Functional remnant liver volumetry using Gd-EOB-DTPA-enhanced magnetic resonance imaging (MRI) predicts post-hepatectomy liver failure in resection of more than one segment

Predicting post-hepatectomy liver failure in patients with hepatocellular carcinoma: nomograms based on deep learning analysis of gadoxetic acid-enhanced MRI

OBJECTIVES

This study aimed to develop nomograms for predicting post-hepatectomy liver failure (PHLF) in patients with hepatocellular carcinoma (HCC), using deep learning analysis of Gadoxetic acid-enhanced hepatobiliary (HBP) MRI.

METHODS

This retrospective study analyzed patients who underwent gadoxetic acid-enhanced MRI and hepatectomy for HCC between 2016 and 2020 at two referral centers. Using a deep learning algorithm, volumes and signal intensities of whole non-tumor liver, expected remnant liver, and spleen were measured on HBP images. Two multivariable logistic regression models were formulated to predict PHLF, defined and graded by the International Study Group of Liver Surgery: one based on whole non-tumor liver measurements (whole liver model) and the other on expected remnant liver measurements (remnant liver model). The models were presented as nomograms and a web-based calculator. Discrimination performance was evaluated using the area under the receiver operating curve (AUC), with internal validation through 1000-fold bootstrapping.

RESULTS

The study included 1760 patients (1395 male; mean age ± standard deviation, 60 ± 10 years), with 137 (7.8%) developing PHLF. Nomogram predictors included sex, gamma-glutamyl transpeptidase, prothrombin time international normalized ratio, platelets, extent of liver resection, and MRI variables derived from the liver volume, liver-to-spleen signal intensity ratio, and spleen volume. The whole liver and the remnant liver nomograms demonstrated strong predictive performance for PHLF (optimism-corrected AUC of 0.78 and 0.81, respectively) and symptomatic (grades B and C) PHLF (optimism-corrected AUC of 0.81 and 0.84, respectively).

CONCLUSION

Nomograms based on deep learning analysis of gadoxetic acid-enhanced HBP images accurately stratify the risk of PHLF.

KEY POINTS

Question Can PHLF be predicted by integrating clinical and MRI-derived volume and functional variables through deep learning analysis of gadoxetic acid-enhanced MRI? Findings Whole liver and remnant liver nomograms demonstrated strong predictive performance for PHLF with the optimism-corrected area under the curve of 0.78 and 0.81, respectively. Clinical relevance These nomograms can effectively stratify the risk of PHLF, providing a valuable tool for treatment decisions regarding hepatectomy for HCC.

Regional quantification of metabolic liver function using hyperpolarized [1-13C] pyruvate MRI

Assessment of liver function is essential before partial hepatectomy to predict the risk of post hepatectomy liver failure, a severe and life-threatening complication. Traditional methods have focused on expected future liver remnant (FLR) volume estimation. However, liver volume does not always correlate with function. We suggest that metabolism might be a better surrogate for function than volume. Therefore, we aimed to investigate the metabolic changes in a porcine model of partial portal vein ligation (PVL) using hyperpolarized magnetic resonance imaging (HP-MRI). Specifically, we sought to quantify and compare the pyruvate metabolism in the FLR and the deportalized liver (DL).Six pigs underwent PVL. HP-MRI with [1-13C] pyruvate was performed at baseline, post-surgery, and 1 week after surgery. Metabolic conversion was quantified with kinetic modelling of the rate constants of pyruvate to lactate (kPL) and pyruvate to alanine (kPA). Mean kPL was increased in FLR compared to DL at post-surgery and 1 week after surgery (P = 0.002), while kPA was unaltered (P = 0.761). These findings indicate a metabolic shift towards glycolysis in the FLR. This non-invasive metabolic imaging technique could serve as a powerful tool for evaluation of regional liver function prior to partial hepatectomy and consequently improve patient outcomes.

Preoperative setting of functional liver volume enhanced by portal and hepatic vein embolization is key in preventing serious morbidity after hepatectomy with bile duct resection for biliary tract cancer

BACKGROUND

The risk of mortality due to serious complications associated with hepatectomy for biliary tract cancer remains high. We aimed to investigate the significance of preoperative functional liver volume in predicting and preventing serious morbidity following hepatectomy with bile duct resection (BDR).

METHODS

Seventy-one patients who underwent hepatectomy with BDR for biliary tract cancer were included. Functional future remnant liver volume (fFRLV) was calculated using future liver remnant (FLR) volume and functional score measured using EOB-MRI. Patients with unsatisfactory fFRLV values underwent portal or sequential portal/hepatic vein embolization (PVE/HVE). We assessed relationship between variables for liver-related morbidity (LRM), including posthepatectomy liver failure, bile leakage, and persistent ascites. Additionally, we assessed Clavien-Dindo grade IV complications (CD ≥ IV) as indicators of serious morbidity.

RESULTS

LRM and CD ≥ IV occurred in 20 (28.2 %) and 6 (8.5 %) cases, respectively. Preoperative FLR volume (p = 0.021), FLR ratio (p = 0.004), fFRLV (p = 0.008), and ICGK-F (p = 0.023) were associated with LRM. fFRLV (p = 0.017) was predictive for LRM but not independent (AUC:0.704). Preoperative FLR volume (p = 0.005), FLR ratio (p = 0.008), and fFRLV (p < 0.001) were associated with CD ≥ IV. fFRLV (p = 0.017) was an independent predictive factor for CD ≥ IV(AUC:0.914), showing greater predictive power compared to other factors.

CONCLUSION

fFRLV predicts CD ≥ IV in patients undergoing hepatectomy with BDR. A sufficient fFRLV, enhanced by PVE/HVE if necessary, may prevent serious morbidity and mortality.

Application of ultrasound elastography and splenic size in predicting post-hepatectomy liver failure: Unveiling new clinical perspectives

In this article, we discuss the study by Cheng et al, published in the World Journal of Gastroenterology, focusing on predictive methods for post-hepatectomy liver failure (PHLF). PHLF is a common and serious complication, and accurate prediction is critical for clinical management. The study examines the potential of ultrasound elastography and splenic size in predicting PHLF. Ultrasound elastography reflects liver functional reserve, while splenic size provides additional predictive value. By integrating these factors with serological markers, we developed a comprehensive prediction model that effectively stratifies patient risk and supports personalized clinical decisions. This approach offers new insights into predicting PHLF. These methods not only assist clinicians in identifying high-risk patients earlier but also provide scientific support for personalized treatment strategies. Future research will aim to validate the model's accuracy with larger sample sizes, further enhancing the clinical application of these non-invasive indicators.

Application of dynamic enhanced scanning with GD-EOB-DTPA MRI based on deep learning algorithm for lesion diagnosis in liver cancer patients

Background

Improvements in the clinical diagnostic use of magnetic resonance imaging (MRI) for the identification of liver disorders have been made possible by gadolinium ethoxybenzyl diethylenetriamine pentaacetic acid (Gd-EOB-DTPA). Gd-EOB-DTPA-enhanced magnetic resonance imaging (MRI) technology is in high demand.

Objectives

The purpose of the study is to segment the liver using an enhanced multi-gradient deep convolution neural network (EMGDCNN) and to identify and categorize a localized liver lesion using a Gd-EOB-DTPA-enhanced MRI.

Methods

We provided the classifier images of the liver in five states (unenhanced, arterial, portal venous, equilibrium, and hepatobiliary) and labeled them with localized liver diseases (hepatocellular carcinoma, metastasis, hemangiomas, cysts, and scarring). The Shanghai Public Health Clinical Center ethics committee recruited 132 participants between August 2021 and February 2022. Fisher's exact test analyses liver lesion Gd-EOB-DTPA-enhanced MRI data.

Results

Our method could identify and classify liver lesions at the same time. On average, 25 false positives and 0.6 real positives were found in the test instances. The percentage of correct answers was 0.790. AUC, sensitivity, and specificity evaluate the procedure. Our technique outperforms others in extensive testing.

Conclusion

EMGDCNN may identify and categorize a localized hepatic lesion in Gd-EOB-DTPA-enhanced MRI. We found that one network can detect and classify. Radiologists need higher detection capability.

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.

Histological and radiological analysis of simultaneous dual hepatic vein embolization for right-sided major hepatectomy

PURPOSE

Simultaneous dual hepatic vein embolization (DHVE) has been proposed for safe right-sided hepatectomy, with good results for liver hypertrophy and function. However, the histological and radiological findings of DHVE have not been thoroughly investigated.

METHODS

This study included 14 patients who underwent DHVE before right-sided major hepatectomy. DHVE was performed if the future liver remnant was < 35% or borderline, but with concomitant vascular resection. The liver function was assessed using the signal intensity on Gd-EOB-DTPA-MRI. A histological evaluation of the area of DHVE and portal vein embolization (PVE) were performed.

RESULTS

The median pre- and post-functional liver remnants were 363 ml and 498 ml, respectively (p < 0.001). The median growth rate was 48.6%, and there was no post-hepatectomy liver failure in the patients who underwent DHVE. The signal intensity ratio in the area of DHVE was lower than that in the areas of PVE and the remnant liver (p < 0.01). The degree of congestion and necrosis was greater in the area of DHVE than in the area of PVE alone (p < 0.01 and p = 0.04, respectively).

CONCLUSIONS

We observed good liver hypertrophy after DHVE and histological and radiological changes in the area of DHVE. Our findings provide a compelling rationale for further investigation of the mechanism of liver hypertrophy in DHVE.

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.

Early drain removal after hepatectomy based on bile leakage prediction using drainage fluid volume and direct bilirubin level

AIMS

This study aimed to determine the value of the drainage fluid volume and direct bilirubin level for predicting significant bile leakage (BL) after hepatectomy and establish novel criteria for early drain removal.

METHODS

Data from 351 patients who underwent hepatic resection at Gunma University in Japan between October 2018 and March 2022 were retrospectively analyzed. Clinical characteristics and surgical outcomes of patients with and without significant BL were compared. Criteria for early drain removal were determined and verified.

RESULTS

Bile leakage occurred in 27 (7.1%) patients; 8 (2.3%) had grade A leakage and 19 (5.4%) had grade B leakage. The optimal cut-off value for the drainage fluid direct bilirubin level on postoperative day (POD) 2 was 0.16 mg/dL, which had the highest area under the curve and negative predictive value (NPV). Patients with BL had significantly larger drainage volumes on POD 2. The best cut-off value was 125 mL because it had the greatest NPV. Patients in both the primary and validation (n = 90) cohorts with bilirubin levels less than 0.16 mg/dL and drainage volumes less than 125 mL did not experience leakage.

CONCLUSIONS

A drainage fluid volume less than 125 mL and direct bilirubin level less than 0.16 mg/dL on POD 2 are criteria for safe early drain removal after hepatectomy.

3-D reconstruction in liver surgery: a systematic review

BACKGROUND

Three-dimensional reconstruction of the liver offers several advantages to the surgeon before and during liver resection. This review discusses the factors behind the use of liver 3-D reconstruction.

METHODS

Systematic electronic search, according to PRISMA criteria, was performed. A literature search of scientific papers was performed until October 2023. Articles were chosen based on reference to 3-D liver reconstruction and their use in liver surgery. GRADE methodology and the modified Newcastle-Ottawa scale were used to assess the quality of the studies.

RESULTS

The research included 47 articles and 7724 patients were analyzed. Preoperative planning was performed with 3-D liver reconstruction in the 87.2% of the studies. Most of preoperative 3-D liver reconstructions were performed in the planning of complex or major hepatectomies. Complex hepatectomies were performed in 64.3% patients. The 55.3% of the studies reported an improved navigation and accuracy during liver resection. Four studies (8.6%) on living donor liver transplant (LDLT) concluded that 3-D liver reconstruction is useful for graft selection and vascular preservation. Nine papers (19.1%) reported an accurate measurement of future liver remnant.

CONCLUSION

Liver 3-D reconstruction helps surgeons in the planning of liver surgery, especially in liver graft and complex liver resections, increasing the accuracy of the surgical resection.

Comparison of T1 Mapping on Gadoxetic Acid-Enhanced Magnetic Resonance Imaging With Conventional Functional Liver Reserve Indices and Technetium-99m Galactosyl Serum Albumin Scintigraphy

Background Gadoxetic acid (EOB)-enhanced magnetic resonance imaging (MRI) (EOB-MRI) can be used as a one-stop examination for detecting liver tumors and evaluating liver function. Purpose The study aimed to assess the functional liver reserve (FLR) using the T1 map from the hepatobiliary phase of EOB-MRI by conducting a comparison with the results of conventional FLR tests and the technetium-99m (99mTc)-galactosyl serum albumin (GSA) scintigraphy. Materials and methods The retrospective data from 43 patients were included in the study. The regions of interest covered the entire liver. The data acquired from each EOB-MRI slice were summed to derive voxel-by-voxel values. The average sum of the T1 values (pre- and post-enhancement), ∆T1, and ∆T1 ratios were calculated. The HH15, LHL15, and LU15 values were calculated from the GSA scintigraphy. The results of conventional FLR tests, such as the indocyanine green retention rate at 15 min (ICGR15), the Child-Pugh classification (CPC), and the albumin-bilirubin (ALBI) and albumin-indocyanine green evaluation (ALICE) scores, were obtained. Results The T1 pre- and post-sum values showed a weak correlation with the LHL15 (r=0.36 and 0.38, respectively). A strong correlation was observed between the liver volume and the T1 pre- and post-sum values (r=0.86 and 0.76, respectively). A moderate correlation was observed between the T1 mean and the ALBI and ALICE values (r=0.58 and 0.49, respectively) and between the ∆T1 ratio and the CPC, ALBI, and ALICE values (r=-0.40, 0.58, and -0.55, respectively). The T1 post-sum values showed a moderate correlation with the ALBI scores (r=0.47) and a weak correlation with the ALICE scores (r=0.38). Furthermore, the LU15 values showed a weak correlation with the ICGR15 and model for end-stage liver disease (MELD) scores (r=-0.32 and -0.34, respectively). Conclusions Representative indices, such as the T1 mean and ∆T1 ratio, demonstrated a better relationship with conventional FLR indices compared with volumetric radiological indices. Therefore, we propose that the T1 post-sum can be used as an FLR index.

Nomogram based on liver stiffness and spleen area with ultrasound for posthepatectomy liver failure: A multicenter study

BACKGROUND

Liver stiffness (LS) measurement with two-dimensional shear wave elastography (2D-SWE) correlates with the degree of liver fibrosis and thus indirectly reflects liver function reserve. The size of the spleen increases due to tissue proliferation, fibrosis, and portal vein congestion, which can indirectly reflect the situation of liver fibrosis/cirrhosis. It was reported that the size of the spleen was related to posthepatectomy liver failure (PHLF). So far, there has been no study combining 2D-SWE measurements of LS with spleen size to predict PHLF. This prospective study aimed to investigate the utility of 2D-SWE assessing LS and spleen area (SPA) for the prediction of PHLF in hepatocellular carcinoma (HCC) patients and to develop a risk prediction model.

AIM

To investigate the utility of 2D-SWE assessing LS and SPA for the prediction of PHLF in HCC patients and to develop a risk prediction model.

METHODS

This was a multicenter observational study prospectively analyzing patients who underwent hepatectomy from October 2020 to March 2022. Within 1 wk before partial hepatectomy, ultrasound examination was performed to measure LS and SPA, and blood was drawn to evaluate the patient's liver function and other conditions. Least absolute shrinkage and selection operator logistic regression and multivariate logistic regression analysis was applied to identify independent predictors of PHLF and develop a nomogram. Nomogram performance was validated further. The diagnostic performance of the nomogram was evaluated with receiver operating characteristic curve compared with the conventional models, including the model for end-stage liver disease (MELD) score and the albumin-bilirubin (ALBI) score.

RESULTS

A total of 562 HCC patients undergoing hepatectomy (500 in the training cohort and 62 in the validation cohort) were enrolled in this study. The independent predictors of PHLF were LS, SPA, range of resection, blood loss, international normalized ratio, and total bilirubin. Better diagnostic performance of the nomogram was obtained in the training [area under receiver operating characteristic curve (AUC): 0.833; 95% confidence interval (95%CI): 0.792-0.873; sensitivity: 83.1%; specificity: 73.5%] and validation (AUC: 0.802; 95%CI: 0.684-0.920; sensitivity: 95.5%; specificity: 52.5%) cohorts compared with the MELD score and the ALBI score.

CONCLUSION

This PHLF nomogram, mainly based on LS by 2D-SWE and SPA, was useful in predicting PHLF in HCC patients and presented better than MELD score and ALBI score.

Challenges and Opportunities for Precision Surgery for Colorectal Liver Metastases

The incidence of colorectal cancer and colorectal liver metastases (CRLM) is increasing globally due to an interaction of environmental and genetic factors. A minority of patients with CRLM have surgically resectable disease, but for those who have resection as part of multimodal therapy for their disease, long-term survival has been shown. Precision surgery-the idea of careful patient selection and targeting of surgical intervention, such that treatments shown to be proven to benefit on a population level are the optimal treatment for each individual patient-is the new paradigm of care. Key to this is the understanding of tumour molecular biology and clinically relevant mutations, such as KRAS, BRAF, and microsatellite instability (MSI), which can predict poorer overall outcomes and a poorer response to systemic therapy. The emergence of immunotherapy and hepatic artery infusion (HAI) pumps show potential to convert previously unresectable disease to resectable disease, in addition to established systemic and locoregional therapies, but the surgeon must be wary of poor-quality livers and the spectre of post-hepatectomy liver failure (PHLF). Volume modulation, a cornerstone of hepatic surgery for a generation, has been given a shot in the arm with the advent of liver venous depletion (LVD) ensuring significantly more hypertrophy of the future liver remnant (FLR). The optimal timing of liver resection for those patients with synchronous disease is yet to be truly established, but evidence would suggest that those patients requiring complex colorectal surgery and major liver resection are best served with a staged approach. In the operating room, parenchyma-preserving minimally invasive surgery (MIS) can dramatically reduce the surgical insult to the patient and lead to better perioperative outcomes, with quicker return to function.

Prediction of post-hepatectomy liver failure by preoperative gadoxetate disodium-enhanced magnetic resonance imaging

BACKGROUND

Approximately 15% of patients experience post-hepatectomy liver failure after major hepatectomy. Poor hepatocyte uptake of gadoxetate disodium, a magnetic resonance imaging contrast agent, may be a predictor of post-hepatectomy liver failure.

METHODS

A retrospective cohort study of patients undergoing major hepatectomy (≥3 segments) with a preoperative gadoxetate disodium-enhanced magnetic resonance imaging was conducted. The liver signal intensity (standardized to the spleen) and the functional liver remnant was calculated to determine if this can predict post-hepatectomy liver failure after major hepatectomy.

RESULTS

In 134 patients, low signal intensity of the remnant liver standardized by signal intensity of the spleen in post-contrast images was associated with post-hepatectomy liver failure in multiple logistic regression analysis (Odds Ratio 0.112; 95% CI 0.023-0.551). In a subgroup of 33 patients with lower quartile of functional liver remnant, area under the curve analysis demonstrated a diagnostic accuracy of functional liver remnant to predict post-hepatectomy liver failure of 0.857 with a cut-off value for functional liver remnant of 1.4985 with 80.0% sensitivity and 89.3% specificity.

CONCLUSION

Functional liver remnant determined by gadoxetate disodium-enhanced magnetic resonance imaging is a predictor of post-hepatectomy liver failure which may help identify patients for resection, reducing morbidity and mortality.

Assessment of liver function by gadoxetic acid avidity in MRI in a model of rapid liver regeneration in rats

BACKGROUND

This animal study investigates the hypothesis of an immature liver growth following ALPPS (associating liver partition and portal vein ligation for staged hepatectomy) by measuring liver volume and function using gadoxetic acid avidity in magnetic resonance imaging (MRI) in models of ALPPS, major liver resection (LR) and portal vein ligation (PVL).

METHODS

Wistar rats were randomly allocated to ALPPS, LR or PVL. In contrast-enhanced MRI scans with gadoxetic acid (Primovist®), liver volume and function of the right median lobe (=future liver remnant, FLR) and the deportalized lobes (DPL) were assessed until post-operative day (POD) 5. Liver functionFLR/DPL was defined as the inverse value of time from injection of gadoxetic acid to the blood pool-corrected maximum signal intensityFLR/DPL multiplied by the volumeFLR/DPL.

RESULTS

In ALPPS (n = 6), LR (n = 6) and PVL (n = 6), volumeFLR and functionFLR increased proportionally, except on POD 1. Thereafter, functionFLR exceeded volumeFLR increase in LR and ALPPS, but not in PVL. Total liver function was significantly reduced after LR until POD 3, but never undercuts 60% of its pre-operative value following ALPPS and PVL.

DISCUSSION

This study shows for the first time that functional increase is proportional to volume increase in ALPPS using gadoxetic acid avidity in MRI.

Predictors for early recurrence beyond up-to-7 or distant metastasis after hepatocellular carcinoma resection: proposal for borderline resectable HCC

BACKGROUND

The recurrence rate after curative resection for hepatocellular carcinoma (HCC) reaches over 70% after 5 years and early recurrence (within 1 year) is now recognized as having a poor prognosis and has limited treatment options.

METHODS

We retrospectively reviewed 184 consecutive patients who underwent curative hepatic resection for HCC. Severe early recurrence was defined as multiple (beyond up-to-7) liver recurrence or distant metastasis after hepatic resection within 1 year. We divided the participants into two groups according to severe early recurrence and analyzed clinicopathological and long-term outcomes.

RESULTS

Among the patients with multiple or distant metastasis (n = 59), 49 patients (83%) had recurrence within 1 year. Overall survival (OS) and recurrence-free survival (RFS) were significantly worse in the severe early recurrence group than in the others group. Logistic regression analysis revealed that severe early recurrence was significantly associated with macroscopic vascular invasion (MVI), tumor burden score (TBS) > 4.70, and ALBI grade 2. In patients with scores of 2 and 3 (the sum of the three factors), OS and RFS rates were significantly poorer than those of patients with scores of 0 or 1. Positive predictive value and negative predictive value for severe early recurrence was 68.4% and 84.2%, respectively. Furthermore, a validation study demonstrated that cases with these factors were at high risk of severe early recurrence and had poor prognosis.

CONCLUSIONS

In this retrospective analysis, MVI, TBS, and ALBI could predict severe early recurrence after hepatic resection for HCC, and patients with these risk factors had a poor prognosis.

A Novel Method Using Gadolinium-Ethoxybenzyl Diethylenetriamine Pentaacetate Acid-Enhanced Magnetic Resonance Imaging for Predicting Post-Hepatectomy Liver Failure in Hepatocellular Carcinoma Patients with a Major Portal Vein Tumor Thrombus

INTRODUCTION

The usefulness of gadolinium-ethoxybenzyl diethylenetriamine pentaacetate acid-enhanced magnetic resonance imaging (EOB-MRI) in assessing the functional future remnant liver volume (fFRLV) to predict post-hepatectomy liver failure (PHLF) has been previously reported. Herein, we evaluated the efficacy of this technique in patients with hepatocellular carcinoma (HCC) with a major portal vein tumor thrombus (PVTT).

METHODS

This study included 21 patients with PVTT in the ipsilateral first-order branch (Vp3) and 30 patients with PVTT in the main trunk/contralateral branch (Vp4). To evaluate fFRLV, the signal intensity (SI) of the remnant liver was determined on T1-weighted images, using both conventional and newly developed methods. The fFRLV was calculated using the SI of the remnant liver and muscle, remnant liver volume, and body surface area. Preoperative factors predicting PHLF (≥grade B) in HCC patients with Vp3/4 PVTT were evaluated.

RESULTS

In the Vp3 group, we found fFRLV area under the receiver-operating characteristic curves (AUCs) above 0.70 (AUC = 0.875, 0.750) using EOB-MRI results calculated using either the plot or whole method. None of the parameters in the Vp4 group had an AUC greater than 0.70.

CONCLUSION

The fFRLV calculated by EOB-MRI using the whole method can be as useful as the conventional method in predicting PHLF (≥grade B) for HCC patients with Vp3 PVTT.

Significance of malnutrition defined with Global Leadership Initiative on Malnutrition criteria in patients with hepatocellular carcinoma after hepatic resection

AIM

A recent study reported the utility of the definition of malnutrition according to the Global Leadership Initiative on Malnutrition (GLIM) criteria in many types of cancers and chronic inflammatory disease. The present retrospective study aimed to investigate the significance of malnutrition defined with GLIM criteria in patients with hepatic resection for hepatocellular carcinoma (HCC) and also to compare malnutrition using handgrip strength.

METHODS

We retrospectively reviewed data from 174 patients who had undergone curative hepatic resection for HCC including both skeletal muscle area and handgrip strength. Patients were divided according to malnutrition defined by GLIM or modified GLIM and clinicopathologic and short- and long-term outcomes were analyzed. The modified GLIM criteria was defined using both handgrip strength and skeletal muscle area.

RESULTS

Malnutrition defined by GLIM criteria was diagnosed in 47 patients (26.7%) and malnutrition defined by modified GLIM criteria was diagnosed in 21 patients (11.9%). Malnutrition defined by GLIM or modified GLIM criteria was associated with poorer liver function and malignant tumor behavior, but modified GLIM criteria predicted the postoperative complication and recurrence-free survival outcome independently. In patients with poor liver function, malnutrition defined by modified GLIM criteria predicted postoperative complication and overall and recurrence-free survival.

CONCLUSIONS

Malnutrition defined by modified GLIM criteria using both handgrip strength and skeletal muscle area can more accurately predict short- and long-term outcomes compared to malnutrition defined by the GLIM criteria. Nutritional and exercise therapy could become more important in patients with malnutrition and poor liver function.

Postoperative Liver Failure: Definitions, Risk factors, Prediction Models and Prevention Strategies

BACKGROUND

Liver resection is the treatment for a variety of benign and malignant conditions. Despite advances in preoperative selection, surgical technique, and perioperative management, post hepatectomy liver failure (PHLF) is still a leading cause of morbidity and mortality following liver resection.

METHODS

A review of the literature was performed utilizing MEDLINE/PubMed and Web of Science databases in May of 2023. The MESH terms "liver failure," "liver insufficiency," and "hepatic failure" in combination with "liver surgery," "liver resection," and "hepatectomy" were searched in the title and/or abstract. The references of relevant articles were reviewed to identify additional eligible publications.

RESULTS

PHLF can have devastating physiological consequences. In general, risk factors can be categorized as patient-related, primary liver function-related, or perioperative factors. Currently, no effective treatment options are available and the management of PHLF is largely supportive. Therefore, identifying risk factors and preventative strategies for PHLF is paramount. Ensuring an adequate future liver remnant is important to mitigate risk of PHLF. Dynamic liver function tests provide more objective assessment of liver function based on the metabolic capacity of the liver and have the advantage of easy administration, low cost, and easy reproducibility.

CONCLUSION

Given the absence of randomized data specifically related to the management of PHLF, current strategies are based on the principles of management of acute liver failure from any cause. In addition, goal-directed therapy for organ dysfunction, as well as identification and treatment of reversible factors in the postoperative period are critical.

Current status of preoperative risk assessment for posthepatectomy liver failure in patients with hepatocellular carcinoma

Liver resection is an effective therapeutic option for patients with hepatocellular carcinoma. However, posthepatectomy liver failure (PHLF) remains a major cause of hepatectomy-related mortality, and the accurate prediction of PHLF based on preoperative assessment of liver functional reserve is a critical issue. The definition of PHLF proposed by the International Study Group for Liver Surgery has gained acceptance as a standard grading criterion. Liver function can be estimated using a variety of parameters, including routine blood biochemical examinations, clinical scoring systems, dynamic liver function tests, liver stiffness and fibrosis markers, and imaging studies. The Child-Pugh score and model for end-stage liver disease scores are conventionally used for estimating liver decompensation, although the alternatively developed albumin-bilirubin score shows superior performance for predicting hepatic dysfunction. Indocyanine green clearance, a dynamic liver function test mostly used in Japan and other Asian countries, serves as a quantitative estimation of liver function reserve and helps determine indications for surgical procedures according to the estimated risk of PHLF. In an attempt to improve predictive accuracy, specific evaluation of liver fibrosis and portal hypertension has gained popularity, including liver stiffness measurements using ultrasonography or magnetic resonance elastography, as well as noninvasive fibrosis markers. Imaging modalities, including Tc-99m-labeled galactosyl serum albumin scintigraphy and gadolinium-enhanced magnetic resonance imaging, are used for preoperative evaluation in combination with liver volume. This review aims to provide an overview of the usefulness of current options for the preoperative assessment of liver function in predicting PHLF.

Lumped parameter liver simulation to predict acute haemodynamic alterations following partial resections

Partial liver resections are routinely performed in living donor liver transplantation and to debulk tumours in liver malignancies, but surgical decisions on vessel reconstruction for adequate inflow and outflow are challenging. Pre-operative evaluation is often limited to radiological imaging, which fails to account for post-resection haemodynamic alterations. Substantial evidence suggests post-surgical increase in local volume flow rate enhances shear stress, signalling hepatic regeneration, but excessive shear stress has been postulated to result in small for size syndrome and liver failure. Predicting haemodynamic alterations throughout the liver is particularly challenging due to the dendritic architecture of the vasculature, spanning several orders of magnitude in diameter. Therefore, we developed a mathematical lumped parameter model with realistic heterogeneities capturing inflow/outflow of the human liver to simulate acute perfusion alterations following surgical resection. Our model is parametrized using clinical measurements, relies on a single free parameter and accurately captures established perfusion characteristics. We quantify acute changes in volume flow rate, flow speed and wall shear stress following variable, realistic liver resections and make comparisons with the intact liver. Our numerical model runs in minutes and can be adapted to patient-specific anatomy, providing a novel computational tool aimed at assisting pre- and intra-operative surgical decisions for liver resections.

Volume-Assisted Estimation of Remnant Liver Function Based on Gd-EOB-DTPA Enhanced MR Relaxometry: A Prospective Observational Trial

In the context of liver surgery, predicting postoperative liver dysfunction is essential. This study explored the potential of preoperative liver function assessment by MRI for predicting postoperative liver dysfunction and compared these results with the established indocyanine green (ICG) clearance test. This prospective study included patients undergoing liver resection with preoperative MRI planning. Liver function was quantified using T1 relaxometry and correlated with established liver function scores. The analysis revealed an improved model for predicting postoperative liver dysfunction, exhibiting an accuracy (ACC) of 0.79, surpassing the 0.70 of the preoperative ICG test, alongside a higher area under the curve (0.75). Notably, the proposed model also successfully predicted all cases of liver failure and showed potential in predicting liver synthesis dysfunction (ACC 0.78). This model showed promise in patient survival rates with a Hazard ratio of 0.87, underscoring its potential as a valuable tool for preoperative evaluation. The findings imply that MRI-based assessment of liver function can provide significant benefits in the early identification and management of patients at risk for postoperative liver dysfunction.

E-AHPBA-ESSO-ESSR Innsbruck consensus guidelines for preoperative liver function assessment before hepatectomy

BACKGROUND

Posthepatectomy liver failure (PHLF) contributes significantly to morbidity and mortality after liver surgery. Standardized assessment of preoperative liver function is crucial to identify patients at risk. These European consensus guidelines provide guidance for preoperative patient assessment.

METHODS

A modified Delphi approach was used to achieve consensus. The expert panel consisted of hepatobiliary surgeons, radiologists, nuclear medicine specialists, and hepatologists. The guideline process was supervised by a methodologist and reviewed by a patient representative. A systematic literature search was performed in PubMed/MEDLINE, the Cochrane library, and the WHO International Clinical Trials Registry. Evidence assessment and statement development followed Scottish Intercollegiate Guidelines Network methodology.

RESULTS

Based on 271 publications covering 4 key areas, 21 statements (at least 85 per cent agreement) were produced (median level of evidence 2- to 2+). Only a few systematic reviews (2++) and one RCT (1+) were identified. Preoperative liver function assessment should be considered before complex resections, and in patients with suspected or known underlying liver disease, or chemotherapy-associated or drug-induced liver injury. Clinical assessment and blood-based scores reflecting liver function or portal hypertension (for example albumin/bilirubin, platelet count) aid in identifying risk of PHLF. Volumetry of the future liver remnant represents the foundation for assessment, and can be combined with indocyanine green clearance or LiMAx® according to local expertise and availability. Functional MRI and liver scintigraphy are alternatives, combining FLR volume and function in one examination.

CONCLUSION

These guidelines reflect established methods to assess preoperative liver function and PHLF risk, and have uncovered evidence gaps of interest for future research.

A prospective study of sequential hepatic vein embolization after portal vein embolization in patients scheduled for right-sided major hepatectomy: Results of feasibility and surgical strategy using functional liver assessment

BACKGROUND

Hepatic vein embolization (HVE) added to portal vein embolization (PVE) can further increase future remnant liver volume (FRLV) compared with PVE alone. This study was aimed to evaluate feasibility of sequential HVE in a prospective trial and to verify surgical strategy using functional FRLV (fFRLV).

METHODS

Hepatic vein embolization was prospectively indicated for post-PVE patients scheduled for right-sided major hepatectomy if the resection limit of fFRLV using EOB-magnetic resonance imaging was not satisfied. The resection limit was fFRLV: 615 mL/m² for predicting post-hepatectomy liver failure. Patients who underwent sequential PVE-HVE (n = 12) were compared with those who underwent PVE alone (n = 31).

RESULTS

All patients underwent HVE with no severe complications. Median fFRLV increased from 396 (range: 251-581) to 634 (range: 422-740) mL/m² by sequential PVE-HVE. From PVE to HVE, both of FRLV (P < .001) and fFRLV (P = .005) significantly increased. The increased width of fFRLV was larger than that of FRLV after performing HVE. Median growth rate was 71.3 (range: 33.3-80.3) %, which was higher than that of PVE alone (27.0%, range: 6.0-78.0). All-cohort resection rate was 88.3%. Strategy of using fFRLV for the resection limit and performing HVE in patients with insufficient functional volume resulted in no liver failure in all patients who underwent hepatectomy.

CONCLUSIONS

Sequential HVE after PVE is feasible and safe, and HVE induced possibility of further liver growth and its functional improvement. Our surgical strategy using fFRLV may be justified.

Preoperative indocyanine green (ICG) clearance test: Can we really trust it to predict post hepatectomy liver failure? A systematic review of the literature and meta-analysis of diagnostic test accuracy

INTRODUCTION

Post hepatectomy liver failure (PHFL) still represents a potentially fatal complication after major liver resection. Indocyanine green (ICG) clearance test represents one of the most widely adopted examinations in the preoperative workup. Despite a copious body of evidence which has been published on this topic, the role of ICG in predicting PHLF is still a matter of debate.

METHODS

A systematic review of the literature was conducted according to PRISMA-DTA guidelines. The primary outcome was the assessment of diagnostic performance of ICG in predicting PHLF. The secondary outcome was the mean ICG_R15 and ICG_PDR in patients experiencing PHLF.

RESULTS

Seventeen studies, for a total of 4852 patients, were deemed eligible. Sensitivity ranged from 25% to 83%; Specificity ranged from 66.1% to 93.8%. ICG clearance test pooled AUC was 0.673 (95% CI: 0.632-0.713). The weighted mean ICG_R15 was 11 (95%CI: 8.3-13.7). The weighted mean ICG_PDR was 16.5 (95%CI: 13.3-19.8). High risk of bias was detected in all examined domains.

CONCLUSIONS

Preoperative ICG clearance test alone may not represent a reliable method to predict post hepatectomy liver failure. Its diagnostic significance should be framed within multiparametric models involving clinical and imaging features.

Predictive value of Gd-EOB-DTPA -enhanced magnetic resonance imaging for post-hepatectomy liver failure: a systematic review and meta-analysis

Background

Accurate preoperative diagnosis of post-hepatectomy liver failure (PHLF) is particularly important to improve the prognosis of patients.

Purpose

To evaluate the predictive value of Gd-EOB-DTPA-enhanced magnetic resonance imaging (MRI) for post-hepatectomy liver failure.

Material and Methods

A systematic search was performed in the PubMed, Embase, the Cochrane Library, and Web of Science databases to find relevant original articles published up to December 2021. The included studies were assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 tool. The bivariate random-effects model was used to assess the diagnostic authenticity. Meta-regression analyses were performed to analyze the potential heterogeneity.

Results

In total, 13 articles were included. The pooled sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, diagnostic odds ratio, and the area under the summary receiver operating characteristic curves were 88% (95% confidence interval [CI] = 0.80–0.94), 80% (95% CI = 0.73–0.86), 4.4 (95% CI = 3.3–5.9), 0.14 (95% CI = 0.08–0.25), 31 (95% CI = 17–57), and 0.91 (95% CI = 0.89–0.94), respectively. There was no publication bias and threshold effect in our study.

Conclusion

Gd-EOB-DTPA-enhanced MRI is a potentially useful for the prediction of PHLF after major hepatectomy.

Laparoscopic hepatectomy for hepatocellular carcinoma in a patient with congenital factor V deficiency: a case report

BACKGROUND

Factor V (FV) deficiency is an extremely rare disease, with an incidence of 1 in 1 million. The bleeding symptoms are mild, and the prognosis is good; however, the safety of surgical treatment is unclear, because there are few available reports. Herein, we report a case of hepatocellular carcinoma with congenital FV deficiency in a patient who safely underwent laparoscopic hepatectomy.

CASE PRESENTATION

A 79-year-old man, diagnosed with hepatocellular carcinoma of liver segment 5, with type C cirrhosis and sustained virological response visited our hospital. He had congenital FV deficiency, and blood tests showed coagulation deficiencies with an FV activity of < 2.6%, prothrombin time activity of 11%, and activated partial thromboplastin time of 100.3 s. Surgery and radiofrequency ablation were considered for treatment. Since the tumor was in contact with the Glissonean pedicle 5 + 6, surgery was judged to be superior from the viewpoint of safety and curability. After discussing the safety of the surgery with a hematologist, it was determined that the operation could be performed safely by transfusing sufficient fresh frozen plasma (FFP). Laparoscopic hepatic segment 5 + 6 subsegmental resection was performed with FFP transfusion, fluid restriction, airway pressure control, and central venous pressure reduction to control the bleeding. Bleeding was minimized during the transection of the liver parenchyma and no bleeding tendency was observed. The operative time was 445 min, and the amount of intraoperative bleeding was 171 mL. No complications, such as postoperative bleeding, were observed, and the patient was discharged on the eighth postoperative day.

CONCLUSIONS

Liver surgery can be performed safely in FV-deficient patients with strict coagulation capacity monitoring and appropriate transfusion of FFP. Preoperative evaluation of cardiac function to determine tolerance to high doses of FFP and ingenuity of surgery and intraoperative management to minimize blood loss are important.

The ratio of creatinine and cystatin C estimated glomerular filtration rates as a surrogate marker in patients with hepatocellular carcinoma undergoing hepatic resection

BACKGROUND

The ratio of creatinine and cystatin C estimated glomerular filtration rates (eGFRcre/eGFRcys) is significantly positively correlated with sarcopenia. However, there are no published reports on the relationship between eGFRcre/eGFRcys and long-term prognosis in patients after hepatic resection for hepatocellular carcinoma (HCC).

METHODS

157 patients who had undergone curative hepatic resection for HCC were retrospectively reviewed. Cystatin C levels were measured in serum samples that had been frozen after collection at surgery. We aimed to investigate the significance of cystatin C in prognostic value following hepatic resection for HCC.

RESULTS

The best cut-off eGFRcre/eGFRcys value for overall survival after hepatic resection for HCC was 1.0025. High eGFRcre/eGFRcys was significantly associated with poor liver function, low skeletal muscle mass, large tumor size, large ascitic volume, worse overall and recurrence-free survival. The eGFRcre/eGFRcys was significantly related to severe recurrence patterns (multiple liver recurrences, distant metastasis).

CONCLUSIONS

Preoperative eGFRcre/eGFRcys can predict overall and recurrence-free survival in HCC patients undergoing hepatic resection. The eGFRcre/eGFRcys is a simple and reliable surrogate marker that indicate for eligibility for hepatic resection for HCC.

Essential updates 2020/2021: Current topics of simulation and navigation in hepatectomy

With the development of three-dimensional (3D) simulation software, preoperative simulation technology is almost completely established. The remaining issue is how to recognize anatomy three-dimensionally. Extended reality is a newly developed technology with several merits for surgical application: no requirement for a sterilized display monitor, better spatial awareness, and the ability to share 3D images among all surgeons. Various technology or devices for intraoperative navigation have also been developed to support the safety and certainty of liver surgery. Consensus recommendations regarding indocyanine green fluorescence were determined in 2021. Extended reality has also been applied to intraoperative navigation, and artificial intelligence (AI) is one of the topics of real-time navigation. AI might overcome the problem of liver deformity with automatic registration. Including the issues described above, this article focuses on recent advances in simulation and navigation in liver surgery from 2020 to 2021.

Significance of zinc deficiency in patients with hepatocellular carcinoma undergoing hepatic resection

AIM

Few reported studies examine the relationship between zinc (Zn) deficiency and short- and long-term outcomes in patients with hepatocellular carcinoma undergoing hepatic resection.

METHODS

We retrospectively reviewed data from 179 consecutive patients who had undergone curative hepatic resection for hepatocellular carcinoma in our institute between January 2016 and May 2019. Zn deficiency was defined in accordance with the Japanese Society of Clinical Nutrition guidelines. We allocated the participants into two groups according to Zn deficiency status, and analyzed the clinicopathological and short- and long-term outcomes.

RESULTS

In this series, 32 patients (17.8%) had Zn deficiency. Zn deficiency was significantly associated with older age, lower serum albumin, higher aspartate aminotransferase, lower hemoglobin, higher creatinine, lower prognostic nutritional index, higher liver fibrosis markers, albumin-bilirubin 2, portal hypertension, larger amount of estimated blood loss, larger amount of maximum ascites, longer hospital stay, postoperative complications, and liver-related complications. Concentrations of liver fibrosis markers were negatively correlated with serum Zn concentrations. Zn deficiency, albumin-bilirubin 2, and non-laparoscopic approach were identified as independent predictors of postoperative complications. Multivariate analyses revealed that the overall survival rate decreased in parallel with decreasing Zn concentrations.

CONCLUSIONS

In this study, Zn deficiency was significantly associated with poorer liver function, more severe liver fibrosis, higher incidence of postoperative complications, and worse overall survival according to multivariate analysis. Serum Zn status could serve as a new surrogate marker for predicting short- and long-term outcomes in patients undergoing hepatic resection for hepatocellular carcinoma.

Prediction with functional liver volume assessment to achieve the resection limit after portal vein embolization in patients scheduled major hepatectomy

BACKGROUND

Preoperative portal vein embolization (PVE) stimulates liver hypertrophy and improves the safety of major hepatectomy. It is essential to predict the future remnant liver volume (FRLV) and resection limit following PVE. Previously, we reported that evaluating functional FRLV (fFRLV) using EOB-MRI could predict post-hepatectomy liver failure. In this study, we investigated the usefulness of fFRLV in predicting the achieving of adequate resection limit for safe hepatectomy following PVE.

METHODS

We included 55 patients who underwent PVE and were scheduled for major hepatectomy. We calculated the liver-to-muscle ratio in the remnant liver and fFRLV using EOB-MRI. We investigated the pre-PVE variables in determining the nonachievement of the resection limit.

RESULTS

The median observation period between PVE and the first evaluation was 21 days, and the median growth rate of FRLV was 26.4%. In 54.5% of patients, the resection limit of fFRLV (615 mL/m²) was achieved. In logistic regression and receiver-operating characteristic analyses, pre-PVE fFRLV (p < 0.001, area under the curve: 0.852) was the reliable predictor of achieving the resection limit; the cutoff value of pre-PVE fFRLV was 446 mL/m².

CONCLUSION

Pre-PVE fFRLV can be useful in predicting the achievement of adequate resection limit following PVE.

Hepatectomy-Induced Alterations in Hepatic Perfusion and Function - Toward Multi-Scale Computational Modeling for a Better Prediction of Post-hepatectomy Liver Function

Liver resection causes marked perfusion alterations in the liver remnant both on the organ scale (vascular anatomy) and on the microscale (sinusoidal blood flow on tissue level). These changes in perfusion affect hepatic functions via direct alterations in blood supply and drainage, followed by indirect changes of biomechanical tissue properties and cellular function. Changes in blood flow impose compression, tension and shear forces on the liver tissue. These forces are perceived by mechanosensors on parenchymal and non-parenchymal cells of the liver and regulate cell-cell and cell-matrix interactions as well as cellular signaling and metabolism. These interactions are key players in tissue growth and remodeling, a prerequisite to restore tissue function after PHx. Their dysregulation is associated with metabolic impairment of the liver eventually leading to liver failure, a serious post-hepatectomy complication with high morbidity and mortality. Though certain links are known, the overall functional change after liver surgery is not understood due to complex feedback loops, non-linearities, spatial heterogeneities and different time-scales of events. Computational modeling is a unique approach to gain a better understanding of complex biomedical systems. This approach allows (i) integration of heterogeneous data and knowledge on multiple scales into a consistent view of how perfusion is related to hepatic function; (ii) testing and generating hypotheses based on predictive models, which must be validated experimentally and clinically. In the long term, computational modeling will (iii) support surgical planning by predicting surgery-induced perfusion perturbations and their functional (metabolic) consequences; and thereby (iv) allow minimizing surgical risks for the individual patient. Here, we review the alterations of hepatic perfusion, biomechanical properties and function associated with hepatectomy. Specifically, we provide an overview over the clinical problem, preoperative diagnostics, functional imaging approaches, experimental approaches in animal models, mechanoperception in the liver and impact on cellular metabolism, omics approaches with a focus on transcriptomics, data integration and uncertainty analysis, and computational modeling on multiple scales. Finally, we provide a perspective on how multi-scale computational models, which couple perfusion changes to hepatic function, could become part of clinical workflows to predict and optimize patient outcome after complex liver surgery.

Predictive value of gadoxetic acid-enhanced MRI for posthepatectomy liver failure: a systematic review

Objectives

Effective and non-invasive biomarkers to predict and avoid posthepatectomy liver failure (PHLF) are urgently needed. This systematic review aims to evaluate the efficacy of gadoxetic acid–enhanced MRI-derived parameters as an imaging biomarker in preoperative prediction of PHLF.

Methods

A systematic literature search was performed in the databases of PubMed/Medline, Web of Science, Embase, and Cochrane Library up to 11 December 2020. Studies evaluating the incidence of PHLF on patients who underwent hepatectomy with preoperative liver function assessment using gadoxetic acid–enhanced MRI were included. Data was extracted using pre-designed tables. The Quality In Prognostic Studies (QUIPS) tool was adopted to evaluate the risk of bias.

Results

A total of 15 studies were identified for qualitative synthesis and most studies were marked as low to moderate risk of bias in each domain of QUIPS. The most commonly used parameter was relative liver enhancement or its related parameters. The reported incidence of PHLF ranged from 3.9 to 40%. The predictive sensitivity and specificity of gadoxetic acid–enhanced MRI parameters varied from 75 to 100% and from 54 to 93% in ten reported studies. A majority of the studies revealed that the gadoxetic acid–enhanced MRI parameter was a predictor for PHLF.

Conclusions

Gadoxetic acid–enhanced MRI showed a high predictive capacity for PHLF and represents a promising imaging biomarker in prediction of PHLF. Multicenter, prospective trials with large sample size and reliable, unified liver function parameters are required to validate the efficacy of individual liver function parameters.

Key Points

• There is an obvious heterogeneity of the published studies, not only in variance of MRI liver function parameters but also in indication and extent of the liver resection.

• Signal intensity (SI)–based parameters derived from gadoxetic acid–enhanced MRI are the commonly used method for PHLF prediction.

• Gadoxetic acid–enhanced MRI-derived parameters showed high predictive efficacy for PHLF and can potentially serve as a predictor for the incidence of PHLF.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00330-021-08297-8.

Does intraoperative and postoperative analgesia cause bile leakage after hepatectomy?

PURPOSE

To evaluate the effect of morphine or morphine equivalents on the risk of bile leakage (BL) after hepatectomy.

METHODS

The subjects of this retrospective study were 379 patients who underwent hepatectomy without biliary reconstruction and biliary decompression tube insertion at Gunma University between 2016 and 2020. Clinical BL was defined as International Study Group of Liver Surgery post-hepatectomy bile leakage Grade B or C.

RESULTS

Intra- and post-operative analgesia comprised intravenous patient-controlled analgesia (IV-PCA) with fentanyl (n = 58), epidural analgesia with fentanyl (n = 157), epidural analgesia with morphine (n = 151), and epidural analgesia with ropivacaine or levobupivacaine (n = 13). Clinical BL was diagnosed in 14 of the 379 (3.7%) patients. The significant risk factors for clinical BL were hepatocellular carcinoma (HCC), elevated serum total bilirubin, high indocyanine green retention at 15 min, elevated Mac-2-binding protein glycosylated isomer, prolonged duration of surgery, and a large volume of blood loss. There was no significant correlation of clinical BL with intra- and post-operative analgesia and total oral morphine equivalents.

CONCLUSION

Intra- and post-operative IV-PCA and epidural analgesia were not related to clinical BL after hepatectomy. Based on our data, fentanyl and morphine can be administered safely as epidural or intravenous analgesic agents.

Hepatocellular uptake index obtained with gadoxetate disodium-enhanced magnetic resonance imaging in the assessment future liver remnant function after major hepatectomy for biliary malignancy

Background

Functional assessment of the future liver remnant (FLR) after major hepatectomy is essential but often difficult in patients with biliary malignancy, owing to obstructive jaundice and portal vein embolization. This study evaluated whether a novel index using gadoxetate disodium-enhanced MRI (EOB-MRI) could predict posthepatectomy liver failure (PHLF) after major hepatectomy for biliary malignancy.

Methods

The remnant hepatocellular uptake index (rHUI) was calculated in patients undergoing EOB-MRI before major hepatectomy for biliary malignancy. Receiver operating characteristic (ROC) curve analyses were used to evaluate the accuracy of rHUI for predicting PHLF grade B or C, according to International Study Group of Liver Surgery criteria. Multivariable logistic regression analyses comprised stepwise selection of parameters, including rHUI and other conventional indices.

Results

This study included 67 patients. The rHUI accurately predicted PHLF (area under the curve (AUC) 0.896). A cut-off value for rHUI of less than 0.410 predicted all patients who developed grade B or C PHLF. In multivariable analysis, only rHUI was an independent risk factor for grade B or C PHLF (odds ratio 2.0 × 10³, 95 per cent c.i. 19.6 to 3.8 × 10⁷; P < 0.001). In patients who underwent preoperative portal vein embolization, rHUI accurately predicted PHLF (AUC 0.885), whereas other conventional indices, such as the plasma disappearance rate of indocyanine green of the FLR and FLR volume, did not.

Conclusion

The rHUI is potentially a useful predictor of PHLF after major hepatectomy for biliary malignancy.

Development and Validation of a Nomogram Based on Perioperative Factors to Predict Post-hepatectomy Liver Failure

BACKGROUND AND AIMS

Post-hepatectomy liver failure (PHLF) is a severe complication and main cause of death in patients undergoing hepatectomy. The aim of this study was to build a predictive model of PHLF in patients undergoing hepatectomy.

METHODS

We retrospectively analyzed patients undergoing hepatectomy at Zhongshan Hospital, Fudan University from July 2015 to June 2018, and randomly divided them into development and internal validation cohorts. External validation was performed in an independent cohort. Least absolute shrinkage and selection operator (commonly referred to as LASSO) logistic regression was applied to identify predictors of PHLF, and multivariate binary logistic regression analysis was performed to establish the predictive model, which was visualized with a nomogram.

RESULTS

A total of 492 eligible patients were analyzed. LASSO and multivariate analysis identified three preoperative variables, total bilirubin (p=0.001), international normalized ratio (p<0.001) and platelet count (p=0.004), and two intraoperative variables, extent of resection (p=0.002) and blood loss (p=0.004), as independent predictors of PHLF. The area under receiver operating characteristic curve (referred to as AUROC) of the predictive model was 0.838 and outperformed the model for end-stage liver disease score, albumin-bilirubin score and platelet-albumin-bilirubin score (AUROCs: 0.723, 0.695 and 0.663, respectively; p<0.001 for all). The optimal cut-off value of the predictive model was 14.7. External validation showed the model could predict PHLF accurately and distinguish high-risk patients.

CONCLUSIONS

PHLF can be accurately predicted by this model in patients undergoing hepatectomy, which may significantly contribute to the postoperative care of these patients.

The Assessment of Regional Liver Function Before Major Hepatectomy Using Magnetic Resonance Imaging

BACKGROUND

The liver-to-spleen signal intensity ratio (LSR) on magnetic resonance imaging with gadolinium-ethoxybenzyl-diethylenetriamine pentaacetic acid has been used as a parameter to assess liver function. LSR of the future remnant liver region (FR-LSR) is included in preoperative assessment of regional liver function. The aim of this study was to investigate the predictability of post-hepatectomy liver failure (PHLF) by FR-LSR.

METHODS

Between May 2013 and May 2019, 127 patients underwent standardized EOB-MRI for diagnosis of liver tumor before major hepatectomy. The FR-LSR on EOB-MRI was calculated by a semiautomated three-dimensional volumetric analysis system. The cutoff value of FR-LSR in association with clinically relevant PHLF was determined according to the areas under the receiver operating characteristic curves. Then, FR-LSR and clinical variables were analyzed to assess the risk of clinically relevant PHLF.

RESULTS

In patients with preoperative biliary drainage, metastatic liver tumor, estimated future remnant liver volume <50%, biliary reconstruction, operation time ≥ 480 min, estimated blood loss ≥ 1000 g, blood transfusion and a FR-LSR < 2.00 were associated with clinically relevant PHLF (P < .05 for all) in univariable analysis. The liver-to-spleen signal intensity ratio of the future remnant liver region < 2.00 was the only independent risk factor for clinically relevant PHLF in multivariable risk analysis (OR, 27.90; 95% CI: 7.99-136.40; P < .05).

DISCUSSION

The present study revealed that FR-LSR calculated using a 3-dimensional volumetric analysis system was an independent risk factor for clinically relevant PHLF. The liver-to-spleen signal intensity ratio of the future remnant liver region might be a reliable preoperative parameter in liver functional assessment, enabling safe performance of major hepatectomy.

Prognostic value of future liver remnant LU15 index of 99mTc-galactosyl serum albumin scintigraphy for predicting posthepatectomy liver failure

There is no gold standard indicator that is currently used to predict posthepatectomy liver failure (PHLF). A novel indicator of liver function, the LU15 index of ^99mTc-galactosyl serum albumin (GSA) scintigraphy, refers to the liver uptake ratio over a 15-min interval. We aimed to evaluate the usefulness of the future liver remnant (FLR)-LU15 in predicting PHLF. The clinical data of 102 patients (70 males and 32 females; median age, 70 years) who underwent liver resection between January 2011 and August 2019 were analyzed. The FLR-LU15 was calculated by a fusion of simulated 3-dimensional images and ^99mTc-GSA scintigraphy. PHLF was determined according to the definition of the International Study Group of Liver Surgery. The FLR-LU15 was an independent risk factor for PHLF ≥ Grade B according to multivariate analysis, and its value correlated with the PHLF grade. The area under the receiver operating characteristic curve of the FLR-LU15 for PHLF ≥ Grade B was 0.816 (95% confidence interval, 0.704–0.929), which was better than that of other indicators. When the cut-off value of FLR-LU15 was set at 16.7, the sensitivity was 86.7%, specificity was 74.7%, and odds ratio was 19.2 (95% confidence interval, 4.0–90.9), all of which were superior to other indicators. If the cut-off value was 13, the positive predictive value was 57.1%. The FLR-LU15 is a useful predictor of PHLF and may be more reliable than other predictors.

Preoperative Remnant Liver Function Evaluation Using a Routine Clinical Dynamic Gd-EOB-DTPA-Enhanced MRI Protocol in Patients with Hepatocellular Carcinoma

BACKGROUND

To investigate the clinical feasibility of preoperative routine clinical dynamic Gd-EOB-DTPA-enhanced MRI alone to predict post-hepatectomy liver failure (PHLF) in patients with hepatocellular carcinoma (HCC).

METHODS

116 patients with HCC who underwent liver resection in Southwest Hospital from 2014 through 2017 were selected in this retrospective cohort study. The remnant function (RF) of the liver RF_UR and RF_RE15 were calculated by the sum of the uptake rate (UR) or relative enhancement at 15 min (RE15) from dynamic Gd-EOB-DTPA-enhanced MR images in the remnant liver regions, and standardized by standard liver volume (SLV) to generate sRF_UR (standardized RF_UR) and sRF_RE15 (standardized RF_RE15). Student's t test or Mann-Whitney U test, logistic regression, and ROC analyses were used to test the associations of preoperative RF_UR, sRF_UR, RF_RE15, sRF_RE15, the remnant liver volume (RLV)/SLV, ICG retention rate at 15 min (ICG R15) and sRF_ICG-K [ICG clearance rate (ICG-K) × RLV/SLV] with PHLF.

RESULTS

28 patients were found to have PHLF, who showed lower RF_UR, sRF_UR, RF_RE15, sRF_RE15, RLV/SLV, sRF_ICG-K, and higher ICG R15 than patients without PHLF (p < 0.001 for all). After adjusting for clinical parameters, RF_UR (p = 0.001), sRF_UR (p = 0.001), RF_RE15 (p = 0.002), or sRF_RE15 (p = 0.003) was found to be independently significant indicator in multivariable logistic regression, respectively. RF_UR (0.882) and sRF_UR (0.882) had larger AUCs than RLV/SLV (0.731, p = 0.008; p = 0.005), ICG R15 (0.765, p = 0.039; p = 0.044) and sRF_ICG-K (0.767, p = 0.031; p = 0.023). RF_RE15 (0.845) and sRF_RE15 (0.839) had larger AUCs than RLV/SLV (0.731, p = 0.027; p = 0.025).

CONCLUSIONS

The remnant liver function parameters preoperatively estimated from a routine clinical dynamic Gd-EOB-DTPA-enhanced MRI protocol can predict PHLF in patients with HCC, and may be better predictors than conventional methods.

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

BACKGROUND

Posthepatectomy liver failure (PHLF) is a relatively rare but feared complication following liver surgery, and associated with high morbidity, mortality and cost implications. Significant advances have been made in detailed preoperative assessment, particularly of the liver function in an attempt to predict and mitigate this complication.

METHODS

A detailed search of PubMed and Medline was performed using keywords "liver failure", "liver insufficiency", "liver resection", "postoperative", and "post-hepatectomy". Only full texts published in English were considered. Particular emphasis was placed on literature published after 2015. A formal systematic review was not found feasible hence a pragmatic review was performed.

RESULTS

The reported incidence of PHLF varies widely in reported literature due to a historical absence of a universal definition. Incorporation of the now accepted definition and grading of PHLF would suggest the incidence to be between 8 and 12%. Major risk factors include background liver disease, extent of resection and intraoperative course. The vast majority of mortality associated with PHLF is related to sepsis, organ failure and cerebral events. Despite multiple attempts, there has been little progress in the definitive and specific management of liver failure. This review article discusses recent advances made in detailed preoperative evaluation of liver function and evidence-based targeted approach to managing PHLF.

CONCLUSION

PHLF remains a major cause of mortality following liver resection. In absence of a specific remedy, the best approach is mitigating the risk of it happening by detailed assessment of liver function, patient selection and general care of a critically ill patient.

Application of Gd-EOB-DTPA-enhanced magnetic resonance imaging (MRI) in hepatocellular carcinoma

BACKGROUND

Hepatocellular carcinoma (HCC) is the most common malignant tumor of the liver, and its morbidity and mortality have been increasing in recent years. The early diagnosis and prompt treatment of small HCC are crucial to improve the prognosis and quality of life of patients. In China, hepatitis B virus infection is the main cause. HCC with a single tumor nodule of ≤ 3 cm in diameter, or HCC with a number of nodules, in which each nodule is ≤ 2 cm in diameter, with a total diameter of ≤ 3 cm, is considered as small HCC. The MRI liver-specific contrast agent can detect small HCC at the early stage. This has important clinical implications for improving the survival rate of patients.

MAIN BODY

Gd-EOB-DTPA-enhanced MRI can significantly improve the sensitivity and specificity of the detection of HBV-related small hepatocellular carcinoma, providing an important basis for the clinical selection of appropriate personalized treatment. Gd-EOB-DTPA-enhanced MRI can reflect the degree of HCC differentiation, and the evaluation of HCC on Gd-EOB-DTPA-enhanced MRI would be helpful for the selection of the treatment and prognosis of HCC patients. The present study reviews the progress of the application of Gd-EOB-DTPA in the early diagnosis of small HCC, its clinical treatment, the prediction of the degree of differentiation, and the assessment of recurrence and prognosis of HCC, including the pharmacoeconomics and application limitations of Gd-EOB-DTPA. The value of the application of HCC with the Gd-EOB-DTPA was summarized to provide information for improving the quality of life and prolonging the survival of patients.

CONCLUSION

Gd-EOB-DTPA-enhanced MRI has the diagnostic capability for small HCC with a diameter of ≤ 2 cm. This will have a broader application prospect in the early diagnosis of small liver cancer with a diameter of ≤ 1 cm in the future. The relationship between GD-EOB-DTPA-MRI and the degree of HCC differentiation has a large research space, and Gd-EOB-DTPA is expected to become a potential tool for the preoperative prediction and postoperative evaluation of HCC, which would be beneficial for more appropriate treatments for HCC patients.

Efficiency of regional functional liver volume assessment using Gd-EOB-DTPA-enhanced magnetic resonance imaging for hepatocellular carcinoma with portal vein tumor thrombus

PURPOSE

We investigated whether functional future remnant liver volume (fFRLV), assessed using gadolinium-ethoxybenzyl-diethylenetriamine pentaacetic acid-enhanced magnetic resonance imaging (EOB-MRI), could evaluate regional liver function in hepatocellular carcinoma (HCC) patients with portal vein tumor thrombus (PVTT) and help establish the indication for hepatectomy.

METHODS

The subjects of this study were 12 patients with PVTT [PVTT(+) group] and 58 patients without PVTT [PVTT(-) group], from among 191 patients who underwent hepatectomy of more than one segment for HCC. We calculated the liver-to-muscle ratio (LMR) in the remnant liver, using EOB-MRI and fFRLV. Preoperative factors and surgical outcome were compared between the groups. The LMR of the area occluded by PVTT was compared with that of the non-occluded area.

RESULTS

The indocyanine green retention rate at 15 min (ICG-R15) and liver fibrosis indices were increased in the PVTT(+) group, but the surgical outcomes of patients in this group were acceptable, with no liver failure, no mortality, and no differences from those in the PVTT(-) group. The fFRLV in the PVTT(+) group was not significantly different from that in the PVTT(-) group (p = 0.663). The LMR was significantly lower in the occluded area than in the non-occluded area (p = 0.004), indicating decreased liver function.

CONCLUSION

Assessing fFRLV using EOB-MRI could be useful for evaluating regional liver function and establishing operative indications for HCC with PVTT.