Preoperative predictors of liver decompensation after mini-invasive liver resection

Prognosis and safety of laparoscopic hepatectomy for BCLC stage 0/A hepatocellular carcinoma with clinically significant portal hypertension: a multicenter, propensity score-matched study

BACKGROUND AND AIM

The latest Barcelona Clinic Liver Cancer (BCLC) staging system suggests considering surgery in patients with resectable BCLC stage 0/A hepatocellular carcinoma (HCC) and clinically significant portal hypertension (CSPH). This study aimed to evaluate the safety and short- and long-term outcomes of laparoscopic hepatectomy for BCLC stage 0/A HCC patients with CSPH.

METHODS

We retrospectively reviewed the medical records of 647 HCC patients in BCLC stage 0/A who were treated at five centers between January 2010 and January 2019. Among these patients, 434 underwent laparoscopic hepatectomy, and 213 underwent open hepatectomy. We used Kaplan-Meier analysis to compare the overall survival (OS) rate and recurrence-free survival (RFS) rate between patients with and without CSPH before and after propensity score matching (PSM). Multivariate Cox regression analysis was performed to identify prognostic factors for BCLC stage 0/A patients, and subgroup analyses were also conducted.

RESULTS

Among the 434 patients who underwent laparoscopic hepatectomy, 186 had CSPH and 248 did not. The Kaplan-Meier analysis showed that the OS and RFS rates were significantly worse in the CSPH group before and after PSM. Multivariate Cox regression analyses identified CSPH as a prognostic factor for poor OS and RFS after laparoscopic hepatectomy. However, CSPH patients treated laparoscopically had a better short- and long-term prognosis than those treated with open surgery.

CONCLUSIONS

CSPH has a negative impact on the prognosis of BCLC stage 0/A HCC patients after laparoscopic hepatectomy. Laparoscopic hepatectomy is still recommended for treatment, but careful patient selection is essential.

Predictors of recurrence following laparoscopic minor hepatectomy for hepatocellular carcinoma in the UK

AIMS

Minor hepatectomy, which is increasingly carried out laparoscopically (LLR), is a cornerstone of curative treatment for hepatocellular carcinoma (HCC). The majority of relevant publications however originate from regions with endemic viral hepatitis. Although the incidence of HCC in the UK is increasing, little is known about outcomes following LLR.

METHODS

Consecutive patients undergoing minor (involving ≤2 segments) LLR or open resection (OLR) at our institute between 2014 and 2021 were compared. Selection from a plethora of factors potentially impacting on overall (OS) and disease free survival (DFS) was optimised with Lasso regression. To enable analysis of patients having repeat resection, multivariate frailty modelling was utilised to calculate hazard ratios (HR).

RESULTS

The analysis of 111 liver resections included 55 LLR and 56 OLR. LLR was associated with a shorter hospital stay (5 ± 2 vs. 7 ± 2 days; p < 0.001) and a lower comprehensive complication index (4.43 vs. 9.96; p = 0.006). Mean OS (52.3 ± 2.3 vs. 49.9 ± 3.0 months) and DFS (33.9 ± 3.4 vs. 36.5 ± 3.6 months; p = 0.59) were comparable between LLR and OLR, respectively (median not reached). Presence of mixed cholangiocarcinoma/HCC, satellite lesions and AFP level predicted OS and DFS. In addition tumour size was predictive of DFS.

CONCLUSIONS

In the studied population minor LLR was associated with shorter hospital stay and fewer complications while offering non-inferior long-term outcomes. A number of predictors for disease free survival have been elucidated that may aid in identifying patients with a high risk of disease recurrence and need for further treatment.

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.

Prognostic role of preoperative albumin-bilirubin score in posthepatectomy liver failure and mortality: a systematic review and meta-analysis

Posthepatectomy liver failure (PHLF) is a life-threatening complication after liver resection, resulting in an increased morbidity and mortality. Epidemiological evidence of the association between preoperative albumin-bilirubin (ALBI) score, a newly established model for assessing liver functional reserve, and the risk of PHLF and mortality remains controversial. A systematical search for relevant literature was performed in PubMed, Embase, and Web of Science databases from December 2014 to September 2020. Odds ratio (OR) value and 95% confidence interval (CI) were extracted or calculated to synthetically estimate the association of preoperative ALBI score with PHLF and mortality. Meta-analyses were performed using a random-effects model. Twelve studies with a total of 21,348 patients were included in this meta-analysis. It was indicated that, compared to patients with a lower preoperative ALBI grade, patients with a higher grade had a significantly elevated risk of PHLF (6 studies, 18,291 patients; OR = 2.48, 95%CI: 2.00-3.07) and mortality (4 studies15, 139 patients; OR = 2.35, 95% CI: 1.38-4.00). In addition, when it was expressed as a continuous variable, ALBI was also a significant predictor of PHLF (6 studies, 3,833 patients; OR = 3.16, 95% CI: 2.07-4.81, per 1-point increase in ALBI score). No significant publication biases were detected as suggested by funnel plots inspection and Begg's tests. The current meta-analysis demonstrates that preoperative elevated ALBI is associated with higher risk of PHLF and mortality after hepatectomy.

Prognostic Value of the Albumin-Bilirubin Grade for the Prediction of Post-Hepatectomy Liver Failure: A Systematic Review and Meta-Analysis

(1) Introduction: Liver resection (LR) for hepatocellular carcinoma (HCC) is often burdened by life-threatening complications, such as post-hepatectomy liver failure (PHLF). The albumin-bilirubin (ALBI) score can accurately evaluate liver function and the long-term prognosis of HCC patients, including PHLF. We aimed to evaluate the diagnostic value of the ALBI grade in predicting PHLF in HCC patients undergoing LR. (2) Methods: MEDLINE, Embase, and Scopus were searched through January 17th, 2021. Studies reporting the ALBI grade and PHLF occurrence in HCC patients undergoing LR were included. The Odds Ratio (OR) prevalence with 95% confidence intervals (CI) was pooled, and the heterogeneity was expressed as I2. The quality of the studies was assessed using QUADAS-2 (Quality Assessment of Diagnostic Accuracy Studies). (3) Results: Seven studies met the inclusion criteria and were included in the analysis. A total of 5377 patients who underwent LR for HCC were considered, of whom 718 (13.4%) developed PHLF. Patients with ALBI grades 2 and 3 before LR showed increased rates of PHLF compared to ALBI grade 1 patients. The pooled OR was 2.572 (95% CI, 1.825 to 3.626, p < 0.001), with substantial heterogeneity between the studies (I2 = 69.6%) and no publication bias (Begg's p = 0.764 and Egger's p = 0.851 tests). All studies were at a 'low risk' or 'unclear risk' of bias. Univariate meta-regression analysis showed that heterogeneity was not dependent on the country of study, the age and sex of the participants, the definition of PHLF used, the rate of patients in Child-Pugh class A or undergoing major hepatectomy. (4) Conclusions: In this meta-analysis of published studies, individuals with ALBI grades of 2 and 3 showed increased rates of PHLF compared to ALBI grade 1 patients.

[Minimally invasive liver surgery]

Minimally invasive liver surgery is safe and can be performed with results practically equal to those in open surgery. There are different techniques of parenchyma dissection and hemostasis available for the safe performance of minor and major resections, both laparoscopically and robotics based. Due to its technical options robotics-based surgery is a further development of laparoscopy. Expertise in minimally invasive and in liver surgery are essential prerequisites.

Minimally Invasive Stage 1 to Protect Against the Risk of Liver Failure: Results from the Hepatocellular Carcinoma Series of the Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy Italian Registry

Introduction: Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) has been described to treat hepatocellular carcinoma (HCC) but burdened, in its pioneering phase, by high morbidity and mortality. With the advent of minimally invasive (MI) techniques in liver surgery, surgical complications, including posthepatectomy liver failure (PHLF), have been dramatically reduced. The primary endpoint of this study was to compare the short-term outcomes of MI- versus open-ALPPS for HCC, with specific focus on PHLF. Methods: Data of patients submitted to ALPPS for HCC between 2012 and 2020 were identified from the ALPPS Italian Registry. Patients receiving an MI Stage 1 (MI-ALPPS) constituted the study group, whereas the patients who received an open Stage 1 (open-ALPPS) constituted the control group. Results: Sixty-six patients were enrolled from 12 Italian centers. Stage 1 of ALPPS was performed in 14 patients using an MI approach (21.2%). MI-ALPPS patients were discharged after Stage 1 at a significantly higher rate compared with open-ALPPS (78.6% versus 9.6%, P < .001). After Stage 2, major morbidity after MI-ALPPS was 8.3% compared with 28.6% reported after open-ALPPS. Mortality was nil after MI-ALPPS. Length of hospital stay was significantly shorter in MI-ALPPS (12 days versus 22 days, P < .001). Univariate logistic regression analysis (Firth method) found that both MI-ALPPS (odds ratio [OR] = 0.05, P = .040) and partial parenchymal transection (OR = 0.04, P = .027) were protective against PHLF. Conclusion: This national multicenter study showed that a less invasive approach to ALPPS first stage was associated with a lower overall risk of PHLF.