Liver Stiffness Assessed by Shear Wave Elastography Predicts Postoperative Liver Failure in Patients with Hepatocellular Carcinoma

Assessment of the postoperative prognosis in patients with hepatocellular carcinoma using vibration-controlled transient elastography: A systemic review and meta-analysis

BACKGROUNDS/AIMS

This meta-analysis examined whether preoperative vibration-controlled transient elastography (VCTE) can predict postoperative complications and recurrence in patients undergoing hepatic resection for hepatocellular carcinoma (HCC).

METHODS

A systematic literature search was conducted using Ovid-Medline, EMBASE, Cochrane, and KoreaMed databases. Out of 431 individual studies, thirteen published between 2008 and 2022 were included. Five studies focused on HCC recurrence, while eight examined postoperative complications.

RESULTS

The meta-analysis of five studies on HCC recurrence showed that the high-risk group with a high VCTE score had a significantly increased recurrence rate after hepatic resection (hazard ratio 2.14). The cutoff value of VCTE in the high-risk group of HCC recurrence was 7.4-13.4 kPa, the sensitivity was 0.60 (95% confidence interval [CI] 0.47-0.72), and the specificity was 0.60 (95% CI 0.46-0.72). The area under the receiver operating characteristic curve (AUC) of the liver stiffness measured by VCTE to predict the HCC recurrence was 0.63 (95% CI 0.59-0.67). The meta-analysis on the postoperative complications revealed a significantly increased risk of postoperative complications in the high-risk group (12-25.6 kPa) with a high VCTE value (odds ratio [OR], 8.32). The AUC of the liver stiffness measured by VCTE to predict the postoperative complications was 0.87 (95% CI 0.84-0.90), the sensitivity was 0.76 (95% CI 0.55-0.89) and the specificity was 0.85 (95% CI 0.73-0.92).

CONCLUSION

This meta-analysis suggests that preoperative VCTE in patients undergoing hepatic resection for HCC is useful in identifying individuals at a high risk of postoperative complications and HCC recurrence.

Preoperative Ultrasound Radomics to Predict Posthepatectomy Liver Failure in Patients With Hepatocellular Carcinoma

PURPOSE

Posthepatectomy liver failure (PHLF) is a major cause of postoperative mortality in hepatocellular carcinoma (HCC) patients. The study aimed to develop a method based on the two-dimensional shear wave elastography and clinical data to evaluate the risk of PHLF in HCC patients with chronic hepatitis B.

METHODS

This multicenter study proposed a deep learning model (PHLF-Net) incorporating dual-modal ultrasound features and clinical indicators to predict the PHLF risk. The datasets were divided into a training cohort, an internal validation cohort, an internal independent testing cohort, and three external independent testing cohorts. Based on ResNet50 pretrained on ImageNet, PHLF-Net used a progressive training strategy with images of varying granularity and incorporated conventional B-mode and elastography images and clinical indicators related to liver reserve function.

RESULTS

In total, 532 HCC patients who underwent hepatectomy at five hospitals were enrolled. PHLF occurred in 147 patients (27.6%, 147/532). The PHLF-Net combining dual-modal ultrasound and clinical indicators demonstrated high effectiveness for predicting PHLF, with AUCs of 0.957 and 0.923 in the internal validation and testing sets, and AUCs of 0.950, 0.860, and 1.000 in the other three independent external testing sets. The performance of PHLF-Net outperformed models of single- and dual-modal US.

CONCLUSIONS

Preoperative ultrasound imaging combining clinical indicators can effectively predict the PHLF probability in patients with HCC. In the internal and external validation sets, PHLF-Net demonstrated its usefulness in predicting PHLF.

Nomogram based on liver stiffness and spleen area with ultrasound for posthepatectomy liver failure: A multicenter study

BACKGROUND

Liver stiffness (LS) measurement with two-dimensional shear wave elastography (2D-SWE) correlates with the degree of liver fibrosis and thus indirectly reflects liver function reserve. The size of the spleen increases due to tissue proliferation, fibrosis, and portal vein congestion, which can indirectly reflect the situation of liver fibrosis/cirrhosis. It was reported that the size of the spleen was related to posthepatectomy liver failure (PHLF). So far, there has been no study combining 2D-SWE measurements of LS with spleen size to predict PHLF. This prospective study aimed to investigate the utility of 2D-SWE assessing LS and spleen area (SPA) for the prediction of PHLF in hepatocellular carcinoma (HCC) patients and to develop a risk prediction model.

AIM

To investigate the utility of 2D-SWE assessing LS and SPA for the prediction of PHLF in HCC patients and to develop a risk prediction model.

METHODS

This was a multicenter observational study prospectively analyzing patients who underwent hepatectomy from October 2020 to March 2022. Within 1 wk before partial hepatectomy, ultrasound examination was performed to measure LS and SPA, and blood was drawn to evaluate the patient's liver function and other conditions. Least absolute shrinkage and selection operator logistic regression and multivariate logistic regression analysis was applied to identify independent predictors of PHLF and develop a nomogram. Nomogram performance was validated further. The diagnostic performance of the nomogram was evaluated with receiver operating characteristic curve compared with the conventional models, including the model for end-stage liver disease (MELD) score and the albumin-bilirubin (ALBI) score.

RESULTS

A total of 562 HCC patients undergoing hepatectomy (500 in the training cohort and 62 in the validation cohort) were enrolled in this study. The independent predictors of PHLF were LS, SPA, range of resection, blood loss, international normalized ratio, and total bilirubin. Better diagnostic performance of the nomogram was obtained in the training [area under receiver operating characteristic curve (AUC): 0.833; 95% confidence interval (95%CI): 0.792-0.873; sensitivity: 83.1%; specificity: 73.5%] and validation (AUC: 0.802; 95%CI: 0.684-0.920; sensitivity: 95.5%; specificity: 52.5%) cohorts compared with the MELD score and the ALBI score.

CONCLUSION

This PHLF nomogram, mainly based on LS by 2D-SWE and SPA, was useful in predicting PHLF in HCC patients and presented better than MELD score and ALBI score.

An Interpretable Radiomics Model Based on Two-Dimensional Shear Wave Elastography for Predicting Symptomatic Post-Hepatectomy Liver Failure in Patients with Hepatocellular Carcinoma

OBJECTIVE

The aim of this study was to develop and validate an interpretable radiomics model based on two-dimensional shear wave elastography (2D-SWE) for symptomatic post-hepatectomy liver failure (PHLF) prediction in patients undergoing liver resection for hepatocellular carcinoma (HCC).

METHODS

A total of 345 consecutive patients were enrolled. A five-fold cross-validation was performed during training, and the models were evaluated in the independent test cohort. A multi-patch radiomics model was established based on the 2D-SWE images for predicting symptomatic PHLF. Clinical features were incorporated into the models to train the clinical-radiomics model. The radiomics model and the clinical-radiomics model were compared with the clinical model comprising clinical variables and other clinical predictive indices, including the model for end-stage liver disease (MELD) score and albumin-bilirubin (ALBI) score. Shapley Additive exPlanations (SHAP) was used for post hoc interpretability of the radiomics model.

RESULTS

The clinical-radiomics model achieved an AUC of 0.867 (95% CI 0.787-0.947) in the five-fold cross-validation, and this score was higher than that of the clinical model (AUC: 0.809; 95% CI: 0.715-0.902) and the radiomics model (AUC: 0.746; 95% CI: 0.681-0.811). The clinical-radiomics model showed an AUC of 0.822 in the test cohort, higher than that of the clinical model (AUC: 0.684, p = 0.007), radiomics model (AUC: 0.784, p = 0.415), MELD score (AUC: 0.529, p < 0.001), and ALBI score (AUC: 0.644, p = 0.016). The SHAP analysis showed that the first-order radiomics features, including first-order maximum 64 × 64, first-order 90th percentile 64 × 64, and first-order 10th percentile 32 × 32, were the most important features for PHLF prediction.

CONCLUSION

An interpretable clinical-radiomics model based on 2D-SWE and clinical variables can help in predicting symptomatic PHLF in HCC.

Predicting symptomatic post-hepatectomy liver failure in patients with hepatocellular carcinoma: development and validation of a preoperative nomogram

OBJECTIVE

To develop and validate a nomogram based on liver stiffness (LS) for predicting symptomatic post-hepatectomy (PHLF) in patients with hepatocellular carcinoma (HCC).

METHODS

A total of 266 patients with HCC were enrolled prospectively from three tertiary referral hospitals from August 2018 to April 2021. All patients underwent preoperative laboratory examination to obtain parameters of liver function. Two-dimensional shear wave elastography (2D-SWE) was performed to measure LS. Three-dimensional virtual resection obtained the different volumes including future liver remnant (FLR). A nomogram was developed by using logistic regression and determined by receiver operating characteristic (ROC) curve analysis and calibration curve analysis, which was validated internally and externally.

RESULTS

A nomogram was constructed with the following variables: FLR ratio (FLR of total liver volume), LS greater than 9.5 kPa, Child-Pugh grade, and the presence of clinically significant portal hypertension (CSPH). This nomogram enabled differentiation of symptomatic PHLF in the derivation cohort (area under curve [AUC], 0.915), internal fivefold cross-validation (mean AUC, 0.918), internal validation cohort (AUC, 0.876) and external validation cohort (AUC, 0.845). The nomogram also showed good calibration in the derivation, internal validation, and external validation cohorts (Hosmer-Lemeshow goodness-of-fit test, p = 0.641, p = 0.06, and p = 0.127, respectively). Accordingly, the safe limit of the FLR ratio was stratified using the nomogram.

CONCLUSION

An elevated level of LS was associated with the occurrence of symptomatic PHLF in HCC. A preoperative nomogram integrating LS, clinical and volumetric features was useful in predicting postoperative outcomes in patients with HCC, which might help surgeons in the management of HCC resection.

CLINICAL RELEVANCE STATEMENT

A serial of the safe limit of the future liver remnant was proposed by a preoperative nomogram for hepatocellular carcinoma, which might help surgeons in 'how much remnant is enough in liver resection'.

KEY POINTS

• An elevated liver stiffness with the best cutoff value of 9.5 kPa was associated with the occurrence of symptomatic post-hepatectomy liver failure in hepatocellular carcinoma. • A nomogram based on both quality (Child-Pugh grade, liver stiffness, and portal hypertension) and quantity of future liver remnant was developed to predict symptomatic post-hepatectomy liver failure for HCC, which enabled good discrimination and calibration in both derivation and validation cohorts. • The safe limit of future liver remnant volume was stratified using the proposed nomogram, which might help surgeons in the management of HCC resection.

Guidelines for the Diagnosis and Treatment of Primary Liver Cancer (2022 Edition)

Background

Primary liver cancer, of which around 75-85% is hepatocellular carcinoma in China, is the fourth most common malignancy and the second leading cause of tumor-related death, thereby posing a significant threat to the life and health of the Chinese people.

Summary

Since the publication of Guidelines for Diagnosis and Treatment of Primary Liver Cancer in China in June 2017, which were updated by the National Health Commission in December 2019, additional high-quality evidence has emerged from researchers worldwide regarding the diagnosis, staging, and treatment of liver cancer, that requires the guidelines to be updated again. The new edition (2022 Edition) was written by more than 100 experts in the field of liver cancer in China, which not only reflects the real-world situation in China but also may reshape the nationwide diagnosis and treatment of liver cancer.

Key Messages

The new guideline aims to encourage the implementation of evidence-based practice and improve the national average 5-year survival rate for patients with liver cancer, as proposed in the "Health China 2030 Blueprint."

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.

Predictive nomograms for postoperative 90-day morbidity and mortality in patients undergoing liver resection for various hepatobiliary diseases

BACKGROUND

Postoperative complications affect the long-term survival and quality of life in patients undergoing liver resection. No model has yet been validated to predict 90-day severe morbidity and mortality.

METHODS

The prospective recruitment of patients undergoing liver resection for various indications was performed. Preoperative clinical and laboratory data, including liver stiffness, indocyanine green retention, and intraoperative parameters, were analyzed to develop predictive nomograms for postoperative severe morbidity and mortality. Calibration plots were used to perform external validation.

RESULTS

The most common indications in 418 liver resections performed were colorectal metastases (N = 149 [35.6%]), hepatocellular carcinoma (N = 106 [25.4%]), and benign liver tumors (N = 60 [14.3%]). Major liver resections were performed in 164 (39.2%) patients. Severe morbidity and mortality were observed in 87 (20.8%) and 9 (2.2%) of patients, respectively, during the 90-day postoperative period. Post-hepatectomy liver failure was observed in 19 (4.5%) patients, resulting in the death of 4. The independent predictors of 90-day severe morbidity were age (odds ratio:1.02, P = .06), liver stiffness (odds ratio: 1.23, P = .04], number of resected segments (odds ratio: 1.28, P = .004), and operative time (odds ratio: 1.01, P = .01). Independent predictors of 90-day mortality were diabetes mellitus (odds ratio: 6.6, P = .04), tumor size >50 mm (odds ratio:4.8, P = .08), liver stiffness ≥22 kPa (odds ratio:7.0, P = .04), and operative time ≥6 hours (odds ratio: 6.1, P = .05). Nomograms were developed using these independent predictors and validated by testing the Goodness of fit in calibration plots (P = .64 for severe morbidity; P = .8 for mortality).

CONCLUSION

Proposed nomograms would enable a personalized approach to identifying patients at risk of complications and adapting surgical treatment according to their clinical profile and the center's expertise.

Predicting Post-hepatectomy Liver Failure Preoperatively for Child-Pugh A5 Hepatocellular Carcinoma Patients by Liver Stiffness

BACKGROUND

Post-hepatectomy liver failure (PHLF) represents the major source of mortality after liver resection (LR) in hepatocellular carcinoma (HCC) patients. Child-Pugh (CP) score 5 is always considered to indicate a normal liver function but represents a heterogeneous population with a considerable number suffering from PHLF. The present study aimed to access the ability of liver stiffness (LS) measured by two-dimensional shear wave elastography (2D-SWE) to predict PHLF in HCC patients with a CP score of 5.

METHODS

From August 2018 to May 2021, 146 HCC patients with a CP score of 5 who underwent LR were reviewed. The patients were randomly divided into training (n = 97) and validation (n = 49) groups. Logistic analyses were conducted for the risk factors and a linear model was built to predict the development of PHLF. The discrimination and calibration were assessed in the training and validation cohorts by the areas under the receiver operating characteristic curve (AUC).

RESULTS

Analyses revealed that the minimum of LS (Emin) higher than 8.05 (p = 0.006, OR = 4.59) and future liver remnant / estimated total liver volume (FLR/eTLV) (p < 0.001, OR < 0.01) were independent predictors of PHLF in HCC patients with CP score 5, and the AUC calculated by the model based on them for differentiation of PHLF in the training and validation group was 0.78 and 0.76, respectively.

CONCLUSION

LS was associated with the development of PHLF. A model combining Emin and FLR/eTLV showed proper ability in predicting PHLF in HCC patients with a CP score of 5.

Clinical application of preoperative shear wave dispersion for prediction of post liver failure in patients with hepatocellular carcinoma after hepatectomy

OBJECTIVE

The aim in this study was to determine the efficacy of shear wave dispersion (SWD) technique for the prediction of post hepatectomy liver failure (PHLF) in patients with hepatocellular carcinoma after hepatectomy and develop an SWD based risk prediction model.

METHODS & MATERIALS

We prospectively enrolled 205 consecutive patients who were scheduled to undergo hepatectomy for hepatocellular carcinoma (HCC), pre-operative SWD examination, laboratory data and some other clinicopathological tests were collected. The risk factors of PHLF were identified according to univariate and multivariate analysis, a predictive model was established based on logistic regression analyses.

RESULTS

SWD examination was successfully performed in 205 patients. PHLF occurred in 51 patients (24.9%), including 37/11/3 patients with Grade A/B/C, respectively. There was a high correlation between SWD value of liver and liver fibrosis stage (r = 0.873, p < 0.05). Patients with PHLF has a higher median SWD value of liver than patients without PHLF [17.4 vs 14.7 (m/s)/kHz, p < 0.05]. The SWD value of liver, total bilirubin (TB), international normalized ratio of prothrombin time (INR) and splenomegaly were significantly related to PHLF based on the multivariate analysis. A new prediction model (PM) for PHLF was established (PM = -12.918 + 0.183× SWD + 6.668× INR +0.100×TB+1.240×splenomegaly). The optimal cutoff value of SWD for predicting PHLF was 16.7 (m/s)/kHz. The area under the curve (AUC) of the PM for PHLF was 0.833, which was higher than that of SWD, INR, Forns, FIB4, APRI (p < 0.005, respectively).

CONCLUSION

SWD is a promising and reliable method for PHLF prediction in patients with HCC who were undergoing hepatectomy. Compared with SWD, Forns, APRI and FIB-4, PM demonstrate better efficacy for preoperative PHLF prediction.

Future liver volume combined with platelet count predicts liver failure after major hepatectomy

BACKGROUND

Major hepatectomy is associated with high incidence of post-hepatectomy liver failure (PHLF). This study aimed to evaluate the effect of future remnant liver volume combined with liver function tests on predicting PHLF.

METHODS

Patients who underwent major hepatectomy from April 2009 to May 2017 were enrolled in the training cohort. Univariate and multivariate logistic regression analyses were performed to identify independent risk factors of PHLF and generate a logistic regression model for the prediction of PHLF. A conditional inference tree was generated based on the optimal cutoff value of independent predictive factors of PHLF. The precedent results were validated in an independent cohort from June 2017 to March 2018.

RESULTS

One hundred and eighteen patients were included in the training cohort, while another 34 in the validation cohort. Future remnant liver volume/estimated standard total liver volume (FLV/eTV) and preoperative platelet count were independent predictive factors of PHLF (P = 0.0021 and P = 0.012, respectively). The conditional inference tree showed that patients with FLV/eTV ≤0.56 and PLT count ≤145 × 109/L were at high risk of developing PHLF.

CONCLUSION

FLV/eTV combined with preoperative PLT count is effective in predicting PHLF after major hepatectomy.

Clinical value of predictive models based on liver stiffness measurement in predicting liver reserve function of compensated chronic liver disease

BACKGROUND

Assessment of liver reserve function (LRF) is essential for predicting the prognosis of patients with chronic liver disease (CLD) and determines the extent of liver resection in patients with hepatocellular carcinoma.

AIM

To establish noninvasive models for LRF assessment based on liver stiffness measurement (LSM) and to evaluate their clinical performance.

METHODS

A total of 360 patients with compensated CLD were retrospectively analyzed as the training cohort. The new predictive models were established through logistic regression analysis and were validated internally in a prospective cohort (132 patients).

RESULTS

Our study defined indocyanine green retention rate at 15 min (ICGR15) ≥ 10% as mildly impaired LRF and ICGR15 ≥ 20% as severely impaired LRF. We constructed predictive models of LRF, named the mLPaM and sLPaM, which involved only LSM, prothrombin time international normalized ratio to albumin ratio (PTAR), age and model for end-stage liver disease (MELD). The area under the curve of the mLPaM model (0.855, 0.872, respectively) and sLPaM model (0.869, 0.876, respectively) were higher than that of the methods for MELD, albumin-bilirubin grade and PTAR in the two cohorts, and their sensitivity and negative predictive value were the highest among these methods in the training cohort. In addition, the new models showed good sensitivity and accuracy for the diagnosis of LRF impairment in the validation cohort.

CONCLUSION

The new models had a good predictive performance for LRF and could replace the indocyanine green (ICG) clearance test, especially in patients who are unable to undergo ICG testing.

Nomogram based on CT-derived extracellular volume for the prediction of post-hepatectomy liver failure in patients with resectable hepatocellular carcinoma

OBJECTIVES

This study aimed to develop and validate a nomogram based on extracellular volume (ECV) derived from computed tomography (CT) for predicting post-hepatectomy liver failure (PHLF) in patients with resectable hepatocellular carcinoma (HCC).

METHODS

A total of 202 patients with resectable HCC from two hospitals were enrolled and underwent multiphasic contrast-enhanced CT before surgery. One hundred twenty-one patients from our hospital and 81 patients from another hospital were assigned to the training cohort and the validation cohort, respectively. CT-derived ECV was measured using nonenhanced and equilibrium-phase-enhanced CT images. The nomogram was developed with independent predictors of PHLF. Predictive performance and calibration were assessed by receiver operator characteristic (ROC) analysis and Hosmer-Lemeshow test, respectively. The Delong test was used to compare the areas under the curve (AUCs).

RESULTS

CT-derived ECV had a strong correlation with the postoperative pathological fibrosis stage of the background liver (p < 0.001, r = 0.591). The nomogram combining CT-derived ECV, serum albumin (Alb), and serum total bilirubin (Tbil) obtained higher AUCs than the albumin-bilirubin (ALBI) score for predicting PHLF in both the training cohort (0.828 vs. 0.708; p = 0.004) and the validation cohort (0.821 vs. 0.630; p < 0.001). The nomogram showed satisfactory goodness of fit for PHLF prediction in the training and validation cohorts (p = 0.621 and 0.697, respectively).

CONCLUSIONS

The nomogram contributes to the preoperative prediction of PHLF in patients with resectable HCC.

KEY POINTS

• CT-derived ECV had a strong correlation with the postoperative pathological fibrosis stage of the background liver. • CT-derived ECV was an independent predictor of PHLF in patients with resectable HCC. • The nomogram based on CT-derived ECV showed a superior prediction efficacy than that of clinical models (including Child-Pugh stage, MELD score, and ALBI score).

Liver stiffness assessed by real-time two-dimensional shear wave elastography predicts hypersplenism in patients with Wilson's disease: a prospective study

Background

The current study aimed to explore the value of liver stiffness assessed by two-dimensional real-time shear wave elastography (2D-SWE) to predict hypersplenism occurrence in Wilson’s disease (WD) patients.

Methods

Ninety WD patients were enrolled in this prospective study between May 2018 and December 2018. Baseline clinical data and ultrasound imaging including 2D-SWE liver stiffness of WD patients were collected. After enrollment, patients had follow-ups for 24 months or until they developed hypersplenism. The hypersplenism risk factors were determined using Cox regressions and receiver operating characteristic curves (ROC).

Results

Twenty-nine (32.2%) patients developed hypersplenism. Age, portal vein diameter, and liver stiffness were independent hypersplenism risk factors in WD patients. The cutoff value of liver stiffness to predict hypersplenism was 10.45 kPa, with sensitivity and specificity of 75.9% and 73.8%, respectively. Patients were divided into two groups according to liver stiffness: ≥ 10.45 kPa (57.9% with hypersplenism) or < 10.45 kPa (13.5% with hypersplenism). The median time between enrollment and hypersplenism development was 15 months vs. 22 months (p < 0.001) for the two groups, respectively.

Conclusion

The measurement of liver stiffness by 2D-SWE can be a reliable hypersplenism predictor in WD patients. Therefore, dynamic monitoring of WD patients using 2D-SWE is crucial for the early diagnosis of hypersplenism.

Liver Stiffness Measured by Two-Dimensional Shear Wave Elastography for Predicting Symptomatic Post-hepatectomy Liver Failure in Patients with Hepatocellular Carcinoma

OBJECTIVES

To evaluate the ability of liver stiffness (LS) measured by two-dimensional shear wave elastography (2D SWE) to predict symptomatic post-hepatectomy liver failure (SPHLF) in patients with hepatocellular carcinoma (HCC).

METHODS

A total of 119 patients who underwent hepatectomy for HCC between August 2018 and July 2019 were enrolled. Preoperative assessments for LS and other clinicopathological tests were performed in all patients. Univariate and multivariate analyses were conducted for the risk factors of SPHLF. Further subgroup analysis was performed according to multivariate analysis results.

RESULTS

SPHLF occurred in 38 patients (31.9%). The best cutoff value of LS for predicting SPHLF was 9.5 kPa. Multivariate analysis identified LS ≥ 9.5 kPa, greater Child-Turcotte-Pugh (CTP) grade, and major hepatectomy as independent predictors of SPHLF. Based on the extent of hepatectomy, CTP grade could stratify the risk of SPHLF in the minor hepatectomy group (12.2% vs. 100.0%, p = 0.001), whereas LS was superior in predicting SPHLF in the major hepatectomy group (18.9% vs. 72.4%, p < 0.001). In patients with CTP grade A, LS could further stratify the risks of SPHLF in both the minor and major hepatectomy groups (3.7% vs. 22.7%, p = 0.043; 17.6% vs. 70.4%, p < 0.001, respectively).

CONCLUSIONS

LS measured using 2D SWE could predict SPHLF using the best cutoff value of 9.5 kPa. CTP grade was a stronger indicator of SPHLF in minor hepatectomy, whereas LS was more effective in selecting candidates for major hepatectomy. LS could further stratify the risk of SPHLF in CTP grade A patients, regardless of the extent of hepatectomy.

Development and Validation of a Nomogram Based on Perioperative Factors to Predict Post-hepatectomy Liver Failure

BACKGROUND AND AIMS

Post-hepatectomy liver failure (PHLF) is a severe complication and main cause of death in patients undergoing hepatectomy. The aim of this study was to build a predictive model of PHLF in patients undergoing hepatectomy.

METHODS

We retrospectively analyzed patients undergoing hepatectomy at Zhongshan Hospital, Fudan University from July 2015 to June 2018, and randomly divided them into development and internal validation cohorts. External validation was performed in an independent cohort. Least absolute shrinkage and selection operator (commonly referred to as LASSO) logistic regression was applied to identify predictors of PHLF, and multivariate binary logistic regression analysis was performed to establish the predictive model, which was visualized with a nomogram.

RESULTS

A total of 492 eligible patients were analyzed. LASSO and multivariate analysis identified three preoperative variables, total bilirubin (p=0.001), international normalized ratio (p<0.001) and platelet count (p=0.004), and two intraoperative variables, extent of resection (p=0.002) and blood loss (p=0.004), as independent predictors of PHLF. The area under receiver operating characteristic curve (referred to as AUROC) of the predictive model was 0.838 and outperformed the model for end-stage liver disease score, albumin-bilirubin score and platelet-albumin-bilirubin score (AUROCs: 0.723, 0.695 and 0.663, respectively; p<0.001 for all). The optimal cut-off value of the predictive model was 14.7. External validation showed the model could predict PHLF accurately and distinguish high-risk patients.

CONCLUSIONS

PHLF can be accurately predicted by this model in patients undergoing hepatectomy, which may significantly contribute to the postoperative care of these patients.

Quantitative Ultrasound Elastography Methods in Focal Liver Lesions Including Hepatocellular Carcinoma: From Diagnosis to Prognosis

ABSTRACT

The ability of ultrasound elastography to diagnose focal liver lesions and determine their prognoses including hepatocellular carcinoma (HCC) is unclear. At present, radiofrequency ablation and liver resection are the most common treatments for HCC. However, the survival rate remains disappointing because of recurrences and postoperative liver failure, necessitating the development of noninvasive approaches. There is currently no systematic definition of an elastic technique for measuring liver stiffness to predict the recurrence of HCC after radiofrequency ablation and postoperative liver failure. In this review, recent advances in ultrasound elastography for the diagnosis and prognosis of focal liver lesions are discussed including HCC.

Increase of Portal Vein Pressure Gradient After Hepatectomy Predicts Post-operative Liver Dysfunction

Background. Post-hepatectomy liver failure (PHLF) is an important cause of mortality and morbidity. Whether Child-Pugh A patients with varying degrees of cirrhosis are good candidates for hepatectomy is disputed. The purpose of this study was to analyze the impact of portal venous pressure gradient (PVPG) variation during surgery on PHLF. Methods. PVPG, the pressure gradient between the portal vein and central vein, was measured in consecutive patients before and after liver resection. The optimal cutoff of PVPG to predict PHLF was determined by receiver operating characteristic curve analysis. Risk factors for PHLF were subjected to univariate and multivariable analysis. Results. Sixty Child-Pugh A patients were recruited. The mean PVPG was increased from 5.17 ± 4.78 mm of mercury (mmHg) to 6.37 ± 4.44 mmHg after liver resection. The optimal cutoff value of PVPG increments to predict PHLF was 1.5 mmHg. Multivariable analysis showed prothrombin time (PT), post-hepatectomy PVPG increments of 1.5 mmHg or greater, and resected liver segments of 3 or more to be independent predictors of PHLF. Conclusions. Acute PVPG increase after hepatectomy is associated with a higher risk of PHLF in Child-Pugh A patients.

Simulation of portal/hepatic vein associated remnant liver ischemia/congestion by three-dimensional visualization technology based on preoperative CT scan

Background

Remnant liver hypoperfusion is frequently observed after hepatectomy, and associated with a higher risk of postoperative complications and poorer survival. However, the development of remnant liver hypoperfusion was not fully understood.

Methods

We retrospectively analyzed patients who received hepatectomy and took contrast-enhanced computed tomography (CT) scans before, 1-week (POW1) and 4-week (POW4) after resection in our department from June 2017 to July 2019. We simulated and estimated the occurrence of portal-vein-related remnant liver ischemia (RLI) and hepatic-vein-related remnant liver congestion (RLC) after hepatectomy via three-dimensional visualization technology (3DVT) according to blood vessels ligated in the resection; then we analyzed association between the estimated RLI, RLC, and postoperative clinical outcomes.

Results

A total of 102 eligible patients were analyzed. Remnant liver hypoperfusion was observed in 47 (46%) patients in the POW1 CT scans and shrunk in the POW4 CT scans. RLC had better diagnostic significance than RLI in predicting remnant liver hypoperfusion [area under receiver operating characteristic (ROC) curve: 0.745 vs. 0.569, P=0.026]. Multivariate analysis showed that larger RLI [odds ratio (OR), 1.154; 95% confidence interval (CI), 1.075-1.240; P<0.001] was independent risk factor for post-hepatectomy liver failure (PHLF). Besides, larger RLC (OR, 1.114; 95% CI, 1.032-1.204; P=0.006) was independent risk factor for major postoperative complications.

Conclusions

Remnant liver hypoperfusion can be predicted during the preoperative surgical plan by 3DVT. Portal vein related RLI was associated with PHLF, and hepatic vein related RLC was associated with major postoperative complications. Preservation of the hepatic vein and complete removal of the perfusion territory of ligated vessels are essential procedures to reduce RLI/RLC and the risk of PHLF or other surgical complications.

Comparison between preoperative two-dimensional shear wave elastography and indocyanine green clearance test for prediction of post-hepatectomy liver failure

Background

Post-hepatectomy liver failure (PHLF) is one of the most serious complications and major causes of liver resection mortality. The purpose of this study is to investigate and compare the performance of preoperative two-dimensional shear wave elastography (2D-SWE) and the indocyanine green (ICG) clearance test for the prediction of PHLF.

Methods

A total of 172 consecutive patients who were undergoing major liver resection were prospectively identified. Patients were evaluated by preoperative 2D-SWE and ICG clearance test. According to the International Study Group of Liver Surgery (ISGLS) recommendations, No PHLF, PHLF A, PHLF B, and PHLF C group classifications were defined. The differences in liver stiffness value (LSV) and ICG retention rate at 15 minutes (ICGR15) among the different PHLF classifications were investigated. The performance of LSV and ICGR15 for diagnosing different classifications of PHLF was compared.

Results

PHLF occurred in 43 (25.0%) patients, and 24 (14.0%) patients were grade A, 14 (8.1%) were grade B, and 5 (2.9%) were grade C. Both LSV and ICGR15 of the PHLF C group were significantly higher than those of the No PHLF group (P=0.025, P=0.001, respectively). According to univariate and multivariate logistic regression analysis, LSV and ICGR15 were significantly related to PHLF (P=0.051, P=0.084, respectively). For diagnosis of ≥ PHLF A, ≥ PHLF B, and ≥ PHLF C, the areas under the receiver operating characteristic curve (AUCs) for 2D-SWE were 0.624 [95% confidence interval (CI): 0.536-0.712, P=0.015], 0.699 (95% CI: 0.576-0.821, P=0.005), and 0.831 (95% CI: 0.737-0.925, P=0.01), respectively. The AUCs of the ICG clearance test were 0.631 (95% CI: 0.542-0.721, P=0.01), 0.570 (95% CI: 0.436-0.704, P=0.32), and 0.717 (95% CI: 0.515-0.920, P=0.098), respectively. The AUC of LSV for the diagnosis of ≥ PHLF A was comparable to that of ICGR15 (P=0.17). The AUCs of LSV were significantly higher than those of ICGR15 for the diagnosis of ≥ PHLF B (P=0.002) and C (P=0.038).

Conclusions

2D-SWE demonstrates the potential to aid in the prediction of the severity of PHLF. Our findings also suggest that the performance of 2D-SWE is better than the ICG clearance test.

Comparison of preoperative two-dimensional shear wave elastography, indocyanine green clearance test and biomarkers for post hepatectomy liver failure prediction in patients with hepatocellular carcinoma

Background

The preoperative prediction of post hepatectomy liver failure (PHLF) is essential, but there is no gold standard for the prediction at present, and the efficacy of different methods for the prediction has not been compared systematically. In this study, we aimed to compare the efficacy of preoperative two-dimensional shear wave elastography (2D-SWE), indocyanine green (ICG) clearance test and biomarkers for PHLF prediction in patients with hepatocellular carcinoma (HCC).

Methods

We retrospectively studied 215 patients with HCC, who had undergone major liver resection in our hospital. Preoperative data of each patient, including liver stiffness value (LSV) of underlying hepatic parenchyma measured by 2D-SWE, ICG retention rate at 15 min (ICG-R15) measured by ICG clearance test, albumin-bilirubin (ALBI) scores, aspartate aminotransferase–platelet ratio index (APRI), and Fibrosis-4 (FIB-4) were collected for analysis. Post hepatectomy outcomes of study patients were also recorded for assessment of PHLF. The study patients were divided into development cohort (133 patients without PHLF, and 17 patients with PHLF) and validation cohort (59 patients without PHLF, and 6 patients with PHLF) randomly.

Results

In the development cohort, LSV, ICG-R15 and ALBI scores were significantly different between patients with and without PHLF, while no significant difference of APRI and FIB-4 scores was found. LSV had higher AUC (the area under the receiver operating characteristic curve) (AUC = 0.795) for PHLF prediction than ICG-R15 (AUC = 0.619) and ALBI scores (AUC = 0.686) (p < 0.05 for all comparisons). In the validation cohort, the cutoff value of LSV obtained from the development cohort, 10.35 kPa,  revealed higher specificity (76.3%) for PHLF prediction than ICG-R15 (specificity: 66.1%) and ALBI scores (specificity: 69.5%) (p < 0.0001).

Conclusions

Compared with ICG-R15, ALBI scores, APRI and FIB-4, LSV measured by 2D-SWE may demonstrate better efficacy for preoperative PHLF prediction in patients with HCC.

Development and validation of a nomogram combining hematological and imaging features for preoperative prediction of microvascular invasion in hepatocellular carcinoma patients

Background

Microvascular invasion (MVI) is a significant hazard factor that influences the recurrence and survival of hepatocellular carcinoma (HCC) patients after undergoing hepatectomy. This study aimed to develop and validate a nomogram that combines hematological and imaging features of HCC patients to preoperatively predict MVI, and investigate the effect of wide resection margin (≥1 cm) on the prognosis of MVI-positive HCC patients.

Methods

A total of 709 HCC patients who underwent hepatectomy at the Liver Cancer Institute of Zhongshan Hospital, Fudan University between June 1, 2015 and December 30, 2016 were included in this study and divided into training (496 patients) and validation cohort (213 patients). Least absolute shrinkage and selection operator (Lasso) regression and multivariable logistic regression were used for variables’ selection and development of the predictive model. The model was presented as a nomogram, and its performance was assessed in terms of discrimination, calibration and clinical usefulness.

Results

Independent prognostic factors such as alkaline phosphatase (ALP, >125 U/L), alpha-fetoprotein (AFP, within 20–400 or >400 ng/mL), protein induced by vitamin K absence-II (PVIKA-II, within 40–400 or >400 mAU/mL), tumor number, diameter, pseudo-capsule, tumor growth pattern and intratumor hemorrhage were incorporated in the nomogram. The model showed good discrimination and calibration, with a concordance index (0.82, 95% CI, 0.782–0.857) in the training cohort and C-index (0.80, 95% CI, 0.772–0.837) in the validation cohort. Decision curve analysis (DCA) also showed that this model is clinically useful. Moreover, HCC patients with wide resection margin had a significantly lower 3-year recurrence rate than those with narrower resection margin (0.5–1 cm).

Conclusions

This study presents an optimal model for preoperative prediction of MVI and shows that wide resection margin for MVI-positive HCC patients has a better prognosis. This model can help surgeons choose the best treatment options for HCC patients before and after the operation.

Guidelines for the Diagnosis and Treatment of Hepatocellular Carcinoma (2019 Edition)

BACKGROUND

Primary liver cancer, around 90% are hepatocellular carcinoma in China, is the fourth most common malignancy and the second leading cause of tumor-related death, thereby posing a significant threat to the life and health of the Chinese people.

SUMMARY

Since the publication of Guidelines for Diagnosis and Treatment of Primary Liver Cancer (2017 Edition) in 2018, additional high-quality evidence has emerged with relevance to the diagnosis, staging, and treatment of liver cancer in and outside China that requires the guidelines to be updated. The new edition (2019 Edition) was written by more than 70 experts in the field of liver cancer in China. They reflect the real-world situation in China regarding diagnosing and treating liver cancer in recent years.

KEY MESSAGES

Most importantly, the new guidelines were endorsed and promulgated by the Bureau of Medical Administration of the National Health Commission of the People's Republic of China in December 2019.

Shear wave elastography for evaluation of the urgency of liver transplantation in pediatric patients with biliary atresia

BACKGROUND

To investigate the role of two-dimensional shear wave elastography (2D-SWE) in the preoperative evaluation of pediatric patients with biliary atresia awaiting liver transplantation.

METHODS

Among a total of 152 pediatric patients enrolled in this single-institution prospective study between March 2018 and August 2019, 143 patients (age range, 4-97 months; median age, 7 months; 84 males, 59 females) who underwent successful routine ultrasound examination, SWE examination, and blood test before liver transplantation were included in the final analysis. The values of liver stiffness measured by SWE were compared with ultrasound and blood test parameters by Spearman's correlation analysis.

RESULTS

The overall median liver stiffness with 2D-SWE was 29.0 ± 10.9 kPa, with a range of 9.0-53.3 kPa. The success rate of 2D-SWE measurements was 98.0% (149/152). Liver stiffness measurement (LSMs) had no significant correlation with gender, age, weight, and height of the pediatric recipients. LSMs were correlated with ultrasound parameters including portal vein (PV) maximum velocity, PV direction, hepatic artery resistance index (HARI), spleen diameter, ascites, and blood test parameters (albumin level, platelet count level, and international normalized ratio). In the pediatric recipients with hepatofugal PV flow, high HARI (HARI ≧ 0.90), and ascites, or without Kasai operation, LSMs were significantly higher (P < .05).

CONCLUSIONS

SWE is feasible and valuable for assessing liver damage in children with biliary atresia awaiting liver transplantation and might be used as selection criteria for children in need of priority access to liver transplantation.

Quantitative ultrasound elastography and serum ferritin level in dogs with liver tumors

Objective:

The objective of this study was to assess the serum ferritin level and quantitate ultrasound elastography as a marker to distinguish dogs with benign and malignant liver tumors.

Materials and Methods:

Twenty-eight dogs were determined the serum ferritin and ultrasound elastography by using fine-needle aspiration biopsy.

Results:

Our results demonstrated that dogs with malignant liver tumors had significantly higher mean serum ferritin concentrations than those with benign liver tumors (p = 0.004). The mean intensity of blue and red colors from elastography was greater in the malignant than those in the benign group, especially for the blue color, meaning that lesions showed more hard tissue. Additionally, histograms of blue color in the malignant tended to be higher than the benign group.

Conclusion:

We suggested that quantitative ultrasound elastography and serum ferritin concentration comprise an alternative and non-invasive diagnostic method that could be used to predict the type of liver tumors in dogs.

Noninvasive Diagnostics for Portal Hypertension: A Comprehensive Review

Noninvasive diagnostics for portal hypertension include imaging and functional tests, as well as blood-based biomarkers, and capture different features of the portal hypertensive syndrome. Definitive conclusions regarding their clinical utility require assessment of their diagnostic value in specific clinical settings (i.e., diagnosing a particular hemodynamic condition within a well-defined target population). Several noninvasive methods are predictive of clinically significant portal hypertension (CSPH; hepatic venous pressure gradient [HVPG] ≥ 10 mm Hg; the threshold for complications of portal hypertension); however, only a minority of them have been evaluated in compensated advanced chronic liver disease (i.e., the target population). Importantly, most methods correlate only weakly with HVPG at high values (i.e., in patients with CSPH). Nevertheless, selected methods show promise for diagnosing HVPG ≥ 16 mm Hg (the cut-off for increased risks of hepatic decompensation and mortality) and monitoring HVPG changes in response to nonselective beta-blockers or etiological treatments. Finally, we review established and potential future clinical applications of noninvasive methods.

Diagnostic performance on multiple parameters of real-time ultrasound shear wave elastography for evaluating nonalcoholic fatty liver disease: A rabbit model

OBJECTIVE

To study the diagnostic value of real-time ultrasound shear wave elastography (US-SWE) in evaluating the histological stages of nonalcoholic fatty liver disease (NAFLD) in a rabbit model.

MATERIALS AND METHODS

Twenty-one 8-week-old rabbits were fed a high-fat, high-cholesterol diet (experimental groups), and seven rabbits were fed a standard diet (control group). All rabbits underwent real-time US-SWE at various time points to document the histological stages of NAFLD. We categorized the histological stages as normal, NAFL, borderline nonalcoholic steatohepatitis (NASH), and NASH. We measured the elastic modulus of the liver parenchyma and analyzed the diagnostic efficacy of real-time US-SWE using the area under receiver operating characteristic curve (AUC) for the four histological stages.

RESULTS

The mean, minimum, and maximum elastic modulus increase for NAFL, borderline NASH, and NASH. For the mean, minimum, and maximum elastic modulus, AUCs are 0.891 (95% confidence interval [CI]: 0.716-0.977), 0.867 (95% CI: 0.686-0.965), and 0.789 (95% CI:0.594-0.919) for differentiating normal liver from liver with NAFLD, respectively; AUCs are 0.846 (95% CI: 0.660-0.954), 0.818 (95% CI: 0.627-0.937), and 0.797 (95% CI:0.627-0.913) for differentiating normal liver or liver with NAFL from liver with borderline NASH or NASH, respectively; AUCs are 0.889 (95% CI: 0.713-0.976), 0.787 (95% CI: 0.591-0.918), and 0.895 (95% CI:0.720-0.978) for differentiating liver with NASH from liver with lower severity NAFLD or normal liver, respectively.

CONCLUSIONS

Real-time US-SWE is an accurate, noninvasive technique for evaluating the histological stages of NAFLD by measuring liver stiffness. We recommend using the mean elastic modulus to differentiate the histological stages, with the minimum and maximum elastic modulus as valuable complements.

Serum Wisteria floribunda agglutinin-positive human Mac-2 binding protein level predicts recurrence of hepatitis B virus-related hepatocellular carcinoma after curative resection

Background/Aims

To investigate whether serum Wisteria floribunda agglutinin-positive human Mac-2-binding protein (WFA⁺-M2BP) can predict the recurrence of hepatitis B virus (HBV)-related hepatocellular carcinoma (HCC) after curative resection.

Methods

Patients with chronic hepatitis B (CHB) who underwent curative resection for HCC between 2004 and 2015 were eligible for the study. Recurrence was sub-classified as early (<2 years) or late (≥2 years).

Results

A total of 170 patients with CHB were selected. During the follow-up period (median, 22.6 months), 64 (37.6%) patients developed recurrence. In multivariate analyses, WFA⁺-M2BP level was an independent predictor of overall (hazard ratio [HR]=1.490), early (HR=1.667), and late recurrence (HR=1.416), together with male sex, des-gamma carboxyprothrombin level, maximal tumor size, portal vein invasion, and satellite nodules (all P<0.05). However, WFA⁺-M2BP level was not predictive of grade B-C posthepatectomy liver failure. The cutoff value that maximized the sum of sensitivity (30.2%) and specificity (90.6%) was 2.14 (area under receiver operating characteristic curve=0.632, P=0.010). Patients with a WFA⁺-M2BP level >2.14 experienced recurrence more frequently than those with a WFA⁺-M2BP level ≤2.14 (P=0.011 by log-rank test), and had poorer postoperative outcomes than those with a WFA⁺-M2BP level ≤2.14 in terms of overall recurrence (56.0 vs. 34.5%, P=0.047) and early recurrence (52.0 vs. 20.7%, P=0.001).

Conclusions

WFA⁺-M2BP level is an independent predictive factor of HBV-related HCC recurrence after curative resection. Further studies should investigate incorporation of WFA⁺-M2BP level into tailored postoperative surveillance strategies for patients with CHB.

Dexamethasone for postoperative hyperbilirubinemia in patients after liver resection: An open-label, randomized controlled trial

BACKGROUND

Although prophylactic glucocorticoids have been used before liver resection to minimize liver dysfunction, it is unknown whether treatment with glucocorticoids will accelerates recovery from hyperbilirubinemia after liver resection.

METHODS

In this open-label, randomized, controlled trial, patients with hyperbilirubinemia (>2.5 × and ≤5 × the upper limit of normal) within 7 days after hepatic resection were assigned randomly to the dexamethasone or control groups. For the dexamethasone group, 10 mg, 10 mg, and 5 mg dexamethasone were administered intravenously on days 0, 1, and 2, respectively, after randomization. For the control group, patients received standard treatment only. The primary outcome was time to recovery from hyperbilirubinemia defined as the period from the day of randomization to the day when serum bilirubin decreased to ≤1.5 times that of the upper limit of normal. Secondary outcomes were the prevalence of postoperative complications, postoperative hospital stay, and hospital expense.

RESULTS

Between March 2016 and December 2017, 76 participants were enrolled (38 in each group). Median time to recovery from hyperbilirubinemia was less in the dexamethasone group than in the control group (2 vs 4 days, P < .001). Serum bilirubin levels were less in the dexamethasone group on days 1-3 after randomization (P < .05). The prevalence of infection, posthepatectomy liver failure, postoperative hospital stay, and hospital expense were not different between the groups.

CONCLUSION

Dexamethasone accelerated recovery from hyperbilirubinemia and decreased serum bilirubin levels without causing more side effects in patients after hepatectomy.

Comparison of Models for Predicting Quality of Life After Surgical Resection of Hepatocellular Carcinoma: a Prospective Study

BACKGROUND

The essential issue of internal validity has not been adequately addressed in prediction models such as artificial neural network (ANN), support vector machine (SVM), Gaussian process regression (GPR), and multiple linear regression (MLR) models.

METHODS

This prospective study compared the accuracy of these four models in predicting quality of life (QOL) after hepatic resection received by 332 patients with hepatocellular carcinoma (HCC) during 2012-2015. An estimation subset was used to train the models, and a validation subset was used to evaluate their performance. Sensitivity score approach was also used to assess the relative significance of input parameters in the system models.

RESULTS

The ANN model had significantly higher performance indicators compared to the SVM, GPR, and MLR models (P < 0.05). Additionally, the ANN prediction of QOL at 6 months after hepatic resection significantly correlated with age, gender, marital status, Charlson comorbidity index (CCI) score, chemotherapy, radiotherapy, hospital volume, surgeon volume, and preoperational functional status (P < 0.05). Preoperational functional status was the most influential (sensitive) variable affecting sixth-month QOL followed by surgeon volume, hospital volume, age, and CCI score.

CONCLUSIONS

The comparisons showed that, in preoperative and postoperative healthcare consultations with HCC surgery candidates, QOL at 6 months post-surgery should be estimated with an ANN model rather than with SVM, GPR, or MLR models. The best QOL predictors identified in this study can also be used to educate candidates for HCC surgery in the expected course of recovery and other surgical outcomes.

Prognostic value of liver stiffness measurement for the liver-related surgical outcomes of patients under hepatic resection: A meta-analysis

BACKGROUND

Previous studies have discussed the liver stiffness measurement (LSM) performance on predicting liver-related surgical outcomes for patients of hepatocellular carcinoma (HCC) under hepatic resection, yet there is much variation in reporting and consistency of findings. Therefore, we report a meta-analysis on this issue.

METHODS

We comprehensively searched PubMed, Embase, and Web of science to find the eligible cohort studies. The pooled Odds Ratios (OR) and 95% confidence intervals (CIs) were calculated to evaluate effect. The weighted mean LSM value was calculated as the optimal LSM cut-off value among studies.

RESULTS

12 prospective cohort studies and one retrospective cohort study, including a total of 1942 cases were identified. The pooled results showed that preoperative LSM is significantly associated with the occurrence of overall postoperative complications (OR 1.76, 95% CI 1.46-2.11). In addition, a weighted mean LSM value of 14.2 kPa and 11.3KPa were suggested as the optimal LSM cut-off value reference using transient elastoqraphy (TE) for predicting overall postoperative complications in Asia countries and European countries, respectively.

CONCLUSIONS

Preoperative LSM should be taken into account cautiously in the management of patients undergoing hepatectomy of HCC. Future studies could focus on setting a prognostic model integrated with LSM in predicting post-hepatectomy outcomes.

Supersonic shear imaging for the diagnosis of liver fibrosis and portal hypertension in liver diseases: a meta-analysis

BACKGROUND AND AIMS

The meta-analysis aimed to summarize the technical success rate of supersonic shear imaging (SSI) and to evaluate the diagnostic performance of liver and spleen stiffness measurement (LSM and SSM) with SSI for the detection of liver fibrosis, portal hypertension, and gastroesophageal varices in liver diseases.

METHODS

PubMed, EMBASE, and Cochrane Library databases were searched. Technical success rate of SSI was pooled. Area under curve (AUC), sensitivity, and specificity with corresponding 95% confidence interval (CI) were calculated.

RESULTS

Included studies regarding the diagnostic performance of SSI for liver fibrosis, portal hypertension, and esophageal varices numbered 28, 4, and 4 respectively. The pooled technical success rates of LSM and SSM were 95.3% and 75.5%, respectively. The AUC, sensitivity, and specificity of LSM/SSM for different stages of liver fibrosis were 0.85-0.94, 0.7-0.89, and 0.82-0.92, respectively. The AUC, sensitivity, and specificity of LSM were 0.84 (95%CI = 0.8-0.86), 0.79 (95%CI = 0.7-0.85), and 0.82 (95%CI = 0.72-0.88) for clinically significant portal hypertension, 0.85 (95%CI = 0.82-0.88), 0.8 (95%CI = 0.68-0.88), and 0.8 (95%CI = 0.6-0.92) for any varices, and 0.86 (95%CI = 0.83-0.89), 0.86 (95%CI = 0.76-0.92), and 0.61 (95%CI = 0.35-0.83) for high-risk varices, respectively.

CONCLUSIONS

LSM with SSI had a high diagnostic accuracy for liver fibrosis, but a moderate diagnostic accuracy for portal hypertension and esophageal varices.

Computational Modeling in Liver Surgery

The need for extended liver resection is increasing due to the growing incidence of liver tumors in aging societies. Individualized surgical planning is the key for identifying the optimal resection strategy and to minimize the risk of postoperative liver failure and tumor recurrence. Current computational tools provide virtual planning of liver resection by taking into account the spatial relationship between the tumor and the hepatic vascular trees, as well as the size of the future liver remnant. However, size and function of the liver are not necessarily equivalent. Hence, determining the future liver volume might misestimate the future liver function, especially in cases of hepatic comorbidities such as hepatic steatosis. A systems medicine approach could be applied, including biological, medical, and surgical aspects, by integrating all available anatomical and functional information of the individual patient. Such an approach holds promise for better prediction of postoperative liver function and hence improved risk assessment. This review provides an overview of mathematical models related to the liver and its function and explores their potential relevance for computational liver surgery. We first summarize key facts of hepatic anatomy, physiology, and pathology relevant for hepatic surgery, followed by a description of the computational tools currently used in liver surgical planning. Then we present selected state-of-the-art computational liver models potentially useful to support liver surgery. Finally, we discuss the main challenges that will need to be addressed when developing advanced computational planning tools in the context of liver surgery.