zone 1 and zone 2 is significantly higher than that in zone 3. The EGFR inhibitor gefitinib inhibits LR by suppressing the proliferation of hepatocytes in the middle zone. These data provide a theoretical basis for the regulation of LR through chemical signals mediated by mechanical stimulation.

Long-term diuretic medication is an independent predictor of posthepatectomy liver failure

BACKGROUND

Posthepatectomy liver failure (PHLF) is the most fatal complication after liver resection, particularly in patients with comorbidities. This study aimed to assess the effect of long-term medication on PHLF incidence after open liver resections.

METHODS

A retrospective analysis of 682 patients who underwent elective open hepatectomies between 2008 and 2015 at 2 academic centers was performed. Preoperative, intraoperative, and postoperative data were collected, including long-term medication. The risk factors for the development of PHLF and other postoperative complications were evaluated using univariate and multivariate logistic regression analyses.

RESULTS

PHLF occurred in 81 patients (11.9%), with a higher incidence in patients taking diuretics as long-term medication than in those not taking diuretics (17.7% vs 5.3%, respectively; P <.001). Diuretic use was identified as a strong independent risk factor for PHLF (odds ratio [OR], 3.8 [95% CI, 2.1-7.0]; P <.001), alongside liver cirrhosis (OR, 3.8 [95% CI, 1.9-7.6]; P <.001), primary liver malignancies (OR, 3.8 [95% CI, 1.6-9.3]; P <.001), major hepatectomies (OR, 3.1 [95% CI, 1.7-5.7]; P <.001), and long operating time (OR, 4.2 [95% CI, 2.4-7.2]; P <.001). Patients with long-term diuretic intake were older, had higher body mass indices, and had more comorbidities, including liver cirrhosis.

CONCLUSION

Long-term diuretic use is associated with a significantly increased risk of PHLF after open hepatectomy.

A Composite Endpoint of Liver Surgery (CELS): Development and Validation of a Clinically Relevant Endpoint Requiring a Smaller Sample Size

BACKGROUND

The feasibility of trials in liver surgery using a single-component clinical endpoint is low because single endpoints require large samples due to their low incidence. The current study sought to develop and validate a novel composite endpoint of liver surgery (CELS) to facilitate the generation of more feasible and robust high-level evidence in the field of liver surgery.

METHODS

Patients who underwent curative-intent hepatectomy for hepatocellular carcinoma, intrahepatic cholangiocarcinoma, or colorectal liver metastasis were identified using a multi-institutional database. Components of CELS were selected based on perioperative liver surgery-specific complications using univariable logistic regression models. The association of CELS with prolonged length of stay (LOS) and surgery-related death was evaluated and externally validated. Sample sizes were calculated for both individual outcomes and CELS.

RESULTS

Among 1958 patients, 377 (19.3%) met CELS criteria based on postoperative bile leak (n = 221, 11.3%), post-hepatectomy liver failure (n = 71, 3.6%), post-hepatectomy hemorrhage (n = 38, 1.9%), or intraoperative blood loss of 2000 ml or greater (n = 101, 5.2%). CELS demonstrated favorable discriminative accuracy of surgery-related death (analytic cohort: area under the curve [AUC], 0.79 vs external validation cohort: AUC, 0.85). In addition LOS was longer among the patients with a positive CELS (analytic cohort: 14 vs. 9 days [p < 0.001] vs. the validation cohort: 10 vs. 6 days [p < 0.001]). Relative to individual endpoints, CELS allowed a 45.8-91.6% reduction in sample size.

CONCLUSION

CELS effectively predicted surgery-related death and can be used as a standardized, clinically relevant endpoint in prospective trials, facilitating smaller sample sizes and enhancing feasibility compared with single quality outcome metrics.

Impact of aortic calcification at the origin of celiac artery on post-operative outcomes of major hepatectomy: A significant risk factor for posthepatectomy liver failure

PURPOSE

Aortic calcification is associated with arteriosclerosis and is often seen in patients undergoing hepatectomy. However, its impact on post-operative outcomes after major hepatectomy is still unclear.

METHODS

From July, 2015 to December, 2022, 127 patients who underwent resection of three or more adjacent liver segments (major hepatectomy) were retrospectively reviewed. Aortic calcification at the origin of celiac artery was assessed on pre-operative abdominal CT scan images. pPerioperative factors and postoperative outcomes were compared between patients with and without aortic calcification. Uni-variable and multi-variable analyses were performed to identify risk factors of posthepatectomy liver failure (PHLF).

RESULTS

Aortic calcification at the origin of celiac artery was observed in 62 (48.8%) of 127 patients. Those with aortic calcification were significantly older and had a higher incidence of hypertension, as a comorbidity, compared to those without. Furthermore, incidences of both post-operative liver failure and other complications were significantly higher among patients with aortic calcification, who also had a longer hospital stay. Multivariable logistic analysis identified aortic calcification and longer operation time as independent risk factors of PHLF. Additionally, stenosis of the celiac artery also impacted the development of PHLF.

CONCLUSION

These findings indicate that aortic calcification at the origin of celiac artery is associated with advanced age and may be a risk factor of PHLF following major hepatectomy.

Role of two-dimensional shear wave elastography in predicting post-hepatectomy liver failure: A step forwards in hepatic surgery

This study explores the significance of using two-dimensional shear wave elastography (2D-SWE) to assess liver stiffness (LS) and spleen area (SPA) for predicting post-hepatectomy liver failure (PHLF). By providing a non-invasive method to measure LS, which correlates with the degree of liver fibrosis, and SPA, an indicator of portal hypertension, 2D-SWE offers a comprehensive evaluation of a patient's hepatic status. These advancements are particularly crucial in hepatic surgery, where accurate preoperative assessments are essential for optimizing surgical outcomes and minimizing complications. This letter highlights the practical implications of integrating 2D-SWE into clinical practice, emphasizing its potential to improve patient safety and surgical precision by enhancing the ability to predict PHLF and tailor surgical approaches accordingly.

Liver function estimation using multiphase hepatic CT: diagnostic performance of iodine-uptake and volumetric parameters

OBJECTIVES

To investigate whether multiphase hepatic CT can predict liver function measured with indocyanine-green-retention test (ICG-R15) and identify patients with severe liver dysfunction contraindicating major hepatectomy, defined as ICG-R15 ≥ 20%, compared to technetium-99m-galactosyl serum albumin (99mTc-GSA) scintigraphy.

MATERIALS AND METHODS

This retrospective study included 118 patients (84 men, mean age, 69.4 ± 11.3 years) who underwent ICG-R15, 99mTc-GSA, and multi-phase CT including early portal-venous-phase and 3-min delayed-phase. CT-derived extracellular volume fraction (ECV), iodine washout rate (IWR), liver and spleen volumes normalized by body-surface-area (LV/BSA and SpV/BSA, respectively), and 99mTc-GSA-derived blood clearance index (HH15) and liver receptor index (LHL15) were quantified. Each parameter was compared between ICG-R15 ≥ 20% (n = 22) and ICG-R15 < 20% (n = 96) groups. Correlations with ICG-R15 were analyzed. The diagnostic performance to predict ICG-R15 ≥ 20% was assessed with areas under the receiver operating characteristic curve (AUC). Multivariable logistic regression analysis was used to identify independent CT predictors, and combined performance was determined.

RESULTS

In the ICG-R15 ≥ 20% group, IWR (p < 0.001), LV/BSA (p = 0.026), LHL15 (p < 0.001) were lower and ECV (p = 0.001), SpV/BSA (p = 0.005), and HH15 (p < 0.001) were higher compared to ICG-R15 < 20% group. ICG-R15 showed positive correlations with ECV (r = 0.355), SpV/BSA (r = 0.248), and HH15 (r = 0.385), while negative correlations with IWR (r = -0.523), LV/BSA (r = -0.123, not statistically significant), and LHL15 (r = -0.504). The AUC of ECV, IWR, LV/BSA, SpV/BSA, HH15, and LHL15 were 0.719, 0.845, 0.653, 0.694, 0.844, and 0.878, respectively. IWR, SpV/BSA, and LV/BSA were independent predictors, with a combined AUC of 0.924.

CONCLUSION

IWR predicted liver function better than ECV and hepatosplenic volumetry. The combined IWR and volumetry yielded an accurate prediction of severe liver dysfunction.

KEY POINTS

Question Despite the widespread use of multiphase CT in patients with hepatobiliary diseases, its potential role in assessing liver function has been scarcely evaluated. Findings Iodine washout rate (IWR), liver volume indexed by body surface area, and spleen volume indexed by body surface area were independent predictors for severe liver dysfunction. Clinical relevance Combined IWR and hepatosplenic volumetry on routine hepatic CT may help assess hepatic function for optimizing treatment strategies and predicting patient prognosis.

Microwave ablation versus radiofrequency ablation for hepatocellular carcinoma in patients with decompensated cirrhosis

BACKGROUND

The efficacy of microwave ablation (MWA) and radiofrequency ablation (RFA) in hepatocellular carcinoma (HCC) patients with decompensated cirrhosis remains unclear.

METHODS

A total of 315 patients with decompensated cirrhosis and HCC who underwent MWA or RFA were recruited. Recurrence beyond the Milan criteria (RBM), local tumor progression (LTP), overall survival (OS), and complications were evaluated and compared.

RESULTS

After propensity score matching, the overall liver-related complication rates were 12.1 % in the current study. The cumulative RBM rates were lower in patients treated with MWA compared to those treated with RFA (21.9 % vs. 23.4 % at 1 year; 42.3 % vs. 66.8 % at 5 years; p = 0.016). In addition, lower cumulative rates of LTP were found in patients treated with MWA compared to those treated with RFA (6.2 % vs. 19.9 % at 1 year; 14.7 % vs. 27.8 % at 3 years; p = 0.032). The OS rates at 1 and 5 years were 89.9 % and 58.9 % in the MWA group, and 80.7 %, and 38.9 % in the RFA group, respectively (p = 0.105).

CONCLUSION

HCC patients with decompensated cirrhosis can undergo MWA or RFA with acceptable mortality, morbidity and liver-rated complications rates. MWA demonstrates superiority over RFA in tumor control.

Role of Steatosis in Preventing Post-hepatectomy Liver Failure After Major Resection: Findings From an Animal Study

Background/Aim

Post-hepatectomy liver failure (PHLF) and hepatic steatosis are evident shortly after extensive partial hepatectomy (PH) in rodents. This study aimed to extrapolate the protein expression and biological pathways involved in recovering PHLF (rPHLF) and non-recovering PHLF (nrPHLF).

Methods

Rats were randomly assigned to 90% PH or sham surgery. rPHLF was distinguished from nrPHLF using a quantitative scoring system. The sham (n = 6), rPHLF (n = 8), and nrPHLF (n = 13) groups were compared 24 h post-PH. Proteomics was used to assess protein variations and to investigate differentially regulated biological pathways. Stereological methods were used to quantify hepatic lipid content. The plasma triglyceride levels were measured.

Results

rPHLF demonstrated substantial downregulation of proteins involved in lipid metabolism compared to nrPHLF (P < 0.001). Several proteins associated with lipogenesis, beta-oxidation, lipolysis, membrane trafficking, and inhibition of cell proliferation were markedly downregulated in rPHLF.The hepatic lipid proportion was significantly higher for rPHLF (61% of hepatocyte volume, 95% confidence interval [CI]: 48%-82%) than for nrPHLF (32% of hepatocyte volume, 95% CI: 22%-39%). The median lipid volume per hepatocyte in rPHLF was 2815 μm3 (95% CI: 2208-3774 μm3) and 1759 μm3 in nrPHLF (95% CI: 1188-2134 μm3). Lipid droplets were not detected in the sham-operated rats. No significant differences in plasma triglyceride levels were found between the groups (P > 0.08).

Conclusion

The degree of hepatic steatosis is a promising prognostic indicator for early liver regeneration and nrPHLF onset immediately following extensive PH. Intrahepatic lipid accumulation appears to be linked to the coordinated downregulation of proteins integral to lipid metabolism and cellular transport.

Effects of Remote Ischemic Conditioning on Postoperative Recovery After Hepatectomy: A Randomised Controlled Trial

BACKGROUND AND AIMS

Remote ischemic conditioning (RIC) has shown promise in preclinical and clinical studies, but its effectiveness in reducing hepatic ischemia-reperfusion injuries (HIRIs) and enhancing postoperative recovery after hepatectomy remains uncertain. In this study, we aimed to evaluate the impact of perioperative RIC (PRIC) on postoperative recovery in patients undergoing hepatectomy.

METHODS

A randomised controlled trial was performed. A total of 135 eligible patients were randomised to either a control group (sham RIC), a PRIC-1 group (RIC once daily for 3 days starting on the day of surgery) or a PRIC-2 group (RIC twice daily). The primary outcome was the time to 2 times the upper limit of normal (2ULN) alanine transaminase (ALT) levels post-hepatectomy. Secondary outcomes included time to reach 2ULN for aspartate transaminase (AST) levels, the area under the concentration-time curve on postoperative Day 7 (AUC-POD7) for ALT, AST, total bilirubin and lactic acid, as well as assessments of gastrointestinal function and postoperative complications.

RESULTS

Median time to 2ULN ALT was shorter in the PRIC-1 and PRIC-2 groups than in the control group (PRIC-1: 5.0 [3.5, 6.0] vs. control: 7.0 [7.0, 10.0] days, p < 0.001; PRIC-2: 5.0 [4.0, 8.0] vs. control: 7.0 [7.0, 10.0] days, p < 0.001). The AUC-POD7 for ALT and AST, time to 2ULN AST, time to gastrointestinal tolerance and postoperative complications were significantly improved in the PRIC groups compared with thecontrols.

CONCLUSIONS

PRIC is safe and effective in reducing HIRIs and enhancing recovery post-hepatectomy. Once-daily PRIC offers similar benefits to twice-daily PRIC.

TRIAL REGISTRATION

NCT06130436 (ClinicalTrials.gov).

Artificial Intelligence-Driven Patient Selection for Preoperative Portal Vein Embolization for Patients with Colorectal Cancer Liver Metastases

PURPOSE

To develop a machine learning algorithm to improve hepatic resection selection for patients with metastatic colorectal cancer (CRC) by predicting post-portal vein embolization (PVE) outcomes.

MATERIALS AND METHODS

This multicenter retrospective study (2000-2020) included 200 consecutive patients with CRC liver metastases planned for PVE before surgery. Data on radiomic features and laboratory values were collected. Patient-specific eigenvalues for each liver shape were calculated using a statistical shape model approach. After semiautomatic segmentation and review by a board-certified radiologist, the data were split 70%/30% for training and testing. Three machine learning algorithms predicting the total liver volume (TLV) after PVE, sufficient future liver remnant (FLR%), and kinetic growth rate (KGR%) were trained, with performance assessed using accuracy, sensitivity, specificity, area under the curve (AUC), or root mean squared error. Significance between the internal and external test sets was assessed by the Student t-test. One institution was kept separate as an external testing set.

RESULTS

A total of 114 (76 men; mean age, 56 years [SD± 12]) and 37 (19 men; mean age, 50 years ± [SD± 11]) patients met the inclusion criteria for the internal validation and external validation, respectively. Prediction accuracy and AUC for sufficient FLR% or liver growth potential (KGR%> 0%) were high in the internal testing set-85.81% (SD ± 1.01) and 0.91 (SD ± 0.01) or 87.44% (SD ± 0.10) and 0.66 (SD ± 0.03), respectively. Similar results occurred in the external testing set-79.66% (SD ± 0.60) and 0.88 (SD ± 0.00) or 72.06% (SD ± 0.30) and 0.69 (SD ± 0.01), respectively. TLV prediction showed discrepancy rates of 12.56% (SD ±4.20%; P = .86) internally and 13.57% (SD ± 3.76%; P = .91) externally.

CONCLUSIONS

Machine learning-based models incorporating radiomics and laboratory test results may help predict the FLR%, KGR%, and TLV as metrics for successful PVE.

Predicting post-hepatectomy liver failure using a nomogram based on portal vein width, inflammatory indices, and the albumin-bilirubin score

BACKGROUND

Post-hepatectomy liver failure (PHLF) after liver resection is one of the main complications causing postoperative death in patients with hepatocellular carcinoma (HCC). It is crucial to help clinicians identify potential high-risk PHLF patients as early as possible through preoperative evaluation.

AIM

To identify risk factors for PHLF and develop a prediction model.

METHODS

This study included 248 patients with HCC at The Second Affiliated Hospital of Air Force Medical University between January 2014 and December 2023; these patients were divided into a training group (n = 164) and a validation group (n = 84) via random sampling. The independent variables for the occurrence of PHLF were identified by univariate and multivariate analyses and visualized as nomograms. Ultimately, comparisons were made with traditional models via receiver operating characteristic (ROC) curves, calibration curves, and decision curve analysis (DCA).

RESULTS

In this study, portal vein width [odds ratio (OR) = 1.603, 95%CI: 1.288-1.994, P ≤ 0.001], the preoperative neutrophil-to-lymphocyte ratio (NLR) (OR = 1.495, 95%CI: 1.126-1.984, P = 0.005), and the albumin-bilirubin (ALBI) score (OR = 8.868, 95%CI: 2.144-36.678, P = 0.003) were independent risk factors for PHLF. A nomogram prediction model was developed using these factors. ROC and DCA analyses revealed that the predictive efficacy and clinical value of this model were better than those of traditional models.

CONCLUSION

A new Nomogram model for predicting PHLF in HCC patients was successfully established based on portal vein width, the NLR, and the ALBI score, which outperforms the traditional model.

Adipose-derived stem cells using fibrin gel as a scaffold enhances post-hepatectomy liver regeneration

We investigated the potential of adipose-derived stem cells (ADSCs) in preventing post-hepatectomy liver failure, emphasizing the necessity of direct administration using a scaffold. A fibrin gel scaffold was employed for ADSCs (gelADSC) to assess their therapeutic impact on liver regeneration in both in vitro and in vivo settings. Experiments were conducted on C57BL/6 mice with normal livers and those with chronic hepatitis. We also explored the role of extracellular vesicles (EVs) secreted by ADSCs in conjunction with fibrin gel. GelADSC showed sustained release of hepatocyte growth factor, vascular endothelial growth factor, and stromal cell-derived factor 1 for at least 7 days in vitro. In vivo, gelADSC significantly enhanced postoperative liver regeneration by upregulating the cell cycle and fatty acid oxidation in both normal and chronically hepatitis-affected mice. The therapeutic effects of gelADSC were potentially favorable over those of intravenously administered ADSCs, especially in mice with chronic hepatitis. Increased EV secretion associated with fibrin gel use was significantly linked to enhanced liver regeneration post-surgery through the promotion of fatty acid oxidation. The findings underscore the enhanced therapeutic potential of gelADSC, particularly in the context of chronic hepatitis, possibly compared to intravenous administration.

Controlled low central venous pressure maintenance level during laparoscopic hepatectomy negatively associated with PHLF incidence: a retrospective propensity score matching study

BACKGROUND

Posthepatectomy liver failure (PHLF), the most serious complication after hepatectomy, may evoke multisystemic complications and even mortality. Despite numerous studies demonstrated the safety and efficacy of controlled low central venous pressure (CLCVP), the optimal central venous pressure (CVP) maintenance level during CLCVP and its relationship with PHLF remain controversial. Therefore, the present study aimed to evaluate the association between the lowest CVP maintenance level during CLCVP and PHLF.

METHODS

755 patients who underwent laparoscopic hepatectomy at Sun Yat-Sen Memorial Hospital between January 2017 and March 2021 were recruited. Univariate and multivariate analyses were performed to determine the effect of the lowest CVP maintenance level on PHLF. After implementing propensity score matching (PSM) to equalize demographic confounders, univariate comparisons and subgroup analyses were conducted to investigate the impact of the lowest CVP maintenance level on PHLF in patients who underwent CLCVP.

RESULTS

Univariate and multivariate analyses identified intraoperative lowest CVP maintenance level < 2 mmHg as an independent risk factor for PHLF (P = 0.041; OR, 0.520; 95% CI 0.277 to 0.974). Following 1:1 PSM in individuals who received CLCVP, the lowest CVP maintenance level < 2 mmHg was associated with heightened PHLF incidence (P = 0.048) and elevated intraoperative lactate level (P = 0.011). Subgroup analyses revealed that the above effect of the lowest CVP maintenance level occurred mainly in elderly individuals or those with prolonged portal blockade.

CONCLUSION

During laparoscopic hepatectomy, excessively low CVP maintenance level should be avoided to decrease the risk of tissue malperfusion and PHLF, especially in elderly or prolonged portal blockade patients.

Advances, challenges and future applications of liver organoids in experimental regenerative medicine

The liver is a vital organ responsible for numerous metabolic processes in the human body, including the metabolism of drugs and nutrients. After liver damage, the organ can rapidly return to its original size if the causative factor is promptly eliminated. However, when the harmful stimulus persists, the liver's regenerative capacity becomes compromised. Substantial theoretical feasibility has been demonstrated at the levels of gene expression, molecular interactions, and intercellular dynamics, complemented by numerous successful animal studies. However, a robust model and carrier that closely resemble human physiology are still lacking for translating these theories into practice. The potential for liver regeneration has been a central focus of ongoing research. Over the past decade, the advent of organoid technology has provided improved models and materials for advancing research efforts. Liver organoid technology represents a novel in vitro culture system. After several years of refinement, human liver organoids can now accurately replicate the liver's morphological structure, nutrient and drug metabolism, gene expression, and secretory functions, providing a robust model for liver disease research. Regenerative medicine aims to replicate human organ or tissue functions to repair or replace damaged tissues, restore their structure or function, or stimulate the regeneration of tissues or organs within the body. Liver organoids possess the same structure and function as liver tissue, offering the potential to serve as a viable replacement for the liver, aligning with the goals of regenerative medicine. This review examines the role of liver organoids in regenerative medicine.

Association between low fasting glucose of the living donor and risk of graft loss in the recipient after liver transplantation

Several donor-specific factors influence the functional recovery and long-term outcomes of liver grafts. This study investigated the association between donor fasting glucose (DFG) and recipient outcomes after living donor liver transplantation (LDLT) in 950 cases at a single center. Patients were divided into two groups: low-DFG (< 85 mg/dL, n = 120) and control (≥ 85 mg/dL, n = 830). The five-year graft survival rate was significantly lower in the low-DFG group (71.5%) compared to the control group (80.0%) (P = 0.02). Multivariable Cox regression analysis showed that low DFG was independently associated with graft loss (hazard ratio 1.72, 95% CI 1.15-2.56, P = 0.008). In propensity score-matched groups, the low-DFG group also had lower survival rates (71% vs. 83.1%, P = 0.004). The presence of additional risk factors, such as low graft-to-recipient weight ratio, older donor age, and longer cold ischemic time, further reduced graft survival in the low-DFG group. A DFG level < 85 mg/dL is associated with higher risk of graft failure after LDLT, especially when combined with other risk factors. Low DFG should be considered a prognostic marker in LDLT planning, with potential to improve patient outcomes as further research clarifies the underlying pathophysiological mechanisms.

Impact of major hepatectomy on recurrence after resection of hepatocellular carcinoma at CNLC Ib stage: a propensity score matching study

OBJECTIVE

Patients with hepatocellular carcinoma (HCC) who undergo curative hepatectomy may experience varying remnant liver volumes. Our study aimed to evaluate whether the extent of liver resection has an effect on postoperative recurrence in HCC patients at China Liver Cancer Staging (CNLC) Ib stage.

METHODS

A retrospective analysis was conducted on 197 patients who underwent hepatectomy for a solitary HCC lesion measuring ≥5 cm (CNLC Ιb stage) between January 2019 and June 2022. Patients were divided into a major hepatectomy (MAH) group ( n =70) and a minor hepatectomy (MIH) group ( n =127) based on the extent of liver resection. Recurrence-free survival (RFS) was compared between the two groups. Propensity score matching (PSM) was employed to minimize bias in the retrospective analysis.

RESULTS

Patients who underwent MAH had a greater total complication rate than those who underwent MIH (35.7 vs. 11.8%, P <0.001). The median RFS was 14.6 months (95% CI: 11.1-18.1) for the MAH group and 24.1 months (95% CI: 21.2-27.1) for the MIH group ( P <0.001). After PSM, patients who underwent MAH still had a greater total complication rate than those who underwent MIH (36.7 vs. 16.3%, P =0.037). The median RFS was 13.2 months (95% CI: 15.1-21.7) for the MAH group and 22.3 months (95% CI: 18.1-26.5) for the MIH group ( P =0.0013). The Cox regression model identified MAH as an independent poor predictor for HCC recurrence (hazard ratios of 1.826 and 2.062 before and after PSM, respectively; both P <0.05).

CONCLUSION

MIH can be performed with fewer postoperative complications and contributes to improved RFS in patients with HCC at CNLC Ιb stage compared to MAH. Parenchyma-sparing resection should be considered the first choice for these HCCs.

Liver Resection for Hepatocellular Carcinoma: Recent Advances

Hepatocellular carcinoma (HCC) represents a significant global health burden. Surgery remains a cornerstone in the curative treatment of HCC, and recent years have witnessed notable advancements aimed at refining surgical techniques and improving patient outcomes. This review presents a detailed examination of the recent innovations in HCC surgery, highlighting key developments in both surgical approaches and adjunctive therapies. Advanced imaging technologies have revolutionized preoperative assessment, enabling precise tumour localization and delineation of vascular anatomy. The use of three-dimensional rendering has significantly augmented surgical planning, facilitating more accurate and margin-free resections. The advent of laparoscopic and robotic-assisted surgical techniques has ushered in an era of minimal access surgery, offering patients the benefits of shorter hospital stays and faster recovery times, while enabling equivalent oncological outcomes. Intraoperative innovations such as intraoperative ultrasound (IOUS) and fluorescence-guided surgery have emerged as valuable adjuncts, allowing real-time assessment of tumour extent and aiding in parenchyma preservation. The integration of multimodal therapies, including neoadjuvant and adjuvant strategies, has allowed for 'bio-selection' and shown the potential to optimize patient outcomes. With the advent of augmented reality and artificial intelligence (AI), the future holds immense potential and may represent significant strides towards optimizing patient outcomes and refining the standard of care.

Liver Vein Deprivation versus Portal Vein Embolization: Retrospective Review of Safety and Effectiveness

PURPOSE

To compare the safety and effectiveness of liver vein deprivation (LVD) and portal vein embolization (PVE) in patients scheduled to undergo liver resection.

MATERIALS AND METHODS

This retrospective cohort study included 59 patients who underwent either PVE (n = 28) or LVD (n = 31) in preparation for liver resection. The primary outcome was percent change in future liver remnant volume (FLRV). The secondary endpoints were degree of hypertrophy (DH) and kinetic growth rate (KGR).

RESULTS

Low baseline FLRV and time interval in days between the procedure and follow-up imaging (Ti) positively impacted the primary and secondary endpoints in both groups. Percent change in FLRV was higher in the LVD group (52.8% ± 5.3) than in the PVE group (22.3% ± 3.0, P < .001). DH was also higher in the LVD group (15.4% ± 1.7) than in the PVE group (6.4% ± 0.9, P < .001). KGR did not differ significantly between groups (LVD, 0.54%/d ± 0.06; PVE, 0.35%/d ± 0.1; P = .239). When patients with a baseline standardized FLRV of >35% were excluded from the analysis, the LVD group demonstrated higher values than the PVE group in KGR (0.57%/d ± 0.06 vs 0.29%/d ± 0.05, P < .001), percent change in FLRV (64.2% ± 6.0 vs 25.9% ± 4.3, P < .001), and DH (15.4% ± 1.4 vs 6.6% ± 1.0, P < .001). No adverse events were noted in either group.

CONCLUSIONS

LVD appears to be safe and may be superior to PVE in inducing hypertrophy of future liver remnant in patients scheduled to undergo surgical resection.

Low functional liver imaging score is associated with poor prognosis following hepatectomy for hepatocellular carcinoma

Liver function affects the prognosis of patients with hepatocellular carcinoma (HCC). This study aimed to investigate the prognostic impact of the functional liver imaging score (FLIS), assessed using gadoxetic acid-enhanced magnetic resonance imaging, on long-term outcomes following hepatectomy for HCC. The FLIS was assessed in 235 patients who underwent initial hepatectomy for HCC. The relationship between FLIS and prognosis was retrospectively analyzed. The FLIS was 6 in 185, and 2-5 in 50, patients. The 5-year recurrence-free and overall survival rates were 43.6% and 76.4% in patients with an FLIS of 6, and 23.0% and 42.4% in patients with an FLIS of 2-5, respectively; both recurrence-free and overall survival were significantly better in patients with an FLIS of 6 (P = 0.012 and 0.001, respectively). Multivariable analyses revealed that microvascular invasion (hazard ratio: 3.611; P = 0.002) and an FLIS of 2-5 (hazard ratio: 2.558; P = 0.027) were independently associated with shorter overall survival. After propensity-score matching, overall survival was significantly better in patients with an FLIS of 6. A low FLIS was significantly associated with poor prognosis following initial hepatectomy for HCC, suggesting that surgical indications must be carefully considered in patients with a low FLIS.

Predictors of Post-Hepatectomy Liver Failure in Klatskin Tumors: The Role of Preoperative Glucose, Future Liver Remnant to Spleen Ratio, and Early Bilirubin Monitoring

Background: Post-hepatectomy liver failure (PHLF) is a serious complication following hepatic resection for Klatskin tumors, significantly affecting patient prognosis. Identifying reliable preoperative and early postoperative predictors of PHLF can help optimize patient outcomes and guide surgical planning. Method: We conducted a retrospective review of 34 patients who underwent hemi-hepatectomy for extrahepatic cholangiocarcinoma at Kosin University Gospel Hospital between April 2019 and April 2024, and at Chonnam National University Hwasun Hospital between September 2017 and April 2024. Demographics, laboratory data, and volumetric measurements including spleen volume, were analyzed to assess their roles in predicting PHLF. Logistic regression and receiver operating characteristic (ROC) curve analyses were performed to evaluate the predictive value of these factors. Results: Elevated preoperative glucose levels and reduced future liver remnant to spleen ratio (FLR/SV) were significantly associated with an increased risk of PHLF. Additionally, elevated postoperative day 1 total bilirubin (POD 1 TB) was identified as a key postoperative predictor of PHLF. Multivariable analysis confirmed the significance of these factors, with FLR/SV, preoperative glucose, and POD 1 TB demonstrating good discriminative ability in ROC analysis, with AUC values of 0.779, 0.782, and 0.786 respectively. Conclusion: Preoperative glucose control, evaluation of FLR/SV, and early postoperative monitoring of TB are useful for improving outcomes in patients undergoing major hepatectomy for Klatskin tumors.

The assessment of impaired liver function and prognosis in hepatocellular carcinoma

INTRODUCTION

The impairment of liver function strongly limits the therapeutic options for hepatocellular carcinoma (HCC), and the assessment of liver function is key to finding the appropriate therapy for patients suffering from this disease. Furthermore, preexisting liver dysfunction has a negative impact on the prognosis of patients in addition to the malignant potential of HCC. Hence, defining the optimal treatment of patients with HCC requires a comprehensive examination with liver function being a crucial part of it.

AREAS COVERED

This review will provide an overview of the currently existing methods for evaluating the liver function in patients with HCC. Assessment of liver function includes scoring systems but also functional and technical methods. In addition, the role of these tests in different treatment facilities such as liver resection, transplantation, interventional and systemic therapy is summarized.

EXPERT OPINION

A comprehensive pretherapeutic assessment of the liver function includes laboratory-based scoring systems, as well as imaging- and non-imaging-based functional tests. Combining diverse parameters can help to improve the safety and efficacy of HCC therapy particularly in patients with compromised liver function. Future research should focus on optimizing pretherapeutic assessment recommendations for each therapy.

Value of gadoxetic acid-enhanced MR imaging for preoperative prediction of future liver regeneration after hemihepatectomy

PURPOSE

Liver resection is currently considered the most effective treatment for patients with liver cancer. To the best of our knowledge, no study has investigated the association between gadoxetic acid-enhanced magnetic resonance imaging (MRI) findings and liver regeneration in patients who underwent hemihepatectomy. We aimed to clarify the relationship between the signal intensity (SI) of the liver parenchyma on gadoxetic acid-enhanced MRI and the degree of liver regeneration in patients who underwent hemihepatectomy.

MATERIALS AND METHODS

Forty-one patients who underwent gadoxetic acid-enhanced MRI before hemihepatectomy were enrolled. We calculated the liver-to-erector spinae muscle SI ratio (LMR) in the hepatobiliary phase and the precontrast images. ΔLMR was calculated using the following equation: ΔLMR = (LMR in the hepatobiliary phase-LMR in the precontrast image)/LMR in the precontrast image. The preoperative and postoperative remnant liver volumes (LVs) were calculated using CT volumetry. We calculated the resection rate (RR) and liver regeneration index (LRI) using the following formulas: RR = Resected LV/Total LV × 100 and LRI = (postoperative remnant LV-preoperative remnant LV)/preoperative remnant LV × 100. The relationships among LRI, imaging, and clinicopathological factors were analyzed.

RESULTS

Univariate analysis showed RR and ΔLMR showed a positive correlation with LRI (ρ = 0.4133, p = 0.0072 and ρ = 0.7773, p < 0.001, respectively). Spleen volume showed a negative correlation with LRI (ρ = -0.3138, p = 0.0486). Stepwise multiple regression analysis showed ΔLMR and RR were independently correlated with LRI (β coefficient = 44.8771, p = 0.0198 and β coefficient = 1.9653, p < 0.001, respectively).

CONCLUSION

ΔLMR may serve as a preoperative predictor of liver regeneration in patients undergoing hemihepatectomy.

Initial experience with Double-vein Embolization in Hungary

Introduction

In recent years several new techniques have emerged to induce hypertrophy of the future liver remnant prior to major hepatectomies. We aimed to summarize our initial experience with Double-vein Embolization as the first center in Hungary.

Methods

Between March 2023 and August 2024 a total of 16 Double-vein Embolization procedures were performed in Semmelweis University. Future liver remnant volume was calculated based on computed tomography scans obtained within 4 weeks prior and 2-3 weeks after the procedure. Tc-99m mebrofenin hepatobiliary scintigraphy results were available for 12/16 patients.

Results

Technical success rate was 100 %. No major complication was observed. Successful resection rate was 93.8 %. One patient died due to post-hepatectomy liver failure. Future liver remnant volume and ratio increased significantly after the procedure compared to baseline (433.1 ± 163.8 cm3 vs. 603.5 ± 201.8 cm3, p < 0.0001 and 27.2 ± 6.5 % vs. 37 ± 8.8 %, p < 0.0001, respectively). Future liver remnant clearance improved significantly 1 and 2 weeks after the procedure (1.68 ± 0.58 %/min/m2 vs. 2.44 ± 0.64 %/min/m2 and 2.39 ± 0.31 %/min/m2, respectively). Mean function gain was 50.6 % after one week and 60.1% after two weeks, respectively.

Discussion

Volumetric and functional outcomes in the present study are comparable with results reported in the literature. Our findings provide further evidence that Double-vein Embolization is a safe procedure that offers sufficient volumetric and functional gain in most candidates for liver resection. However, further studies are needed to define the exact place of this new technique in clinical practice.

Preoperative Ultrasound Radomics to Predict Posthepatectomy Liver Failure in Patients With Hepatocellular Carcinoma

PURPOSE

Posthepatectomy liver failure (PHLF) is a major cause of postoperative mortality in hepatocellular carcinoma (HCC) patients. The study aimed to develop a method based on the two-dimensional shear wave elastography and clinical data to evaluate the risk of PHLF in HCC patients with chronic hepatitis B.

METHODS

This multicenter study proposed a deep learning model (PHLF-Net) incorporating dual-modal ultrasound features and clinical indicators to predict the PHLF risk. The datasets were divided into a training cohort, an internal validation cohort, an internal independent testing cohort, and three external independent testing cohorts. Based on ResNet50 pretrained on ImageNet, PHLF-Net used a progressive training strategy with images of varying granularity and incorporated conventional B-mode and elastography images and clinical indicators related to liver reserve function.

RESULTS

In total, 532 HCC patients who underwent hepatectomy at five hospitals were enrolled. PHLF occurred in 147 patients (27.6%, 147/532). The PHLF-Net combining dual-modal ultrasound and clinical indicators demonstrated high effectiveness for predicting PHLF, with AUCs of 0.957 and 0.923 in the internal validation and testing sets, and AUCs of 0.950, 0.860, and 1.000 in the other three independent external testing sets. The performance of PHLF-Net outperformed models of single- and dual-modal US.

CONCLUSIONS

Preoperative ultrasound imaging combining clinical indicators can effectively predict the PHLF probability in patients with HCC. In the internal and external validation sets, PHLF-Net demonstrated its usefulness in predicting PHLF.

Functional liver imaging score (FLIS) can predict adverse events in HCC patients

PURPOSE

To assess the performance of FLIS in predicting adverse outcomes, namely post-hepatectomy liver failure (PHLF) and death, in patients who underwent liver surgery for malignancies.

METHODS

All consecutive patients who underwent liver resection and 1.5 T gadoxetic acid MR were enrolled. PHLF and overall survival (OS) were collected. Two radiologists with 18 and 8 years of experience in abdominal imaging, blinded to clinical data, evaluated all images. Radiologists evaluated liver parenchymal enhancement (EnQS), biliary contrast excretion (ExQS), and signal intensity of the portal vein relative to the liver parenchyma (PVsQs). Reliability analysis was computed with Cohen's Kappa. Cox regression analysis was calculated to determine which factors are associated with PHLF and OS. Area Under the Receiver Operating Characteristic curve (AUROC) was computed.

RESULTS

150 patients were enrolled, 58 (38.7 %) in the HCC group and 92 (61.3 %) in the non-HCC group. The reliability analysis between the two readers was almost perfect (κ = 0.998). The multivariate Cox analysis showed that only post-surgical blood transfusions and major resection were associated with adverse events [HR=8.96 (7.98-9.88), p = 0.034, and HR=0.99 (0.781-1.121), p = 0.032, respectively] in the whole population. In the HCC group, the multivariable Cox analysis showed that blood transfusions, major resection and FLIS were associated with adverse outcomes [HR=13.133 (2.988-55.142), p = 0.009, HR=0.987 (0.244-1.987), p = 0.021, and HR=1.891 (1.772-3.471), p = 0.039]. The FLIS AUROC to predict adverse outcomes was 0.660 (95 %CIs = 0.484-0.836), with 87 % sensitivity and 33.3 % specificity (81.1-94.4 and 22.1-42.1).

CONCLUSIONS

FLIS can be considered a promising tool to preoperative depict patients at risk of PHLF and death.

99mTc-GSA scintigraphy and modified albumin-bilirubin score can be complementary to ICG for predicting posthepatectomy liver failure

BACKGROUND

Posthepatectomy liver failure (PHLF) remains a severe complication after liver resection. This retrospective study investigated the correlation of three hepatic functional tests and whether 99mTc-galactosyl human serum albumin (99mTc-GSA) scintigraphy and modified albumin-bilirubin (ALBI) score are useful for predicting PHLF.

METHODS

This retrospective cohort study included 413 consecutive patients undergoing hepatectomies between January 2017 and December 2020. To evaluate preoperative hepatic functional reserve, modified ALBI grade, indocyanine green clearance (ICG-R15), and 99mTc-GSA scintigraphy (LHL15) were examined before scheduled hepatectomy. Based on a retrospective chart review, multivariable logistic regression analysis adjusted for confounding factors was performed to confirm that mALBI, ICG-R15, and LHL15 are independent risk factors for PHLF.

RESULTS

ICG-R15 and LHL15 were moderately correlated (r =  - 0.61) but this correlation weakened when ICG-R15 was about ≥ 20. Weak correlations were observed between LHL15 and ALBI score (r =  - 0.269) and ALBI score and ICG-R15 (r = 0.339). Of 413 patients, 66 (19%) developed PHLF (20 grade A, 44 grade B, 2 grade C). Multivariable logistic regression analyses, major hepatectomy (P < 0.001), mALBI grade (P = 0.01), ICG-R15 (P < 0.001), and Esophagogastric varices (P = 0.007) were significant independent risk factors for PHLF. Subgroup analysis showed that ICG-R15 < 19, major hepatectomy, and mALBI grade and ICG-R15 ≥ 19, major hepatectomy, LHL15, and Esophagogastric varices were significant independent risk factors for PHLF (P = 0.033, 0.017, 0.02, 0.02, and 0.001, respectively).

CONCLUSION

LHL15, the assessment of Esophagogastric varices, and mALBI grade are complementary to ICG-R15 for predicting PHLF risk.

Does the Surgical Approach Affect the Incidence of Post-Hepatectomy Liver Failure in Cirrhotic Patients? An Analysis of the NSQIP Database

Background: The association between surgical approach and post-hepatectomy liver failure (PHLF) in cirrhotic patients is poorly understood. We hypothesize that patients will have similar rates of liver failure regardless of whether they undergo minimally invasive liver resection (MILR) or open liver resection (OLR) in major liver resections. In contrast, there will be lower rates of PHLF in patients undergoing minor hepatectomy via the MILR approach.Methods: Propensity score matching was used to analyze regression by matching the MILR to the OLR cohort. Patient demographics from the American College of Surgeons National Surgical Quality Improvement Program, including race, age, gender, and ethnicity, were matched. Chronic obstructive pulmonary disease, congestive heart failure, smoking, hypertension, diabetes, renal failure, dyspnea, dialysis dependence, body mass index, and American Society of Anesthesiologists (ASA) classification (>ASA III) were among the preoperative patient characteristics subject to matching. PHLF (Grade A vs B. vs C) was our primary outcome measure.Results: A total of 2129 cirrhotic patients were included in the study. In the minor hepatectomy group, patients undergoing an OLR were more likely to get discharged to a facility (7.0% vs 4.4%; P = .03), had greater hospital length of stay (5 vs 3 days; P = .02), and had a greater need for invasive postoperative interventions (10.7% vs 4.6%; P < .01). They were also noted to have higher rates of organ space superficial surgical infections (SSIs) (7.3% vs 3.7%; P = .003), Clostridium difficile infection (.9% vs .1%; P = .05), renal insufficiency (2.1% vs .1%; P < .01), unplanned intubations (3.1% vs 1.4%; P = .03), and Grade C liver failure (2.3% vs .9%; P = .03).Conclusion: A higher incidence of PHLF grade C was found in patients undergoing OLR in the minor hepatectomy group. Therefore, in cirrhotic patients who can tolerate minimally invasive approaches, MILR should be offered to prevent postoperative complications as part of their optimization plan.

The impact of tumor burden score on prognosis in patients after radical resection of hepatocellular carcinoma: a single-center retrospective study

Purpose

This study examines the relationship between tumor burden score (TBS) and survival and recurrence following radical resection of hepatocellular carcinoma through a cohort study conducted in the Guangxi population of China.

Methods

This cohort study eventually recruited 576 HCC patients undergoing radical resection of HCC in the People's Hospital of Guangxi Zhuang Autonomous Region during 2013-2022. After determining the best threshold TBS, all cases were grouped to evaluate the relationship between TBS versus overall survival (OS) and cumulative recurrence. Using X-Tile software, the best threshold TBS to judge patient prognostic outcome following radical resection of HCC was 10.77.

Results

Kaplan-Meier curve analysis revealed that patients with high TBS showed considerably decreased OS relative to the control group, accompanied by an increased recurrence rate. According to multivariate Cox proportional regression, the patients with high TBS were associated with poorer OS (HR = 2.56, 95% CI 1.64-3.99, P < 0.001) and recurrence-free survival (RFS) (HR = 1.55, 95% CI 1.02-2.35, P < 0.001).

Conclusion

In patients undergoing radical resection for HCC, higher TBS was significantly related to shorter OS and RFS.

Effect of clustered nursing on liver function indexes, nutrition, and emotional status of patients with severe liver failure

Liver failure is a metabolic disorder caused by a variety of mixed factors. For such diseases, adopting cluster care can effectively improve the relevant symptoms of patients. To explore the nursing effect of nutritional nursing combined with clustered nursing for patients with severe liver failure. A total of 129 patients with severe liver failure were selected as retrospective study subjects. Nine cases were due to an end event, such as death. The other patients were divided into control group and observation group according to different nursing methods. Among them, the control group adopted nutrition nursing, and the observation group implemented cluster nursing on this basis. The differences of liver function, anxiety and depression score, gastrointestinal recovery, nutritional status, and sleep quality were compared between the 2 groups before and after nursing. After nursing, the total bilirubin, albumin, and aspartate aminotransferase of the observation group were significantly higher than those of the control group (P < .05). The nursing staff used Self-Rating Anxiety Scale and Self-Rating Depression Scale of the observation group, which were slightly lower than those of the control group. The difference was statistically significant after testing (P < .05). After nursing, the observation group's upper arm circumference, brachial tri-scalp fold thickness, and hemoglobin were better than those of the control group. Statistics showed that the difference was statistically significant (P < .05). The depth of sleep, time to fall asleep, number of awakenings, time to fall asleep after awakening, overall sleep quality, and intensive care unit environmental noise intensity in the Richards-Campbell Sleep Questionnaire sleep scale after nursing in the 2 groups were significantly higher than those before nursing, and the scores of the observation group were significantly lower than those in the observation group. In the control group, this difference was statistically significant (P < .05). Nutritional nursing combined with clustered nursing can effectively promote the recovery of gastrointestinal function in patients with severe liver failure.

Systematic review and meta-analysis of the effect of N-acetylcysteine on outcomes after liver resection

BACKGROUND

N-Acetylcysteine (NAC) is a recognized antioxidative agent that facilitates the conjugation of toxic metabolites. In recent years, NAC has been routinely used to limit ischaemia-reperfusion injury in liver transplantation. There remains, however, contradictory evidence on its effectiveness in liver resection. This meta-analysis examines the effectiveness of NAC in improving outcomes following hepatectomy.

METHODS

A comprehensive search of the MEDLINE, EMBASE, and Cochrane databases was performed to identify relevant randomized controlled trials (RCTs) published since database inception until November 2023. The outcomes of Day 1 biochemical markers (lactate, ALT, bilirubin, and INR), length of stay, transfusion rates, and morbidity were extracted. Quantitative pooling of data was based on a random-effects model. The study protocol was registered on PROSPERO (Registration no: CRD42023442429).

RESULTS

Five RCTs reporting on 388 patients undergoing hepatectomy were included in the analysis. There were no significant differences in patient demographics between groups. Post-operative lactate was lower in patients receiving NAC (WMD -0.61, 95% CI -1.19 to -0.04, I2 = 67%). There were, however, no differences in the post-operative INR (WMD -0.04, 95% CI -0.19 to 0.12, I2 = 96%) and ALT (WMD -94.94, 95% CI -228.46 to 40.38; I2 = 67%). More importantly, there were no statistically significant differences in length of stay, transfusion rates, and morbidity between the two groups.

CONCLUSION

The administration of NAC in liver resection did not alter important biochemical parameters suggesting any real effectiveness in reducing hepatic dysfunction. There were no improvements in the clinical outcomes of length of stay, transfusion rates, and overall morbidity.

Liver Status Assessment After Coronary Artery Bypass Grafting

Background Coronary artery bypass grafting (CABG) is a common surgical intervention used to treat severe coronary artery disease. The Model for End-Stage Liver Disease (MELD) score has become a widely used prognostic index for assessing the severity of liver disease and prioritizing liver transplantation. However, its utility in predicting outcomes in cardiac surgery procedures has not been extensively evaluated. Methods This retrospective study gathered data on patients who underwent CABG or CABG combined with other concomitant surgical interventions, such as carotid common or external carotid artery endarterectomy, thoracic aortic aneurysm repair, and aortic or mitral valve replacement or decalcification procedures, at a single tertiary care facility from January 2011 to December 2020. Researchers collected demographic, clinical, and laboratory information, including MELD score and European System for Cardiac Operative Risk Evaluation (EuroSCORE) data. The patients were divided into two groups: the first group included only those who underwent CABG, while the second group comprised patients who underwent CABG along with other concomitant cardiac interventions. Results The MELD score at discharge was significantly higher in the CABG and other interventions group compared to the CABG-only group (median = 14.09, IQR = 7.41-18.7 vs. median = 6.41, IQR = 4.61-9.44, p < 0.001). However, the difference in MELD score at admission between the two groups was not statistically significant (p = 0.328). A p-value < 0.05 was considered statistically relevant, indicating that liver function worsened postoperatively in the patients with additional interventions. The EuroSCORE was also significantly higher in the CABG and other interventions group, suggesting a higher surgical risk as expected (median = 5.74, IQR = 3.54-11.47 vs. median = 3.34, IQR = 1.97-5.66, p < 0.001). Additionally, differences in laboratory parameters, especially coagulation and hemostasis indicators throughout the postoperative period, including the ICU stay (divided into four equal periods based on each patient's total ICU length of stay) and at discharge, indicate a more complex biological state in patients with additional interventions. These findings may have implications for perioperative management and long-term outcomes. Conclusions The elevated MELD score in patients undergoing CABG with additional interventions emphasizes the need for close monitoring of liver function and coagulation status. Evaluating hepatic status preoperatively would be beneficial, and incorporating liver-protective strategies could help mitigate postoperative repercussions. It may also be useful to include liver function parameters in existing cardiovascular risk scores to improve risk assessment.

Preoperative imaging of colorectal liver metastases: what the radiologist and the multidisciplinary team need to know

The management of patients with colorectal liver metastases (CRLM) has transformed over the past 2 decades. Advances in surgical techniques, systemic therapies, and local treatments have resulted in a paradigm shift. Disease that would once have been considered terminal is now frequently treated aggressively with both a disease-free and overall survival benefit. In line with the expanding range of treatment options, there has been an increase in the volume and complexity of imaging required in the management of these patients to ensure optimal patient selection and outcome. The radiologist plays a pivotal role in interpreting these studies, conveying the relevant information and informing the discussion at multidisciplinary team meetings. The purpose of this review is to provide an update for radiologists on the current surgical management of patients with CRLM highlighting specific imaging information that is required by the multidisciplinary team when assessing resectability and/or the need for additional liver-directed therapies.

Exosome-related gene identification and diagnostic model construction in hepatic ischemia-reperfusion injury

Hepatic ischemia-reperfusion injury (HIRI) may cause severe hepatic impairment, acute hepatic insufficiency, and multiorgan system collapse. Exosomes can alleviate HIRI. Therefore, this study explored the role of exosomal-related genes (ERGs) in HIRI using bioinformatics to determine the underlying molecular mechanisms and novel diagnostic markers for HIRI. We merged the GSE12720, GSE14951, and GSE15480 datasets obtained from the Gene Expression Omnibus (GEO) database into a combined gene dataset (CGD). CGD was used to identify differentially expressed genes (DEGs) based on a comparison of the HIRI and healthy control cohorts. The impact of these DEGs on HIRI was assessed through gene set enrichment analysis (GSEA) and gene set variation analysis (GSVA). ERGs were retrieved from the GeneCards database and prior studies, and overlapped with the identified DEGs to yield the set of exosome-related differentially expressed genes (ERDEGs). Functional annotations and enrichment pathways of these genes were determined using Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) analyses. Diagnostic models for HIRI were developed using least absolute shrinkage and selection operator (LASSO) regression and support vector machine (SVM) algorithms. Key genes with diagnostic value were identified from the overlap, and single-sample gene-set enrichment analysis (ssGSEA) was conducted to evaluate the immune infiltration characteristics. A molecular regulatory interaction network was established using Cytoscape software to elucidate the intricate regulatory mechanisms of key genes in HIRI. Finally, exosome score (Es) was obtained using ssGSEA and the HIRI group was divided into the Es_High and Es_Low groups based on the median Es. Gene expression was analyzed to understand the impact of all genes in the CGD on HIRI. Finally, the relative expression levels of the five key genes in the hypoxia-reoxygenation (H/R) model were determined using quantitative real-time PCR (qRT-PCR). A total of 3810 DEGs were identified through differential expression analysis of the CGD, and 61 of these ERDEGs were screened. Based on GO and KEGG enrichment analyses, the ERDEGs were mainly enriched in wound healing, MAPK, protein kinase B signaling, and other pathways. GSEA and GSVA revealed that these genes were mainly enriched in the TP53, MAPK, TGF[Formula: see text], JAK-STAT, MAPK, and NFKB pathways. Five key genes (ANXA1, HNRNPA2B1, ICAM1, PTEN, and THBS1) with diagnostic value were screened using the LASSO regression and SVM algorithms and their molecular interaction network was established using Cytoscape software. Based on ssGSEA, substantial variations were found in the expression of 18 immune cell types among the groups (p < 0.05). Finally, the Es of each HIRI patient was calculated. ERDEGs in the Es_High and Es_Low groups were enriched in the IL18, TP53, MAPK, TGF[Formula: see text], and JAK-STAT pathways. The differential expression of these five key genes in the H/R model was verified using qRT-PCR. Herein, five key genes were identified as potential diagnostic markers. Moreover, the potential impact of these genes on pathways and the regulatory mechanisms of their interaction network in HIRI were revealed. Altogether, our findings may serve as a theoretical foundation for enhancing clinical diagnosis and elucidating underlying pathogeneses.

Effects of perioperative steroid use on surgical stress and prognosis in patients undergoing hepatectomy: a systematic review and meta-analysis of randomized controlled trials

The objective of this study was to evaluate the clinical effects of perioperative steroid hormone usage in hepatectomy patients through a comprehensive systematic review and meta-analysis. Prospective randomized controlled trials (RCTs) investigating the perioperative use of steroid hormones in hepatectomy patients were systematically searched using various databases, including PubMed, Medline, Embase, the Cochrane Library, the Chinese Biomedical Literature Database, Wanfang Data, and the CNKI database. Two researchers independently screened and extracted data from selected studies. Data analysis was performed using RevMan 5.3 software. The results revealed significantly lower levels of total bilirubin (standard mean difference [SMD] = -0.7; 95% CI: -1.23 to -0.18; and p = 0.009), interleukin-6 (SMD = -1.02; 95% CI: -1.27 to -0.77; and p < 0.001), and C-reactive protein (SMD = -0 .65; 95% CI: -1 .18 to -0.11; and p = 0.02) on postoperative day 1 (POD 1), as well as a reduced incidence of postoperative complications in the steroid group compared to the placebo group. No significant differences were observed between the two groups regarding alanine aminotransferase (ALT) levels, aspartic aminotransferase (AST) levels, or specific complications such as intra-abdominal infection (p = 0.72), wound infection (p = 0.1), pleural effusion (p = 0.43), bile leakage (p = 0.66), and liver failure (p = 0.16). The meta-analysis results indicate that perioperative steroid usage can effectively alleviate liver function impairment and inflammation response following hepatectomy while improving patient prognosis.

Extracellular NAD+ response to post-hepatectomy liver failure: bridging preclinical and clinical findings

Liver fibrosis progressing to cirrhosis is a major risk factor for liver cancer, impacting surgical treatment and survival. Our study focuses on the role of extracellular nicotinamide adenine dinucleotide (eNAD+) in liver fibrosis, analyzing liver disease patients undergoing surgery. Additionally, we explore NAD+'s therapeutic potential in a mouse model of extended liver resection and in vitro using 3D hepatocyte spheroids. eNAD+ correlated with aspartate transaminase (AST) and bilirubin after liver resection (AST: r = 0.2828, p = 0.0087; Bilirubin: r = 0.2584, p = 0.0176). Concordantly, post-hepatectomy liver failure (PHLF) was associated with higher eNAD+ peaks (n = 10; p = 0.0063). Post-operative eNAD+ levels decreased significantly (p < 0.05), but in advanced stages of liver fibrosis or cirrhosis, this decline not only diminished but actually showed a trend towards an increase. The expression of NAD+ biosynthesis rate-limiting enzymes, nicotinamide phosphoribosyltransferase (NAMPT) and nicotinamide mononucleotide adenylyltransferase 3 (NMNAT3), were upregulated significantly in the liver tissue of patients with higher liver fibrosis stages (p < 0.0001). Finally, the administration of NAD+ in a 3D hepatocyte spheroid model rescued hepatocytes from TNFalpha-induced cell death and improved viability (p < 0.0001). In a mouse model of extended liver resection, NAD+ treatment significantly improved survival (p = 0.0158) and liver regeneration (p = 0.0186). Our findings reveal that eNAD+ was upregulated in PHLF, and rate-limiting enzymes of NAD+ biosynthesis demonstrated higher expressions under liver fibrosis. Further, eNAD+ administration improved survival after extended liver resection in mice and enhanced hepatocyte viability in vitro. These insights may offer a potential target for future therapies.

Risk factors for secondary infection after liver failure and effect of comprehensive nursing intervention

BACKGROUND

In patients with liver failure (LF), the high rate of secondary infections, which are associated with poor prognosis, highlights the clinical significance of understanding the underlying risk factors and implementing targeted intervention programs.

AIM

To investigate risk factors for secondary infections in patients with LF and evaluate the effectiveness of comprehensive nursing interventions.

METHODS

This retrospective study included 64 patients with LF, including 32 with and 32 without secondary infections. A questionnaire was used to collect data on age; laboratory parameters, including total and direct bilirubin, prothrombin time, blood ammonia, and other biochemical parameters; invasive procedures; and complications. Patients with secondary infections received comprehensive nursing intervention in addition to routine nursing care, whereas those without secondary infections received only routine nursing care to compare the effect of nursing intervention on outcomes.

RESULTS

The infection rate, which was not associated with age or complications, was significantly associated with biochemical parameters and invasive procedures (P < 0.05). The infection rate was 61.6% in patients who had undergone invasive procedures and 32.1% in those who had not undergone invasive procedures during the hospital stay. The infection rate was also significantly associated with the type of LF (P < 0.05), with the lowest rate observed in patients with acute LF and the highest rate observed in those with subacute LF. The nursing satisfaction rate was 58.3% in the uninfected group and 91.7% in the infected group, indicating significantly higher satisfaction in the infected group (P < 0.05).

CONCLUSION

In patients with LF, the rate of secondary infections was high and associated with biochemical parameters and type of LF. Comprehensive nursing intervention can improve patient satisfaction.

Liver regeneration after injury: Mechanisms, cellular interactions and therapeutic innovations

The liver possesses a distinctive capacity for regeneration within the human body. Under normal circumstances, liver cells replicate themselves to maintain liver function. Compensatory replication of healthy hepatocytes is sufficient for the regeneration after acute liver injuries. In the late stage of chronic liver damage, a large number of hepatocytes die and hepatocyte replication is blocked. Liver regeneration has more complex mechanisms, such as the transdifferentiation between cell types or hepatic progenitor cells mediated. Dysregulation of liver regeneration causes severe chronic liver disease. Gaining a more comprehensive understanding of liver regeneration mechanisms would facilitate the advancement of efficient therapeutic approaches. This review provides an overview of the signalling pathways linked to different aspects of liver regeneration in various liver diseases. Moreover, new knowledge on cellular interactions during the regenerative process is also presented. Finally, this paper explores the potential applications of new technologies, such as nanotechnology, stem cell transplantation and organoids, in liver regeneration after injury, offering fresh perspectives on treating liver disease.

Interaction between the albumin-bilirubin score and nutritional risk index in the prediction of post-hepatectomy liver failure

BACKGROUND

Post-hepatectomy liver failure (PHLF) is the most common postoperative complication and the leading cause of death after hepatectomy. The albumin-bilirubin (ALBI) score and nutritional risk index (NRI) have been shown to assess end-stage liver disease and predict PHLF and patient survival. We hypothesized that the ALBI score and NRI interact in the prediction of PHLF.

AIM

To analyze the interaction between the ALBI score and NRI in PHLF in patients with hepatocellular carcinoma.

METHODS

This retrospective study included 186 patients who underwent hepatectomy for hepatocellular carcinoma at the Affiliated Hospital of Youjiang Medical University for Nationalities between January 2020 and July 2023. Data on patient characteristics and laboratory indices were collected from their medical records. Univariate and multivariate logistic regression were performed to determine the interaction effect between the ALBI score and NRI in PHLF.

RESULTS

Of the 186 patients included in the study, PHLF occurred in 44 (23.66%). After adjusting for confounders, multivariate logistic regression identified ALBI grade 2/3 [odds ratio (OR) = 73.713, 95% confidence interval (CI): 9.175-592.199] and NRI > 97.5 (OR = 58.990, 95%CI: 7.337-474.297) as risk factors for PHLF. No multiplicative interaction was observed between the ALBI score and NRI (OR = 0.357, 95%CI: 0.022-5.889). However, the risk of PHLF in patients with ALBI grade 2/3 and NRI < 97.5 was 101 times greater than that in patients with ALBI grade 1 and NRI ≥ 97.5 (95%CI: 56.445-523.839), indicating a significant additive interaction between the ALBI score and NRI in PHLF.

CONCLUSION

Both the ALBI score and NRI were risk factors for PHLF, and there was an additive interaction between the ALBI score and NRI in PHLF.

Heparin is an effective treatment for preventing liver failure after hepatectomy

BACKGROUND

Posthepatectomy liver failure (PHLF) is one of the most important causes of death following liver resection. Heparin, an established anticoagulant, can protect liver function through a number of mechanisms, and thus, prevent liver failure.

AIM

To look at the safety and efficacy of heparin in preventing hepatic dysfunction after hepatectomy.

METHODS

The data was extracted from Multiparameter Intelligent Monitoring in Intensive Care III (MIMIC-III) v1. 4 pinpointed patients who had undergone hepatectomy for liver cancer, subdividing them into two cohorts: Those who were injected with heparin and those who were not. The statistical evaluations used were unpaired t-tests, Mann-Whitney U tests, chi-square tests, and Fisher's exact tests to assess the effect of heparin administration on PHLF, duration of intensive care unit (ICU) stay, need for mechanical ventilation, use of continuous renal replacement therapy (CRRT), incidence of hypoxemia, development of acute kidney injury, and ICU mortality. Logistic regression was utilized to analyze the factors related to PHLF, with propensity score matching (PSM) aiming to balance the preoperative disparities between the two groups.

RESULTS

In this study, 1388 patients who underwent liver cancer hepatectomy were analyzed. PSM yielded 213 matched pairs from the heparin-treated and control groups. Initial univariate analyses indicated that heparin potentially reduces the risk of PHLF in both matched and unmatched samples. Further analysis in the matched cohorts confirmed a significant association, with heparin reducing the risk of PHLF (odds ratio: 0.518; 95% confidence interval: 0.295-0.910; P = 0.022). Additionally, heparin treatment correlated with improved short-term postoperative outcomes such as reduced ICU stay durations, diminished requirements for respiratory support and CRRT, and lower incidences of hypoxemia and ICU mortality.

CONCLUSION

Liver failure is an important hazard following hepatic surgery. During ICU care heparin administration has been proved to decrease the occurrence of hepatectomy induced liver failure. This indicates that heparin may provide a hopeful option for controlling PHLF.

Major liver resections, perioperative issues and posthepatectomy liver failure: A comprehensive update for the anesthesiologist

Significant advances in surgical techniques and relevant medium- and long-term outcomes over the past two decades have led to a substantial expansion in the indications for major liver resections. To support these outstanding results and to reduce perioperative complications, anesthesiologists must address and master key perioperative issues (preoperative assessment, proactive intraoperative anesthesia strategies, and implementation of the Enhanced Recovery After Surgery approach). Intensive care unit monitoring immediately following liver surgery remains a subject of active and often unresolved debate. Among postoperative complications, posthepatectomy liver failure (PHLF) occurs in different grades of severity (A-C) and frequency (9%-30%), and it is the main cause of 90-d postoperative mortality. PHLF, recently redefined with pragmatic clinical criteria and perioperative scores, can be predicted, prevented, or anticipated. This review highlights: (1) The systemic consequences of surgical manipulations anesthesiologists must respond to or prevent, to positively impact PHLF (a proactive approach); and (2) the maximal intensive treatment of PHLF, including artificial options, mainly based, so far, on Acute Liver Failure treatment(s), to buy time waiting for the recovery of the native liver or, when appropriate and in very selected cases, toward liver transplant. Such a clinical context requires a strong commitment to surgeons, anesthesiologists, and intensivists to work together, for a fruitful collaboration in a mandatory clinical continuum.

Rapid Self-Assembly Mini-Livers Protect Mice Against Severe Hepatectomy-Induced Liver Failure

The construction of bioartificial livers, such as liver organoids, offers significant promise for disease modeling, drug development, and regenerative medicine. However, existing methods for generating liver organoids have limitations, including lengthy and complex processes (taking 6-8 weeks or longer), safety concerns associated with pluripotency, limited functionality of pluripotent stem cell-derived hepatocytes, and small, highly variable sizes (typically ≈50-500 µm in diameter). Prolonged culture also leads to the formation of necrotic cores, further restricting size and function. In this study, a straightforward and time-efficient approach is developed for creating rapid self-assembly mini-livers (RSALs) within 12 h. Additionally, primary hepatocytes are significantly expanded in vitro for use as seeding cells. RSALs exhibit consistent larger sizes (5.5 mm in diameter), improved cell viability (99%), and enhanced liver functionality. Notably, RSALs are functionally vascularized within 2 weeks post-transplantation into the mesentery of mice. These authentic hepatocyte-based RSALs effectively protect mice from 90%-hepatectomy-induced liver failure, demonstrating the potential of bioartificial liver-based therapy.

Transarterial embolization with bleomycin-lipiodol emulsion: a successful minimal invasive approach for giant liver hemangioma

Hemangiomas are most common benign liver tumor. Most patients have an excellent prognosis because of the small size and benign nature of tumor. On some occasions, giant liver hemangioma may cause symptoms and significant challenges due to its complication. We report a case of giant liver hemangioma treated with minimal invasive approach by transarterial embolization (TAE). Following three TAE sessions over a specific timeframe, the patient was successfully managed, addressing that TAE may be a useful alternative to hepatic surgery in such cases.

Hybrid operating room applications for precision hepatobiliary surgery: A narrative review

This review summarizes the key applications of a hybrid operating room (HOR) in hepatobiliary surgery and explores the advantages, limitations, and future directions of its utilization. A comprehensive literature search was conducted in PubMed to identify articles reporting on the utilization of HORs in liver surgery. So far, the HOR has been limitedly applied in hepatobiliary surgery. It can offer an optimal environment for combining radiological and surgical interventions and for performing image-guided surgical navigation.

The Interplay between Perioperative Oxidative Stress and Hepatic Dysfunction after Human Liver Resection: A Prospective Observational Pilot Study

Post-hepatectomy liver failure (PHLF) remains the major contributor to death after liver resection. Oxidative stress is associated with postoperative complications, but its impact on liver function is unclear. This first in-human, prospective, single-center, observational pilot study evaluated perioperative oxidative stress and PHLF according to the ISGLS (International Study Group for Liver Surgery). Serum 8-isoprostane, 4-hydroxynonenal (4-HNE), total antioxidative capacity, vitamins A and E, and intraoperative, sequential hepatic tissue 4-HNE and UCP2 (uncoupling protein 2) immunohistochemistry (IHC) were assessed. The interaction with known risk factors for PHLF and the predictive potential of oxidative stress markers were analyzed. Overall, 52 patients were included (69.2% major liver resection). Thirteen patients (25%) experienced PHLF, a major factor for 90-day mortality (23% vs. 0%; p = 0.013). Post-resection, pro-oxidative 8-isoprostane significantly increased (p = 0.038), while 4-HNE declined immediately (p < 0.001). Antioxidative markers showed patterns of consumption starting post-resection (p < 0.001). Liver tissue oxidative stress increased stepwise from biopsies taken after laparotomy to post-resection in situ liver and resection specimens (all p < 0.001). Cholangiocarcinoma patients demonstrated significantly higher serum and tissue oxidative stress levels at various timepoints, with consistently higher preoperative values in advanced tumor stages. Combining intraoperative, post-resection 4-HNE serum levels and in situ IHC early predicted PHLF with an AUC of 0.855 (63.6% vs. 0%; p < 0.001). This was also associated with grade B/C PHLF (36.4% vs. 0%; p = 0.021) and 90-day mortality (18.2% vs. 0%; p = 0.036). In conclusion, distinct patterns of perioperative oxidative stress levels occur in patients with liver dysfunction. Combining intraoperative serum and liver tissue markers predicts subsequent PHLF. Cholangiocarcinoma patients demonstrated pronounced systemic and hepatic oxidative stress, with increasing levels in advanced tumor stages, thus representing a worthwhile target for future exploratory and therapeutic studies.

Molecular Pathways Governing the Termination of Liver Regeneration

The liver has the unique capacity to regenerate, and up to 70% of the liver can be removed without detrimental consequences to the organism. Liver regeneration is a complex process involving multiple signaling networks and organs. Liver regeneration proceeds through three phases: the initiation phase, the growth phase, and the termination phase. Termination of liver regeneration occurs when the liver reaches a liver-to-body weight that is required for homeostasis, the so-called "hepatostat." The initiation and growth phases have been the subject of many studies. The molecular pathways that govern the termination phase, however, remain to be fully elucidated. This review summarizes the pathways and molecules that signal the cessation of liver regrowth after partial hepatectomy and answers the question, "What factors drive the hepatostat?" SIGNIFICANCE STATEMENT: Unraveling the pathways underlying the cessation of liver regeneration enables the identification of druggable targets that will allow us to gain pharmacological control over liver regeneration. For these purposes, it would be useful to understand why the regenerative capacity of the liver is hampered under certain pathological circumstances so as to artificially modulate the regenerative processes (e.g., by blocking the cessation pathways) to improve clinical outcomes and safeguard the patient's life.

ALBI score combined with FIB-4 index to predict post-hepatectomy liver failure in patients with hepatocellular carcinoma

Post-hepatectomy liver failure (PHLF) is a potentially life-threatening complication following liver resection. Hepatocellular carcinoma (HCC) often occurs in patients with chronic liver disease, which increases the risk of PHLF. This study aimed to investigate the ability of the combination of liver function and fibrosis markers (ALBI score and FIB-4 index) to predict PHLF in patients with HCC. Patients who underwent hepatectomy for HCC between August 2012 and September 2022 were considered for inclusion. Multivariable logistic regression analysis was used to identify factors associated with PHLF, and ALBI score and FIB-4 index were combined based on their regression coefficients. The performance of the combined ALBI-FIB4 score in predicting PHLF and postoperative mortality was compared with Child-Pugh score, MELD score, ALBI score, and FIB-4 index. A total of 215 patients were enrolled in this study. PHLF occurred in 35 patients (16.3%). The incidence of severe PHLF (grade B and grade C PHLF) was 9.3%. Postoperative 90-d mortality was 2.8%. ALBI score, FIB-4 index, prothrombin time, and extent of liver resection were identified as independent factors for predicting PHLF. The AUC of the ALBI-FIB4 score in predicting PHLF was 0.783(95%CI: 0.694-0.872), higher than other models. The ALBI-FIB4 score could divide patients into two risk groups based on a cut-off value of - 1.82. High-risk patients had a high incidence of PHLF of 39.1%, while PHLF just occurred in 6.6% of low-risk patients. Similarly, the AUCs of the ALBI-FIB4 score in predicting severe PHLF and postoperative 90-d mortality were also higher than other models. Preoperative ALBI-FIB4 score showed good performance in predicting PHLF and postoperative mortality in patients undergoing hepatectomy for HCC, superior to the currently commonly used liver function and fibrosis scoring systems.

Preclinical efficacy and safety of encapsulated proliferating human hepatocyte organoids in treating liver failure

Alginate-encapsulated hepatocyte transplantation is a promising strategy to treat liver failure. However, its clinical application was impeded by the lack of primary human hepatocytes and difficulty in controlling their quality. We previously reported proliferating human hepatocytes (ProliHHs). Here, quality-controlled ProliHHs were produced in mass and engineered as liver organoids to improve their maturity. Encapsulated ProliHHs liver organoids (eLO) were intraperitoneally transplanted to treat liver failure animals. Notably, eLO treatment increased the survival of mice with post-hepatectomy liver failure (PHLF) and ameliorated hyperammonemia and hypoglycemia by providing liver functions. Additionally, eLO treatment protected the gut from PHLF-augmented permeability and normalized the increased serum endotoxin and inflammatory response, which facilitated liver regeneration. The therapeutic effect of eLO was additionally proved in acetaminophen-induced liver failure. Furthermore, we performed assessments of toxicity and biodistribution, demonstrating that eLO had no adverse effects on animals and remained non-tumorigenic.

Rescue Liver Transplantation for Posthepatectomy Liver Failure: A Systematic Review and Survey of an International Experience

BACKGROUND

Rescue liver transplantation (LT) is the only life-saving option for posthepatectomy liver failure (PHLF) whenever it is deemed as irreversible and likely to be fatal. The goals were to perform a qualitative systematic review of rescue LT for PHLF and a survey among various international LT experts.

METHODS

A literature search was performed from 2000 to 2022 using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses and Population, Intervention, Comparison, Outcome framework, and to this, the authors' experience was added. The international online open survey included 6 cases of PHLF extracted from the literature and submitted to 976 LT experts. The primary outcome was whether experts would consider rescue LT for each case. Interrater agreement among experts was calculated using the free-marginal multirater kappa methodology.

RESULTS

The review included 40 patients. Post-LT mortality occurred in 8 (20%) cases (7/28 with proven cancer and 1/12 with benign disease). In the long term, 6 of 21 (28.6%) survivors with cancer died of recurrence (median = 38 mo) and 15 (71.4%) were alive with no recurrence (median = 111 mo). All 11 survivors with benign disease were alive and well (median = 39 mo). In the international survey among experts in LT, the percentage agreement to consider rescue LT was 28%-98%, higher for benign than for malignant disease ( P = 0.011). Interrater agreement for the primary endpoint was low, expected 5-y survival >50% being the strongest independent predictor to consider LT.

CONCLUSIONS

Rescue LT for PHLF may achieve good results in selected patients. Considerable inconsistencies of decision-making exist among LT experts when considering LT for PHLF.

Therapeutic potential of ADSC-EV-derived lncRNA DLEU2: A novel molecular pathway in alleviating sepsis-induced lung injury via the miR-106a-5p/LXN axis

This study investigates the molecular mechanisms by which extracellular vesicles (EVs) derived from adipose-derived mesenchymal stem cells (ADSCs) promote M2 polarization of macrophages and thus reduce lung injury caused by sepsis. High-throughput sequencing was used to identify differentially expressed genes related to long non-coding RNA (lncRNA) in ADSC-derived EVs (ADSC-EVs) in sepsis lung tissue. Weighted gene co-expression network analysis (WGCNA) was employed to predict the downstream target genes of the lncRNA DLEU2. The RNAInter database predicted miRNAs that interact with DLEU2 and LXN. Functional and pathway enrichment analyses were performed using GO and KEGG analysis. A mouse model of sepsis was established, and treatment with a placebo or ADSC-EVs was administered, followed by RT-qPCR analysis. ADSC-EVs were isolated and identified. In vitro cell experiments were conducted using the mouse lung epithelial cell line MLE-12, mouse macrophage cell line RAW264.7, and mouse lung epithelial cell line (LEPC). ADSC-EVs were co-cultured with RAW264.7 and MLE-12/LEPC cells to study the regulatory mechanism of the lncRNA DLEU2. Cell viability, proliferation, and apoptosis of lung injury cells were assessed using CCK-8, EdU, and flow cytometry. ELISA was used to measure the levels of inflammatory cytokines in the sepsis mouse model, flow cytometry was performed to determine the number of M1 and M2 macrophages, lung tissue pathology was evaluated by H&E staining, and immunohistochemistry was conducted to examine the expression of proliferation- and apoptosis-related proteins. High-throughput sequencing and bioinformatics analysis revealed enrichment of the lncRNA DLEU2 in ADSC-EVs in sepsis lung tissue. Animal and in vitro cell experiments showed increased expression of the lncRNA DLEU2 in sepsis lung tissue after treatment with ADSC-EVs. Furthermore, ADSC-EVs were found to transfer the lncRNA DLEU2 to macrophages, promoting M2 polarization, reducing inflammation response in lung injury cells, and enhancing their viability, proliferation, and apoptosis inhibition. Further functional experiments indicated that lncRNA DLEU2 promotes M2 polarization of macrophages by regulating miR-106a-5p/LXN, thereby enhancing the viability and proliferation of lung injury cells and inhibiting apoptosis. Overexpression of miR-106a-5p could reverse the biological effects of ADSC-EVs-DLEU2 on MLE-12 and LEPC in vitro cell models. Lastly, in vivo animal experiments confirmed that ADSC-EVs-DLEU2 promotes high expression of LXN by inhibiting the expression of miR-106a-5p, further facilitating M2 macrophage polarization and reducing lung edema, thus alleviating sepsis-induced lung injury. lncRNA DLEU2 in ADSC-EVs may promote M2 polarization of macrophages and enhance the viability and proliferation of lung injury cells while inhibiting inflammation and apoptosis reactions, thus ameliorating sepsis-induced lung injury in a mechanism involving the regulation of the miR-106a-5p/LXN axis.