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Vaghiri S, Lehwald-Tywuschik N, Prassas D, Safi SA, Kalmuk S, Knoefel WT, Dizdar L, Alexander A. Predictive factors of 90-day mortality after curative hepatic resection for hepatocellular carcinoma: a western single-center observational study. Langenbecks Arch Surg 2024; 409:149. [PMID: 38698255 PMCID: PMC11065924 DOI: 10.1007/s00423-024-03337-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Accepted: 04/24/2024] [Indexed: 05/05/2024]
Abstract
PURPOSE The aim of this study was to identify predictive risk factors associated with 90-day mortality after hepatic resection (HR) in hepatocellular carcinoma (HCC). METHODS All patients undergoing elective resection for HCC from a single- institutional and prospectively maintained database were included. Multivariate regression analysis was conducted to identify pre- and intraoperative as well as histopathological predictive factors of 90-day mortality after elective HR. RESULTS Between August 2004 and October 2021, 196 patients were enrolled (148 male /48 female). The median age of the study cohort was 68.5 years (range19-84 years). The rate of major hepatectomy (≥ 3 segments) was 43.88%. Multivariate analysis revealed patient age ≥ 70 years [HR 2.798; (95% CI 1.263-6.198); p = 0.011], preoperative chronic renal insufficiency [HR 3.673; (95% CI 1.598-8.443); p = 0.002], Child-Pugh Score [HR 2.240; (95% CI 1.188-4.224); p = 0.013], V-Stage [HR 2.420; (95% CI 1.187-4.936); p = 0.015], and resected segments ≥ 3 [HR 4.700; (95% 1.926-11.467); p = 0.001] as the major significant determinants of the 90-day mortality. CONCLUSION Advanced patient age, pre-existing chronic renal insufficiency, Child-Pugh Score, extended hepatic resection, and vascular tumor involvement were identified as significant predictive factors of 90-day mortality. Proper patient selection and adjustment of treatment strategies could potentially reduce short-term mortality.
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Affiliation(s)
- Sascha Vaghiri
- Department of Surgery (A), Heinrich-Heine-University and University Hospital Duesseldorf, Duesseldorf, Germany
| | - Nadja Lehwald-Tywuschik
- Department of Surgery (A), Heinrich-Heine-University and University Hospital Duesseldorf, Duesseldorf, Germany
| | - Dimitrios Prassas
- Department of Surgery (A), Heinrich-Heine-University and University Hospital Duesseldorf, Duesseldorf, Germany
- Department of Surgery, Katholisches Klinikum Essen, Philippusstift, Teaching Hospital of Duisburg-Essen University, Huelsmannstrasse 17, 45355, Essen, Germany
| | - Sami Alexander Safi
- Department of Surgery (A), Heinrich-Heine-University and University Hospital Duesseldorf, Duesseldorf, Germany
| | - Sinan Kalmuk
- Department of Surgery (A), Heinrich-Heine-University and University Hospital Duesseldorf, Duesseldorf, Germany
| | - Wolfram Trudo Knoefel
- Department of Surgery (A), Heinrich-Heine-University and University Hospital Duesseldorf, Duesseldorf, Germany.
| | - Levent Dizdar
- Department of Surgery (A), Heinrich-Heine-University and University Hospital Duesseldorf, Duesseldorf, Germany
| | - Andrea Alexander
- Department of Surgery (A), Heinrich-Heine-University and University Hospital Duesseldorf, Duesseldorf, Germany
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Li C, Chen HX, Lai YH. Comparison of different preoperative objective nutritional indices for evaluating 30-d mortality and complications after liver transplantation. World J Gastrointest Surg 2024; 16:143-154. [PMID: 38328316 PMCID: PMC10845289 DOI: 10.4240/wjgs.v16.i1.143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2023] [Revised: 12/17/2023] [Accepted: 01/08/2024] [Indexed: 01/25/2024] Open
Abstract
BACKGROUND The nutritional status is closely related to the prognosis of liver transplant recipients, but few studies have reported the role of preoperative objective nutritional indices in predicting liver transplant outcomes. AIM To compare the predictive value of various preoperative objective nutritional indicators for determining 30-d mortality and complications following liver transplantation (LT). METHODS A retrospective analysis was conducted on 162 recipients who underwent LT at our institution from December 2019 to June 2022. RESULTS This study identified several independent risk factors associated with 30-d mortality, including blood loss, the prognostic nutritional index (PNI), the nutritional risk index (NRI), and the control nutritional status. The 30-d mortality rate was 8.6%. Blood loss, the NRI, and the PNI were found to be independent risk factors for the occurrence of severe postoperative complications. The NRI achieved the highest prediction values for 30-d mortality [area under the curve (AUC) = 0.861, P < 0.001] and severe complications (AUC = 0.643, P = 0.011). Compared to those in the high NRI group, the low patients in the NRI group had lower preoperative body mass index and prealbumin and albumin levels, as well as higher alanine aminotransferase and total bilirubin levels, Model for End-stage Liver Disease scores and prothrombin time (P < 0.05). Furthermore, the group with a low NRI exhibited significantly greater incidences of intraabdominal bleeding, primary graft nonfunction, and mortality. CONCLUSION The NRI has good predictive value for 30-d mortality and severe complications following LT. The NRI could be an effective tool for transplant surgeons to evaluate perioperative nutritional risk and develop relevant nutritional therapy.
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Affiliation(s)
- Chuan Li
- Department of Transplantation, People’s Hospital of Guangxi Zhuang Autonomous Region, Nanning 530021, Guangxi Zhuang Autonomous Region, China
| | - Hong-Xia Chen
- Department of Clinical Pharmacy, People’s Hospital of Guangxi Zhuang Autonomous Region, Nanning 530021, Guangxi Zhuang Autonomous Region, China
| | - Yan-Hua Lai
- Department of Transplantation, People’s Hospital of Guangxi Zhuang Autonomous Region, Nanning 530021, Guangxi Zhuang Autonomous Region, China
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Eguia E, Baker T, Baker M. Hepatocellular Carcinoma: Surgical Management and Evolving Therapies. Cancer Treat Res 2024; 192:185-206. [PMID: 39212922 DOI: 10.1007/978-3-031-61238-1_10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/04/2024]
Abstract
Hepatocellular carcinoma (HCC) is the fifth most common cancer in men and the eighth most common cancer in women worldwide. It is also the second leading cause of cancer death worldwide, with 780,000 deaths in 2018. Seventy-two percent of HCC cases occur in Asia, 10% in Europe, 8% in Africa, 5% in North America, and 5% in Latin America (Singal et al. in J Hepatol 72(2):250-261, 2020 [1]).
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Affiliation(s)
- Emanuel Eguia
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Talia Baker
- Huntsman Cancer Center, University of Utah Eccles School of Medicine, Salt Lake City, UT, USA
| | - Marshall Baker
- Huntsman Cancer Center, University of Utah Eccles School of Medicine, Salt Lake City, UT, USA.
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Merath K, Tiwari A, Court C, Parikh A, Dillhoff M, Cloyd J, Ejaz A, Pawlik TM. Postoperative Liver Failure: Definitions, Risk factors, Prediction Models and Prevention Strategies. J Gastrointest Surg 2023; 27:2640-2649. [PMID: 37783906 DOI: 10.1007/s11605-023-05834-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 09/07/2023] [Indexed: 10/04/2023]
Abstract
BACKGROUND Liver resection is the treatment for a variety of benign and malignant conditions. Despite advances in preoperative selection, surgical technique, and perioperative management, post hepatectomy liver failure (PHLF) is still a leading cause of morbidity and mortality following liver resection. METHODS A review of the literature was performed utilizing MEDLINE/PubMed and Web of Science databases in May of 2023. The MESH terms "liver failure," "liver insufficiency," and "hepatic failure" in combination with "liver surgery," "liver resection," and "hepatectomy" were searched in the title and/or abstract. The references of relevant articles were reviewed to identify additional eligible publications. RESULTS PHLF can have devastating physiological consequences. In general, risk factors can be categorized as patient-related, primary liver function-related, or perioperative factors. Currently, no effective treatment options are available and the management of PHLF is largely supportive. Therefore, identifying risk factors and preventative strategies for PHLF is paramount. Ensuring an adequate future liver remnant is important to mitigate risk of PHLF. Dynamic liver function tests provide more objective assessment of liver function based on the metabolic capacity of the liver and have the advantage of easy administration, low cost, and easy reproducibility. CONCLUSION Given the absence of randomized data specifically related to the management of PHLF, current strategies are based on the principles of management of acute liver failure from any cause. In addition, goal-directed therapy for organ dysfunction, as well as identification and treatment of reversible factors in the postoperative period are critical.
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Affiliation(s)
- Katiuscha Merath
- Division of Surgical Oncology, University of Texas Health Science Center San Antonio MD Anderson Cancer Center, San Antonio, TX, USA
| | - Ankur Tiwari
- Division of Surgical Oncology, University of Texas Health Science Center San Antonio MD Anderson Cancer Center, San Antonio, TX, USA
| | - Colin Court
- Division of Surgical Oncology, University of Texas Health Science Center San Antonio MD Anderson Cancer Center, San Antonio, TX, USA
| | - Alexander Parikh
- Division of Surgical Oncology, University of Texas Health Science Center San Antonio MD Anderson Cancer Center, San Antonio, TX, USA
| | - Mary Dillhoff
- Department of Surgery, Division of Surgical Oncology, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, 395 W. 12Th Ave., Suite 670, Columbus, OH, USA
| | - Jordan Cloyd
- Department of Surgery, Division of Surgical Oncology, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, 395 W. 12Th Ave., Suite 670, Columbus, OH, USA
| | - Aslam Ejaz
- Department of Surgery, Division of Surgical Oncology, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, 395 W. 12Th Ave., Suite 670, Columbus, OH, USA
| | - Timothy M Pawlik
- Department of Surgery, Division of Surgical Oncology, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, 395 W. 12Th Ave., Suite 670, Columbus, OH, USA.
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Bedewy A, El-Kassas M. Anesthesia in patients with chronic liver disease: An updated review. Clin Res Hepatol Gastroenterol 2023; 47:102205. [PMID: 37678609 DOI: 10.1016/j.clinre.2023.102205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 08/18/2023] [Accepted: 09/04/2023] [Indexed: 09/09/2023]
Abstract
Anesthesia in chronic liver disease patients can be challenging because of the medications given or interventions performed and their effects on liver physiology. Also, the effects of liver disease on coagulation and metabolism should be considered carefully. This review focuses on anesthesia in patients with different chronic liver disease stages. A literature search was performed for Scopus and PubMed databases for articles discussing different types of anesthesia in patients with chronic liver disease, their safety, usage, and risks. The choice of anesthesia is of crucial importance. Regional anesthesia, especially neuroaxial anesthesia, may benefit some patients with liver disease, but coagulopathy should be considered. Regional anesthesia provides optimum intraoperative relaxation and analgesia that extends to the postoperative period while avoiding the side effects of intravenous anesthetics and opioids. Pharmacodynamics and pharmacokinetics of anesthetic medications must guard against complications related to overdose or decreased metabolism. The choice of anesthesia in chronic liver disease patients is crucial and could be tailored according to the degree of liver compensation and the magnitude of the surgical procedure.
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Affiliation(s)
- Ahmed Bedewy
- Anesthesia and Surgical Intensive Care Department, Faculty of Medicine, Helwan University, Cairo, Egypt
| | - Mohamed El-Kassas
- Endemic Medicine Department, Faculty of Medicine, Helwan University, Postal Code: 11795, Cairo, Egypt.
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6
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Morandi A, Risaliti M, Montori M, Buccianti S, Bartolini I, Moraldi L. Predicting Post-Hepatectomy Liver Failure in HCC Patients: A Review of Liver Function Assessment Based on Laboratory Tests Scores. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1099. [PMID: 37374303 DOI: 10.3390/medicina59061099] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 05/30/2023] [Accepted: 06/05/2023] [Indexed: 06/29/2023]
Abstract
The assessment of liver function is crucial in predicting the risk of post-hepatectomy liver failure (PHLF) in patients undergoing liver resection, especially in cases of hepatocellular carcinoma (HCC) which is often associated with cirrhosis. There are currently no standardized criteria for predicting the risk of PHLF. Blood tests are often the first- and least invasive expensive method for assessing hepatic function. The Child-Pugh score (CP score) and the Model for End Stage Liver Disease (MELD) score are widely used tools for predicting PHLF, but they have some limitations. The CP score does not consider renal function, and the evaluation of ascites and encephalopathy is subjective. The MELD score can accurately predict outcomes in cirrhotic patients, but its predictive capabilities diminish in non-cirrhotic patients. The albumin-bilirubin score (ALBI) is based on serum bilirubin and albumin levels and allows the most accurate prediction of PHLF for HCC patients. However, this score does not consider liver cirrhosis or portal hypertension. To overcome this limitation, researchers suggest combining the ALBI score with platelet count, a surrogate marker of portal hypertension, into the platelet-albumin-bilirubin (PALBI) grade. Non-invasive markers of fibrosis, such as FIB-4 and APRI, are also available for predicting PHLF but they focus only on cirrhosis related aspects and are potentially incomplete in assessing the global liver function. To improve the predictive power of the PHLF of these models, it has been proposed to combine them into a new score, such as the ALBI-APRI score. In conclusion, blood test scores may be combined to achieve a better predictive value of PHLF. However, even if combined, they may not be sufficient to evaluate liver function and to predict PHLF; thus, the inclusion of dynamic and imaging tests such as liver volumetry and ICG r15 may be helpful to potentially improve the predictive capacity of these models.
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Affiliation(s)
- Alessio Morandi
- HPB Surgery Unit, Department of Experimental and Clinical Medicine, Azienda Ospedaliero Universitaria Careggi, 50134 Florence, Italy
| | - Matteo Risaliti
- HPB Surgery Unit, Department of Experimental and Clinical Medicine, Azienda Ospedaliero Universitaria Careggi, 50134 Florence, Italy
| | - Michele Montori
- Clinic of Gastroenterology, Hepatology, and Emergency Digestive Endoscopy, Università Politecnica delle Marche, 60126 Ancona, Italy
| | - Simone Buccianti
- HPB Surgery Unit, Department of Experimental and Clinical Medicine, Azienda Ospedaliero Universitaria Careggi, 50134 Florence, Italy
| | - Ilenia Bartolini
- HPB Surgery Unit, Department of Experimental and Clinical Medicine, Azienda Ospedaliero Universitaria Careggi, 50134 Florence, Italy
| | - Luca Moraldi
- HPB Surgery Unit, Department of Experimental and Clinical Medicine, Azienda Ospedaliero Universitaria Careggi, 50134 Florence, Italy
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Brown ZJ, Tsilimigras DI, Ruff SM, Mohseni A, Kamel IR, Cloyd JM, Pawlik TM. Management of Hepatocellular Carcinoma: A Review. JAMA Surg 2023; 158:410-420. [PMID: 36790767 DOI: 10.1001/jamasurg.2022.7989] [Citation(s) in RCA: 137] [Impact Index Per Article: 137.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
Abstract
Importance Hepatocellular carcinoma (HCC) is the sixth most common malignancy and fourth leading cause of cancer-related death worldwide. Recent advances in systemic and locoregional therapies have led to changes in many guidelines regarding systemic therapy, as well as the possibility to downstage patients to undergo resection. This review examines the advances in surgical and medical therapies relative to multidisciplinary treatment strategies for HCC. Observations HCC is a major health problem worldwide. The obesity epidemic has made nonalcoholic fatty liver disease a major risk factor for the development of HCC. Multiple societies, such as the American Association for the Study of Liver Diseases, the European Association for the Study of the Liver, the Asian Pacific Association for the Study of the Liver, and the National Comprehensive Cancer Network, provide guidelines for screening at-risk patients, as well as define staging systems to guide optimal treatment strategies. The Barcelona Clinic Liver Cancer staging system is widely accepted and has recently undergone updates with the introduction of new systemic therapies and stage migration. Conclusions and Relevance The treatment of patients with HCC should involve a multidisciplinary approach with collaboration among surgeons, medical oncologists, radiation oncologists, and interventional radiologists to provide optimal care. Treatment paradigms must consider both tumor and patient-related factors such as extent of liver disease, which is a main driver of morbidity and mortality. The advent of more effective systemic and locoregional therapies has prolonged survival among patients with advanced disease and allowed some patients to undergo surgical intervention who would otherwise have disease considered unresectable.
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Affiliation(s)
- Zachary J Brown
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus
| | | | - Samantha M Ruff
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus
| | - Alireza Mohseni
- Department of Radiology, John Hopkins University, Baltimore, Maryland
| | - Ihab R Kamel
- Department of Radiology, John Hopkins University, Baltimore, Maryland
| | - Jordan M Cloyd
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus
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Mahmud N, Panchal S, Turrentine FE, Kaplan DE, Zaydfudim VM. Performance of risk prediction models for post-operative mortality in patients undergoing liver resection. Am J Surg 2023; 225:198-205. [PMID: 35985849 PMCID: PMC9994627 DOI: 10.1016/j.amjsurg.2022.07.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 07/22/2022] [Accepted: 07/28/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND Liver resection is commonly performed for hepatic tumors, however preoperative risk stratification remains challenging. We evaluated the performance of contemporary prediction models for short-term mortality after liver resection in patients with and without cirrhosis. METHODS This retrospective cohort study examined National Surgical Quality Improvement Program data. We included patients who underwent liver resections from 2014 to 2019. VOCAL-Penn, MELD, MELD-Na, ALBI, and Mayo risk scores were evaluated in terms of model discrimination and calibration for 30-day post-operative mortality. RESULTS A total 15,198 patients underwent liver resection, of whom 249 (1.6%) experienced 30-day post-operative mortality. The VOCAL-Penn score had the highest discrimination (area under the ROC curve [AUC] 0.74) compared to all other models. The VOCAL-Penn score similarly outperformed other models in patients with (AUC 0.70) and without (AUC 0.74) cirrhosis. CONCLUSION The VOCAL-Penn score demonstrated superior predictive performance for 30-day post-operative mortality after liver resection as compared to existing clinical standards.
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Affiliation(s)
- Nadim Mahmud
- Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Department of Medicine, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA; Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics, Epidemiology & Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Leonard David Institute of Health Economics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
| | - Sarjukumar Panchal
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Florence E Turrentine
- Department of Surgery, Surgical Outcomes Research Center, University of Virginia, Charlottesville, VA, USA
| | - David E Kaplan
- Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Department of Medicine, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA
| | - Victor M Zaydfudim
- Department of Surgery, Surgical Outcomes Research Center, University of Virginia, Charlottesville, VA, USA
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Ashouri Y, Hsu CH, Riall TS, Konstantinidis IT, Maegawa FB. Aspartate Aminotransferase-to-Platelet Ratio Index Predicts Liver Failure After Resection of Colorectal Liver Metastases. Dig Dis Sci 2022; 67:4950-4958. [PMID: 34981310 DOI: 10.1007/s10620-021-07333-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Accepted: 11/15/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND Chemotherapy agents for metastatic colorectal cancer can cause liver injury, increasing the risk of post-hepatectomy liver failure after hepatectomy for metastases. The role of noninvasive fibrosis markers in this setting is not well established. AIMS To evaluate the aspartate aminotransferase-to-platelet ratio index (APRI) as a predictor of postoperative liver failure. METHODS The National Surgical Quality Improvement Program database was utilized to identify patients who received preoperative chemotherapy and underwent hepatectomy for colorectal metastases between 2015 and 2017. Concordance index analysis was conducted to determine APRI's contribution to the prediction of liver failure. The optimal cutoff value was defined and its ability to predict post-hepatectomy liver failure and perioperative bleeding were examined. RESULTS A total of 2374 patients were identified and included in the analysis. APRI demonstrated to be a better predictor of postoperative liver failure than MELD score, with a statistically significant larger area under the curve. The optimal APRI cutoff value to predict liver failure was 0.365. The multivariable logistic regression showed that APRI ≥ 0.365 was independently associated with PHLF, odds ratio (OR) 2.51, 95% confidence interval (CI) 1.67-3.77, P < .0001. Likewise, APRI ≥ 0.365 was independently associated with perioperative bleeding complications requiring transfusions, OR 1.41, 95% CI 1.13-1.77, P = 0.002. MELD score was not statistically associated with PHLF or bleeding complications. CONCLUSIONS APRI was independently associated with post-hepatectomy liver failure and perioperative bleeding requiring transfusions after resection of colorectal metastases in patients who received preoperative chemotherapy. Concordance index showed APRI to add significant contribution as a predictor of postoperative liver failure.
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Affiliation(s)
- Yazan Ashouri
- Department of Surgery, Southern Arizona VA Health Care System, University of Arizona, Tucson, AZ, USA
| | - Chiu-Hsieh Hsu
- Mel&Enid Zuckerman College of Public Health, University of Arizona, Tucson, AZ, USA
| | - Taylor S Riall
- Department of Surgery, University of Arizona, Tucson, AZ, USA
| | | | - Felipe B Maegawa
- Division of General and GI Surgery, Department of Surgery, Emory University, 5673 Peachtree Dunwoody Road, Suite 680, Atlanta, GA, 30342, USA.
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Prediction of Posthepatectomy Liver Failure with a Combination of Albumin-Bilirubin Score and Liver Resection Percentage. J Am Coll Surg 2022; 234:155-165. [PMID: 35213436 DOI: 10.1097/xcs.0000000000000027] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND Posthepatectomy liver failure (PHLF) is a main cause of death after partial hepatectomy. The aim of this study was to develop a practical stratification system using the albumin-bilirubin (ALBI) score and liver resection percentage to predict severe PHLF and conduct safe hepatectomy. METHODS Between January 2002 and March 2021, 361 hepatocellular carcinoma (HCC) patients who underwent partial hepatectomy were enrolled. Medical image analysis software was applied postoperatively to accurately simulate hepatectomy. The liver resection percentage was calculated as follows: (postoperatively reconstructed resected specimen volume [ml] - tumor volume [ml])/total functional liver volume (ml) × 100. Multivariate analysis was performed to identify risk factors for PHLF grade B/C. A heatmap for predicting grade B/C PHLF was generated by combining the ALBI score and liver resection percentage. RESULTS Thirty-nine patients developed grade B/C PHLF; 2 of these patients (5.1%) died. Multivariate analysis demonstrated that a high ALBI score and high liver resection percentage were independent predictors of severe PHLF (odds ratio [OR], 8.68, p < 0.001; OR, 1.10, p < 0.001). With a threshold PHLF probability of 50% for the heatmap, hepatectomy was performed for 346 patients meeting our criteria (95.8%) and 325 patients meeting the Makuuchi criteria (90.0%). The positive predictive value and negative predictive value for severe PHLF were 91.6% and 66.7% for our system and 91.7% and 33.3% for the Makuuchi criteria. CONCLUSION Our stratification system could increase the number of hepatectomy candidates and is practical for deciding the surgical indications and determining the upper limit of the liver resection percentage corresponding to each patient's liver function reserve, which could prevent PHLF and yield better postoperative outcomes.
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Zaydfudim VM, Turrentine FE, Smolkin ME, Bauer TB, Adams RB, McMurry TL. The impact of cirrhosis and MELD score on postoperative morbidity and mortality among patients selected for liver resection. Am J Surg 2020; 220:682-686. [PMID: 31983407 DOI: 10.1016/j.amjsurg.2020.01.022] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Revised: 01/14/2020] [Accepted: 01/14/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Independent associations between chronic liver disease, MELD, and postoperative outcomes among patients selected for liver resection have not been completely established. We hypothesized independent associations between MELD, cirrhosis, and postoperative mortality. METHODS Patient-level data from the targeted hepatectomy module and ACS NSQIP PUF during 2014-2015 were merged. Multivariable regression models with interaction effect between MELD and liver texture (normal, congested/fatty, cirrhotic) tested the independent effects of covariates on mortality and morbidity. RESULTS 3,530 patients were included, of whom 668 patients (19%) had cirrhosis. ACS NSQIP defined mortality (3.9%vs1.1%) and morbidity (23.5%vs15.8%) were higher in patients with cirrhosis (both p < 0.001). In multivariable models, cirrhosis (OR = 2.24; 95%CI:1.16-4.34, p = 0.016) and MELD (OR = 1.10; 95%CI:1.03-1.18, p = 0.007) were independently associated with mortality. MELD (OR = 1.04; 95%CI:1.002-1.08, p = 0.038) was associated with postoperative morbidity. CONCLUSIONS Higher MELD and presence of cirrhosis have an independent negative effect on mortality after liver resection. MELD could be used to estimate postoperative risk in patients with and without cirrhosis.
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Affiliation(s)
- Victor M Zaydfudim
- Department of Surgery, University of Virginia, Charlottesville, VA, USA; Surgical Outcomes Research Center, University of Virginia, Charlottesville, VA, USA; Section of Hepatobiliary and Pancreatic Surgery, University of Virginia, Charlottesville, VA, USA.
| | - Florence E Turrentine
- Department of Surgery, University of Virginia, Charlottesville, VA, USA; Surgical Outcomes Research Center, University of Virginia, Charlottesville, VA, USA
| | - Mark E Smolkin
- Department of Public Health Sciences, University of Virginia, Charlottesville, VA, USA
| | - Todd B Bauer
- Department of Surgery, University of Virginia, Charlottesville, VA, USA; Section of Hepatobiliary and Pancreatic Surgery, University of Virginia, Charlottesville, VA, USA
| | - Reid B Adams
- Department of Surgery, University of Virginia, Charlottesville, VA, USA; Section of Hepatobiliary and Pancreatic Surgery, University of Virginia, Charlottesville, VA, USA
| | - Timothy L McMurry
- Surgical Outcomes Research Center, University of Virginia, Charlottesville, VA, USA; Department of Public Health Sciences, University of Virginia, Charlottesville, VA, USA
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12
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Zhang ZQ, Xiong L, Zhou JJ, Miao XY, Li QL, Wen Y, Zou H. Ability of the ALBI grade to predict posthepatectomy liver failure and long-term survival after liver resection for different BCLC stages of HCC. World J Surg Oncol 2018; 16:208. [PMID: 30326907 PMCID: PMC6192221 DOI: 10.1186/s12957-018-1500-9] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Accepted: 09/25/2018] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Underlying liver function is a major concern when applying surgical resection for hepatocellular carcinoma (HCC). We aimed to explore the capability of the albumin-bilirubin (ALBI) grade to predict post-hepatectomy liver failure (PHLF) and long-term survival after hepatectomy for HCC patients with different Barcelona Clinic Liver Cancer (BCLC) stages. METHODS Between January 2010 and December 2014, 338 HCC patients who were treated with liver resection were enrolled. The predictive accuracy of ALBI grade system for PHLF and long-term survival across different BCLC stages was examined. RESULTS A total of 26 (7.7%) patients developed PHLF. Patients were divided into BCLC 0/A and BCLC B/C categories. ALBI score was found to be a strong independent predictor of PHLF across different BCLC stages by multivariate analysis. In terms of overall survival (OS), it exhibited high discriminative power in the total cohort and in BCLC 0/A subgroup. However, differences in OS between ALBI grade 1 and 2 patients in BCLC B/C subgroup were not significant (P = 0.222). CONCLUSION The ALBI grade showed good predictive ability for PHLF in HCC patients across different BCLC stages. However, the ALBI grade was only a significant predictor of OS in BCLC stage 0/A patients and failed to predict OS in BCLC stage B/C patients.
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Affiliation(s)
- Ze-Qun Zhang
- Department of General Surgery, The Second Xiangya Hospital, Central South University, Changsha, 410011, Hunan, China
| | - Li Xiong
- Department of General Surgery, The Second Xiangya Hospital, Central South University, Changsha, 410011, Hunan, China
| | - Jiang-Jiao Zhou
- Department of General Surgery, The Second Xiangya Hospital, Central South University, Changsha, 410011, Hunan, China
| | - Xiong-Ying Miao
- Department of General Surgery, The Second Xiangya Hospital, Central South University, Changsha, 410011, Hunan, China
| | - Qing-Long Li
- Department of General Surgery, The Second Xiangya Hospital, Central South University, Changsha, 410011, Hunan, China
| | - Yu Wen
- Department of General Surgery, The Second Xiangya Hospital, Central South University, Changsha, 410011, Hunan, China.
| | - Heng Zou
- Department of General Surgery, The Second Xiangya Hospital, Central South University, Changsha, 410011, Hunan, China.
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13
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Burkhart RA, Pawlik TM. Staging and Prognostic Models for Hepatocellular Carcinoma and Intrahepatic Cholangiocarcinoma. Cancer Control 2018; 24:1073274817729235. [PMID: 28975828 PMCID: PMC5937249 DOI: 10.1177/1073274817729235] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
There are several important roles that staging systems and prognostic models play in the modern medical care of patients with cancer. First, accurate staging systems can assist clinicians by identifying optimal treatment selection based on the scope of disease at the time of diagnosis. Second, both physicians and patients may infer prognostic information from staging and models that may help decision makers identify appropriate therapies for individual patients. Third, in research, there is benefit to classifying patients with disease into subgroups ensuring greater parity between experimental and control arms. Staging systems in most solid organ malignancies rely heavily on an accurate pathologic assessment of the tumor (size, site, number of tumors, locoregional spread, and distant spread). Another consideration in primary liver cancer, such as hepatocellular carcinoma (HCC) and intrahepatic cholangiocarcinoma (ICC), is the fact that the underlying liver function can significantly impact patient survival. In HCC, there are at least a dozen options that have been proposed for staging the disease. Herein, we review the most widely used systems and discuss their strengths and weaknesses. Prognostic models and nomograms are also discussed for a variety of subpopulations with HCC. Interestingly, until 2010, the staging system proposed by the American Joint Committee on Cancer for ICC was identical to HCC. The modern staging system, unique to ICC, is reviewed, and future modifications are identified with the primary supporting literature discussed.
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Affiliation(s)
| | - Timothy M Pawlik
- 2 Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
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14
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Pak LM, Chakraborty J, Gonen M, Chapman WC, Do RKG, Groot Koerkamp B, Verhoef K, Lee SY, Massani M, van der Stok EP, Simpson AL. Quantitative Imaging Features and Postoperative Hepatic Insufficiency: A Multi-Institutional Expanded Cohort. J Am Coll Surg 2018; 226:835-843. [PMID: 29454098 DOI: 10.1016/j.jamcollsurg.2018.02.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Revised: 11/22/2017] [Accepted: 02/06/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND Post-hepatectomy liver insufficiency (PHLI) is a significant cause of morbidity and mortality after liver resection. Quantitative imaging analysis using CT scans measures variations in pixel intensity related to perfusion. A preliminary study demonstrated a correlation between quantitative imaging features of the future liver remnant (FLR) parenchyma from preoperative CT scans and PHLI. The objective of this study was to explore the potential application of quantitative imaging analysis in PHLI in an expanded, multi-institutional cohort. STUDY DESIGN We retrospectively identified patients from 5 high-volume academic centers who developed PHLI after major hepatectomy, and matched them to control patients without PHLI (by extent of resection, preoperative chemotherapy treatment, age [±5 years], and sex). Quantitative imaging features were extracted from the FLR in the preoperative CT scan, and the most discriminatory features were identified using conditional logistic regression. Percent remnant liver volume (RLV) was defined as follows: (FLR volume)/(total liver volume) × 100. Significant clinical and imaging features were combined in a multivariate analysis using conditional logistic regression. RESULTS From 2000 to 2015, 74 patients with PHLI and 74 matched controls were identified. The most common indications for surgery were colorectal liver metastases (53%), hepatocellular carcinoma (37%), and cholangiocarcinoma (9%). Two CT imaging features (FD1_4: image complexity; ACM1_10: spatial distribution of pixel intensity) were strongly associated with PHLI and remained associated with PHLI on multivariate analysis (p = 0.018 and p = 0.023, respectively), independent of clinical variables, including preoperative bilirubin and %RLV. CONCLUSIONS Quantitative imaging features are independently associated with PHLI and are a promising preoperative risk stratification tool.
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Affiliation(s)
- Linda M Pak
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | | | - Mithat Gonen
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - William C Chapman
- Department of Surgery, Washington University in St Louis, St Louis, MO
| | - Richard K G Do
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY
| | | | - Kees Verhoef
- Department of Surgery, Erasmus Medical Center, Rotterdam, Netherlands
| | - Ser Yee Lee
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore; Duke-National University of Singapore Medical School, Singapore
| | - Marco Massani
- Regional Center for HPB Surgery, Regional Hospital of Treviso, Treviso, Italy
| | | | - Amber L Simpson
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY.
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15
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Radiation Therapy in Hepatocellular Carcinoma. Radiat Oncol 2018. [DOI: 10.1007/978-3-319-52619-5_44-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
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16
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Alizai PH, Haelsig A, Bruners P, Ulmer F, Klink CD, Dejong CH, Neumann UP, Schmeding M. Impact of liver volume and liver function on posthepatectomy liver failure after portal vein embolization- A multivariable cohort analysis. Ann Med Surg (Lond) 2018; 25:6-11. [PMID: 29326811 PMCID: PMC5758836 DOI: 10.1016/j.amsu.2017.12.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Revised: 11/25/2017] [Accepted: 12/04/2017] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Liver failure remains a life-threatening complication after liver resection, and is difficult to predict preoperatively. This retrospective cohort study evaluated different preoperative factors in regard to their impact on posthepatectomy liver failure (PHLF) after extended liver resection and previous portal vein embolization (PVE). METHODS Patient characteristics, liver function and liver volumes of patients undergoing PVE and subsequent liver resection were analyzed. Liver function was determined by the LiMAx test (enzymatic capacity of cytochrome P450 1A2). Factors associated with the primary end point PHLF (according to ISGLS definition) were identified through multivariable analysis. Secondary end points were 30-day mortality and morbidity. RESULTS 95 patients received PVE, of which 64 patients underwent major liver resection. PHLF occurred in 7 patients (11%). Calculated postoperative liver function was significantly lower in patients with PHLF than in patients without PHLF (67 vs. 109 μg/kg/h; p = 0.01). Other factors associated with PHLF by univariable analysis were age, future liver remnant, MELD score, ASA score, renal insufficiency and heart insufficiency. By multivariable analysis, future liver remnant was the only factor significantly associated with PHLF (p = 0.03). Mortality and morbidity rates were 4.7% and 29.7% respectively. CONCLUSION Future liver remnant is the only preoperative factor with a significant impact on PHLF. Assessment of preoperative liver function may additionally help identify patients at risk for PHLF.
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Affiliation(s)
- Patrick H. Alizai
- Department of General, Visceral and Transplantation Surgery, RWTH Aachen University Hospital, Pauwelsstr. 30, 52074 Aachen, Germany
| | - Annabel Haelsig
- Department of General, Visceral and Transplantation Surgery, RWTH Aachen University Hospital, Pauwelsstr. 30, 52074 Aachen, Germany
| | - Philipp Bruners
- Department for Diagnostic and Interventional Radiology, RWTH Aachen University Hospital, Pauwelsstr. 30, 52074 Aachen, Germany
| | - Florian Ulmer
- Department of General, Visceral and Transplantation Surgery, RWTH Aachen University Hospital, Pauwelsstr. 30, 52074 Aachen, Germany
| | - Christian D. Klink
- Department of General, Visceral and Transplantation Surgery, RWTH Aachen University Hospital, Pauwelsstr. 30, 52074 Aachen, Germany
| | - Cornelis H.C. Dejong
- Department of Surgery, Maastricht University Medical Center, P. Debyelaan 25, 6229 HX Maastricht, The Netherlands
| | - Ulf P. Neumann
- Department of General, Visceral and Transplantation Surgery, RWTH Aachen University Hospital, Pauwelsstr. 30, 52074 Aachen, Germany
- Department of Surgery, Maastricht University Medical Center, P. Debyelaan 25, 6229 HX Maastricht, The Netherlands
| | - Maximilian Schmeding
- Department of General, Visceral and Transplantation Surgery, RWTH Aachen University Hospital, Pauwelsstr. 30, 52074 Aachen, Germany
- Department of Surgery, Klinikum Dortmund, Beurhausstraße 40, 44137 Dortmund, Germany
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17
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Fromer MW, Gaughan JP, Atabek UM, Spitz FR. Primary Malignancy is an Independent Determinant of Morbidity and Mortality after Liver Resection. Am Surg 2017. [DOI: 10.1177/000313481708300515] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Although outcomes after liver resection have improved, there remains considerable perioperative morbidity and mortality with these procedures. Studies suggest a primary liver cancer diagnosis is associated with poorer outcomes, but the extent to which this is attributable to a higher degree of hepatic dysfunction is unclear. To better delineate this, we performed a matched pair analysis of primary versus metastatic malignancies using a national database. The American College of Surgeons National Surgical Quality Improvement Program (2005–2013) was analyzed to select elective liver resections. Diagnoses were sorted as follows: 1) primary liver cancers and 2) metastatic neoplasms. A literature review identified factors known to impact hepatectomy outcomes; these variables were evaluated by a univariate analysis. The most predictive factors were used to create similar groups from each diagnosis category via propensity matching. Multivariate regression was used to validate results in the wider study population. Outcomes were compared using chi-squared test and Fisher exact test. Matched groups of 4838 patients were similar by all variables, including indicators of liver function. A number of major complications were significantly more prevalent with a primary diagnosis; overall major morbidity rates in the metastatic and primary groups were 29.3 versus 41.6 per cent, respectively. The mortality rate for primary neoplasms was 4.6 per cent (vs 1.6%); this represents a risk of death nearly three-times greater (95% confidence interval = 2.20–3.81, P < 0.0001) in cancers of hepatic origin. Hepatectomy carries substantially higher perioperative risk when performed for primary liver cancers, independent of hepatic function and resection extent. This knowledge will help to improve treatment planning, patient education, and resource allocation in oncologic liver resection.
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Affiliation(s)
- Marc W. Fromer
- Department of Surgery, Cooper University Hospital, Camden, New Jersey
| | - John P. Gaughan
- Department of Surgery, Cooper University Hospital, Camden, New Jersey
| | - Umur M. Atabek
- Department of Surgery, Cooper University Hospital, Camden, New Jersey
| | - Francis R. Spitz
- Department of Surgery, Cooper University Hospital, Camden, New Jersey
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18
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Modern Technical Approaches in Hepatic Surgery for Colorectal Metastases. CURRENT COLORECTAL CANCER REPORTS 2016. [DOI: 10.1007/s11888-016-0327-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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19
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van Mierlo KMC, Lodewick TM, Dhar DK, van Woerden V, Kurstjens R, Schaap FG, van Dam RM, Vyas S, Malagó M, Dejong CHC, Olde Damink SWM. Validation of the peak bilirubin criterion for outcome after partial hepatectomy. HPB (Oxford) 2016; 18:806-812. [PMID: 27506991 PMCID: PMC5061023 DOI: 10.1016/j.hpb.2016.06.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Revised: 05/18/2016] [Accepted: 06/05/2016] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Postoperative liver failure (PLF) is a dreaded complication after partial hepatectomy. The peak bilirubin criterion (>7.0 mg/dL or ≥120 μmol/L) is used to define PLF. This study aimed to validate the peak bilirubin criterion as postoperative risk indicator for 90-day liver-related mortality. METHODS Characteristics of 956 consecutive patients who underwent partial hepatectomy at the Maastricht University Medical Centre or Royal Free London between 2005 and 2012 were analyzed by uni- and multivariable analyses with odds ratios (OR) and 95% confidence intervals (95%CI). RESULTS Thirty-five patients (3.7%) met the postoperative peak bilirubin criterion at median day 19 with a median bilirubin level of 183 [121-588] μmol/L. Sensitivity and specificity for liver-related mortality after major hepatectomy were 41.2% and 94.6%, respectively. The positive predictive value was 22.6%. Predictors of liver-related mortality were the peak bilirubin criterion (p < 0.001, OR = 15.9 [95%CI 5.2-48.7]), moderate-severe steatosis and fibrosis (p = 0.013, OR = 8.5 [95%CI 1.6-46.6]), ASA 3-4 (p = 0.047, OR = 3.0 [95%CI 1.0-8.8]) and age (p = 0.044, OR = 1.1 [95%CI 1.0-1.1]). CONCLUSION The peak bilirubin criterion has a low sensitivity and positive predictive value for 90-day liver-related mortality after major hepatectomy.
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Affiliation(s)
- Kim M C van Mierlo
- Department of Surgery, Maastricht University Medical Centre and NUTRIM School of Nutrition and Translational Research, Maastricht University, Maastricht, The Netherlands
| | - Toine M Lodewick
- Department of Surgery, Maastricht University Medical Centre and NUTRIM School of Nutrition and Translational Research, Maastricht University, Maastricht, The Netherlands; Department of Surgery, University Hospital Aachen, Division of General, Visceral and Transplantation Surgery, Aachen, Germany
| | - Dipok K Dhar
- Department of Surgery, Royal Free & Institute for Liver and Digestive Health University College London Hospitals, and University College London, London, United Kingdom; Organ Transplantation Centre and Comparative Medicine Department, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Victor van Woerden
- Department of Surgery, Maastricht University Medical Centre and NUTRIM School of Nutrition and Translational Research, Maastricht University, Maastricht, The Netherlands
| | - Ralph Kurstjens
- Department of Surgery, Maastricht University Medical Centre and NUTRIM School of Nutrition and Translational Research, Maastricht University, Maastricht, The Netherlands
| | - Frank G Schaap
- Department of Surgery, Maastricht University Medical Centre and NUTRIM School of Nutrition and Translational Research, Maastricht University, Maastricht, The Netherlands
| | - Ronald M van Dam
- Department of Surgery, Maastricht University Medical Centre and NUTRIM School of Nutrition and Translational Research, Maastricht University, Maastricht, The Netherlands
| | - Soumil Vyas
- Department of Surgery, Royal Free & Institute for Liver and Digestive Health University College London Hospitals, and University College London, London, United Kingdom
| | - Massimo Malagó
- Department of Surgery, Royal Free & Institute for Liver and Digestive Health University College London Hospitals, and University College London, London, United Kingdom
| | - Cornelis H C Dejong
- Department of Surgery, Maastricht University Medical Centre and NUTRIM School of Nutrition and Translational Research, Maastricht University, Maastricht, The Netherlands; GROW School for Oncology and Developmental Biology, Maastricht University, Maastricht, The Netherlands
| | - Steven W M Olde Damink
- Department of Surgery, Maastricht University Medical Centre and NUTRIM School of Nutrition and Translational Research, Maastricht University, Maastricht, The Netherlands; Department of Surgery, Royal Free & Institute for Liver and Digestive Health University College London Hospitals, and University College London, London, United Kingdom.
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20
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Fromer MW, Aloia TA, Gaughan JP, Atabek UM, Spitz FR. The utility of the MELD score in predicting mortality following liver resection for metastasis. Eur J Surg Oncol 2016; 42:1568-75. [PMID: 27365199 DOI: 10.1016/j.ejso.2016.05.035] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2016] [Revised: 05/17/2016] [Accepted: 05/24/2016] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND The MELD score has been demonstrated to be predictive of hepatectomy outcomes in mixed patient samples of primary and secondary liver cancers. Because MELD is a measure of hepatic dysfunction, prior conclusions may rely on the high prevalence of cirrhosis observed with primary lesions. This study aims to evaluate MELD score as a predictor of mortality and develop a risk prediction model for patients specifically undergoing hepatic metastasectomy. METHODS ACS-NSQIP 2005-2013 was analyzed to select patients who had undergone liver resections for metastases. A receiver operating characteristic (ROC) analysis determined the MELD score most associated with 30-day mortality. A literature review identified variables that impact hepatectomy outcomes. Significant factors were included in a multivariable analysis (MVA). A risk calculator was derived from the final multivariable model. RESULTS Among the 14,919 patients assessed, the mortality rate was 2.7%, and the median MELD was 7.3 (range = 34.4). A MELD of 7.24 was identified by ROC (sensitivity = 81%, specificity = 51%, c-statistic = 0.71). Of all patients above this threshold, 4.4% died at 30 days vs. 1.1% in the group ≤7.24. This faction represented 50.1% of the population but accounted for 80.3% of all deaths (p < 0.001). The MVA revealed mortality to be increased 2.6-times (OR = 2.55, 95%CI 1.69-3.84, p < 0.001). A risk calculator was successfully developed and validated. CONCLUSIONS MELD>7.24 is an important predictor of death following hepatectomy for metastasis and may prompt a detailed assessment with the provided risk calculator. Attention to MELD in the preoperative setting will improve treatment planning and patient education prior to oncologic liver resection.
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Affiliation(s)
- M W Fromer
- Department of Surgery, Cooper University Hospital, 3 Cooper Plaza, Suite 411, Camden, NJ, 08103, USA.
| | - T A Aloia
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1400 Herman Pressler, Unit 1484, Houston, TX, 77030, USA.
| | - J P Gaughan
- Department of Surgery, Cooper University Hospital, 3 Cooper Plaza, Suite 411, Camden, NJ, 08103, USA.
| | - U M Atabek
- Department of Surgery, Cooper University Hospital, 3 Cooper Plaza, Suite 411, Camden, NJ, 08103, USA.
| | - F R Spitz
- Department of Surgery, Cooper University Hospital, 3 Cooper Plaza, Suite 411, Camden, NJ, 08103, USA.
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21
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Preoperative thrombocytopenia and outcomes of hepatectomy for hepatocellular carcinoma. J Surg Res 2016; 201:498-505. [DOI: 10.1016/j.jss.2015.08.038] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2015] [Revised: 07/25/2015] [Accepted: 08/21/2015] [Indexed: 02/08/2023]
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22
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Ross SW, Seshadri R, Walters AL, Augenstein VA, Heniford BT, Iannitti DA, Martinie JB, Vrochides D, Swan RZ. Mortality in hepatectomy: Model for End-Stage Liver Disease as a predictor of death using the National Surgical Quality Improvement Program database. Surgery 2015; 159:777-92. [PMID: 26474653 DOI: 10.1016/j.surg.2015.08.021] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2015] [Revised: 08/16/2015] [Accepted: 08/20/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND The predictive value of the Model for End-stage Liver Disease (MELD) for mortality after hepatectomy is unclear. This study aimed to evaluate whether MELD score predicts death after hepatectomy and to identify the most useful score type for predicting mortality. We hypothesized that an increase in this score is correlated with 30-day mortality in patients undergoing hepatic resection. METHODS The American College of Surgeons National Surgical Quality Improvement Program database was queried for hepatectomy. Original MELD, United Network of Organ Sharing-modified MELD (uMELD), integrated MELD (i-MELD), and sodium-corrected MELD (MELD-Na) scores were calculated. Mortality was analyzed by multivariate logistic regression. MELD types were compared using receiver operating characteristic (ROC) curves. RESULTS From 2005 to 2011, 11,933 hepatic resections were performed, including 7,519 partial, 2,104 right, and 1,210 left resections, and 1,100 trisectionectomies. The mean duration of stay was 8.4 ± 22.0 days, and there were 275 deaths (2.4%). The 30-day mortality rates were 1.8%, 6.9%, 15.4%, and 25% according to uMELD strata of 0-9, 10-19, 20-29, and ≥ 30, respectively. Multivariate analysis revealed that increasing MELD stratum was independently associated with higher mortality (P < .001) for all MELD types. The uMELD had the largest effect size (odds ratio [OR], 1.16; 95% CI, 1.10-1.20), whereas i-MELD had the narrowest CI (OR, 1.13; 95% CI, 1.10-1.17) and largest area under the ROC curve. CONCLUSION The postoperative 30-day mortality after hepatectomy increases with increasing MELD score across all MELD types. There is a 16% increase in the odds of mortality for each point increase in uMELD.
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Affiliation(s)
- Samuel W Ross
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC
| | - Ramanathan Seshadri
- Division of Hepatopancreatobiliary Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC
| | - Amanda L Walters
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC
| | - Vedra A Augenstein
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC
| | - B Todd Heniford
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC
| | - David A Iannitti
- Division of Hepatopancreatobiliary Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC
| | - John B Martinie
- Division of Hepatopancreatobiliary Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC
| | - Dionisios Vrochides
- Division of Hepatopancreatobiliary Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC
| | - Ryan Z Swan
- Division of Hepatopancreatobiliary Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC.
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Abstract
The burden of hepatocellular carcinoma is rising and anticipated to escalate and while the best chance for long term cure remains transplantation, however the shortage of available organs remains a limitation. Liver directed therapy can serve the role of bridge/downstaging to transplant or as palliative care. Despite an improved overall survival among patients with HCC, due to advancements in surgical techniques, liver directed and systemic therapy, the 5 year overall survival remains low at 18% high-lightening the need for novel therapies. Surveillance for HCC is key to detect disease at an early stage to increase the chances for a potentially curative option.
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Affiliation(s)
- Laura M Kulik
- Kovler Organ Transplantation Center, NMH, Arkes Family Pavilion, Suite 1900, 676 North Saint Clair, Chicago, IL 60611, USA.
| | - Attasit Chokechanachaisakul
- Kovler Organ Transplantation Center, NMH, Arkes Family Pavilion, Suite 1900, 676 North Saint Clair, Chicago, IL 60611, USA
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Relevance of the ISGLS Definition of Posthepatectomy Liver Failure in Early Prediction of Poor Outcome After Liver Resection. Ann Surg 2014; 260:865-70; discussion 870. [DOI: 10.1097/sla.0000000000000944] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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25
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Vos JJ, Wietasch JKG, Absalom AR, Hendriks HGD, Scheeren TWL. Green light for liver function monitoring using indocyanine green? An overview of current clinical applications. Anaesthesia 2014; 69:1364-76. [PMID: 24894115 DOI: 10.1111/anae.12755] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/27/2014] [Indexed: 12/12/2022]
Abstract
The dye indocyanine green is familiar to anaesthetists, and has been studied for more than half a century for cardiovascular and hepatic function monitoring. It is still, however, not yet in routine clinical use in anaesthesia and critical care, at least in Europe. This review is intended to provide a critical analysis of the available evidence concerning the indications for clinical measurement of indocyanine green elimination as a diagnostic and prognostic tool in two areas: its role in peri-operative liver function monitoring during major hepatic resection and liver transplantation; and its role in critically ill patients on the intensive care unit, where it is used for prediction of mortality, and for assessment of the severity of acute liver failure or that of intra-abdominal hypertension. Although numerous studies have demonstrated that indocyanine green elimination measurements in these patient populations can provide diagnostic or prognostic information to the clinician, 'hard' evidence - i.e. high-quality prospective randomised controlled trials - is lacking, and therefore it is not yet time to give a green light for use of indocyanine green in routine clinical practice.
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Affiliation(s)
- J J Vos
- Department of Anesthesiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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Fonseca AL, Cha CH. Hepatocellular carcinoma: a comprehensive overview of surgical therapy. J Surg Oncol 2014; 110:712-9. [PMID: 24894746 DOI: 10.1002/jso.23673] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2014] [Accepted: 05/13/2014] [Indexed: 12/21/2022]
Abstract
Hepatocellular carcinoma (HCC) is one of the most common malignancies worldwide, with a rising incidence in the United States. The increase in medical and locally ablative therapies have improved prognosis, however surgery, either liver resection or transplantation, remains the mainstay of therapy. An increased understanding of liver anatomy, improved imaging modalities and refinements of surgical technique have all led to improved outcomes after surgery. Both resection and transplantation may be used in a complementary manner. Resection remains the treatment of choice for HCC when feasible. Liver transplantation, which removes both the tumor and the underlying diseased liver offers excellent outcomes in patients that meet the Milan criteria. While both these modalities have relatively well defined roles, the treatment of these patients must be tailored individually, using a multidisciplinary approach, to maximize survival, quality of life and allocation of scarce organs.
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Affiliation(s)
- Annabelle L Fonseca
- Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
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Proneth A, Zeman F, Schlitt HJ, Schnitzbauer AA. Is Resection or Transplantation the ideal Treatment in Patients with Hepatocellular Carcinoma in Cirrhosis if Both Are Possible? A Systematic Review and Metaanalysis. Ann Surg Oncol 2014; 21:3096-107. [DOI: 10.1245/s10434-014-3808-1] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2014] [Indexed: 02/06/2023]
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Kim JM, Kwon CHD, Joh JW, Park JB, Lee JH, Kim GS, Kim SJ, Paik SW. Can the model for end-stage liver disease score replace the indocyanine green clearance test in the selection of right hemihepatectomy in Child-Pugh class A? Ann Surg Treat Res 2014; 86:122-9. [PMID: 24761420 PMCID: PMC3994621 DOI: 10.4174/astr.2014.86.3.122] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2013] [Revised: 11/02/2013] [Accepted: 11/15/2013] [Indexed: 12/22/2022] Open
Abstract
Purpose To identify the correlation of the model for end-stage liver disease (MELD) scores with the assessment of the risk of hepatic function after hemihepatectomy in patients with hepatocellular carcinoma (HCC) related to hepatitis B virus (HBV). Methods A case-control study was performed based on data for 141 consecutive patients who underwent curative right hepatic resection between January 2006 and June 2010. Results All patients were Child-Pugh class A. The mean age of the patients was 50 years (range, 29-73 years). The group included 114 men (80.9%) and 27 women (19.1%). The distribution of MELD scores (median, 7; range, 6-14) and indocyanine green retention rate at 15 minutes (ICG-R15) (median, 9.2%; range, 1.1%-19.5%) showed no significant correlation (P = 0.615). Only one perioperative death (0.7%) occurred within 30 days, which was the result of liver failure by hepatic artery dissection during the Pringle maneuver. Hepatic dysfunction occurred in 25 patients (17.7%) after liver resection. In multivariate analysis, male gender, increased HBV DNA level, and elevated serum aspartate transaminase level were significantly related with hepatic dysfunction. Tumor size and satellite nodule were closely associated with tumor recurrence in HBV-related HCC after right hemihepatectomy and satellite nodule was a predisposing factor for mortality in those patients. Conclusion MELD score does not accurately predict hepatic function after right hemihepatectomy in patients with resectable HBV-related HCC. MELD scores were not correlated with the ICG-R15 values in patients with Child-Pugh class A.
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Affiliation(s)
- Jong Man Kim
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Choon Hyuck David Kwon
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jae-Won Joh
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jae Berm Park
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Joon Hyeok Lee
- Division of Gastroenterology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Gaab Soo Kim
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Sung Joo Kim
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seung Woon Paik
- Division of Gastroenterology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Yu DC, Chen WB, Jiang CP, Ding YT. Risk assessment in patients undergoing liver resection. Hepatobiliary Pancreat Dis Int 2013; 12:473-9. [PMID: 24103276 DOI: 10.1016/s1499-3872(13)60075-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Liver resection is still a risky procedure with high morbidity and mortality. It is significant to predict the morbidity and mortality with some models after liver resection. DATA SOURCES The MEDLINE/PubMed, Web of Science, Google Scholar, and Cochrane Library databases were searched using the terms "hepatectomy" and "risk assessment" for relevant studies before August 2012. Papers published in English were included. RESULTS Thirty-four original papers were included finally. Some models, such as MELD, APACHE II, E-PASS, or POSSUM, widely used in other populations, are useful to predict the morbidity and mortality after liver resection. Some special models for liver resection are used to predict outcomes after liver resection, such as mortality, liver dysfunction, transfusion, or acute renal failure. However, there is no good scoring system to predict or classify surgical complications because of shortage of internal or external validation. CONCLUSION It is important to validate the models for the major complications after liver resection with further internal or external databases.
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Affiliation(s)
- De-Cai Yu
- Department of Hepatobiliary Surgery, Drum Tower Hospital, the Affiliated Medical School of Nanjing University, Nanjing 210008, China.
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Abstract
Hepatocellular carcinoma (HCC) is the most common primary malignancy of the liver and is a common cause of cancer death worldwide. Treatment of HCC usually consists of combinations of locoregional therapy, surgical resection, orthotopic liver transplantation, and in advanced cases, systemic chemotherapy. The best rates of cure are achieved with surgical resection or orthotopic liver transplantation in well-selected patients. The success of surgical resection depends on the adequacy of the extent of resection, balanced with the need to preserve functional hepatic parenchyma. Nonanatomic resection for HCC has been proposed as a surgical technique to maximize residual liver mass, but has been shown by some to yield inferior oncologic outcomes compared with formal anatomic resection. This review discusses relevant surgical anatomy of the liver, classifications of hepatic resection, and the current literature regarding outcomes of anatomic and nonanatomic resection of the liver.
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Abstract
Model for end-stage liver disease (MELD) score, initially developed to predict survival following transjugular intrahepatic portosystemic shunt was subsequently found to be accurate predictor of mortality amongst patents with end-stage liver disease. Since 2002, MELD score using 3 objective variables (serum bilirubin, serum creatinine, and institutional normalized ratio) has been used worldwide for listing and transplanting patients with end-stage liver disease allowing transplanting sicker patients first irrespective of the wait time on the list. MELD score has also been shown to be accurate predictor of survival amongst patients with alcoholic hepatitis, following variceal hemorrhage, infections in cirrhosis, after surgery in patients with cirrhosis including liver resection, trauma, and hepatorenal syndrome (HRS). Although, MELD score is closest to the ideal score, there are some limitations including its inaccuracy in predicting survival in 15-20% cases. Over the last decade, many efforts have been made to further improve and refine MELD score. Until, a better score is developed, liver allocation would continue based on the currently used MELD score.
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Key Words
- AH, alcoholic hepatitis
- BAR, balance risk
- CTP, Child–Pugh–Turcotte
- Cirrhosis
- DFI, discriminate function index
- EDC, extended donor criteria
- ESLD, end-stage liver disease
- FHF, fulminant hepatic failure
- GFR, glomerular filtration rate
- HVPG, hepatic venous pressure gradient
- LT, liver transplantation
- Liver transplantation
- MDRD, modification of diet in renal disease
- MELD
- MELD, model for end-stage liver disease
- MLP, multi-layer perceptron
- QALY, quality adjusted life years
- SLK, simultaneous liver kidney transplantation
- SOFA, sequential organ failure assessment
- SOFT, survival outcomes following transplantation
- TIPS, transjugular intrahepatic portosystemic
- UKELD, UK end stage liver disease score
- UNOS, United Network for Organ Sharing
- VH, variceal hemorrhage
- deMELD, drop-out equivalent MELD
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Affiliation(s)
| | - Patrick S. Kamath
- Address for correspondence: Patrick S. Kamath, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA.
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Filicori F, Keutgen XM, Zanello M, Ercolani G, Di Saverio S, Sacchetti F, Pinna AD, Grazi GL. Prognostic criteria for postoperative mortality in 170 patients undergoing major right hepatectomy. Hepatobiliary Pancreat Dis Int 2012; 11:507-12. [PMID: 23060396 DOI: 10.1016/s1499-3872(12)60215-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Postoperative hepatic failure is a dreadful complication after major hepatectomy and carries high morbidity and mortality rates. In this study, we assessed the accuracy of the 50/50 criteria (bilirubin >2.9 mg/dL and international normalized ratio >1.7 on postoperative day 5) and the Mullen criteria (bilirubin peak >7 mg/dL on postoperative days 1-7) in predicting death from hepatic failure in patients undergoing right hepatectomy only. In addition, we identified prognostic factors linked to intra-hospital morbidity and mortality in these patients. METHODS One hundred seventy consecutive patients underwent major right hepatectomy at a tertiary medical center from 2000 to 2008. Nineteen (11.2%) patients suffered from liver cirrhosis. Univariate and multivariate analyses were performed to identify predictors of intra-hospital mortality, morbidity and death from hepatic failure. RESULTS The intra-hospital mortality was 6.5% (11/170). Of the six patients who died from hepatic failure, one was positive for the 50/50 criteria, but all six patients were positive for the Mullen criteria. Multivariate analysis showed that male gender, hepatitis C (HCV), hepatocellular carcinoma, postoperative bilirubin >7 mg/dL and ALT<188 U/L on postoperative day 1 were predictive of death from hepatic failure in the postoperative period. Age >65 years, HCV, reoperation, and renal failure were significant predictors of overall intra-hospital mortality on multivariate analysis. CONCLUSIONS The Mullen criteria were more accurate than the 50/50 criteria in predicting death from hepatic failure in patients undergoing right hepatectomy. A bilirubin peak >7 mg/dL in the postoperative period, HCV positivity, hepatocellular carcinoma, and an ALT level <188 U/L on postoperative day 1 were associated with death from hepatic failure in our patient population.
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Affiliation(s)
- Filippo Filicori
- General Surgery and Transplant Unit, Department of General Surgery and Organ Transplantation, University of Bologna, Via Massarenti 9, 40138 Bologna, Italy.
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Sabaté A, Acosta Villegas F, Dalmau A, Koo M, Sansano Sánchez T, García Palenciano C. [Anesthesia in the patient with impaired liver function]. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2012; 58:574-81. [PMID: 22279877 DOI: 10.1016/s0034-9356(11)70142-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
We review information on impaired liver function, focusing on concepts relevant to anesthesia and postoperative recovery. The effects of impaired function are analyzed by systems of the body, with attention to the complications the patient with liver cirrhosis may develop according to type of surgery. Approaches to correcting coagulation disorders in the cirrhotic patient are particularly controversial because an increase in volume may be a factor in bleeding owing to increased portal venous pressure and imbalances in the factors that favor or inhibit coagulation. Perioperative morbidity and mortality correlate closely to Child-Pugh class and the score derived from the model for end-stage liver disease (MELD). Patients in Child class A are at moderate risk and surgery is therefore not contraindicated. Patients in Child class C or with a MELD score over 20, on the other hand, are at high risk and should not undergo elective surgical procedures. Abdominal surgery is generally considered to put patients with impaired liver function at high risk because it causes changes in hepatic blood flow and increases intraoperative bleeding because of high portal venous pressures.
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Affiliation(s)
- A Sabaté
- Servicio de Anestesiología y Reanimación, Hospital Universitari de Bellvitge, IDIBELL, Hospitalet de Llobregat, Barcelona.
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Rahbari NN, Reissfelder C, Koch M, Elbers H, Striebel F, Büchler MW, Weitz J. The Predictive Value of Postoperative Clinical Risk Scores for Outcome After Hepatic Resection: A Validation Analysis in 807 Patients. Ann Surg Oncol 2011; 18:3640-9. [DOI: 10.1245/s10434-011-1829-6] [Citation(s) in RCA: 102] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2011] [Indexed: 12/11/2022]
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Paes-Barbosa FC, Ferreira FG, Szutan LA. Hepatectomy preoperative planning. Rev Col Bras Cir 2011; 37:370-5. [PMID: 21181004 DOI: 10.1590/s0100-69912010000500011] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2009] [Accepted: 07/15/2009] [Indexed: 01/27/2023] Open
Abstract
Hepatectomy can comprise excision of peripheral tumors as well as major surgeries like trisegmentectomies or central resections. Patients can be healthy, have localized liver disease or possess a cirrhotic liver with high operative risk. The preoperative evaluation of the risk of postoperative liver failure is critical in determining the appropriate surgical procedure. The nature of liver disease, its severity and the operation to be performed should be considered for correct preparation. Liver resection should be evaluated in relation to residual parenchyma, especially in cirrhotic patients, subjects with portal hypertension and when large resections are needed. The surgeon should assess the rationale for the use of hepatic volumetry. Child-Pugh, MELD and retention of indocyanine green are measures for assessing liver function that can be used prior to hepatectomy. Extreme care should be taken regarding the possibility of infectious complications with high morbidity and mortality in the postoperative period. Several centers are developing liver surgery in the world, reducing the number of complications. The development of surgical technique, anesthesia, infectious diseases, oncology, intensive care, possible resection in patients deemed inoperable in the past, will deliver improved results in the future.
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Luo YX, Li C, Wen TF, Yan LN, Li B. Surgical treatment of patients with hepatocellular carcinoma and portal hypertension: an analysis of 43 cases. Shijie Huaren Xiaohua Zazhi 2010; 18:3576-3579. [DOI: 10.11569/wcjd.v18.i33.3576] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the efficacy and safety of surgical management of hepatocellular carcinoma with portal hypertension.
METHODS: The clinical data for 43 patients with hepatocellular carcinoma and portal hypertension who were treated from 2006 to 2010 were retrospectively analyzed. Of all the patients, 13 were treated by combined pericardial devascularization, splenectomy and hepatic resection, 16 by combined splenectomy and hepatic resection, and 14 by hepatic resection alone. Postoperative laboratory parameters and surgical complications were analyzed in these patients.
RESULTS: Ascites was apt to occur in patients who underwent hepatic resection alone. White blood cell and platelet counts increased significantly in patients who received splenectomy (257.1 × 109/L ± 48.3 × 109/L vs 48.7 × 109/L ± 24.9 × 109/L, 227.1 × 109/L ± 46.1 × 109/L vs 47.8 × 109/L ± 18.8 × 109/L; 12.3 × 109/L ± 2.4 × 109/L vs 3.1 × 109/L ± 1.4 × 109/L, 11.9 × 109/L ± 2.4 × 109/L vs 2.8 × 109/L ± 1.6 × 109/L, all P < 0.05). The incidence of postoperative complications was significantly higher in patients undergoing hepatic resection alone than in the other two groups of patients (64.3% vs 27.6%, P< 0.05). The rate of postoperative complications was significantly higher in patients who had grade B liver function than in those who had grade A liver function (85.7% vs 22.2%).
CONCLUSION: Combined hepatic resection and splenectomy are an efficient and safe method for management of patient with hepatocellular carcinoma and portal hypertension. The indications for combined pericardial devascularization, splenectomy and hepatic resection should be applied strictly.
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Lao OB, Farjah F, Flum DR, Yeung RS. Adverse events after radiofrequency ablation of unresectable liver tumors: a single-center experience. Am J Surg 2009; 198:76-82. [DOI: 10.1016/j.amjsurg.2008.09.025] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2008] [Revised: 09/23/2008] [Accepted: 09/23/2008] [Indexed: 12/22/2022]
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Value of MELD and MELD-Based Indices in Surgical Risk Evaluation of Cirrhotic Patients: Retrospective Analysis of 190 Cases. World J Surg 2009; 33:1711-9. [DOI: 10.1007/s00268-009-0093-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Frye JW, Perri RE. Perioperative risk assessment for patients with cirrhosis and liver disease. Expert Rev Gastroenterol Hepatol 2009; 3:65-75. [PMID: 19210114 DOI: 10.1586/17474124.3.1.65] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Patients with cirrhosis are at an increased risk of complications of operative procedures. There is a growing understanding of the nature of the risks that cirrhotic patients experience, as well as more precise and objective tools to gauge the patients at risk for surgical complications. Surgical procedures that are common and high risk for patients with cirrhosis are cardiac surgery, cholecystectomy and hepatic resections, as well as other abdominal surgeries and orthopedic surgeries. The physicians who care for patients with cirrhosis who require a surgical procedure can apply an understanding of the type of surgery anticipated with knowledge of the severity of the patient's liver disease to predict those patients at risk for operative morbidity and mortality. A sound knowledge of the specific operative risks faced by patients with cirrhosis should prompt the clinician to take steps to prevent these complications.
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Affiliation(s)
- Jeanetta W Frye
- Department of Internal Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.
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Abstract
The preoperative assessment of liver function is extremely important for preventing postoperative liver failure and mortality after hepatic resection. Liver function tests may be divided into three types; conventional liver function tests, general scores, and quantitative liver function tests. General scores are based on selected clinical symptoms and conventional test results. Child-Turcotte-Pugh score has been the gold standard for four decades, but the Child-Turcotte-Pugh score has difficulty discriminating a good risk from a poor risk in patients with mild to moderate liver dysfunction. The model for end-stage liver disease score has also been applied to predict short-term outcome after hepatectomy, but it is only useful in patients with advanced cirrhosis. Quantitative liver function tests overcome the drawbacks of general scores. The indocyanine green retention rate at 15 minutes (ICG R15) has been reported to be a significant predictor of postoperative liver failure and mortality. The safety limit of the hepatic parenchymal resection rate can be estimated using the ICG R15, and a decision tree (known as the Makuuchi criteria) for selecting patients and hepatectomy procedures has been proposed. Hepatic resection can be performed with a mortality rate of nearly zero using this decision tree. If the future remnant liver volume does not fulfill the Makuuchi criteria, preoperative portal vein embolization should be performed to prevent postoperative liver failure. Galactosyl human serum albumin-diethylenetriamine-pentaacetic acid scintigraphy also provides data that complement the ICG test. Other quantitative liver function tests, however, require further validation and simplification.
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Affiliation(s)
- Yasuji Seyama
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
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