Clinical outcomes of patients with and without diabetes mellitus after hepatectomy: A systematic review and meta-analysis

Comprehensive Review of Future Liver Remnant (FLR) Assessment and Hypertrophy Techniques Before Major Hepatectomy: How to Assess and Manage the FLR

BACKGROUND

The regenerative capacities of the liver and improvements in surgical techniques have expanded the possibilities of resectability. Liver resection is often the only curative treatment for primary and secondary malignancies, despite the risk of post-hepatectomy liver failure (PHLF). This serious complication (with a 50% mortality rate) can be avoided by better assessment of liver volume and function of the future liver remnant (FLR).

OBJECTIVE

The aim of this review was to understand and assess clinical, biological, and imaging predictors of PHLF risk, as well as the various hypertrophy techniques, to achieve an adequate FLR before hepatectomy.

METHOD

We reviewed the state of the art in liver regeneration and FLR hypertrophy techniques.

RESULTS

The use of new biological scores (such as the aspartate aminotransferase/platelet ratio index + albumin-bilirubin [APRI+ALBI] score), concurrent utilization of 99mTc-mebrofenin scintigraphy (HBS), or dynamic hepatocyte contrast-enhanced MRI (DHCE-MRI) for liver volumetry helps predict the risk of PHLF. Besides portal vein embolization, there are other FLR optimization techniques that have their indications in case of risk of failure (e.g., associating liver partition and portal vein ligation for staged hepatectomy, liver venous deprivation) or in specific situations (transarterial radioembolization).

CONCLUSION

There is a need to standardize volumetry and function measurement techniques, as well as FLR hypertrophy techniques, to limit the risk of PHLF.

Metabolic dysfunction-associated fatty liver disease increases the risk of complications after radical resection in patients with hepatocellular carcinoma

BACKGROUND AND AIMS

The prevalence of metabolic dysfunction-associated fatty liver disease (MAFLD) in hepatocellular carcinoma (HCC) patients is increasing, yet its association with postoperative complications of HCC remains unclear. The aim of this study was to investigate the impact of MAFLD on complications after radical resection in HCC patients.

METHODS

Patients with HCC who underwent radical resection were included. Patients were stratified into MAFLD group and non-MAFLD group. Clinical features and post-hepatectomy complications were compared between the two groups, and logistic regression analysis was used to determine independent risk factors associated with post-hepatectomy complications.

RESULTS

Among the 936 eligible patients with HCC who underwent radical resection, concurrent MAFLD was diagnosed in 201 (21.5%) patients. Compared to the non-MAFLD group, the MAFLD group exhibited a higher incidence of complications, including infectious and major complications after radical resection in HCC patients. The logistic regression analysis found that MAFLD was an independent risk factor for complications, including infectious and major complications in HCC patients following radical resection (OR 1.565, 95%CI 1.109-2.343, P = 0.012; OR 2.092, 95%CI 1.386-3.156, P < 0.001; OR 1.859, 95% CI 1.106-3.124, P = 0.019; respectively). Subgroup analysis of HBV-related HCC patients yielded similar findings, and MAFLD patients with type 2 diabetes mellitus (T2DM) exhibited a higher incidence of postoperative complications compared to those without T2DM (all P < 0.05).

CONCLUSIONS

Concurrent MAFLD was associated with an increased incidence of complications after radical resection in patients with HCC, especially MAFLD with T2DM.

Which factors predict tumor recurrence and survival after curative hepatectomy in hepatocellular carcinoma? Results from a European institution

BACKGROUND

High tumor recurrence and dismal survival rates after curative intended resection for hepatocellular carcinoma (HCC) are still concerning. The primary goal was to assess predictive factors associated with disease-free (DFS) and overall survival (OS) in a subset of patients with HCC undergoing hepatic resection (HR).

METHODS

Between 08/2004-7/2021, HR for HCC was performed in 188 patients at our institution. Data allocation was conducted from a prospectively maintained database. The prognostic impact of clinico-pathological factors on DFS and OS was assessed by using uni- and multivariate Cox regression analyses. Survival curves were generated with the Kaplan Meier method.

RESULTS

The postoperative 1-, 3- and 5- year overall DFS and OS rates were 77.9%, 49.7%, 41% and 72.7%, 54.7%, 38.8%, respectively. Tumor diameter ≥ 45 mm [HR 1.725; (95% CI 1.091-2.727); p = 0.020], intra-abdominal abscess [HR 3.812; (95% CI 1.859-7.815); p < 0.0001], and preoperative chronic alcohol abuse [HR 1.831; (95% CI 1.102-3.042); p = 0.020] were independently predictive for DFS while diabetes mellitus [HR 1.714; (95% CI 1.147-2.561); p = 0.009), M-Stage [HR 2.656; (95% CI 1.034-6.826); p = 0.042], V-Stage [HR 1.946; (95% CI 1.299-2.915); p = 0.001, Sepsis [HR 10.999; (95% CI 5.167-23.412); p < 0.0001], and ISGLS B/C [HR 2.008; (95% CI 1.273-3.168); p = 0.003] were significant determinants of OS.

CONCLUSIONS

Despite high postoperative recurrence rates, an acceptable long-term survival in patients after curative HR could be achieved. The Identification of parameters related to OS and DFS improves patient-centered treatment and surveillance strategies.

Impact of Preoperative Diabetes Mellitus on Postoperative Outcomes in Elective Pancreatic Surgery and Its Implications for Prehabilitation Practice

OBJECTIVES

Patients with pancreatic disease(s) have a high risk of developing diabetes mellitus (DM). Diabetes mellitus is associated with adverse postoperative outcomes. This study aimed to investigate the prevalence and effects of DM on postoperative outcomes in pancreatic surgery.

METHODS

Subgroup analysis of a prospective cohort study conducted at an academic hospital. Patients undergoing pancreatoduodenectomy between January 2019 and November 2022 were included and screened for DM preoperatively using glycated hemoglobin (HbA1c). New-onset DM was diagnosed based on HbA1c ≥ 6.5% (48 mmol/mol). Postoperative outcomes were compared between patients with and without DM.

RESULTS

From 117 patients, 29 (24.8%) were given a diagnosis of DM, and of those, 5 (17.2%) were diagnosed with new-onset DM, and 15 (51.8%) displayed poorly controlled preoperative DM (HbA 1c ≥ 7% [53 mmol/mol]). The incidence of surgical site infections (48.3% vs 27.3% in the non-DM group; P = 0.04) was higher for patients with DM. This association remained significant after adjusting for confounders (odds ratio, 2.60 [95% confidence interval, 1.03-6.66]; P = 0.04).

CONCLUSIONS

One-quarter of the patients scheduled for pancreatoduodenectomy had DM; over half of them had poor glycemic control. The association between DM status and surgical site infections revealed in this study emphasizes the importance of adequate preoperative glycemic control.

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.

Obesity contributes to hepatocellular carcinoma development via immunosuppressive microenvironment remodeling

It is generally recognized that the initiation of obesity-related hepatocellular carcinoma (HCC) is closely associated with hepatic inflammation. However, the paradoxical role of inflammation in the initiation and progression of HCC is highlighted by the fact that the inflammatory HCC is accompanied by significant immune effector cells infiltration compared to non-inflammatory HCC and HCC with enhanced immune response exhibits better survival. Importantly, the cancer progression has been primarily attributed to the immunosuppression, which can also be induced by obesity. Furthermore, the increased risk of viral infection and thus viral-HCC in obese individuals supports the view that obesity contributes to HCC via immunosuppression. Here, we have reviewed the various mechanisms responsible for obesity-induced tumor immune microenvironment and immunosuppression in obesity-related HCC. We highlight that the obesity-induced immunosuppression originates from lipid disorder as well as metabolic reprogramming and propose potential therapeutic strategy for HCC based on the current success of immunotherapy.

A Web-Based Prediction Model for Estimating the Probability of Post-hepatectomy Major Complications in Patients with Hepatocellular Carcinoma: A Multicenter Study from a Hepatitis B Virus-Endemic Area

BACKGROUND

The identification of patients at high risk of developing postoperative complications is important to improve surgical safety. We sought to develop an individualized tool to predict post-hepatectomy major complications in hepatitis B virus (HBV)-infected patients with hepatocellular carcinoma (HCC).

METHODS

A multicenter database of patients undergoing hepatectomy for HCC were analyzed; 2/3 and 1/3 of patients were assigned to the training and validation cohorts, respectively. Independent risks of postoperative 30-day major complications (Clavien-Dindo grades III-V) were identified and used to construct a web-based prediction model, which predictive accuracy was assessed using C-index and calibration curves, which was further validated by the validation cohort and compared with conventional scores.

RESULTS

Among 2762 patients, 391 (14.2%) developed major complications after hepatectomy. Diabetes mellitus, concurrent hepatitis C virus infection, HCC beyond the Milan criteria, cirrhosis, preoperative HBV-DNA level, albumin-bilirubin (ALBI), and aspartate transaminase to platelet ratio index (APRI) were identified as independent predictors of developing major complications, which were used to construct the online calculator ( http://www.asapcalculate.top/Cal11_en.html ). This model demonstrated good calibration and discrimination, with the C-indexes of 0.752 and 0.743 in the training and validation cohorts, respectively, which were significantly higher than those conventional scores (the training and validation cohorts: 0.565 ~ 0.650 and 0.568 ~ 0.614, all P < 0.001).

CONCLUSIONS

A web-based prediction model was developed to predict the probability of post-hepatectomy major complications in an individual HBV-infected patient with HCC. It can be used easily in the real-world clinical setting to help management-related decision-making and early warning, especially in areas with endemic HBV infection.

Postoperative fever after liver resection: Incidence, risk factors, and characteristics associated with febrile infectious complication

Purpose

To evaluate the incidence and risk factors of postoperative fever (POF) after liver resection. In patients with POF, predictors of febrile infectious complications were determined.

Methods

A total of 797 consecutive patients undergoing liver resection from January 2015 to December 2019 were retrospectively investigated. POF was defined as body temperature ≥ 38.0°C in the postoperative period. POF was characterized by time of first fever, the highest temperature, and frequency of fever. The Institut Mutualiste Montsouris (IMM) classification was used to stratify surgical difficulty, from grade I (low), grade II (intermediate) to grade III (high). Postoperative leukocytosis was defined as a 70% increase of white blood cell count from the preoperative value. Multivariate analysis was performed to identify risk factors for POF and predictors of febrile infectious complications.

Results

Overall, 401 patients (50.3%) developed POF. Of these, 10.5% had the time of first fever > postoperative day (POD) 2, 25.9% had fever > 38.6°C, and 60.6% had multiple fever spikes. In multivariate analysis, risk factors for POF were: IMM grade III resection (OR 1.572, p = 0.008), Charlson Comorbidity Index score > 3 (OR 1.872, p < 0.001), and serum albumin < 3.2 g/dL (OR 3.236, p = 0.023). 14.6% patients developed infectious complication, 21.9% of febrile patients and 7.1% of afebrile patients (p < 0.001). Predictors of febrile infectious complications were: fever > 38.6°C (OR 2.242, p = 0.003), time of first fever > POD2 (OR 6.002, p < 0.001), and multiple fever spikes (OR 2.039, p = 0.019). Sensitivity, specificity, positive predictive value and negative predictive value for fever > 38.6°C were 39.8%, 78.0%, 33.7% and 82.2%, respectively. A combination of fever > 38.6°C and leukocytosis provided high specificity of 95.2%.

Conclusion

In this study, we found that IMM classification, CCI score, and serum albumin level related with POF development in patients undergone liver resection. Time of first fever > POD2, fever > 38.6°C, and multiple fever spikes indicate an increased risk of febrile infectious complication. These findings may aid decision-making in patients with POF who require further diagnostic workup.

Meta-Analysis of Risk Factors for Bile Leakage After Hepatectomy Without Biliary Reconstruction

Background and Aim: The risk factors for bile leakage after hepatectomy without biliary reconstruction are controversial. This study investigated the risk factors for bile leakage after hepatectomy without biliary reconstruction.

Methods: We searched databases (Embase (Ovid), Medline (Ovid), PubMed, Cochrane Library, and Web of Science) for articles published between January 1, 2000, and May 1, 2021, to evaluate the risk factors for bile leakage after hepatectomy without biliary reconstruction.

Results: A total of 16 articles were included in this study, and the overall results showed that sex (OR: 1.21, 95% CI: 1.04–1.42), diabetes (OR: 1.21, 95% CI: 1.05–1.38), left trisectionectomy (OR: 3.53, 95% CI: 2.32–5.36), central hepatectomy (OR: 3.28, 95% CI: 2.63–4.08), extended hemihepatectomy (OR: 2.56, 95% CI: 1.55–4.22), segment I hepatectomy (OR: 2.56, 95% CI: 1.50–4.40), intraoperative blood transfusion (OR:2.40 95%CI:1.79–3.22), anatomical hepatectomy (OR: 1.70, 95% CI: 1.19–2.44) and intraoperative bleeding ≥1,000 ml (OR: 2.46, 95% CI: 2.12–2.85) were risk factors for biliary leakage. Age >75 years, cirrhosis, underlying liver disease, left hepatectomy, right hepatectomy, benign disease, Child–Pugh class A/B, and pre-operative albumin <3.5 g/dL were not risk factors for bile leakage after hepatectomy without biliary reconstruction.

Conclusion: Comprehensive research in the literature revealed that sex, diabetes, left trisectionectomy, central hepatectomy, extended hemihepatectomy, segment I hepatectomy, intraoperative blood transfusion, anatomical hepatectomy and intraoperative bleeding ≥1,000 ml were risk factors for biliary leakage.

High HbA1c is a risk factor for complications after hepatectomy and influences for hepatocellular carcinoma without HBV and HCV infection

Background

Currently, the population with type 2 diabetes mellitus (DM) is increasing worldwide. However, the influence of DM or hyperglycemia on the outcome of resected hepatocellular carcinoma (HCC) is unclear.

Methods

We analyzed 756 patients with HCC who underwent hepatectomy. These patients were assigned to an HbA1c ≥7.0% (H-A1c; n=100) or HbA1c <7.0% (L-A1c; n=656) group depending on their HbA1c level at admission. We investigated prognoses, clinicopathological characteristics and surgical outcomes including morbidities of HCC patients with high HbA1c, prognoses according to the treatment for DM were also investigated.

Results

Among all patients and those with hepatitis B virus (HBV) and hepatitis C virus (HCV) infection, overall survival (OS) and relapse-free survival (RFS) did not differ significantly between the H-A1c and L-A1c groups. In contrast, the 5-year OS rate of the H-A1c group was 55% and that of the L-A1c group 71% among patients without HBV and HCV (NBNC patients) (P=0.03). Among NBNC patients, the median RFS of the H-A1c group was 13 months, and that of the L-A1c group was 26 months (P=0.02). In addition, metformin use was an independent favorable factor for both OS and RFS. The H-A1c group had significantly higher rates of hyperbilirubinemia, wound infection, and pneumonia.

Conclusions

HCC patients with high HbA1c might have poor prognoses for both survival and recurrence in NBNC-HCC. High HbA1c may also be a risk factor for morbidities after hepatectomy. Metformin use may constitute a good option for NBNC patients with HCC.

Differences in the safety line of the future liver remnant plasma clearance rate of indocyanine green necessary to prevent post-hepatectomy liver failure associated with underlying diseases

PURPOSE

To evaluate differences in the safety line of the future liver remnant plasma clearance rate of indocyanine green (RemK) necessary to prevent posthepatectomy liver failure (PHLF) associated with liver tumors and comorbidities.

METHODS

The subjects of this retrospective study were patients who underwent trisectionectomy, hemihepatectomy, or sectionectomy, other than left lateral sectionectomy, between 2011 and 2018, at the Shizuoka Cancer Center. We analyzed the risk factors for PHLF grades B and C and then evaluated the RemK in these groups, according to various risk factors.

RESULTS

A total of 463 patients were selected for the analyses. Among the patients with PHLF grades B and C, those with diabetes mellitus (DM), liver cirrhosis (LC), or hepatocellular carcinoma (HCC) had significantly higher RemK than those without these diseases. Multivariate analysis identified RemK ≤ 0.078, DM, and creatinine clearance rate < 60 mL/min as independent risk factors for PHLF grades B and C.

CONCLUSIONS

Hepatectomy for patients with DM, HCC, or LC requires more functional hepatic reserve than that evaluated by RemK.

Cyclin-dependent kinase inhibitors p21 and p27 function as critical regulators of liver regeneration following 90% hepatectomy in the rat

BACKGROUND

Liver reduction is the main curative treatment for primary liver cancer, but its use remains limited as liver regeneration requires a minimum of 30% functional parenchyma.

AIM

To study the dynamics of the liver regeneration process and consequent behavior of cell cycle regulators in rats after extended hepatectomy (90%) and postoperative glucose infusions.

METHODS

Post-hepatectomy liver failure was triggered in 84 Wistar rats by reducing their liver mass by 90%. The animals received a post-operative glucose infusion and were randomly assigned to two groups: One to investigate the survival rate and the other for biochemical analyses. Animals that underwent laparotomy or 70% hepatectomy were used as controls. Blood and liver samples were collected on postoperative days 1 to 7. Liver morphology, function, and regeneration were studied with histology, immunohistochemistry, and western blotting.

RESULTS

Postoperative mortality after major resection reached 20% and 55% in the first 24 h and 48 h, respectively, with an overall total of 70% 7 d after surgery. No apparent signs of apoptotic cell death were detected in the extended hepatectomy rat livers, but hepatocytes displaying a clear cytoplasm and an accumulation of hyaline material testified to changes affecting their functional activities. Liver regeneration started properly, as early events initiating cell proliferation occurred within the first 3 h, and the G1 to S transition was detected in less than 12 h. However, a rise in p27 (Kip1) followed by p21 (Waf1/Cip1) cell cycle inhibitor levels led to a delayed S phase progression and mitosis. Overall, liver regeneration in rats with a 90% hepatectomy was delayed by 24 h and associated with a delayed onset and lower peak magnitude of hepatocellular deoxyribonucleic acid synthesis.

CONCLUSION

This work highlights the critical importance of the cyclin/cyclin-dependent kinase inhibitors of the Cip/Kip family in regulating the liver regeneration timeline following extended hepatectomy.

A novel online calculator based on albumin-bilirubin and aspartate transaminase-to-platelet ratio index for predicting postoperative morbidity following hepatectomy for hepatocellular carcinoma

Email

zhangchengwuzr@hotmail.com; Prof. Tian Yang, MD. Department of Hepatobiliary Surgery, Eastern Hepatobiliary Surgery Hospital, Navy Medical University, Shanghai 200438, China. Email: yangtiandfgd@hotmail.com.

Background

Identifying patients at high risks of developing postoperative morbidity is important to improve perioperative outcomes. We sought to define the accuracy of two objective and non-invasive serological-based scores, i.e., albumin-bilirubin (ALBI) and aspartate transaminase-to-platelet ratio index (APRI), to predict postoperative morbidity among patients undergoing hepatectomy for hepatocellular carcinoma (HCC), and build up a personalized predictive tool for clinical practice.

Methods

Clinical data of patients who underwent hepatectomy for HCC at 8 hospitals from a multicenter database were retrospectively analyzed. The predictive accuracy of ALBI and APRI relative to 30-day overall and major morbidity were evaluated using area under the receiver operating characteristic curves (AUC). Based on multivariable logistic regression analyses, preoperative and postoperative nomogram models and consequent online calculators were constructed to predict overall and major morbidity, respectively.

Results

Among 2,301 patients, 725 (31.5%) experienced postoperative complications (major morbidity, 35.9%, 260/725). Multivariable analyses identified high ALBI grade (>−2.6) and APRI grade (>1.5) as independent risk factors associated with overall and major morbidity in both preoperative and postoperative prediction models. Two nomogram predictive models and corresponding online calculators that combined ALBI and APRI were subsequently constructed. The AUCs of the preoperative and postoperative models were 0.728 and 0.742 to predict overall morbidity, and 0.739 and 0.713 to predict major morbidity, respectively, which were much higher than those of Child-Pugh score and the model for end-stage liver disease (MELD). Using the bootstrap validation method, the resulting models were internally validated well.

Conclusions

Preoperative ALBI and APRI scores can predict postoperative morbidity following hepatectomy for HCC. An easy-to-use online calculator that combined ALBI and APRI was proposed for individually predicting the probabilities of postoperative overall and major morbidity before and immediately after surgery, so as to provide useful information to inform conversations about surgical risks.

Influence of diabetes on short-term outcome after major hepatectomy: an underestimated risk?

BACKGROUND

Patient-related risk factors such as diabetes mellitus and obesity are increasing in western countries. At the same time the indications for liver resection in both benign and malignant diseases have been significantly extended in recent years. Major liver resection is performed more frequently in a patient population of old age, comorbidity and high rates of neoadjuvant chemotherapy. The aim of this study was to evaluate whether diabetes mellitus, obesity and overweight are risk factors for the short-term post-operative outcome after major liver resection.

METHODS

Four hundred seventeen major liver resections (≥ 3 segments) were selected from a prospective database. Exclusion criteria were prior liver resection in patient's history and synchronous major intra-abdominal procedures. Overweight was defined as BMI ≥ 25 kg/m2 and < 30 kg/m2 and obesity as BMI ≥ 30 kg/m2. Primary end point was 90-day mortality and logistic regression was used for multivariate analysis. Secondary end points included morbidity, complications according to Clavien-Dindo classification, unplanned readmission, bile leakage, and liver failure. Morbidity was defined as occurrence of a post-operative complication during hospital stay or within 90 days postoperatively.

RESULTS

Fifty-nine patients had diabetes mellitus (14.1%), 48 were obese (11.6%) and 147 were overweight (35.5%). There were no statistically significant differences in mortality rates between the groups. In the multivariate analysis, diabetes was an independent predictor of morbidity (OR = 2.44, p = 0.02), Clavien-Dindo grade IV complications (OR = 3.6, p = 0.004), unplanned readmission (OR = 2.44, p = 0.04) and bile leakage (OR = 2.06, p = 0.046). Obese and overweight patients did not have an impaired post-operative outcome compared patients with normal weight.

CONCLUSIONS

Diabetes has direct influence on the short-term postoperative outcome with an increased risk of morbidity but not mortality. Preoperative identification of high-risk patients will potentially decrease complication rates and allow for individual patient counseling as part of a shared decision-making process. For obese and overweight patients, major liver resection is a safe procedure.

Metabolic syndrome and hepatic surgery

In Europe, the prevalence of metabolic syndrome (MS) has reached the endemic rate of 25%. Non-alcoholic fatty liver disease (NAFLD) is the hepatic manifestation of MS. Its definition is histological, bringing together the different lesions associated with hepatic steatosis (fat deposits on more than 5% of hepatocytes) without alcohol consumption and following exclusion of other causes. MS and NAFLD are implicated in the carcinogenesis of hepatocellular carcinoma (HCC) and intrahepatic cholangiocarcinoma (ICC). At present, HCC and ICC involving MS represent 15-20% and 20-30% respectively of indications for hepatic resection in HCC and ICC. Moreover, in the industrialized nations NAFLD is tending to become the most frequent indication for liver transplantation. MS patients combine the operative risk associated with their general condition and comorbidities and the risk associated with the presence and/or severity of NAFLD. Following hepatic resection in cases of HCC and ICC complicating MS, the morbidity rate ranges from 20 to 30%, and due to cardiovascular and infectious complications, post-transplantation mortality is heightened. The operative risk incurred by MS patients necessitates appropriate management including: (i) precise characterization of the subjacent liver; (ii) an accurately targeted approach privileging detection and optimization of treatment taking into account the relevant cardiovascular risk factors; (iii) a surgical strategy adapted to the histology of the underlying liver, with optimization of the volume of the remaining (postoperative) liver.

Propensity-matched analysis of the influence of perioperative statin therapy on outcomes after liver resection

Background

Perioperative use of statins is reported to improve postoperative outcomes after cardiac and non‐cardiovascular surgery. The aim of this study was to investigate the influence of statins on postoperative outcomes including complications of grade IIIa and above, posthepatectomy liver failure (PHLF), and 90‐day mortality rates after liver resection.

Methods

Patients who underwent hepatectomy between 2013 and 2017 were reviewed to identify statin users and non‐users (controls). Propensity matching was conducted for age, BMI, type of surgery and preoperative co‐morbidities to compare subgroups. Univariable and multivariable analyses were performed for the following outcomes: 90‐day mortality, significant postoperative complications and PHLF.

Results

Of 890 patients who had liver resection during the study period, 162 (18·2 per cent) were taking perioperative statins. Propensity analysis selected two matched groups, each comprising 154 patients. Overall, 81 patients (9·1 per cent) developed complications of grade IIIa or above, and the 90‐day mortality rate was 3·4 per cent (30 patients), with no statistically significant difference when the groups were compared before and after matching. The rate of PHLF was significantly lower in patients on perioperative statins than in those not taking statins (10·5 versus 17·3 per cent respectively; P = 0·033); similar results were found after propensity matching (10·4 versus 20·8 per cent respectively; P = 0·026).

Conclusion

The rate of PHLF was significantly lower in patients taking perioperative statins, but there was no statistically significant difference in severe complications and mortality rates.

Developing and validating a preoperative risk score to predict 90-day mortality after liver resection

BACKGROUND

Hepatobiliary surgeons continue to expand the pool of patients undergoing liver resection using combinations of surgical and interventional procedures with chemotherapy. Improved perioperative care allows for operation on higher risk surgical patients. Postoperative outcomes, including 90-day mortality that improved over the past decade but still varies across cohorts. This study developed a preoperative risk score, on the basis significant clinical and laboratory variables, to predict 90-day mortality after hepatectomy.

METHODS

All patients who underwent hepatectomy between 2011 and 2016 were included. Univariable and multivariable analyses were performed to identify the predictors of postoperative mortality and a risk score was derived and validated.

RESULTS

The overall 90-day mortality rate in the derivation cohort (n = 1269 patients) was 4.0% (N = 51). Increasing patient age (P < 0.001), extent of resection (P = 0.001), diabetes mellitus (P = 0.006), and low preoperative sodium (P = 0.012) were predictors of the increased 90-day mortality in the multivariable analysis. The risk model developed based on these factors had an AUROC of 0.778 (P < 0.001) and remained significant in a validation cohort of 788 patients (AUROC: 0.703, P < 0.001).

CONCLUSION

The proposed preoperative risk score to predict 90-day mortality after liver resection could be useful for appropriate counseling, optimization, and risk-adjusted assessment of surgical outcomes.

Diabetes Mellitus and Liver Surgery: The Effect of Diabetes on Oxidative Stress and Inflammation

Diabetes mellitus (DM) is a metabolic disorder characterized by hyperglycaemia and high morbidity worldwide. The detrimental effects of hyperglycaemia include an increase in the oxidative stress (OS) response and an enhanced inflammatory response. DM compromises the ability of the liver to regenerate and is particularly associated with poor prognosis after ischaemia-reperfusion (I/R) injury. Considering the growing need for knowledge of the impact of DM on the liver following a surgical procedure, this review aims to present recent publications addressing the effects of DM (hyperglycaemia) on OS and the inflammatory process, which play an essential role in I/R injury and impaired hepatic regeneration after liver surgery.