Predictors of post-hepatectomy liver failure in patients undergoing extensive liver resections for hepatocellular carcinoma

Outcomes after laparoscopic or open liver resection for nonalcoholic fatty liver disease-associated hepatocellular carcinoma: a propensity score-matching study

BACKGROUND

Laparoscopic liver resection (LLR) is rapidly gaining popularity; however, its efficacy for nonalcoholic fatty liver disease (NAFLD)-associated hepatocellular carcinoma (HCC) (NAFLD-HCC) has been not evaluated. The purpose of this study was to compare short- and long-term outcomes between LLR and open liver resection (OLR) among patients with NAFLD-HCC.

METHODS

We used a single-institution database to analyze data for patients who underwent LLR or OLR for NAFLD-HCC from January 2007 to December 2022. We performed propensity score-matching analyses to compare overall postoperative complications, major morbidities, duration of surgery, blood loss, transfusion, length of stay, recurrence, and survival between the two groups.

RESULTS

Among 210 eligible patients, 46 pairs were created by propensity score matching. Complication rates were 28% for OLR and 11% for LLR (p = 0.036). There were no significant differences in major morbidities (15% vs. 8.7%, p = 0.522) or duration of surgery (199 min vs. 189 min, p = 0.785). LLR was associated with a lower incidence of blood transfusion (22% vs. 4.4%, p = 0.013), less blood loss (415 vs. 54 mL, p < 0.001), and shorter postoperative hospital stay (9 vs. 6 days, p < 0.001). Differences in recurrence-free survival and overall survival between the two groups were not statistically significant (p = 0.222 and 0.301, respectively).

CONCLUSIONS

LLR was superior to OLR for NAFLD-HCC in terms of overall postoperative complications, blood loss, blood transfusion, and postoperative length of stay. Moreover, recurrence-free survival and overall survival were comparable between LLR and OLR. Although there is a need for careful LLR candidate selection according to tumor size and location, LLR can be regarded as a preferred treatment for NAFLD-HCC over OLR.

Meta-analysis of Prognostic Factors for Overall Survival Among Resected Patients with Spontaneous Ruptured Hepatocellular Carcinoma

OBJECTIVE

Our meta-analysis was performed to explore the prognostic factors for overall survival among post-hepatectomy patients with spontaneous ruptured hepatocellular carcinoma (SRHCC).

METHODS

PubMed, EMBASE, the Cochrane Library, and Web of Science were all searched up for relevant studies regarding prognostic factors with SRHCC. RevMan5.3 software and Stata 14.0 software were used for statistical analysis.

RESULTS

A total of nineteen studies with 1876 resected SRHCC patients were finally identified. Pooled results indicated that preoperative AFP (high vs low) (P = 0.003), concurrent liver cirrhosis (yes vs no) (P = 0.02), preoperative liver function (child A vs non-child A) (P = 0.0007), tumor size (large vs small) (P < 0.00001), tumor number (solitary vs multiple) (P = 0.002), satellite foci (yes vs no) (P = 0.0006), micro-vascular invasion (yes vs no) (P < 0.00001), type of hepatectomy (major or minor) (P = 0.04), surgical margin (R + vs R -) (P < 0.00001), and type of hepatectomy (emergency hepatectomy vs staged hepatectomy) (P = 0.005) were prognostic factors for overall survival among post-hepatectomy SRHCC patients.

CONCLUSION

Apart from some conventional prognostic factors identified in resected patients with SRHCC, numerous prognostic factors have also been unmasked, which might provide clinical reference to stratify patients with different therapeutic regimes.

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 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.

Impact of the Intermittent Pringle Maneuver for Predicting Post-hepatectomy Liver Failure: A Cohort Study of 597 Consecutive Patients

BACKGROUND

Intermittent Pringle maneuver (PM) is widely performed to reduce blood loss during hepatectomy; however, its impact on clinically relevant post-hepatectomy liver failure (PHLF) remains controversial. This study aimed to assess the impact of PM on PHLF and explore whether PM provides additional value for predicting PHLF.

METHODS

Consecutive patients, who underwent hepatectomy without biliary and/or vascular reconstruction between 2011 and 2018 in a single institution, were retrospectively analyzed. The main outcome was PHLF grades B/C as defined by the International Study Group of Liver Surgery. A multivariable logistic regression model of variables significantly associated with PHLF was established. The model's predictive ability was assessed by the area under the receiver operating characteristic curve (AUROC).

RESULTS

Among 597 patients, PHLF occurred in 42 (7.0%). PM was applied in 421 patients (70.5%) and was associated with the development of PHLF (PM vs. no-PM: 9.7 vs. 0.6%, P < 0.001). After the propensity score matching, patients with PM experienced significantly increased rates of PHLF (P = 0.010). Rem-ALPlat index (including future liver remnant, preoperative albumin level, and platelet count; P < 0.001), the number of PMs (P = 0.032), and blood loss (P = 0.007) were identified as significant predictors of PHLF. The model's AUROC combined with the intraoperative variables was higher than that of the preoperative model alone (0.877 vs. 0.789, P = 0.004).

CONCLUSIONS

PM was involved in the occurrence of clinically relevant PHLF. Further, intraoperative factors including PM may provide additional value to predict PHLF and may facilitate early post-hepatectomy intervention.

A comprehensive preoperative predictive score for post-hepatectomy liver failure after hepatocellular carcinoma resection based on patient comorbidities, tumor burden, and liver function: the CTF score

BACKGROUND

Post-hepatectomy liver failure (PHLF) is a dreaded complication following liver resection for hepatocellular carcinoma (HCC) with a high mortality rate. We sought to develop a score based on preoperative factors to predict PHLF.

METHODS

Patients who underwent resection for HCC between 2000 and 2020 were identified from an international multi-institutional database. Factors associated with PHLF were identified and used to develop a preoperative comorbidity-tumor burden-liver function (CTF) predictive score.

RESULTS

Among 1785 patients, 106 (5.9%) experienced PHLF. On multivariate analysis, several factors were associated with PHLF including high Charlson comorbidity index (CCI ≥ 5) (OR 2.80, 95%CI, 1.08-7.26), albumin-bilirubin (ALBI) (OR 1.99, 95%CI, 1.10-3.56), and tumor burden score (TBS) (OR 1.06, 95%CI, 1.02-1.11) (all p < 0.05). Using the beta-coefficients of these variables, a weighted predictive score was developed and made available online ( https://alaimolaura.shinyapps.io/PHLFriskCalculator/ ). The CTF score (c-index = 0.67) performed better than Child-Pugh score (CPS) (c-index = 0.53) or Barcelona clinic liver cancer system (BCLC) (c-index = 0.57) to predict PHLF. A high CTF score was also an independent adverse prognostic factor for survival (HR 1.61, 95%CI, 1.12-2.30) and recurrence (HR 1.36, 95%CI, 1.08-1.71) (both p = 0.01).

CONCLUSION

Roughly 1 in 20 patients experienced PHLF following resection of HCC. Patient (i.e., CCI), tumor (i.e., TBS), and liver function (i.e., ALBI) factors were associated with risk of PHLF. These preoperative factors were incorporated into a novel CTF tool that was made available online, which outperformed other previously proposed tools.

Machine learning prediction model for post- hepatectomy liver failure in hepatocellular carcinoma: A multicenter study

Introduction

Post-hepatectomy liver failure (PHLF) is one of the most serious complications and causes of death in patients with hepatocellular carcinoma (HCC) after hepatectomy. This study aimed to develop a novel machine learning (ML) model based on the light gradient boosting machines (LightGBM) algorithm for predicting PHLF.

Methods

A total of 875 patients with HCC who underwent hepatectomy were randomized into a training cohort (n=612), a validation cohort (n=88), and a testing cohort (n=175). Shapley additive explanation (SHAP) was performed to determine the importance of individual variables. By combining these independent risk factors, an ML model for predicting PHLF was established. The area under the receiver operating characteristic curve (AUC), sensitivity, specificity, positive predictive value, negative predictive value, and decision curve analyses (DCA) were used to evaluate the accuracy of the ML model and compare it to that of other noninvasive models.

Results

The AUCs of the ML model for predicting PHLF in the training cohort, validation cohort, and testing cohort were 0.944, 0.870, and 0.822, respectively. The ML model had a higher AUC for predicting PHLF than did other non-invasive models. The ML model for predicting PHLF was found to be more valuable than other noninvasive models.

Conclusion

A novel ML model for the prediction of PHLF using common clinical parameters was constructed and validated. The novel ML model performed better than did existing noninvasive models for the prediction of PHLF.

Outcomes of patients with post-hepatectomy hypophosphatemia: A narrative review

Phosphate is an essential electrolyte for proper mineralisation of bone, buffering of urine, and diverse cellular actions. Hypophosphatemia (HP) is a clinical spectrum which range from asymptomatic to severe complications such as neuromuscular and pulmonary complications, or even death. Post-hepatectomy HP (PHH) has been reported to be 55.5%-100%. Post-hepatectomy, there is rapid uptake of phosphate and increased mitotic counts to aid in regeneration of residual liver. Concurrently, PHH may be due to increased urinary phosphorous from activation of matrix extracellular phosphoglycoprotein in the injured liver, which decreases phosphate influx into hepatocytes to sustain adenosine triphosphate synthesis. A literature review was performed on PubMed till January 2022. We included 8 studies which reported on impact of PHH on post-operative outcomes. In patients with diseased liver, PHH was reported to have either beneficial or deleterious effects on post-hepatectomy liver failure (PHLF), morbidity and/or mortality in various cohorts. In living donor hepatectomy, PHLF was higher in PHH. Benefits of correction of PHH with reduced post-operative complications have been shown. Correction of PHH should be done based on extent of PHH. Existing studies were however heterogenous; further studies should be conducted to assess PHH on post-operative outcomes with standardized phosphate replacement regimes.

A Novel Nomogram for Prediction of Post-Hepatectomy Liver Failure in Patients with Resectable Hepatocellular Carcinoma: A Multicenter Study

Objective

To develop a nomogram for predicting post-hepatectomy liver failure (PHLF) in patients with resectable hepatocellular carcinoma (HCC) based on portal hypertension, the extent of resection, ALT, total bilirubin, and platelet count.

Methods

Patients with HCC hospitalized from January 2015 to December 2020 were included in a retrospective cohort study. 595 HCC patients were divided into a training cohort (n=416) and a validation cohort (n=179) by random sampling. Univariate and multivariable analyses were performed to identify the independent variables to predict PHLF. The nomogram models for predicting the overall risk of PHLF and the risk of PHLF B+C were constructed based on the independent variables. Comparisons were made by using receiver operating characteristic (ROC) curve, calibration curve, and decision curve analysis (DCA) with traditional models, such as FIB-4 score, APRI score, CP class (Child-Pugh), MELD score (model of end-stage liver disease), and ALBI score (albumin-bilirubin) to analyze the accuracy and superiority of the nomogram.

Results

We discovered that portal hypertension (yes vs no) (OR=1.677,95% CI:1.817–4.083, p=0.002), the extent of liver resection (OR=1.872,95% CI:3.937–47.096, p=0.001), ALT (OR=1.003,95% CI:1.003–1.016, P=0.003), total bilirubin (OR=1.036,95% CI:1.031–1.184, p=0.005), and platelet count (OR= 1.004, 95% CI:0.982–0.998, p=0.020) were independent risk factors for PHLF using multifactorial analysis. The nomogram models were constructed using well-fit calibration curves for each of these five covariates. When compared to the FIB4, ALBI, MELD, and CP score, our nomogram models have a better predictive value for predicting the overall risk of PHLF or the risk of PHLF B+C. The validation cohort’s results were consistent. DCA also confirmed the conclusion.

Conclusion

Our models, in the form of static nomogram or web application, were developed to predict PHLF overall risk and PHLF B+C risk in patients with HCC, with a high prediction sensitivity and specificity performance than other commonly used scoring systems.

Individualized risk estimation for postoperative pulmonary complications after hepatectomy based on perioperative variables

BACKGROUND

At present, there is no perfect system to evaluate pulmonary complications of liver surgery using perioperative variables.

AIM

To design and verify a risk assessment system for predicting postoperative pulmonary complications (PPCs) after hepatectomy based on perioperative variables.

METHODS

A retrospective analysis was performed on 1633 patients who underwent liver surgery. The variables were screened using univariate and multivariate analyses, and graded scores were assigned to the selected variables. Logistic regression was used to develop the liver operation pulmonary complication scoring system (LOPCSS) for the prediction of PPCs. The LOPCSS was verified using the receiver operating characteristic curve.

RESULTS

According to the multivariate correlation analysis, the independent factors which influenced PPCs of liver surgery were age [≥ 65 years old/< 65 years old, odds ratio (OR) = 1.926, P = 0.011], medical diseases requiring drug treatment (yes/no, OR = 3.523, P < 0.001), number of liver segments to be removed (≥ 3/≤ 2, OR = 1.683, P = 0.002), operation duration (≥ 180 min/< 180 min, OR = 1.896, P = 0.004), and blood transfusion (yes/no, OR = 1.836, P = 0.003). The area under the curve (AUC) of the LOPCSS was 0.742. The cut-off value of the expected score for complications was 5. The incidence of complications in the group with ≤ 4 points was significantly lower than that in the group with ≥ 6 points (2.95% vs 33.40%, P < 0.001). Furthermore, in the validation dataset, the corresponding AUC of LOPCSS was 0.767.

CONCLUSION

As a novel and simplified assessment system, the LOPCSS can effectively predict PPCs of liver surgery through perioperative variables.

Appraisal of multivariable prognostic models for post-operative liver decompensation following partial hepatectomy: a systematic review

BACKGROUND

Few reports have evaluated prognostic modelling studies of tools used for surgical decision-making. This systematic review aimed to describe and critically appraise studies that have developed or validated multivariable prognostic models for post-operative liver decompensation following partial hepatectomy.

METHODS

This study was designed using the CHARMS checklist. Following a comprehensive literature search, two reviewers independently screened candidate references for inclusion and abstracted relevant study details. Qualitative assessment was performed using the PROBAST tool.

RESULTS

We identified 36 prognostic modelling studies; 25 focused on development only, 3 developed and validated models, and 8 validated pre-existing models. None compared routine use of a prognostic model against standard clinical practice. Most studies used single-institution, retrospective cohort designs, conducted in Eastern populations. In total, 15 different outcome definitions for post-operative liver decompensation events were used. Statistical concerns surrounding model overfitting, performance assessment, and internal validation led to high risk of bias for all studies.

CONCLUSIONS

Current prognostic models for post-operative liver decompensation following partial hepatectomy may not be valid for routine clinical use due to design and methodologic concerns. Landmark resources and reporting guidelines such as the TRIPOD statement may assist researchers, and additionally, model impact assessment studies represent opportunities for future research.

Diabetes mellitus and postoperative blood glucose value help predict posthepatectomy liver failure in patients with hepatocellular carcinoma

Background

Many complications after hepatectomy can lead to perioperative death, among which posthepatectomy liver failure (PHLF) is the leading one. Existing studies suggest that one of the most important risk factors for PHLF is cirrhosis. Hepatitis B virus (HBV) infection is an important factor in the occurrence of cirrhosis, and the exact relationship between HBV infection and PHLF is not obvious. Diabetes mellitus and postoperative blood glucose are closely associated with liver regeneration, but its exact relationship with PHLF remains unclear.

Methods

We collected clinical indicators from 920 adult patients treated at the Liver Surgery and Transplantation Center of West China Hospital of Sichuan University from April 2009 and April 2019. We conducted a univariate analysis find out the risk factors of PHLF, follow by a multivariate analysis to ascertain the independent risk factors. Receiver operating characteristic (ROC) curves were plotted to evaluate the predictive efficiency of each risk factor.

Results

Following hepatectomy, 205 (22.2%) of patients were diagnosed with PHLF. Several variables were confirmed to related with PHLF significantly: diabetes [P<0.01, odds ratio (OR) =10.845, 95% confidence interval (CI): 5.450-21.579], HBV (P<0.01, OR =0.345, 95% CI: 0.187-0.635), blood glucose on the first postoperative day (post-BG1) (P=0.027, OR =1.059, 95% CI: 1.006-1.115), blood glucose on the third postoperative day (post-BG3) (P=0.021, OR =1.085, 95% CI: 1.012-1.162), blood glucose on the fifth postoperative day (post-BG5) (P=0.014, OR =1.119, 95% CI: 1.023-1.225), postoperative total bilirubin (post-TB) (P<0.01, OR =1.160, 95% CI: 1.133-1.187), and liver cirrhosis (P<0.01, OR =0.982, 95% CI: 0.561-1.717) identified to be independent risk factors of PHLF.

Conclusions

Diabetes, HBV, post-BG1, post-BG3, and post-BG5 are related to the development of PHLF, and diabetes and post-BG can be used as predictors of the development of PHLF in patients with hepatocellular carcinoma (HCC).

A novel preoperative predictive model of 90-day mortality after liver resection for huge hepatocellular carcinoma

Background

Hepatectomy for huge hepatocellular carcinoma (HCC) (diameter ≥10 cm) is characterized by high mortality. This study aimed to establish a preoperative model to evaluate the risk of postoperative 90-day mortality for huge HCC patients.

Methods

We retrospectively enrolled 1,127 consecutive patients and prospectively enrolled 93 patients with huge HCC who underwent hepatectomy (training cohort, n=798; validation cohort, n=329; prospective cohort, n=93) in our institute. Based on independent preoperative predictors of 90-day mortality, we established a logistic regression model and visualized the model by nomogram.

Results

The 90-day mortality rates were 9.6%, 9.2%, and 10.9% in the training, validation, and prospective cohort. The α-fetoprotein (AFP) level, the prealbumin levels, and the presence of portal vein tumor thrombosis (PVTT) were preoperative independent predictors of 90-day mortality. A logistic regression model, AFP-prealbumin-PVTT score (APP score), was subsequently established and showed good performance in predicting 90-day mortality (training cohort, AUC =0.87; validation cohort, AUC =0.91; prospective cohort, AUC =0.93). Using a cut-off of −1.96, the model could stratify patients into low risk (≤−1.96) and high risk (>−1.96) with different 90-day mortality rates (~30% vs. ~2%). Furthermore, the predictive performance for 90-day mortality and overall survival was significantly superior to the Child-Pugh score, the model of end-stage liver disease (MELD) score, and the albumin-bilirubin (ALBI) score.

Conclusions

The APP score can precisely predict postoperative 90-day mortality as well as long-term survival for patients with huge HCC, assisting physician selection of suitable candidates for liver resection and improving the safety and efficacy of surgical treatment.

Prediction of Post-hepatectomy Liver Failure in Patients With Hepatocellular Carcinoma Based on Radiomics Using Gd-EOB-DTPA-Enhanced MRI: The Liver Failure Model

Objectives: Preoperative prediction of post-hepatectomy liver failure (PHLF) in patients with hepatocellular carcinoma (HCC) is significant for developing appropriate treatment strategies. We aimed to establish a radiomics-based clinical model for preoperative prediction of PHLF in HCC patients using gadolinium-ethoxybenzyl-diethylenetriamine (Gd-EOB-DTPA)-enhanced magnetic resonance imaging (MRI).

Methods: A total of 144 HCC patients from two medical centers were included, with 111 patients as the training cohort and 33 patients as the test cohort, respectively. Radiomics features and clinical variables were selected to construct a radiomics model and a clinical model, respectively. A combined logistic regression model, the liver failure (LF) model that incorporated the developed radiomics signature and clinical risk factors was then constructed. The performance of these models was evaluated and compared by plotting the receiver operating characteristic (ROC) curve and calculating the area under the curve (AUC) with 95% confidence interval (CI).

Results: The radiomics model showed a higher AUC than the clinical model in the training cohort and the test cohort for predicting PHLF in HCC patients. Moreover, the LF model had the highest AUCs in both cohorts [0.956 (95% CI: 0.955–0.962) and 0.844 (95% CI: 0.833–0.886), respectively], compared with the radiomics model and the clinical model.

Conclusions: We evaluated quantitative radiomics features from MRI images and presented an externally validated radiomics-based clinical model, the LF model for the prediction of PHLF in HCC patients, which could assist clinicians in making treatment strategies before surgery.

[Liver Resections Can Be Safely Performed in Cirrhotic Patients after Careful Patient Selection]

BACKGROUND

Hepatocellular Carcinoma (HCC) is the most frequent malignant primary liver tumour in a cirrhotic liver. Liver transplantation and resection are the only curative treatment options in compensated liver cirrhosis, but liver resections are associated with increased perioperative morbidity and mortality.

PATIENTS

We identified 108 cirrhotic patients, who underwent liver resections at the University Hospital of Mainz between January 2008 and December 2019. During the same period, 185 liver resections were performed for HCC in non-cirrhotic livers. Furthermore, 167 liver resections served as control group, which were performed for colorectal liver metastases (CRLM) with comparable extent of resection to HCC in cirrhotic livers. Preoperatively, we assessed the Charlson Comorbidity Index (CCI), MELD and Child scores in addition to the general patient characteristics. Perioperative morbidity was graded according to the Clavien-Dindo classification. Resections of HCC in cirrhosis and liver metastases were additionally compared by a matched-pair analysis.

RESULTS

The three groups were comparable in age. Preoperative liver function was best in patients with CRLM (p < 0.001). Resections for HCC in non-cirrhotic livers were more extended than in cirrhotic livers (p < 0.001). The overall morbidity (Clavien/Dindo stage III - IV) was higher after resections in cirrhotic livers than in CRLM resections (p = 0.026). Postoperative mortality was comparably low in all three groups (2.2%). Neither MELD nor Child score was predictive for postoperative morbidity or mortality (area under the curve: AUC < 0.6, each). Preoperative CCI was predictive for postoperative mortality (AUC = 0.78).

CONCLUSIONS

Liver resections in cirrhotic livers are feasible after adequate patient selection and limitation of the extent of surgery. Comorbidities additionally increase the postoperative mortality in addition to impaired liver function and should therefore always be included into the preoperative assessment of patients undergoing liver surgery.

Early Prediction of Post-hepatectomy Liver Failure in Patients Undergoing Major Hepatectomy Using a PHLF Prognostic Nomogram

BACKGROUND

Liver resection (LR) is the main modality of treatment for hepatocellular carcinoma (HCC) and colorectal liver metastasis (CRLM). Post-hepatectomy liver failure (PHLF) remains the most dreaded complication. We aim to create a prognostic score for early risk stratification of patients undergoing LR.

METHODOLOGY

Clinical and operative data of 472 patients between 2000 and 2016 with HCC or CRLM undergoing major hepatectomy were extracted and analysed from a prospectively maintained database. PHLF was defined using the 50-50 criteria.

RESULTS

Liver cirrhosis and fatty liver were histologically confirmed in 35.6% and 53% of patients. 4.7% (n = 22) of patients had PHLF. A 90-day mortality was 5.1% (n = 24). Pre-operative albumin-bilirubin score (p = 0.0385), prothrombin time (p < 0.0001) and the natural logarithm of the ratio of post-operative day 1 to pre-operative serum bilirubin (SB) (ln(_POD1Bil/_pre-opBil); p < 0.0001) were significantly independent predictors of PHLF. The PHLF prognostic nomogram was developed using these factors with receiver operating curve showing area under curve of 0.88. Excellent sensitivity (94.7%) and specificity (95.7%) for the prediction of PHLF (50-50 criteria) were achieved at cut-offs of 9 and 11 points on this model. This score was also predictive of PHLF according to _PeakBil > 7 and International Study Group for Liver Surgery criteria, intensive care unit admissions, length of stay, all complications, major complications, re-admissions and mortality (p < 0.05).

CONCLUSIONS

The PHLF nomogram ( https://tinyurl.com/SGH-PHLF-Risk-Calculator ) can serve as a useful tool for early identification of patients at high risk of PHLF before the 'point of no return'. This allows enforcement of closer monitoring, timely intervention and mitigation of adverse outcomes.

An Improved Scoring System Based on Platelet-Albumin-Bilirubin in Predicting Posthepatectomy Liver Failure Outcomes

BACKGROUND

Posthepatectomy liver failure (PHLF) is one of the major complications of liver resection that causes perioperative mortality. Accurate preoperative assessment of PHLF is of great significance to reduce the complication rate after hepatectomy and improve the survival rate.

METHODS

A retrospective study of patients who received hepatectomy from January 2016 to October 2019 at Tang Du Hospital was performed. The area under the receiver operating characteristic (ROC) curve was used to compare the predictive effects of various scoring models on PHLF.

RESULTS

The area under the ROC curve of platelet-albumin-bilirubin (PALBI) score, new platelet-albumin-bilirubin (I-PALBI) score, ALBI score, and MELD score was, respectively, 0.647, 0.772, 0.677, and 0.686 (p < 0.01). The I-PALBI score was significantly better than the other scores.

CONCLUSIONS

I-PALBI score can be used as a predictive score of PHLF, and its prediction accuracy is better than other scoring systems.

Does preoperative MELD score affect outcomes following robotic hepatectomy for liver tumors?

The model for end-stage liver disease (MELD) score is objective, reproducible, and it has shown to predict mortality related to cirrhosis. This study was undertaken to investigate safety of robotic hepatectomy in patients with elevated preoperative MELD score and to examine correlation between preoperative MELD scores and postoperative outcomes after robotic hepatectomy for liver tumors. Demographic data, MELD score, and clinical outcomes were prospectively collected. Regression analysis was used. Data are presented as median (mean ± SD). 75 patients underwent robotic hepatectomy. Age was 64 (62.5 ± 14.2) years and BMI 28 (29 ± 7.0) kg/m²; 56% women. 60 (81%) of the hepatectomies were undertaken for malignancy (25% hepatocellular carcinoma, 20% colorectal metastasis, 15% cholangiocarcinoma). On regression analysis, MELD score did not correlate with operative time (p = 0.518) or blood loss (p = 0.583). MELD score, however, correlated with length of stay (p = 0.002). 8 (11%) patients experienced postoperative complications; their MELD score was 7 (8 ± 2.5). 68 (91%) patients did not experience postoperative complications; their MELD score was 7 (8 ± 2.8) (p = 0.803). One patient died in this series. In patients undergoing robotic hepatectomy to treat liver tumors, preoperative MELD score only correlates with length of stay. Preoperative MELD score does not correlate with operative time and amount of blood loss. An elevated MELD score should not deter surgeons from offering robotic hepatectomy.

Albumin-Bilirubin Score vs Model for End-Stage Liver Disease in Predicting Post-Hepatectomy Outcomes

BACKGROUND

The Albumin-Bilirubin score (ALBI) has been established to predict outcomes after hepatectomy. However, the relative value of ALBI and Model for End-Stage Liver Disease (MELD) in predicting post-hepatectomy liver failure and mortality has not been adequately evaluated. Therefore, the aim of this study was to validate and compare ALBI and MELD with respect to post-hepatectomy liver failure and mortality.

STUDY DESIGN

Patients undergoing major hepatectomy (≥3 segments) or partial hepatectomy (≤2 segments) were identified in the 2014 to 2017 American College of Surgeons NSQIP Procedure Targeted Participant Use File. Univariable and multivariable analyses were performed for 30-day post-hepatectomy liver failure (PHLF) and mortality. Predictive accuracy was assessed using a receiver operator characteristic curve and calculating the area under the curve (AUC).

RESULTS

For 13,783 patients, median ALBI was -2.6, and median MELD score was 6.9. Severe PHLF (grade B to C) and mortality rates were 2.9% and 1.8%, respectively. Multivariable analyses revealed ALBI grade 2/3 to be a stronger predictor than MELD ≥10 with respect to severe PHLF (odds ratio [OR] 2.30; 95% CI, 1.95 to 2.73; p < 0.001 vs OR 1.00; 95% CI, 0.78 to 1.23; p = 0.99) and mortality (OR 3.35; 95% CI, 2.49 to 4.52; p < 0.001 vs OR 1.73; 95% CI, 1.36 to 2.20; p < 0.001). ALBI also had better discrimination compared with MELD for severe PHLF (AUC 0.67 vs AUC 0.60) and mortality (AUC 0.70 vs AUC 0.58) in patients with hepatocellular carcinoma.

CONCLUSIONS

ALBI is a powerful predictor of PHLF and mortality. Compared with MELD, ALBI is more accurate, especially in patients with hepatocellular carcinoma.

Liver Resection for Nonalcoholic Fatty Liver Disease-Associated Hepatocellular Carcinoma

BACKGROUND

Nonalcoholic fatty liver disease (NAFLD)-related hepatocellular carcinoma (HCC) is on the rise worldwide, but data on long-term outcomes after curative operations are limited. The primary aim of this study was to characterize the perioperative and long-term outcomes after liver resection. The secondary aim was to investigate the influence of the histologic severity of nonalcoholic steatohepatitis and its impact on perioperative outcomes and long-term survival.

METHODS

A total of 996 patients who underwent liver resection for HCC in our institution were analyzed. Patients were categorized into subgroups of NAFLD vs non-NAFLD HCC based on histologic evidence of hepatic steatosis. Comparisons of patients' demographic, clinical, and surgical characteristics; postoperative complications; and survival outcomes were performed.

RESULTS

Eight hundred and forty-four patients had non-NAFLD HCC and 152 patients had NAFLD HCC. Comorbidities were significantly more common in the NAFLD group (p < 0.0001). In the non-NAFLD group, larger median tumor size, higher liver cirrhosis, and lower median neutrophil to lymphocyte ratio were observed (p < 0.0001). The NAFLD group had a greater amount of intraoperative blood loss, more postoperative complications, and longer length of stay. Five-year overall survival was significantly better in the NAFLD group (p = 0.0355). Significant factors that contribute to poorer survival outcomes include age, congestive cardiac failure, Child-Pugh's class B, cirrhosis, tumor size, multinodularity, and R1 resection. For NAFLD group, patients with abnormal parenchyma showed poorer survival and 5-year overall survival rates (64.8% vs 75.6%; p = 0.2291).

CONCLUSIONS

Nonalcoholic fatty liver disease-related HCC is associated with greater surgical morbidity and post-hepatectomy liver failure. Despite this, long-term survival outcomes are favorable compared with non-NAFLD etiologies.

Oncological Outcomes of Hepatic Resection vs Transplantation for Localized Hepatocellular Carcinoma

BACKGROUND

Scarce data are available comparing outcomes of hepatic resection vs orthotopic liver transplantation (OLT) for localized hepatocellular carcinoma (HCC) patients both meeting and exceeding the Milan criteria. This study compared the clinical and oncological outcomes of patients undergoing hepatic resection vs transplantation localized HCC.

METHOD

Between January 2005 and February 2017, clinical and oncological outcomes of patients who underwent liver resection (n = 38) vs OLT (n = 28) for localized HCC were compared using a prospectively maintained database.

RESULTS

A total of 66 patients (with a median age of 62) who met the study criteria were analyzed. Comparable postoperative complications (13.2% vs 28.6%, P = .45) and perioperative mortality rates (7.9% vs 10.7%, P = .2) were noted for the resection vs OLT groups. While Child-Pugh Class A patients were more prevalent in the resection group (78.9% vs 7.1%, P = .0001), the rate of patients who met the Milan criteria was higher in the OLT group (89.3% vs 34.25, P = .0001). Recurrence rates were 36.8% in the resection group and 3.6% in the OLT group at the end of the median follow-up period (32 vs 39 months, respectively). The HCC-related mortality rate was significantly higher in the resection group (39.5% vs 10.7%, P = .034). However, a subgroup analysis of patients who met the Milan criteria revealed similar rates of recurrence and HCC-related mortality (15.4% vs 8%, P = .63). Based on logistic regression analysis, number of tumors (P = .034, odds ratio: 2.1) and "resection"-type surgery (P = .008, odds ratio: 20.2) were independently associated with recurrence.

CONCLUSION

Compared to liver transplantation, hepatic resection for localized hepatocellular carcinoma is associated with a higher rate of recurrence and disease-related mortality.