Preoperative Thrombocytopenia May Predict Poor Surgical Outcome after Extended Hepatectomy

Does Preoperative Thrombocytopenia in Patients Undergoing Robotic Hepatectomy for Liver Tumors Predict Poor Outcomes? A Propensity-Score Match Analysis

INTRODUCTION

Thrombocytopenia is a known surrogate marker for cirrhosis and portal hypertension and has been associated with increased risk of poor perioperative outcomes when studied in "open" operations. This study was undertaken to assess thrombocytopenia as an independent risk factor for undesirable perioperative outcomes after robotic hepatectomy.

METHODS

We retrospectively reviewed 279 patients who underwent robotic hepatectomy at our institution. Patients were stratified into two cohorts based on preoperative platelet counts. Thrombocytopenia was classified as having a platelet count less than 150 /μL. Patients were 2:1 ratio propensity-score matched based on IWATE score and age. Data are presented as median (mean ± SD).

RESULTS

Thirty-six patients with thrombocytopenia were matched to 72 patients without thrombocytopenia. Patients with thrombocytopenia had higher MELD scores [p = 0.02] and higher Child-Pugh Scores [p <0.001]. Intraoperatively, patients with thrombocytopenia had shorter operative duration [p = 0.03] but similar estimated blood loss (EBL) [p = 0.78]. Postoperatively, there were more fresh frozen plasma transfusions in patients with thrombocytopenia [p = 0.04]. There were no differences in IWATE scores, tumor size, conversions to "open" operations, intraoperative complications, patient length of stay (LOS), Clavien-Dindo score ≥ III complications, perioperative RBC transfusion, in-hospital mortality, or 30-day readmissions.

CONCLUSIONS

In our propensity-score matched study, patients with thrombocytopenia had more severe liver disease; however, there were no differences in their EBL, LOS, or perioperative complications. Preoperative thrombocytopenia, while being an indicator of severity of liver disease potentially promoting perioperative bleeding, does not negatively affect the perioperative course of patients undergoing robotic hepatectomy.

Low Platelet Count Predicts Reduced Survival in Potentially Resectable Hepatocellular Carcinoma

The prognostic role of platelet count in hepatocellular carcinoma (HCC) remains unclear, and in fact both thrombocytopenia and thrombocytosis are reported as predictors of unfavourable outcomes. This study aimed to clarify the prognostic value of preoperative platelet count in potentially resectable HCC. We retrospectively reviewed 128 patients who underwent hepatic resection for HCC at a tertiary academic centre (2007−2019). Patient data were modelled by regression analysis, and platelet count was treated as a continuous variable. 89 patients had BCLC 0/A tumours and 39 had BCLC B tumours. Platelet count was higher in patients with larger tumours and lower in patients with higher MELD scores, advanced fibrosis, and portal hypertension (p < 0.001 for all listed variables). After adjusting for BCLC stage and tumour diameter, low platelet count associated with reduced overall survival (hazard ratio 1.25 per 50/nL decrease in platelet count, 95% confidence interval (CI) 1.02−1.53, p = 0.034) and increased perioperative mortality (odds ratio 1.96 per 50/nL decrease in platelet count, 95% CI 1.19−3.53, p = 0.014). Overall, low platelet count correlates with increased liver disease severity, inferior survival, and excess perioperative mortality in resectable HCC. These insights might be applied in clinical practice to better select patients for resection.

Liver regeneration biology: Implications for liver tumour therapies

The liver has remarkable regenerative potential, with the capacity to regenerate after 75% hepatectomy in humans and up to 90% hepatectomy in some rodent models, enabling it to meet the challenge of diverse injury types, including physical trauma, infection, inflammatory processes, direct toxicity, and immunological insults. Current understanding of liver regeneration is based largely on animal research, historically in large animals, and more recently in rodents and zebrafish, which provide powerful genetic manipulation experimental tools. Whilst immensely valuable, these models have limitations in extrapolation to the human situation. In vitro models have evolved from 2-dimensional culture to complex 3 dimensional organoids, but also have shortcomings in replicating the complex hepatic micro-anatomical and physiological milieu. The process of liver regeneration is only partially understood and characterized by layers of complexity. Liver regeneration is triggered and controlled by a multitude of mitogens acting in autocrine, paracrine, and endocrine ways, with much redundancy and cross-talk between biochemical pathways. The regenerative response is variable, involving both hypertrophy and true proliferative hyperplasia, which is itself variable, including both cellular phenotypic fidelity and cellular trans-differentiation, according to the type of injury. Complex interactions occur between parenchymal and non-parenchymal cells, and regeneration is affected by the status of the liver parenchyma, with differences between healthy and diseased liver. Finally, the process of termination of liver regeneration is even less well understood than its triggers. The complexity of liver regeneration biology combined with limited understanding has restricted specific clinical interventions to enhance liver regeneration. Moreover, manipulating the fundamental biochemical pathways involved would require cautious assessment, for fear of unintended consequences. Nevertheless, current knowledge provides guiding principles for strategies to optimise liver regeneration potential.

CT radiomics nomogram for the preoperative prediction of severe post-hepatectomy liver failure in patients with huge (≥ 10 cm) hepatocellular carcinoma

Background

This study aimed to establish a radiomics-based nomogram for predicting severe (grade B or C) post-hepatectomy liver failure (PHLF) in patients with huge (≥ 10 cm) hepatocellular carcinoma (HCC).

Methods

One hundred eighty-six patients with huge HCC (training dataset, n = 131 and test dataset, n = 55) that underwent curative hepatic resection were included in this study. The least absolute shrinkage and selection operator (LASSO) approach was applied to develop a radiomics signature for grade B or C PHLF prediction using the training dataset. A multivariable logistic regression model was used by incorporating radiomics signature and other clinical predictors to establish a radiomics nomogram. Decision tree analysis was performed to stratify the risk for severe PHLF.

Results

The radiomics signature consisting of nine features predicted severe PHLF with AUCs of 0.766 and 0.745 for the training and test datasets. The radiomics nomogram was generated by integrating the radiomics signature, the extent of resection and the model for end-stage liver disease (MELD) score. The nomogram exhibited satisfactory discrimination ability, with AUCs of 0.842 and 0.863 for the training and test datasets, respectively. Based on decision tree analysis, patients were divided into three risk classes: low-risk patients with radiomics score < -0.247 and MELD score < 10 or radiomics score ≥ − 0.247 but underwent partial resections; intermediate-risk patients with radiomics score < − 0.247 but MELD score ≥10; high-risk patients with radiomics score ≥ − 0.247 and underwent extended resections.

Conclusions

The radiomics nomogram could predict severe PHLF in huge HCC patients. A decision tree may be useful in surgical decision-making for huge HCC hepatectomy.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12957-021-02459-0.

Impact of Platelet Count on Perioperative Bleeding in Patients With Cirrhosis Undergoing Surgical Treatments of Liver Cancer

In patients with cirrhosis with severe thrombocytopenia (platelet count [PC] <50 × 10⁹/L) and undergoing invasive procedures, it is common clinical practice to increase the PC with platelet transfusions or thrombopoietin receptor agonists to reduce the risk of major periprocedural bleeding. The aim of our study was to investigate the association between native PC and perioperative bleeding in patients with cirrhosis undergoing surgical procedures for the treatment of hepatocellular carcinoma (HCC). We retrospectively evaluated 996 patients with cirrhosis between 1996 and 2018 who underwent surgical treatments of HCC by liver resection (LR) or radiofrequency ablation (RFA) without prophylactic platelet transfusions. Patients were allocated to the following three groups based on PC: high (>100 × 10⁹/L), intermediate (51‐100 × 10⁹/L), and low (≤50 × 10⁹/L). PC was also analyzed as a continuous covariate on multivariable analysis. The primary endpoint was major perioperative bleeding. The overall event rate of major perioperative bleeding was 8.9% and was not found to differ significantly between the high, intermediate, and low platelet groups (8.1% vs. 10.2% vs. 10.8%, P = 0.48). On multivariable analysis, greater age, aspartate aminotransferase, lower hemoglobin, and treatment with LR (vs. RFA) were found to be significant independent predictors of major perioperative bleeding, with associations with disease etiology and year of surgery also observed. After adjusting for these factors, the association between PC and major perioperative bleeding remained nonsignificant. Conclusion: Major perioperative bleeding was not significantly associated with PC in patients with cirrhosis undergoing surgical treatment of HCC, even when their PC was <50 × 10⁹/L. With the limit of a retrospective analysis, our data do not support the recommendation of increasing PC in patients with severe thrombocytopenia in order to decrease their perioperative bleeding risk.

A cohort study of hepatectomy-related complications and prediction model for postoperative liver failure after major liver resection in 1,441 patients without obstructive jaundice

Background

This cohort study, based on a large sample of extensive hepatectomy cases, aimed to analyze the distribution of hepatectomy-related complications and to develop a predictive model of posthepatectomy liver failure (PHLF).

Methods

Data of patients who underwent hepatectomy of ≥3 liver segments at the Eastern Hepatobiliary Surgery Hospital from 2000 to 2016 were collected and analyzed. Information on hepatectomy-related complications was collected and risk factors were analyzed. A total of 1,441 eligible patients were randomly assigned at 3:1 ratio into the derivation (n=1,080) and validation (n=361) cohorts. The multivariable logistic regression model was used to establish the prediction model of PHLF in the derivation cohort.

Results

The incidence rates of PHLF, ascites, bile leakage, intra-abdominal bleeding, and abscesses were 58.22%, 10.76%, 11.17%, 9.71%, and 4.16%, respectively. The 90-day perioperative mortality rate was 1.32%. Multivariate analyses found that age, gender, platelet, creatinine, gamma-glutamyltransferase, thrombin time, fibrinogen, hepatitis B e (HBe) antigen positive, and number of resected liver segments were independent prognostic factors of PHLF in the derivation cohort and included in the nomogram. The prediction model demonstrated good discrimination [area under the curve =0.726, 95% confidence interval (CI), 0.696–0.760, P<0.0001] and calibration.

Conclusions

Our study showed a high perioperative safety and a low risk of serious complications in patients who underwent major liver resection (MLR) at a large hepatobiliary surgery center. Routine preoperative clinical information can be used to develop a postoperative liver failure risk prediction model for rational planning of surgery.

Regional liver function analysis with gadoxetic acid-enhanced MRI and virtual hepatectomy: prediction of postoperative short-term outcomes for HCC

OBJECTIVES

To explore the role of quantitative regional liver function assessed by preoperative gadoxetic acid-enhanced MRI with computer-aided virtual hepatectomy to predict short-term outcomes after major hepatectomy for HCC.

METHODS

We retrospectively reviewed the records of 133 consecutive patients with HCC who underwent preoperative gadoxetic acid-enhanced MRI and indocyanine green (ICG) test. Forty-five patients received open major hepatectomy. Liver function reserve and the future liver remnant were evaluated by computer-aided virtual hepatectomy. Global liver functional parameters included the T1 relaxation time reduction rate (T1_ratio) and functional liver volume (FV), whereas regional parameters included the rT1_pos, rT1_ratio, remnant FV (rFV), and remnant FV ratio (rFV_ratio) of the remnant liver. The functional parameters of the MRI and ICG were used to predict the short-term outcomes (liver failure and major complications) after major hepatectomy.

RESULTS

The T1_ratio and FV were correlated with the ICG test (rho = - 0.304 and - 0.449, p < 0.05). FV < 682.8 ml indicated preoperative ICG-_R15 ≥ 14% with 0.765 value of the area under the curve (AUC). No patient who underwent major resection with good liver functional reserve (ICG < 14%) and enough future remnant volume (> 30% standard LV) developed liver failure. Low rT1_ratio (< 66.5%) and high rT1_pos (> 217.5 ms) may predict major complications (AUC = 0.831 and 0.756, respectively; p < 0.05). The rT1_ratio was an independent risk factor for postoperative major complications (odds ratio [OR] = 0.845, 95% CI, 0.736-0.966; p < 0.05).

CONCLUSION

Preoperative gadoxetic acid-enhanced MRI with computer-aided virtual hepatectomy may facilitate optimal assessment of regional liver functional reserve to predict short-term outcomes after major hepatectomy for HCC.

KEY POINTS

• Preoperative gadoxetic acid-enhanced MRI with virtual hepatectomy and volumetric analysis can provide precise liver volume and regional functional assessment. • Quantitative regional liver function assessed by gadoxetic acid-enhanced MRI can predict the short-term outcomes after major hepatectomy in patients with HCC. • The regional liver function assessed by gadoxetic acid-enhanced MRI is an independent risk factor for postoperative major complications.

Issues to be considered to address the future liver remnant prior to major hepatectomy

An accurate preoperative evaluation of the hepatic function and application of portal vein embolization in selected patients have helped improve the safety of major hepatectomy. In planning major hepatectomy, however, several issues remain to be addressed. The first is which cut-off values for serum total bilirubin level and prothrombin time should be used to define post-hepatectomy liver failure. Other issues include what minimum future liver remnant (FLR) volume is required; whether the total liver volume measured using computed tomography or the standard liver volume calculated based on the body surface area should be used to assess the adequacy of the FLR volume; whether there is a discrepancy between the FLR volume and function during the recovery period after portal vein embolization or hepatectomy; and how best the function of a specific FLR can be assessed. Various studies concerning these issues have been reported with controversial results. We should also be aware that different strategies and management are required for different types of liver damage, such as cirrhosis in hepatocellular carcinoma, cholangitis in biliary tract cancer, and chemotherapy-induced hepatic injury.

Clinical Implications of Thrombocytopenia for the Cirrhotic Patient

Thrombocytopenia is a frequent complication in patients with cirrhosis. As many as 84% of patients with cirrhosis have thrombocytopenia, and it is an independent variable indicative of advanced disease and poor prognosis. Although there is great concern that it may aggravate bleeding during surgical procedures, there is limited evidence to inform decisions regarding the treatment of cirrhotic patients with thrombocytopenia undergoing invasive procedures. Finally, there is evidence that platelets play a significant role in liver regeneration. In this report, the clinical implications of thrombocytopenia in cirrhotic patients are reviewed. The utility of platelet counts in the prognosis of cirrhosis and relationship to complications of advanced liver disease, including portal hypertension, esophageal varices, and hepatocellular carcinoma. The impact of low platelet counts on bleeding complications during invasive procedures is outlined. Finally, the role of platelets and potential adverse impact in liver regeneration is reviewed.

Comparison of score-based prediction of 90-day mortality after liver resection

BACKGROUND

Indications for liver surgery are expanding fast and complexity of procedures increases. Preoperative mortality risk assessment by scoring systems is debatable. A previously published externally validated Mortality Risk Score allowed easy applicable and precise prediction of postoperative mortality. Aim of the study was to compare the performance of the Mortality Risk Score with the standard scores MELD and P-POSSUM.

METHODS

Data of 529 patients undergoing liver resection were analysed. Mortality Risk Score, the labMELD Score and the P-POSSUM Scores (PS, OS, P-POSSUM mortality %) were calculated. The ROC curves of the three scoring systems were computed and the areas under the curve (C-index) were calculated using logistic regression models. Comparisons between the ROC curves were performed using the corresponding Wald tests.

RESULTS

Internal validation confirmed that the risk model was predictive for a 90-day mortality rate with a C-index of 0.8421. The labMELD Score had a C-index of 0.7352 and the P-POSSUM system 0.6795 (PS 0.6953, OS 0.5413). The 90-day mortality rate increased with increasing labMELD values (p < 0.0001). Categorized according to the Mortality Risk Score Groups the labMELD Score showed a linear increase while the POSSUM Scores showed variable results.

CONCLUSIONS

By accurately predicting the risk of postoperative mortality after liver surgery the Mortality Risk Score should be useful at the selection stage. Prediction can be adjusted by use of the well-established labMELD Score. In contrast, the performance of standard P-POSSUM Scores is limited.

Comparative Analysis of the Discriminatory Performance of Different Well-Known Risk Assessment Scores for Extended Hepatectomy

The aim of this study was to assess and compare the discriminatory performance of well-known risk assessment scores in predicting mortality risk after extended hepatectomy (EH). A series of 250 patients who underwent EH (≥5 segments resection) were evaluated. Aspartate aminotransferase-to-platelet ratio index (APRI), albumin to bilirubin (ALBI) grade, predictive score developed by Breitenstein et al., liver fibrosis (FIB-4) index, and Heidelberg reference lines charting were used to compute cut-off values, and the sensitivity and specificity of each risk assessment score for predicting mortality were also calculated. Major morbidity and 90-day mortality after EH increased with increasing risk scores. APRI (86%), ALBI (86%), Heidelberg score (81%), and FIB-4 index (79%) had the highest sensitivity for 90-day mortality. However, only the FIB-4 index and Heidelberg score had an acceptable specificity (70% and 65%, respectively). A two-stage risk assessment strategy (Heidelberg–FIB-4 model) with a sensitivity of 70% and a specificity 86% for 90-day mortality was proposed. There is no single specific risk assessment score for patients who undergo EH. A two-stage screening strategy using Heidelberg score and FIB-4 index was proposed to predict mortality after major liver resection.

Evaluation of the role of transhepatic flow in postoperative outcomes following major hepatectomy (THEFLOW): study protocol for a single-centre, non-interventional cohort study

INTRODUCTION

Liver resection is the only curative treatment for primary and secondary hepatic tumours. Improvements in perioperative preparation of patients and new surgical developments have made complex liver resections possible. However, small for size and flow syndrome (SFSF) is still a challenging issue, rendering patients inoperable and causing postoperative morbidity and mortality. Although the role of transhepatic flow in the postoperative outcome has been shown in small partial liver transplantation and experimental studies of SFSF, this has never been studied in the clinical setting following liver resection. The aim of this study is to systematically evaluate transhepatic flow changes following major liver resection and its correlation with postoperative outcomes.

METHODS AND ANALYSIS

The TransHEpatic FLOW (THEFLOW) study is a single-centre, non-interventional cohort study, and aims to enrol 50 patients undergoing major hepatectomy (defined as hemihepatectomy or extended hepatectomy based on the Brisbane classification) with or without prior chemotherapy. The portal venous flow, hepatic artery flow and portal venous pressure are measured before and after each resection. All patients are followed-up for 3 months after the operation. During each evaluation, standard clinical data, posthepatectomy liver failure and overall morbidity and mortality will be recorded. THEFLOW study was initiated on 25 March 2018 and is expected to progress for 2 years.

ETHICS AND DISSEMINATION

This protocol study received approval from the Ethics Committee of the University of Heidelberg (registration number: S576/2017). The results of this study will be published in a peer-reviewed journal, and will also be presented at medical meetings.

TRIAL REGISTRATION NUMBER

NCT03762876.

A novel model for predicting posthepatectomy liver failure in patients with hepatocellular carcinoma

Posthepatectomy liver failure (PHLF) is the most leading cause of mortality following hepatectomy in patients with hepatocellular carcinoma (HCC). Platelet count was reported to be a simple but useful indicator of liver cirrhosis and function of spleen. Spleen stiffness (SS) was used to evaluate the morphological change of spleen and was reported to be related to liver cirrhosis and portal hypertension. However, the predictive value of platelet to spleen stiffness ratio (PSR) on PHLF remains unknown. A retrospective study was performed to analyze 158 patients with HCC following hepatectomy from August 2015 to February 2016. Univariate and multivariate analyses were performed to evaluate the value of each risk factor for predicting PHLF. The predictive efficiency of the risk factors was evaluated by receiver operating characteristic (ROC) curve. PHLF occured in 23 (14.6%) patients. PSR (P<0.001, odds ratio (OR) = 0.622, 95% confidence interval (CI) 0.493~0.784), hepatic inflow occlusion (HIO) (P = 0.003, OR = 1.044, 95% CI 1.015~1.075) and major hepatectomy (P = 0.019, OR = 5.967, 95% CI 1.346~26.443) were demonstrated to be the independent predictive factors for development of PHLF in a multivariate analysis. Results of the present study suggested PSR is a novel and non-invasive model for predicting PHLF in patients with HCC.

Meta-analysis of the prognostic role of perioperative platelet count in posthepatectomy liver failure and mortality

BACKGROUND

Emerging evidence suggests that the perioperative platelet count (PLT) can predict posthepatectomy liver failure (PHLF). In this systematic review and meta-analysis, the impact of perioperative PLT on PHLF and mortality was evaluated.

METHODS

MEDLINE and Web of Science databases were searched systematically for relevant literature up to January 2018. All studies comparing PHLF or mortality in patients with a low versus high perioperative PLT were included. Study quality was assessed using methodological index for non-randomized studies (MINORS) criteria. Meta-analyses were performed using Mantel-Haenszel tests with a random-effects model, and presented as odds ratios (ORs) with 95 per cent confidence intervals.

RESULTS

Thirteen studies containing 5260 patients were included in the meta-analysis. Two different cut-off values for PLT were used: 150 and 100/nl. Patients with a perioperative PLT below 150/nl had higher PHLF (4 studies, 817 patients; OR 4·79, 95 per cent c.i. 2·89 to 7·94) and mortality (4 studies, 3307 patients; OR 3·78, 1·48 to 9·62) rates than patients with a perioperative PLT of 150/nl or more. Similarly, patients with a PLT below 100/nl had a significantly higher risk of PHLF (4 studies, 949 patients; OR 4·65, 2·60 to 8·31) and higher mortality rates (7 studies, 3487 patients; OR 6·35, 2·99 to 13·47) than patients with a PLT of 100/nl or greater.

CONCLUSION

A low perioperative PLT correlates with higher PHLF and mortality rates after hepatectomy.