A comprehensive method for predicting fatal liver failure of patients with liver cancer resection

Current status of preoperative risk assessment for posthepatectomy liver failure in patients with hepatocellular carcinoma

Liver resection is an effective therapeutic option for patients with hepatocellular carcinoma. However, posthepatectomy liver failure (PHLF) remains a major cause of hepatectomy-related mortality, and the accurate prediction of PHLF based on preoperative assessment of liver functional reserve is a critical issue. The definition of PHLF proposed by the International Study Group for Liver Surgery has gained acceptance as a standard grading criterion. Liver function can be estimated using a variety of parameters, including routine blood biochemical examinations, clinical scoring systems, dynamic liver function tests, liver stiffness and fibrosis markers, and imaging studies. The Child-Pugh score and model for end-stage liver disease scores are conventionally used for estimating liver decompensation, although the alternatively developed albumin-bilirubin score shows superior performance for predicting hepatic dysfunction. Indocyanine green clearance, a dynamic liver function test mostly used in Japan and other Asian countries, serves as a quantitative estimation of liver function reserve and helps determine indications for surgical procedures according to the estimated risk of PHLF. In an attempt to improve predictive accuracy, specific evaluation of liver fibrosis and portal hypertension has gained popularity, including liver stiffness measurements using ultrasonography or magnetic resonance elastography, as well as noninvasive fibrosis markers. Imaging modalities, including Tc-99m-labeled galactosyl serum albumin scintigraphy and gadolinium-enhanced magnetic resonance imaging, are used for preoperative evaluation in combination with liver volume. This review aims to provide an overview of the usefulness of current options for the preoperative assessment of liver function in predicting PHLF.

A systematic review of prediction models for post-hepatectomy liver failure in patients undergoing liver surgery

BACKGROUND

The aim of this systematic review is to evaluate the current evidence in the context of clinical prediction model for post-hepatectomy liver failure (PHLF).

METHODS

A systematic search of the English literature for a period from December 2005 to September 2020 was conducted. Primary outcome was defined using the three common PHLF criteria (50-50 criteria, peak bilirubin>7 mg/dl criteria, and ≥ grade B PHLF criteria by the International Study Group of Liver Surgery). Studies that reported the value of area under receiver operative characteristic curve (AUC) for the occurrence of PHLF were included.

RESULTS

Twenty eight of 1327 screened articles were eligible for inclusion. Eighteen studies developed the prediction models. The median AUC was found to be 0.79 (0.65-0.933). The parameters related to the amount of future liver remnant volume were most commonly identified as significant predictors for PHLF in statistical analysis (24 studies) and were most frequently incorporated in the prediction models (18 studies). The parameters associated with portal hypertension were significant for predicting PHLF in 16 studies and were adopted in the prediction models in 14 studies.

CONCLUSION

Parameters related to future liver remnant volume and portal hypertension seem to be facilitating in predicting PHLF.

Safe standard remnant liver volume after hepatectomy in HCC patients in different stages of hepatic fibrosis

Background

To determine the standard remnant liver volume (SRLV) threshold to avoid postoperative hepatic insufficiency inpatients in different stages of hepatic fibrosis who undergo right hemi-hepatectomy.

Methods

Data for 85 patients at our single medical center were analysed prospectively to examine whether the following factors differed significantly between those who experienced postoperative hepatic insufficiency and those who did not: height, prothrombin time, remnant liver volume, SRLV or hepatic fibrosis stage.

Results

Logistic regression showed SRLV and hepatic fibrosis stage to be independent risk factors for postoperative hepatic insufficiency. The threshold SRLV for predicting insufficiency was 203.2 ml/m² across all patients [area under receiver operating characteristic curve (AUC) 0.778, sensitivity 66.67%, specificity 83.64%, p<0.0001), 193.8 ml/m² for patients with severe hepatic fibrosis (AUC 0.938, sensitivity 91.30%, specificity 85.71%, p<0.0001), and 224.3 ml/m² for patients with cirrhosis (AUC 0.888, sensitivity 100%, specificity 64.29%, p<0.0001).

Conclusions

Right hemi-hepatectomy may be safer in Chinese patients when the standard remnant liver volume is more than 203.2 ml/m² in the absence of hepatic fibrosis or cirrhosis, 193.8 ml/m² in the presence of severe hepatic fibrosis or 224.3 ml/m² in the presence of cirrhosis.

Predictive Value of Indocyanine Green Plasma Disappearance Rate on Liver Function and Complications After Liver Transplantation

BACKGROUND The aim of this study was to investigate the correlation between indocyanine green plasma disappearance rate (ICG-PDR) and allograft function as well as postoperative complications after liver transplantation. MATERIAL AND METHODS In this prospective study, 115 cases of adult liver transplantation performed from 1 June 2016 to 1 December 2016 were enrolled. These 115 patients were divided into a group of PDR <18%/min (50 cases) and a group of PDR ≥18%/min (65 cases). The rates of liver recovery, postoperative complications, and survival were compared between these 2 groups. RESULTS Among the total of 115 patients, 111 patients recovered well and were discharged, whereas 4 patients died during the first month after the operation. Between the 2 groups, significant differences were observed in terms of the model for end-stage liver disease (MELD) score, intraoperative bleeding volume, and the level of hemoglobin (Hb), pre-albumin (PA) and total bilirubin (TB) the first week after the operation. Overall, the incidence of hepatic arterial complications and pneumonia was much higher in the PDR<18%/min group (P<0.05). CONCLUSIONS The early postoperative value of ICG-PDR was closely related to graft function and could act as a good predictor for the incidence of postoperative arterial complications.

Assessment of the feasibility of TACE combined with intratumoral injection of cisplatin in hepatocellular carcinoma

The feasibility of transcatheter arterial chemo-embolization (TACE) combined with intratumoral injection of cisplatin as treatment for hepatocellular carcinoma. 30 cases receiving TACE were denoted the TACE group, another 30 cases receiving TACE combined with an intratumoral multi-point injection of cisplatin were denoted the TACE/cisplatin group. Cases with partial remission/complete remission (PR/CR) were analyzed using 2 tests; alpha fetoprotein (AFP), aspartate amino transferase (AST), total bilirubin (TBIL), erythrocyte, and platelet levels were detected and the differences between two groups were analyzed using the Student's t-test; cases with complications, including intrahepatic metastasis (IM), upper gastrointestinal bleeding (UGB), and liver failure were also counted. The correlation of clinical parameters with PR/CR was analyzed using multifactorial correlation analysis. Cases with PR/CR in the TACE/cisplatin group were significantly more than in TACE group, accompanied by significant declination in FAP. There were no significant differences of AST, ALT, TBIL, blood urea nitrogen (BUN), white blood cells (WBC), red blood cells (RBC), and platelets (PLT) between two groups; 3 cases with IM, one case with UGB and one case with LF were found in the TACE group, but only 1 case with IM was found in the TACE/cisplatin group. In addition, tumor stage was correlated with PR/CR. We concluded that TACE combined with intratumoral injection of cisplatin was more effective than TACE, and with fewer complications and side effects.