Utility of remnant liver volume for predicting posthepatectomy liver failure after hepatectomy with extrahepatic bile duct resection

New criteria for preoperative liver function assessment with safety margins to avoid postoperative mortality during liver resection for hilar cholangiocarcinoma

BACKGROUND

Despite recent medical advancements, surgery for hilar cholangiocarcinoma is associated with high complication and mortality rates. This may be partly attributed to the absence of established preoperative liver evaluation criteria for safe surgery. This study aimed to propose a reliable indicator for safe and well-planned management of major hepatectomy with extrahepatic bile duct resection.

METHODS

We included 150 patients who underwent major hepatectomy with extrahepatic bile duct resection between 2013 and 2021 in Japan. The risk factors for post-hepatectomy liver failure (PHLF) were retrospectively analyzed.

RESULTS

PHLF was observed in 24 (16.0 %) patients who underwent major hepatectomy with extrahepatic bile duct resection. In the multivariate analysis, the identified risk factors for PHLF were the ratio of future remnant liver volume to total liver volume (FRLV/TLV) ≤ 42 % and indocyanine green clearance fraction of the future remnant liver (ICGK-F) ≤ 0.07. Patients with these two factors were significantly associated with PHLF compared with those with either one or none of the risk factors (60.0 % vs 15.1 % and 8.1 %, respectively).

CONCLUSION

The combinational use of ICGK-F and FRLV/TLV is useful for preoperative liver function assessment with a safety margin to avoid PHLF and postoperative mortality in hepatectomy for hilar cholangiocarcinoma.

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.

Positive impact of laparoscopic hepatectomy versus open hepatectomy on body size-corrected bleeding in obese patients

PURPOSE

Laparoscopic hepatectomy (LH) is reported to cause less bleeding than open hepatectomy (OH) in obese patients; however, there are no reports addressing this issue in terms of body size-corrected bleeding.

METHODS

The subjects of this study were 31 obese and 149 non-obese patients who underwent LH and 32 obese and 245 non-obese patients who underwent OH. Bleeding corrected for body surface area (C-BL) was compared between the obese and non-obese patients who underwent each procedure. A multivariate analysis for increased C-BL was performed using the median C-BL for each procedure.

RESULTS

The median C-BL tended to be higher in the obese patients than in the non-obese patients who underwent LH, but there was no significant difference (72 vs. 42 mL/m2, P = 0.050). However, it was significantly higher in the obese patients than in the non-obese patients who underwent OH (542 vs. 333 mL/m2, P = 0.002). In a multivariate analysis, for OH, sectionectomy or more (OR 3.20, P < 0.001) and a high BMI (OR 2.76, P = 0.018) were found to be independent risk factors, whereas for LH, a high BMI was not (OR 1.58, P = 0.301).

CONCLUSIONS

Obesity was identified as a risk factor for increased bleeding with body size correction for OH, but the risk was reduced for LH.

Intraoperatively measured prehepatectomy portal vein pressure as a useful predictor of posthepatectomy liver failure

BACKGROUND

Predicting posthepatectomy liver failure (PHLF) may be a critical requirement for liver disease patients undergoing hepatectomy. This study retrospectively analyzed the impact of the intraoperatively measured portal vein pressure (PVP) prior to hepatectomy on the prediction of PHLF in hepatectomized patients.

METHODS

A total of 334 hepatectomized patients in whom the PVP was intraoperatively measured before resection at our institution were enrolled in the present study. Outcomes were assessed according to the International Study Group of Liver Surgery definition and the severity of PHLF grading.

RESULTS

Thirty-nine of the 334 patients (11.6%) developed grade B/C PHLF. The following factors were significantly associated with grade B/C PHLF in a univariate analysis: indocyanine green retention rate after 15 min, Child-Pugh score, prehepatectomy PVP, and transfusion (each P < 0.0001). A prehepatectomy PVP value of 19.5 cmH2O was the optimal cutoff value for predicting grade B/C PHLF. In a multivariate analysis, prehepatectomy PVP (≥ 19.5 cmH2O) was selected as the most relevant risk factor for grade B/C PHLF (P = 0.0003, hazard ratio: 5.96, 95% CI: 1.80-19.70).

CONCLUSIONS

Prehepatectomy PVP can serve as a useful predictor of the risk of PHLF in patients who have undergone hepatectomy. The results emphasize the possibility of reducing the planned extent of hepatic resection when the prehepatectomy PVP value measured intraoperatively exceeds 19.5 cmH2O, and the importance of predicting the PVP before the operation.

Liver remnant volume to body weight ratio of 0.65% as a lower limit in right hepatic trisectionectomy with bile duct resection

BACKGROUND

Previous studies have suggested the utility of an indocyanine green plasma clearance rate of the future liver remnant (FLR) (ICGK-F) ≥0.05 in hepatobiliary resection to reduce the surgical risk. The present study aimed to verify whether future liver remnant size rather than ICGK-F matters in extended hepatobiliary resection.

METHODS

Between 2004 and 2021, patients who underwent right hepatic trisectionectomy with bile duct resection were included. The effect of the FLR volume-to-body weight ratio (FLR/BW) and ICGK-F on posthepatectomy liver failure was evaluated along with other parameters.

RESULTS

Among 91 study patients, the median ICGK-F, FLR, and FLR/BW were 0.057 (range, 0.027-0.099), 392 mL (145-705), and 0.78% (0.40-1.37), respectively. Posthepatectomy liver failure occurred in 23 patients. The incidence was 10 (40%) in 25 patients with an ICGK-F <0.05 and 12 (18%) in 65 patients with an ICGK-F ≥0.05 (P = .053); 13 (52%) in 25 patients with a FLR/BW <0.65% and 10 (15%) in 66 patients with a FLR/BW ≥0.65% (P = .001). Multivariate analysis showed that a FLR/BW <0.65% (odds ratio, 11.7; P = .005), age ≥65 years (odds ratio, 31.7; P < .001), and blood loss ≥25 mL/kg (odds ratio, 22.1; P = .004) were independent predictors of posthepatectomy liver failure, but ICGK-F <0.05 was not (P = .499). According to the meeting number of 3 factors, posthepatectomy liver failure incidence was 0 of 22 (0%) in patients with 0 factors, 6 of 43 (14%) in patients with 1, and 17 of 26 (65%) in patients with 2 or 3 (P < .001).

CONCLUSION

A FLR/BW ≥0.65% may serve as a volumetric basis to reduce posthepatectomy liver failure after extended hepatobiliary resection.

A radiomics model based on preoperative gadoxetic acid-enhanced magnetic resonance imaging for predicting post-hepatectomy liver failure in patients with hepatocellular carcinoma

Background

Post-hepatectomy liver failure (PHLF) is a fatal complication after liver resection in patients with hepatocellular carcinoma (HCC). It is of clinical importance to estimate the risk of PHLF preoperatively.

Aims

This study aimed to develop and validate a prediction model based on preoperative gadoxetic acid-enhanced magnetic resonance imaging to estimate the risk of PHLF in patients with HCC.

Methods

A total of 276 patients were retrospectively included and randomly divided into training and test cohorts (194:82). Clinicopathological variables were assessed to identify significant indicators for PHLF prediction. Radiomics features were extracted from the normal liver parenchyma at the hepatobiliary phase and the reproducible, robust and non-redundant ones were filtered for modeling. Prediction models were developed using clinicopathological variables (Clin-model), radiomics features (Rad-model), and their combination.

Results

The PHLF incidence rate was 24% in the whole cohort. The combined model, consisting of albumin-bilirubin (ALBI) score, indocyanine green retention test at 15 min (ICG-R15), and Rad-score (derived from 16 radiomics features) outperformed the Clin-model and the Rad-model. It yielded an area under the receiver operating characteristic curve (AUC) of 0.84 (95% confidence interval (CI): 0.77-0.90) in the training cohort and 0.82 (95% CI: 0.72-0.91) in the test cohort. The model demonstrated a good consistency by the Hosmer-Lemeshow test and the calibration curve. The combined model was visualized as a nomogram for estimating individual risk of PHLF.

Conclusion

A model combining clinicopathological risk factors and radiomics signature can be applied to identify patients with high risk of PHLF and serve as a decision aid when planning surgery treatment in patients with HCC.

Converted-hepatopancreatoduodenectomy for an intraoperative positive ductal margin after pancreatoduodenectomy in distal cholangiocarcinoma

PURPOSE

Pancreatoduodenectomy (PD) is the standard treatment for distal cholangiocarcinoma, and a negative ductal margin (DM0) is indispensable for the long-term survival. When intraoperative frozen sections of ductal margin after PD are positive, converted-hepatopancreatoduodenectomy (C-HPD) is the final option available to gain an additional ductal margin. However, the efficacy of C-HPD remains unclear.

METHODS

Patients who underwent PD or C-HPD for distal cholangiocarcinoma between 2002 and 2019 were analyzed. The type of hepatectomy in C-HPD was restricted to left hepatectomy to prevent posthepatectomy liver failure.

RESULTS

Of 203 patients who underwent PD for distal cholangiocarcinoma, 49 patients exhibited intraoperative positive ductal margin (DM1) after PD. Eleven patients underwent C-HPD for intraoperative DM1 after PD, in which intraoperative DM1 with invasive carcinoma (DM1inv) was observed in 3 patients, and intraoperative DM1 with carcinoma in situ (DM1cis) was observed in 8 patients. The median additional ductal margin yielded by C-HPD was 9 mm (interquartile range 7-13 mm). C-HPD eradicated intraoperative DM1inv in 3 patients, with 2 patients showing DM0 and 1 patient showing DM1cis. Regarding 8 patients who underwent C-HPD for intraoperative DM1cis, 4 patients had DM0, but the others had DM1cis. C-HPD was associated with a high complication rate, but no mortality was observed. The median survival time of patients who underwent C-HPD was 48.8 months.

CONCLUSION

C-HPD was able to safely eradicate intraoperative DM1inv after PD. However, the length of the resected bile duct according to C-HPD may not be sufficient to remove intraoperative DM1cis after PD.

Impact of post-hepatectomy liver failure on morbidity and short- and long-term survival after major hepatectomy

Background

Post-hepatectomy liver failure (PHLF) is one of the most serious postoperative complications after hepatectomy. The aim of this study was to assess the impact of the International Study Group of Liver Surgery (ISGLS) definition of PHLF on morbidity and short- and long-term survival after major hepatectomy.

Methods

This was a retrospective review of all patients who underwent major hepatectomy (three or more liver segments) for various liver tumours between 2010 and 2018 at two Swedish tertiary centres for hepatopancreatobiliary surgery. Descriptive statistics, regression models, and survival analyses were used.

Results

A total of 799 patients underwent major hepatectomy, of which 218 patients (27 per cent) developed ISGLS-defined PHLF, including 115 patients (14 per cent) with ISGLS grade A, 76 patients (10 per cent) with grade B, and 27 patients (3 per cent) with grade C. The presence of cirrhosis, perihilar cholangiocarcinoma, and gallbladder cancer, right-sided hemihepatectomy and trisectionectomy all significantly increased the risk of clinically relevant PHLF (grades B and C). Clinically relevant PHLF increased the risk of 90-day mortality and was associated with impaired long-term survival. ISGLS grade A had more major postoperative complications compared with no PHLF but failed to be an independent predictor of both 90-day mortality and long-term survival. The impact of PHLF grade B/C on long-term survival was no longer present in patients surviving the first 90 days after surgery.

Conclusions

The presently used ISGLS definition for PHLF should be reconsidered regarding mortality as only PHLF grade B/C was associated with a negative impact on short-term survival; however, even ISGLS grade A had clinical implications.

Prognostic Value of Carbohydrate Antigen 19-9 and the Surgical Margin in Extrahepatic Cholangiocarcinoma

Aim

The prognostic value of the perioperative carbohydrate antigen 19-9 (CA19-9) value and the prognostic relationship between the CA19-9 value and the surgical margin in extrahepatic cholangiocarcinoma (EHCC) have not been fully discussed.

Methods

A total of 390 patients who underwent curative resection for EHCC between 2002 and 2018 were retrospectively analyzed. According to the perioperative CA19-9 value, patients were divided into three groups: preoperative normal (Normal, n = 178), preoperative high and postoperative normal (Normalization, n = 155), and preoperative high and postoperative high (Nonnormalization, n = 57). Survival was analyzed according to the perioperative CA19-9 value and surgical margin.

Results

The optimal cutoff value of CA19-9 was 37 U/mL. Overall survival (OS) was significantly stratified according to the perioperative CA19-9 value. The 5-y OS rates in the Normal, Normalization, and Nonnormalization groups were 53%, 38%, and 23%, respectively (P < .001). Although the locoregional recurrence rate was comparable among the groups, the Normal group exhibited distant recurrence less frequently in comparison to the other groups. In the Normal group, the margin status had a significant impact on the OS (surgical resection with a negative margin [R0], 59% vs a microscopically positive margin [R1], 7% at 5-y, P < .001). In contrast, in the Normalization and Nonnormalization groups, the OS rate of the R0 and R1 resection groups did not differ to a statistically significant extent.

Conclusion

The perioperative CA19-9 value was related to the prognosis of resectable EHCC. A preoperative CA19-9 value of ≥37 U/mL reflected systemic disease. R0 resection did not affect the survival in this patient group.