Expanded Makuuchi's criteria using estimated indocyanine green clearance rate of future liver remnant as a safety limit for maximum extent of liver resection

Harmonization of quantitative liver function evaluation using gadoxetate disodium-enhanced magnetic resonance imaging

OBJECTIVES

This study aimed to develop a clinically applicable harmonization method for the hepatocellular uptake index (HUI), a quantitative liver function index, using gadoxetate disodium-enhanced (EOB)-MRI, to ensure consistency across diverse MR systems.

MATERIALS AND METHODS

This retrospective study, approved by our institutional review board, included consecutive patients who underwent three-dimensional gradient-echo T1-weighted EOB-MRI, HUI measurements, indocyanine green disappearance rate (ICG-PDR), and albumin-bilirubin linear predictor (ALBI-LP) between April 2011 and June 2024. Six different MR systems were used for HUI measurements. A harmonization method using ALBI-LP was developed and validated for estimating liver reserves corresponding to ICG-PDR through statistical analysis of residuals.

RESULTS

A total of 498 patients (mean age, 68.0 years ± 11.6; 320 men) were evaluated. A statistically significant linear correlation was observed between HUI, ICG-PDR, and ALBI-LP in each MR system, leading to the determination of conversion factors for HUI harmonization. The harmonizing equation, harmonized HUI (h-HUI) = HUI･(Slope2'/-1.425)･0.955, was derived, with Slope2' representing the regression slope between HUI and ALBI-LP for each MR system. The standard deviation of the estimation error for ICG-PDR was significantly smaller using h-HUI by ALBI-LP (0.051, [0.048-0.054]) compared to non-harmonized HUI (0.060, [0.056-0.063]) or ALBI-LP (0.060, [0.057-0.064]), and equivalent to h-HUI by ICG-PDR (0.051, [0.045, 0.055]).

CONCLUSION

The HUI harmonized by the ALBI-LP is a clinically applicable method for ensuring the comparability of MR devices in quantitative liver reserve prediction using gadoxetate disodium-enhanced MR imaging.

KEY POINTS

Question The accurate prediction of quantitative liver function by hepatocyte-specific contrast-enhanced MRI necessitates the harmonization of MR systems. However, no established method has yet been identified. Findings In quantitative hepatic function assessment, albumin-bilirubin linear predictor can be employed to achieve harmonization between MR systems equivalent to the indocyanine green clearance test. Clinical relevance Quantitative liver function, as measured by the indocyanine green clearance test, can be accurately estimated using the hepatocellular uptake index, harmonized with the albumin-bilirubin linear predictor, across diverse MR systems.

Precision surgery for hepatocellular carcinoma

Hepatocellular carcinoma arises in the setting of cirrhosis in most cases, requiring multidisciplinary input to define resectability. In this regard, more precise surgical management considers patient factors and anatomical states, including resection margins, tumour biology, and perioperative therapy. Together with advances in surgical techniques, this integrated approach has resulted in considerable improvements in patient morbidity and oncological outcomes. Despite this, recurrence rates in hepatocellular carcinoma remain high. As the systemic treatment landscape in hepatocellular carcinoma continues to evolve and locoregional options are increasingly used, we review current and future opportunities to individualise the surgical management of patients with hepatocellular carcinoma.

Hepatocellular carcinoma: Revising the surgical approach in light of the concept of multiparametric therapeutic hierarchy

The clinical management of hepatocellular carcinoma (HCC) is strongly influenced by several prognostic factors, mainly tumor stage, patient's health, liver function and specific characteristics of each intervention. The interplay between these factors should be carefully evaluated by a multidisciplinary tumor board. To support this, the novel "multiparametric therapeutic hierarchy" (MTH) concept has been recently proposed. This review will present the main features of available surgical treatments for HCC (liver transplantation, liver resection, ablation). Strengths and weaknesses are reported in the light of clinical decision making and of treatment allocation, with a special focus on the collocation of each treatment in the MTH framework and on how MTH may be useful in supporting clinical decision. Sequential treatments and their role to allow further surgical treatments will also be analyzed.

Histological and radiological analysis of simultaneous dual hepatic vein embolization for right-sided major hepatectomy

PURPOSE

Simultaneous dual hepatic vein embolization (DHVE) has been proposed for safe right-sided hepatectomy, with good results for liver hypertrophy and function. However, the histological and radiological findings of DHVE have not been thoroughly investigated.

METHODS

This study included 14 patients who underwent DHVE before right-sided major hepatectomy. DHVE was performed if the future liver remnant was < 35% or borderline, but with concomitant vascular resection. The liver function was assessed using the signal intensity on Gd-EOB-DTPA-MRI. A histological evaluation of the area of DHVE and portal vein embolization (PVE) were performed.

RESULTS

The median pre- and post-functional liver remnants were 363 ml and 498 ml, respectively (p < 0.001). The median growth rate was 48.6%, and there was no post-hepatectomy liver failure in the patients who underwent DHVE. The signal intensity ratio in the area of DHVE was lower than that in the areas of PVE and the remnant liver (p < 0.01). The degree of congestion and necrosis was greater in the area of DHVE than in the area of PVE alone (p < 0.01 and p = 0.04, respectively).

CONCLUSIONS

We observed good liver hypertrophy after DHVE and histological and radiological changes in the area of DHVE. Our findings provide a compelling rationale for further investigation of the mechanism of liver hypertrophy in DHVE.

Indocyanine Green and Hepatobiliary Surgery: An Overview of the Current Literature

Indocyanine green (ICG) is an inert polypeptide that almost totally binds to high molecular weight plasma proteins; it is cleared by the hepatocytes and directly excreted into the bile with a half-life of about 3-5 minutes. Specific systems are required to see fluorescent images. The use of this dye has been reported in different surgical specialties, and the applications in hepatobiliary surgery are widening. Being firstly used to evaluate the preoperative liver function, intra- and postoperative dynamic checking of hepatic activity has been reported and integrated within perioperative protocols allowing a tailored treatment allocation. Intravenous injection (IV) or injection into the gallbladder can ease difficult cholecystectomy. Biliary leakage detection could be enhanced by IV ICG injection. Although with some contrasting results, the use of ICG for both delineating the limits of the resection and tumor-enhanced visualization was demonstrated to improve short- and long-term outcomes. Although the lack of strong evidence still precludes the introduction of this tool in clinical practice, it harbors great potential in liver surgery.

The successful posterior sectionectomy accompanied with caudate lobectomy for hepatocellular carcinoma located in segment 1 after LEN-TACE: a case report

Nowadays, the novel molecular targeting chemotherapy provides possibility of safe hepatectomy for progressive hepatocellular carcinoma (HCC). Further, combination of the conventional transarterial chemoembolization (TACE) may add an effect of tumor shrink. We present a successful radical hepatectomy for a large HCC located in segment 1 accompanied with the preoperative Lenvatinib (LEN)-TACE sequential treatment. We present a woman patient without any complaints who had a 7 cm-in-size of solitary HCC compressing vena cava and right portal pedicle. To achieve radical hepatectomy by tumor shrinking, LEN-TACE for 2 months. After confirming downsizing or devascularization of the HCC, we scheduled radical posterior sectionectomy combined with caudate lobectomy according to tumor location and expected future remnant liver volume from three-dimensional computed tomography simulation before surgery. Under the thoraco-abdominal incision laparotomy, we safely achieved scheduled radical hepatectomy without any vascular injuries. The postoperative course was uneventful and no tumor recurrence were observed for 1 year. Histological findings showed the Japan TNM stage III HCC with 70% necrosis. The multi-modal strategy of LEN-TACE followed by radical hepatectomy by confirming downsizing or devascularization in tumor is supposed to be useful and would be a preoperative chemotherapy option, and promising for curative treatment in HCC patients with progressive or large HCC, which may lead to safety by prevention surrounding major vascular injury.

Outcomes of liver resection in hepatitis C virus-related intrahepatic cholangiocarcinoma: A systematic review and meta-analysis

BACKGROUND

Cholangiocarcinoma is the second most common primary liver malignancy. Its incidence and mortality rates have been increasing in recent years. Hepatitis C virus (HCV) infection is a risk factor for development of cirrhosis and cholangiocarcinoma. Currently, surgical resection remains the only curative treatment option for cholangiocarcinoma. We aim to study the impact of HCV infection on outcomes of liver resection (LR) in intrahepatic cholangiocarcinoma (ICC).

AIM

To study the outcomes of curative resection of ICC in patients with HCV (i.e., HCV+) compared to patients without HCV (i.e., HCV-).

METHODS

We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) and observational studies to assess the outcomes of LR in ICC in HCV+ patients compared to HCV- patients in tertiary care hospitals. PubMed, EMBASE, The Cochrane Library and Scopus were systematically searched from inception till August 2023. Included studies were RCTs and non-RCTs on patients ≥ 18 years old with a diagnosis of ICC who underwent LR, and compared outcomes between patients with HCV+ vs HCV-. The primary outcomes were overall survival (OS) and recurrence-free survival. Secondary outcomes include perioperative mortality, operation duration, blood loss, intrahepatic and extrahepatic recurrence.

RESULTS

Seven articles, published between 2004 and 2021, fulfilled the selection criteria. All of the studies were retrospective studies. Age, incidence of male patients, albumin, bilirubin, platelets, tumor size, incidence of multiple tumors, vascular invasion, bile duct invasion, lymph node metastases, and stage 4 disease were comparable between HCV+ and HCV- group. Alanine transaminase [MD 22.20, 95%confidence interval (CI): 13.75, 30.65, P < 0.00001] and aspartate transaminase levels (MD 27.27, 95%CI: 20.20, 34.34, P < 0.00001) were significantly higher in HCV+ group compared to HCV- group. Incidence of cirrhosis was significantly higher in HCV+ group [odds ratio (OR) 5.78, 95%CI: 1.38, 24.14, P = 0.02] compared to HCV- group. Incidence of poorly differentiated disease was significantly higher in HCV+ group (OR 2.55, 95%CI: 1.34, 4.82, P = 0.004) compared to HCV- group. Incidence of simultaneous hepatocellular carcinoma lesions was significantly higher in HCV+ group (OR 8.31, 95%CI: 2.36, 29.26, P = 0.001) compared to HCV- group. OS was significantly worse in the HCV+ group (hazard ratio 2.05, 95%CI: 1.46, 2.88, P < 0.0001) compared to HCV- group.

CONCLUSION

This meta-analysis demonstrated significantly worse OS in HCV+ patients with ICC who underwent curative resection compared to HCV- patients.

Neoadjuvant therapies in resectable hepatocellular carcinoma: Exploring strategies to improve prognosis

Hepatocellular carcinoma (HCC), a challenging malignancy, often necessitates surgical intervention, notably liver resection. However, the high recurrence rate, reaching 70% within 5 years post-resection, significantly impacts patient outcomes. Neoadjuvant therapies aim to preoperatively address this challenge, reducing lesion size, improving surgical resection rates, deactivating potential micro-metastases, and ultimately lowering postoperative recurrence rates. This review concentrates on advances in research on and clinical use of neoadjuvant therapies for HCC, with particular attention to the use of immune checkpoint inhibitors (ICIs) targeting programmed cell death-1 (PD-1), programmed cell death ligand-1 (PD-L1), and cytotoxic T-lymphocyte-associated protein-4 (CTLA-4). Ongoing clinical studies exploring immunotherapy combined with a tyrosine kinase inhibitor (TKI), interventional therapy, radiotherapy, and other modalities offer promising insights into overcoming resistance to monotherapies. In summary, neoadjuvant therapies hold significant promise in terms of improving the prognosis for patients with HCC and enhancing long-term survival, particularly through innovative combination strategies.

Albumin-indocyanine green evaluation of future liver remnant predicts liver failure after anatomical hepatectomy for hepatocellular carcinoma: A dual-center retrospective study

Aim

The albumin-indocyanine green evaluation (ALICE) score is a useful predictor of post-hepatectomy liver failure (PHLF); however, its usefulness in combination with future liver remnant (FLR), measured by 3-D volumetry, has not been investigated. This study aimed to investigate the relationship between the ALICE of the FLR (ALICE-FLR) score and severe PHLF.

Methods

The clinical data of 215 patients who underwent anatomical hepatectomy for hepatocellular carcinoma without portal vein embolization at two institutes between January 2010 and December 2021 were analyzed retrospectively. PHLF occurrence and severity were determined according to the International Study Group of Liver Surgery's definition. Grades B and C PHLF were defined as severe PHLF. The ALICE-FLR, ALICE scores, and indocyanine green clearance of FLR (ICGK-FLR) were evaluated for severe PHLF prediction.

Results

Severe PHLF was observed in 40 patients (18.6%). The areas under the curve (AUCs) for the ALICE-FLR, ALICE scores, ICGK-FLR, and FLR were 0.76, 0.64, 0.73, and 0.69, respectively. The AUC of the ALICE-FLR score was significantly higher than that of the ALICE score. The ALICE-FLR score was identified as an independent predictor of severe PHLF (the odds ratio for every 0.01 increment in the ALICE-FLR score was 1.24; 95% confidence interval, 1.070-1.453; p = 0.004). Among patients with severe PHLF, the ALICE-FLR score was significantly higher in the grade C than in the grade B PHLF group.

Conclusion

The combination of liver function models, including indocyanine green, albumin, and FLR is considered compatible for predicting severe PHLF.

Efficacy and safety of postoperative preemptive use of tolvaptan for patients with cirrhosis undergoing hepatectomy for hepatocellular carcinoma

PURPOSE

Optimal choice of diuretics in perioperative management remains unclear in enhanced recovery after liver surgery. This study investigated the efficacy and safety of tolvaptan (oral vasopressin V2-receptor antagonist) in postoperative management of patients with liver injury and hepatocellular carcinoma.

METHODS

The patients clinically diagnosed with liver cirrhosis were included in this study. Clinical outcomes of 51 prospective cohort managed with a modified postoperative protocol using tolvaptan (validation group) were compared with 83 patients treated with a conventional management protocol (control group).

RESULTS

Postoperative urine output were significantly larger and excessive body weight increase were reduced with no impairment in renal function or serum sodium levels in the validation group. Although the total amount of discharge and trend of serum albumin level were not significantly different among the groups, global incidence of postoperative morbidity was less frequent (19.6% vs. 44.6%, P=0.005) and postoperative stay was significantly shorter (8 days vs.10 days, P=0.008) in the validation group compared with the control group.

CONCLUSIONS

Tolvaptan could be safely used for the patients with injured liver in postoperative management after hepatectomy and potentially advantageous in the era of enhanced recovery after surgery with its strong diuretic effect and better fluid management.

How Much Is Enough? A Surgical Perspective on Imaging Modalities to Estimate Function and Volume of the Future Liver Remnant before Hepatic Resection

Liver resection is the first curative option for most hepatic primary and secondary malignancies. However, post-hepatectomy liver failure (PHLF) still represents a non-negligible postoperative complication, embodying the most frequent cause of hepatic-related mortality. In the absence of a specific treatment, the most effective way to deal with PHLF is its prevention through a careful preoperative assessment of future liver remnant (FLR) volume and function. Apart from the clinical score and classical criteria to define the safe limit of resectability, new imaging modalities have shown their ability to assist surgeons in planning the best operative strategy with a precise estimation of the FLR amount. New technologies leading to liver and tumor 3D reconstruction may guide the surgeon along the best resection planes combining the least liver parenchymal sacrifice with oncological appropriateness. Integration with imaging modalities, such as hepatobiliary scintigraphy, capable of estimating total and regional liver function, may bring about a decrease in postoperative complications. Magnetic resonance imaging with hepatobiliary contrast seems to be predominant since it simultaneously integrates hepatic function and volume information along with a precise characterization of the target malignancy.

Risk Stratification of Patients with Marginal Hepatic Functional Reserve Using the Remnant Hepatocyte Uptake Index in Gadoxetic Acid-Enhanced Magnetic Resonance Imaging for Safe Liver Surgery

BACKGROUND

This study aimed to explore the efficacy of gadoxetic acid-enhanced (Gd-EOB) magnetic resonance imaging (MRI) in surgical risk estimation among patients with marginal hepatic function estimated by indocyanine green (ICG) clearance test.

METHODS

This analysis focused on 120 patients with marginal hepatic functional reserve (ICG clearance rate of future liver remnant [ICG-Krem] < 0.10). Preoperative Gd-EOB MRI was retrospectively reviewed, and the remnant hepatocyte uptake index (rHUI) was calculated for quantitative measurement of liver function. The predictive power of rHUI for posthepatectomy liver failure was compared with several clinical measures used in current risk estimation before hepatectomy.

RESULTS

Receiver operating curve analysis showed that rHUI had the best predictive power for posthepatectomy liver failure among the tested variables (ICG-R15, ICG-Krem, albumin + bilirubin score, and albumin + ICG-R15 score). Cross-validation showed that a threshold of 925 could be the best cut-off value for estimating the postoperative risk of liver failure with sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio of 0.689, 0.884, 5.94, and 0.352, respectively.

CONCLUSION

rHUI could be a sensitive substitute measure for posthepatectomy liver failure risk estimation among patients with marginal hepatic functional reserve.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

A preoperative risk score based on multifrequency bioelectrical impedance analysis in patients undergoing liver resection

PURPOSE

To investigate if body composition parameters measured by bioelectrical impedance analysis (BIA) and are reportedly correlated with clinical outcomes of patients undergoing digestive tract surgery could be useful for reliably evaluating the perioperative risk in patients undergoing hepatectomy.

METHODS

Consecutive 200 patients who underwent BIA before hepatectomy were retrospectively reviewed. A risk prediction model for postoperative morbidity was created using the initial 100 patients, and its performance was validated using the remaining 100 patients.

RESULTS

Based on the correlation with postoperative morbidity, a novel risk prediction model, the protein-edema score, was created using net protein weight and extracellular water/total body water ratio measured through BIA. The protein-edema score (score 0 vs. ≥ 1) showed a reproducible correlation with Clavien-Dindo 2 or greater postoperative morbidity in the validation set (17.7% vs. 46.4%, P = 0.002) as observed in the training set (18.8% vs. 49.0%, P = 0.002) after statistical adjustment. Similar tendency was also confirmed in Clavien-Dindo 3a or greater postoperative morbidity (5.9% vs. 18.2%, P = 0.037) and postoperative refractory ascites (5.5% vs. 17.4%, P = 0.037) in the validation set.

CONCLUSIONS

The protein-edema score created based on BIA is significantly correlated with postoperative morbidity in patients undergoing liver resection.

A Conceptual Classification of Resectability for Hepatocellular Carcinoma

BACKGROUNDS

In the era of multidisciplinary treatment strategy, resectability for hepatocellular carcinoma (HCC) should be defined. This study aimed to propose and validate a resectability classification of HCC.

METHODS

We proposed following the three groups; resectable-(R), borderline resectable-(BR), and unresectable (UR)-HCCs. Resectable two groups were sub-divided according to the value of indocyanine green clearance of remnant liver (ICG-Krem) and presence of macrovascular invasion (MVI); BR-HCC was defined as resectable HCCs with MVI and/or ICG-Krem≥0.03-<0.05, and R-HCC was the remaining. Consecutive patients with HCC who underwent liver resection (LR) and non-surgical treatment(s) (i.e., UR-HCC) between 2011 and 2017 were retrospectively analyzed to validate the proposed classification.

RESULTS

A total of 361 patients were enrolled in the study. Of these, R-, BR- and UR-HCC were found in 251, 46, and 64 patients, respectively. In patients with resected HCC, ICG-Krem≥0.05 was associated with decreased risk of clinically relevant posthepatectomy liver failure (p=0.013) and the presence of MVI was associated with worse overall survival (OS) (p<0.001). The 3-5-years OS rates according to the proposed classification were 80.3, and 68.3% versus 51.4, and 35.6%, in the R and BR groups, respectively (both p<0.001). Multivariate analysis showed BR-HCC was independently associated with poorer OS (p<0.001) after adjusting for known tumor prognostic factors. Meanwhile, BR-HCC was associated with benefit in terms of OS compared with UR-HCC (p<0.001).

CONCLUSION

Our proposal of resectability for HCC allows for stratifying survival outcomes of HCC and may help to determine treatment strategy.

Surgery

This chapter provides a comprehensive background from basic to applied knowledge of surgical anatomy which is necessary for the surgical treatment of cholangiocarcinoma (CCA) patients. Significant advances that have been made in the surgical treatment of CCA were examined. For instance, in-depth details are provided for appropriate preoperative assessment and treatment to optimize patient status and to improve the outcome of surgical treatment(s). Comprehensive details are provided for the surgical techniques and outcomes of treatments for each type of CCA with clear illustrations and images. This chapter also describes the role of minimally invasive surgery and liver transplantation in CCA treatment.

The second Mexican consensus on hepatocellular carcinoma. Part II: Treatment

Hepatocellular carcinoma (HCC) is more frequently manifesting as one of the main complications of cirrhosis of the liver, its principal risk factor. There have been modifications in its incidence over the past decade, related to an epidemiologic transition in the etiology of cirrhosis, with a decrease in the prevalence of hepatitis C and an increase in nonalcoholic fatty liver disease (NAFLD) as a cause, as well as the development of HCC in the non-cirrhotic liver due to NAFLD. Genetic markers associated with the disease have been identified, and surveillance and diagnosis have improved. Regarding treatment, surgical techniques, in both resection and transplantation, have advanced and radiologic techniques, at the curative stage of the disease, have enhanced survival in those patients. And finally, there have been radical changes in the systemic approach, with much more optimistic expectations, when compared with the options available a decade ago. Therefore, the Asociación Mexicana de Hepatología decided to carry out the Second Mexican Consensus on Hepatocellular Carcinoma, which is an updated review of the available national and international evidence on the epidemiology, risk factors, surveillance, diagnosis, and treatment of the disease, to offer the Mexican physician current information on the different topics regarding hepatocellular carcinoma. In this second part of the document, the topics related to the treatment of HCC are presented.

The first years of liver transplantation: experiences at a single center

Background

The aim of this study was to analyze the first stages of progress in liver transplantation (LT) at a single center in Vietnam.

Methods

This study analyzed data from patients and donors who participated in the LT program between August 2018 and December 2021 at University Medical Center, Ho Chi Minh City. Study measures included any difficulties encountered, as well as the post-LT outcomes for living donor LT (LDLT) and deceased donor LT (DDLT). The chi-square test and Kaplan Meier survival analysis were used to test the factors that influenced the outcomes.

Results

A total of 18 adult recipients with LT (LDLT, n=16; DDLT, n=2) were included (mean age, 55.2±2.6 years; male, 88.9%). The most common post-LT complications were middle hepatic venous stenosis (20%) and graft rejection (22.2%). These complications were observed in LDLT patients. For DDLT, graft rejection (50%) was the only complication recorded. The survival rates for recipients at 3 months, 6 months, and 1 year were 100%, 88.9%, and 88.9%, respectively. The LDs had their right livers without the middle hepatic veins harvested, and biliary leakage (6.25%) was the only complication observed. There were no deaths among recipients or LDs during the operations or hospital stays.

Conclusions

This study provides key details about the process of LT, and these positive outcomes support LT as an important therapy for end-stage liver disease and early hepatocellular carcinomas.

Future remnant Liver optimization: preoperative assessment, volume augmentation procedures and management of PVE failure

Surgery is the cornerstone treatment for patients with primary or metastatic hepatic tumors. Thanks to surgical and anesthetic technological advances, current indications for liver resections have been significantly expanded to include any patient in whom all disease can be resected with a negative margin (R0) while preserving an adequate future residual liver (FRL). Post-hepatectomy liver failure (PHLF) is still a feared complication following major liver surgery, associated with high morbidity, mortality and cost implications. PHLF is mainly linked to both the size and quality of the FRL. Significant advances have been made in detailed preoperative assessment, to predict and mitigate this complication, even if an ideal methodology has yet to be defined. Several procedures have been described to induce hypertrophy of the FRL when needed. Each technique has its advantages and limitations, and among them portal vein embolization (PVE) is still considered the standard of care. About 20% of patients after PVE fail to undergo the scheduled hepatectomy, and newer secondary procedures, such as segment 4 embolization, ALPPS and HVE, have been proposed as salvage strategies. The aim of this review is to discuss the current modalities available and new perspectives in the optimization of FRL in patients undergoing major liver resection.

99mTc-GSA scintigraphy for assessing the functional volume ratio of the future liver remnant in the routine practice of liver resection

Background

The significance of incorporating regional functional heterogeneity assessment by liver scintigraphy into the calculation of the future liver remnant has been reported. However, liver scintigraphy entails additional costs and radiation exposure. Nevertheless, studies describing when liver scintigraphy demonstrates an actual benefit over computed tomography liver volumetry are lacking. Thus, we evaluated the degree of agreement between future liver remnant % values calculated by technetium ^99mTc diethylenetriaminepentaacetic acid-galactosyl human serum albumin scintigraphy (galactosyl human serum albumin–based future liver remnant %) and those by computed tomography volumetry and investigated the practical impact of performing regional functional heterogeneity assessment.

Methods

The Bland–Altman method was used to retrospectively analyze the agreement between computed tomography– and galactosyl human serum albumin–based future liver remnant % measurements in 84 patients.

Results

In ordinary patients with a computed tomography–based future liver remnant % greater than 50%, there was a good agreement between both measurements. However, in cases with a computed tomography–based future liver remnant % less than 40%, galactosyl human serum albumin–based measurements were significantly smaller than computed tomography–based values, with 88% of these patients exhibiting a galactosyl human serum albumin–based future liver remnant % less than 30%. After portal vein embolization, galactosyl human serum albumin–based measurements were primarily greater than or in agreement with computed tomography–based values, even in cases with a computed tomography–based future liver remnant % less than 40%.

Conclusion

Adding ^99mTc diethylenetriaminepentaacetic acid-galactosyl human serum albumin scintigraphy to computed tomography liver volumetry is advised when deciding on hepatectomy in patients with a computed tomography–based future liver remnant % less than 50%. If the computed tomography–based future liver remnant % is smaller than 40%, it is strongly recommended to check future liver remnant % by ^99mTc diethylenetriaminepentaacetic acid-galactosyl human serum albumin scintigraphy. In other cases, computed tomography–based future liver remnant % calculation alone can be regarded as the gold standard of safe hepatectomy.

Preoperative nutritional score predicts underlying liver status and surgical risk of hepatocellular carcinoma

BACKGROUND

Given the scarce evidence regarding the impact of preoperative nutritional status on surgical outcomes of patients with hepatocellular carcinoma, predictive powers of nutritional/inflammatory scores for short-term surgical outcomes in patients with hepatocellular carcinoma were investigated.

METHODS

Outcomes of 1272 patients with hepatocellular carcinoma were reviewed, and predictive powers of nine nutritional/inflammatory scores for short-term surgical outcomes were compared using the receiver-operating characteristic curve analysis. Clinical relevance of the best nutritional score was then studied in detail to clarify its utility as an alternative predictive measure for surgical risk of patients with hepatocellular carcinoma.

RESULTS

Receiver-operating characteristic curve analysis showed the controlling nutritional status score has the best performance in prediction of morbidity after hepatectomy for hepatocellular carcinoma (area under the curve, 0.593; 95% confidence interval: 0.552-0.635; p < 0.001), and multivariate analysis confirmed its correlation with the risk of any morbidity (odds ratio per +1 point, 1.17; 95% confidence interval: 1.08-1.27; p < 0.001) and major morbidity (odds ratio per +1 point, 1.14; 95% confidence interval: 0.99-1.27; p = 0.052). The undernutrition grade based on the controlling nutritional status score showed strong correlation with the degree of fibrosis in the liver (p < 0.001), platelet count (p < 0.001), and indocyanine green retention rate at 15 min (p < 0.001). In addition, the controlling nutritional status undernutrition grade well stratified the risk of postoperative morbidity especially in cirrhotic subpopulation (odds ratio, 1.17 per +1 point; 95% confidence interval: 1.05-1.29 for any morbidity and odds ratio, 1.20 per +1 point; 95% confidence interval: 1.03-1.40 for major morbidity).

CONCLUSION

The controlling nutritional status score could be an alternative measure for underlying liver injury and the surgical risk of hepatocellular carcinoma.

Adhesions as a risk factor for postoperative morbidity in patients undergoing repeat hepatectomy and the potential efficacy of adhesion barriers

BACKGROUND

The actual efficacy of use of adhesion barriers during liver surgery remains to be fully understood.

METHODS

We conducted an extensive review of clinical data and operation videos of 210 patients who underwent repeat hepatectomy to clarify the factors associated with the degree of adhesion as evaluated by the TORAD score.

RESULTS

Adhesion barriers were placed in 131 patients (Seprafilm^® [n = 77], Adspray^® [n = 32], and Interceed^® [n = 22)]), but not in the remaining 79 patients during the previous surgery. Multivariate analysis identified a high adhesion severity score at relaparotomy as being associated with an increased risk of postoperative global morbidity (odds ratio [OR], 1.75 per +1 point, P < .001) and major morbidity (OR, 1.88 per +1 point; P < .001), and use of an adhesion barrier at the previous surgery as being an independent predictor of a low adhesion severity score (OR, 0.21; P < .001). Use of adhesion barriers showed tendency toward lower adhesion severity scores at relaparotomy as compared to the control group, irrespective of the type of adhesion barrier used.

CONCLUSION

A high degree of adhesion formation was directly associated with an increased risk of postoperative morbidity after relaparotomy, and use of adhesion barriers appears to reduce the extent of adhesion.

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.

Clinical implication of ICG test in major hepatectomy for biliary tract cancer

BACKGROUND

Major hepatectomy with bile duct resection (BDR) is associated with severe postoperative complications; therefore, evaluation of preoperative liver function is important. However, little is known about mechanisms of increased severe complications in patients with poor liver function. The aim of this study was to evaluate whether indocyanine green retention rate after 15 minutes of injection (ICG-R15) is useful for predicting the risk of severe postoperative complications in this operation, and to reveal the mechanisms of increasing severe complications by focusing on immune function and liver regeneration after hepatectomy.

METHODS

Patients receiving major hepatectomy with BDR between 2000 and 2017 were retrospectively reviewed. Severe postoperative complications were defined as Clavien-Dindo grade ≥IV.

RESULTS

In 284 patients undergoing major hepatectomy with BDR, ICG-R15 was correlated with severe postoperative complications, with cut-off value of 11.8%. In brief, the incidences of hyperbilirubinemia, coagulopathy, liver failure, respiratory failure, severe complications, and mortality were higher in the high ICG-R15 group. Moreover, high ICG-R15 (≥11.8%) was an independent factor for predicting severe complications after major hepatectomy with BDR. Immune dysfunction in the early phase after operation, prolonged postoperative immunosuppression, and delayed liver regeneration were reasons for increasing severe postoperative complications in patients with high ICG-R15.

CONCLUSIONS

High ICG-R15 is an independent risk factor for severe complications after major hepatectomy with BDR, and its cut-off value is 11.8%. Compromised condition and delayed liver regeneration induced by immune dysfunction are reasons of increased severe postoperative complications in patients with high ICG-R15.

Changes in the Role and Mode of Liver Resection for Hepatocellular Carcinoma Over 20 Years: A Single-Center Analysis

INTRODUCTION

The aim of this study was to analyze changes in characteristics of HCC and the modes of LR over 20 years in order to show the impact of those changes in the outcome of LR. In addition, BCLC staging was used to assess the limitations of this classification system and changes over the decade.

PATIENTS AND METHODS

In our department, 500 liver resections (LR) were performed for hepatocellular carcinoma (HCC) over the 20 years between January 2000 and February 2020. The 208 cases performed through 2009 were designated as Era 1, and the 292 cases between 2010 and February 2020 were termed Era 2. We analyzed changes in the characteristics of HCC and mode of LR (Study 1), and final outcomes of LR are shown according to the BCLC staging classifications and eras using data from the 5 years after LR (Study 2).

RESULTS

In Era 1, the mean age of the patients was 68, while in Era 2 the mean age was 71, which was significantly older than the patients in Era 1. HCC that developed from non-B, non-C liver cirrhosis was significantly increased in Era 2 (45%) as compared to that in Era 1 (34%). Laboratory data were all comparable between the eras in patients undergoing LR for HCC. The size and numbers of the HCC as well as tumor markers were similar between the eras. As to the mode of LR, although the extent of LR was similar between the eras, the laparoscopic method was significantly increased in Era 2. Blood loss was significantly lower in Era 2 (mean 519 g) than in Era 1 (1,085 g). Patient survival and recurrence-free survival (RFS) were similar between the two eras, while RFS at 5 years after LR was better in Era 2. Even in the BCLC A category, only patients with a single HCC less than 5 cm showed best results, while patients with HCC within the rest of BCLC A and BCLC B showed a dismal outcome. There was no difference in OS and RFS between the eras after stratification by BCLC.

CONCLUSION

There are conspicuous changes in the baseline characteristics and mode of LR over 20 years, which should be taken into account for patient care and informed consent for patients undergoing LR going forward.

Successful Anatomic Resection of Tumor-Bearing Portal Territory Delays Long-Term Stage Progression of Hepatocellular Carcinoma

BACKGROUND

Optimal choice of surgical procedure for hepatocellular carcinoma (HCC) remains inconclusive. This study seeks to investigate the oncological superiority of anatomic resection (AR) of the tumor-bearing portal territory and potential mechanism of survival benefit for patients undergoing AR.

PATIENTS AND METHODS

In 203 patients who underwent curative resection for primary solitary HCC measuring ≤ 5 cm in diameter, which was resectable either by AR or limited resection (non-AR), long-term outcomes were compared with propensity score adjustment. Advantages of AR in local tumor control and postprogression survival were then evaluated by a multivariate analysis and a Markov model.

RESULTS

The AR group showed better recurrence-free survival [hazard ratio (HR), 0.51; 95% CI, 0.28-0.91; P = 0.023), time-to-interventional failure (TIF) (HR, 0.08; 95% CI, 0.01-0.60; P = 0.014), and overall survival (HR, 0.11; 95% CI, 0.01-0.79, P = 0.029) than the non-AR group. Competing-risks regression revealed that AR significantly decreases local recurrence (HR, 0.13; 95% CI, 0.02-0.97; P = 0.047) and is correlated with smaller number and size of recurrent lesions, both of which were predictors for better TIF and postprogression survival. A Markov model demonstrated that annual transition rate from the early recurrence stage (i.e., curative-intent treatment indicated) to the intermediate stage (i.e., only palliative-intent treatment indicated) was significantly lower (9.0% versus 35.6%, P = 0.027) when AR was completed at the initial hepatectomy.

CONCLUSIONS

AR is oncologically advantageous for patients with primary solitary HCC. Initial choice of surgical procedure may have significant influence on the pattern of recurrence and postprogression clinical course that may affect overall survival of patients with HCC.

Microvascular Invasion and a Size Cutoff Value of 2 cm Predict Long-Term Oncological Outcome in Multiple Hepatocellular Carcinoma: Reappraisal of the American Joint Committee on Cancer Staging System and Validation Using the Surveillance, Epidemiology, and End-Results Database

INTRODUCTION

For prognostication of hepatocellular carcinoma (HCC), the optimal size cutoff value and the significance of microvascular invasion (mvi) remain inconclusive.

OBJECTIVE

This study sought to revisit the inconclusive components of current American Joint Committee on Cancer (AJCC) staging system and to develop a new practical prognostication model for patients with HCC based on 2 large cohorts.

METHOD

In 1,175 patients who underwent resection for HCC (training cohort), prognostic significance of mvi, and optimal size cutoff value were revisited and a new staging model was established. Then, its performance was validated using 5,249 patients derived from a population-based database (validation cohort).

RESULTS

The optimal size cutoff value was 2 cm in multiple HCC, similar to that for solitary HCC. Multivariate analyses confirmed that mvi, a size >2 cm, and multiple lesions were independent predictors with similar weights for disease-specific survival. Based on these results, earlier stages of HCC were reclassified according to the number of the following factors: multiple tumors, >2 cm in diameter, and presence of mvi. Also, given the similar prognosis of Stages IIIB and IVA according to the AJCC 8th edition, these groups were reclassified into the same stage. This new staging model had a better performance than the AJCC 8th edition in both training cohort (c-statistics, 0.648 vs. 0.629) and the validation cohort (c-statistics, 0.646 vs. 0.645) regardless of the presence of cirrhosis.

CONCLUSIONS

Inclusion of a size cutoff value of 2 cm and mvi could reclassify the current version of the AJCC staging system and offer an alternative prognostication model using a single size-cutoff value of HCC.

Indocyanine green clearance of remnant liver (ICG-Krem) predicts postoperative subclinical hepatic insufficiency after resection of colorectal liver metastasis: theoretical validation for safe expansion of Makuuchi's criteria

BACKGROUND

Multidisciplinary treatment for colorectal liver metastases (CLMs) often includes major hepatectomy for preoperative chemotherapy-related hepatic injury, although the safety limit for resection extent is unclear. We investigated this parameter using the estimated indocyanine green clearance rate (ICG-K) of liver remnants, focusing on postoperative subclinical hepatic insufficiency (PHI).

METHODS

Altogether, 225 patients who underwent resection of CLMs were studied. The predictive power of estimated ICG-K of liver remnant (ICG-Krem) for subclinical PHI (peak bilirubin ≥3 mg/dL or refractory ascites) was compared with those of other potential predictors. The suggested safety limit of ICG-Krem ≥0.05 was also assessed.

RESULTS

Receiver-operating curve analysis revealed that ICG-Krem [area under the curve (AUC) 0.752, cutoff 0.102] was the best predictor of subclinical PHI (AUC range for others was 0.632-0.668). Makuuchi's criteria corresponded to ICG-Krem 0.10. Subclinical PHI incidence was significantly elevated at ICG-Krem <0.10 (26% vs 8%, p = 0.002), while potentially fatal PHI (peak bilirubin >7 mg/dL) was not observed until down to ICG-Krem of 0.05.

CONCLUSIONS

ICG-Krem sensitively predicts subclinical PHI. Liver failure-related death could be avoided so long as ICG-Krem remains at ≥0.05. However, patients with ICG-Krem 0.05-0.10 are at high risk of subclinical PHI and require intensive care postoperatively.