Previous research has demonstrated the impact of postoperative phosphate levels on liver regeneration and outcomes after liver resection surgeries, a potential predictor for regenerative success and ...liver failure. However, little is known about the association between low preoperative serum phosphate levels and outcomes in liver resections.
We performed a retrospective analysis of liver resections performed at our institution. Patients were categorized based on preoperative phosphate levels (low versus normal). Our primary outcome measure was posthepatectomy liver failure.
A total of 265 cases met the study criteria. 71 patients (26.7%) had low preoperative phosphate levels. The incidence of posthepatectomy liver failure was higher in the low preoperative phosphate group (19.2% versus 12.4%). However, after propensity score matching, rates of posthepatectomy liver failure were similar between low and normal preoperative phosphate cohorts (13% versus 14%, P = 0.83).
Low preoperative phosphate levels were not associated with worse postoperative outcomes in this study. Further studies are warranted to investigate this association and its relevance as a clinical prognostic factor for postoperative liver failure.
To compare different criteria for post-hepatectomy liver failure (PHLF) and evaluate the association between International Study Group of Liver Surgery (ISGLS) PHLF and the Comprehensive Complication ...Index (CCI)" and 90-day mortality.
PHLF is a serious complication following hepatic resection. Multiple criteria have been developed to characterize PHLF.
Adults who underwent major hepatectomies at twelve international centers (2010-2020) were included. We identified patients who met criteria for PHLF based on three definitions: 1) ISGLS, 2) Balzan (INR > 1.7 and bilirubin > 2.92mg/dL) or 3) Mullen (peak bilirubin >7mg/dL). We compared the 90-day mortality and major morbidity predicted by each definition. We then used logistic regression to determine the odds of CCI>40 and 90-day mortality associated with ISGLS grades.
Among 1646 included patients, 19 (1.1%) met Balzan, 68 (4.1%) met Mullen, and 444 (27.0%) met ISGLS criteria for PHLF. Of the three definitions, the ISGLS criteria best predicted 90-day mortality (AUC = 0.72; sensitivity 69.4%). Patients with ISGLS grades B&C were at increased odds of CCI > 40 (grade B OR 4.0; 95% CI: 2.2-7.2; grade C OR 137.0; 95% CI: 59.2-317.4). Patients with ISGLS grade C were at increased odds of 90-day mortality (OR 113.6; 95% CI: 55.6-232.1). Grade A was not associated with CCI> 40 or 90-day mortality.
In this diverse international cohort of major hepatectomies, ISGLS grade A was not associated with 90-day mortality or high CCI, calling into question the current classification of patients in this group as having clinically significant PHLF.
The aim of this study was to assess intraoperative changes of hepatic macrohemodynamics and their association with ascites and posthepatectomy liver failure (PHLF) after major hepatectomy.
...Large-scale ascites and PHLF remain clinical challenges after major hepatectomy. No study has concomitantly evaluated arterial and venous liver macrohemodynamics in patients undergoing liver resection.
Portal venous pressure (PVP), portal venous flow (PVF), and hepatic arterial flow (HAF) were measured intraoperatively pre- and postresection in 67 consecutive patients with major hepatectomy (ie, resection of ≥3 liver segments). A group of 30 patients with minor hepatectomy served as controls. Liver macrohemodynamics and their intraoperative changes (ie, Δ) were analyzed as predictive biomarkers of ascites and PHLF using Fisher exact, t test, or Wilcoxon rank sum test for univariate and logistic regression for multivariate analyses.
Major hepatectomy increased PVP by 26.9% (P = 0.001), markedly decreased HAF by 40.7% (P < 0.001), and slightly decreased PVF by 13.4% (P = 0.011). Minor resections had little effects on hepatic macrohemodynamics. There was no significant association of liver macrohemodynamics with ascites. While middle hepatic vein resection caused higher postresection PVP after right hepatectomy (P = 0.04), the Pringle maneuver was associated with a significant PVF (P = 0.03) and HAF reduction (P = 0.03). Uni- and multivariate analysis revealed an intraoperative PVP increase as an independent predictor of PHLF (P = 0.025).
Intraoperative PVP kinetics serve as independent predictive biomarker of PHLF after major hepatectomy. These data highlight the importance to assess intraoperative dynamics rather than the pre- and postresection PVP values.
Hyperbilirubinemia is known to increase morbidity and mortality in patients undergoing liver resection for cholangiocarcinoma (CCA). Preoperative biliary drainage (PBD) in patients who have no acute ...cholangitis or require portal vein embolization is still debatable. The goal of this study is to investigate how PBD affects the surgical results after liver resection.
Between October 2013 and December 2020, CCA patients presenting with obstructive jaundice who underwent liver resection were retrospectively reviewed. The pre-operative, peri-operative and post-operative characteristics were extracted. To compare the outcomes of the PBD and direct surgery groups, propensity score matching analysis (PSM) and multivariable risk regression analysis were used to analyze.
A total of 355 patients were enrolled, with 99 of them undergoing PBD. At diagnosis, those with PBD showed significantly greater bilirubin levels than those without (20.7 vs 9.6 mg/dL, p < 0.001). However, after drainage, the bilirubin level in the PBD group was lower than the direct surgery group (5.5 vs 9.6 mg/dL, p < 0.001). Overall postoperative morbidity and mortality were unaffected by PBD in full patient cohort. However, after PSM, PBD was associated with decreased major post-hepatectomy liver failure (PHLF) and 90-day mortality rate, (20.3% vs 39.24%, p = 0.014 and 3.8% vs 22.8%, p = 0.001, respectively). At multivariable analysis of PSM patient cohort, PBD was associated with decreased major post-operative complication (RR 0.64, 95%CI 0.419–0.986), PHLF (RR 0.40, 95%CI 0.227–0.705) and 90-day mortality (RR 0.21, 95%CI 0.086–0.629).
PBD was associated with decreased post-hepatectomy liver failure and postoperative mortality after liver resection in jaundiced CCA patients.
To evaluate the predictive value of portal vein pressure (PVP) after major liver resection for posthepatectomy liver failure (PLF) and 90-day mortality in patients without cirrhosis.
As elevated PVP ...is associated with liver failure after living donor liver transplantation, we hypothesized that the outcome after major hepatectomy may be influenced by posthepatectomy PVP.
All patients without severe fibrosis or cirrhosis who underwent a major liver resection (≥3 segments) with an intraoperative measurement of PVP at the end of the procedure were included. Outcome was analyzed regarding 3 most widely used definitions of PLF: "50-50" criteria, peak of serum bilirubin greater than 120 μmol/L, and grade C PLF proposed by the International Study Group of Liver Surgery (ISGLS). Receiver operating characteristic curves and logistic regression model were used to determine the optimal cutoff of PVP and independent risk factors of PLF.
The study population consisted of 277 patients. Posthepatectomy PVP was gradually correlated with the PLF risk. Probability for PLF was nil when PVP was 10 mm Hg or less, ranges from 13% to 16%, depending on PLF definitions, when PVP was 20 mm Hg, and from 24% to 33% when PVP was 30 mm Hg. The optimal value of posthepatectomy PVP to predict PLF was 22 mm Hg when considering the "50-50" criteria and grade C PLF (proposed by the International Study Group of Liver Surgery). A value of 21 mm Hg best predicted PLF defined by peak of serum bilirubin greater than 120 μmol/L and 90-day mortality. At multivariate analysis, posthepatectomy PVP remained an independent predictor of PLF as well as the extent of resection, intraoperative transfusion, and the presence of diabetes. The 90-day mortality was associated with PVP greater than 21 mm Hg, older than 70 years, and intraoperative transfusion.
Posthepatectomy PVP is an independent predictive factor of PLF and of 90-day mortality after major liver resection in patients without cirrhosis. Intraoperative modulation of PVP would be advisable when PVP exceeds 20 mm Hg.
Background
Assessing hepatic functional reserve before hepatectomy is beneficial to reduce the incidence of posthepatectomy liver failure (PHLF). This study aimed to compare the ability of the ...Child‐Pugh score, model for end‐stage liver disease (MELD) score, and retention test at 15 minutes (indocyanine green ICG‐R15) to assess hepatic functional reserve.
Methods
A total of 185 patients with hepatocellular carcinoma (HCC) undergoing hepatectomy were enrolled in this study. The ability of Child‐Pugh score, MELD score, and ICG‐R15 predicting severe PHLF were compared.
Results
A total of 23 patients (12.4%) developed severe PHLF. Multivariate analyses identified that platelet count, ICG‐R15, clinically significant portal hypertension, and major resection were independent factors for predicting severe PHLF. The area under the receiver operating characteristic curve of ICG‐R15 for predicting severe PHLF was higher than that of both Child‐Pugh score and MELD score. With an optimal cutoff value of 7.1%, the sensitivity and specificity of ICG‐R15 for predicting severe PHLF were 52.2% and 89.5%, respectively. Both the incidence of severe PHLF and mortality in patients with ICG‐R15 >7.1% were significantly higher than the figures for patients with ICG‐R15 ≤7.1%.
Conclusion
ICG‐R15 is more accurate than the Child‐Pugh score and MELD score in predicting hepatic functional reserve before hepatectomy.
Background
We assessed the usefulness of gadolinium ethoxybenzyl diethylenetriamine pentaacetic acid enhanced magnetic resonance imaging for the prediction of posthepatectomy liver failure (PHLF) ...after a major hepatectomy.
Methods
We reviewed 140 cases involving a hepatectomy of two or more sections between 2010 and 2016 (study cohort). We used the standardized remnant hepatocellular uptake index (SrHUI) which was calculated by: SrHUI = future remnant liver volume × (signal intensity of remnant liver on hepatobiliary phase images/signal intensity of spleen on hepatobiliary phase images) − 1/body surface area. Validation of the SrHUI was performed in another cohort of 52 major hepatectomy cases between 2017 and 2018 (validation cohort).
Results
The SrHUI of patients with PHLF was significantly lower than that of non‐PHLF cases. Receiver operating characteristic analysis and the Youden index revealed that the SrHUI cutoff value for the prediction of PHLF and PHLF grade ≥ B were 0.313 L/m2 and 0.257 L/m2, respectively. In the validation cohort, the cutoff value of SrHUI for the prediction of PHLF or PHLF grade ≥ B had a sensitivity of 75.0% or 88.8%, and specificity of 78.1% or 91.6%, respectively.
Conclusions
The SrHUI value is a predictor for PHLF after a major hepatectomy.
Highlight
Orimo and colleagues investigated the usefulness of EOB‐MRI for post‐hepatectomy liver failure (PHLF) after a major hepatectomy. The standardized remnant hepatocellular uptake index was significantly lower in PHLF cases than in non‐PHLF cases in the study cohort, and a predictor for PHLF after a major hepatectomy in the validation cohort.
Hepatectomy in patients with large tumor load may result in postoperative liver failure and associated complications due to excessive liver parenchyma removal. Conventional two-stage hepatectomy ...(TSH) and associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) technique are possible solutions to this problem. Colorectal liver metastases (CRLM) is the most frequent indication, and there is a need to assess outcomes for both techniques to improve surgical and long-term oncological outcomes in these patients.
A single-center retrospective study was designed to compare TSH with ALPPS in patients with initially unresectable bilateral liver tumors between January 2005 and January 2020. ALPPS was performed from January 2012 onwards as the technique of choice. Long-term overall survival (OS) and disease-free survival (DFS) were evaluated as primary outcome in CRLM patients. Postoperative morbidity, mortality and liver growth in all patients were also evaluated.
A total of 38 staged hepatectomies were performed: 17 TSH and 21 ALPPS. Complete resection rate was 76.5% (n = 13) in the TSH group and 85.7% (n = 18) in the ALPPS group (P = 0.426). Overall major morbidity (Clavien-Dindo ≥ 3a) (stage 1 + stage 2) was 41.2% (n = 7) in TSH and 33.3% (n = 7) in ALPPS patients (P = 0.389), and perioperative 90-day mortalities were 11.8% (n = 2) vs. 19.0% (n = 4) in each group, respectively (P = 0.654). Intention-to-treat OS rates at 1 and 5 years in CRLM patients for TSH (n = 15) were 80% and 33%, and for ALPPS (n = 17) 76% and 35%, respectively. DFS rates at 1 and 5 years were 36% and 27% in the TSH group vs. 33% and 27% in the ALPPS group, respectively.
ALPPS is an effective alternative to TSH in bilateral affecting liver tumors, allowing higher resection rate, but patients must be carefully selected. In CRLM patients similar long-term OS and DFS can be achieved with both techniques.
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