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

The Influence of Hepatic Steatosis and Fibrosis on Postoperative Outcomes After Major Liver Resection of Perihilar Cholangiocarcinoma

BACKGROUND

Surgical resection for perihilar cholangiocarcinoma (pCCA) is associated with high operative risks. Impaired liver regeneration in patients with pre-existing liver disease may contribute to posthepatectomy liver failure (PHLF) and postoperative mortality. This study aimed to determine the incidence of hepatic steatosis and fibrosis and their association with PHLF and 90-day postoperative mortality in pCCA patients.

METHODS

Patients who underwent a major liver resection for pCCA were included in the study between 2000 and 2021 from three tertiary referral hospitals. Histopathologic assessment of hepatic steatosis and fibrosis was performed. The primary outcomes were PHLF and 90-day mortality.

RESULTS

Of the 401 included patients, steatosis was absent in 334 patients (83.3%), mild in 58 patients (14.5%) and moderate to severe in 9 patients (2.2%). There was no fibrosis in 92 patients (23.1%), periportal fibrosis in 150 patients (37.6%), septal fibrosis in 123 patients (30.8%), and biliary cirrhosis in 34 patients (8.5%). Steatosis (≥ 5%) was not associated with PHLF (odds ratio [OR] 1.36; 95% confidence interval [CI] 0.69-2.68) or 90-day mortality (OR 1.22; 95% CI 0.62-2.39). Neither was fibrosis (i.e., periportal, septal, or biliary cirrhosis) associated with PHLF (OR 0.76; 95% CI 0.41-1.41) or 90-day mortality (OR 0.60; 95% CI 0.33-1.06). The independent risk factors for PHLF were preoperative cholangitis (OR 2.38; 95% CI 1. 36-4.17) and future liver remnant smaller than 40% (OR 2.40; 95% CI 1.31-4.38). The independent risk factors for 90-day mortality were age of 65 years or older (OR 2.40; 95% CI 1.36-4.23) and preoperative cholangitis (OR 2.25; 95% CI 1.30-3.87).

CONCLUSION

In this study, no association could be demonstrated between hepatic steatosis or fibrosis and postoperative outcomes after resection of pCCA.

CT-derived extracellular volume and liver volumetry can predict posthepatectomy liver failure in hepatocellular carcinoma

OBJECTIVES

Posthepatectomy liver failure (PHLF) is a severe complication of liver resection. We aimed to develop and validate a model based on extracellular volume (ECV) and liver volumetry derived from computed tomography (CT) for preoperative predicting PHLF in resectable hepatocellular carcinoma (HCC) patients.

METHODS

A total of 393 resectable HCC patients from two hospitals were enrolled and underwent multiphasic contrast-enhanced CT before surgery. A total of 281 patients from our hospital were randomly divided into a training cohort (n = 181) and an internal validation cohort (n = 100), and 112 patients from another hospital formed the external validation cohort. CT-derived ECV was measured on nonenhanced and equilibrium phase images, and liver volumetry was measured on portal phase images. The model is composed of independent predictors of PHLF. The under the receiver operator characteristic curve (AUC) and calibration curve were used to reflect the predictive performance and calibration of the model. Comparison of AUCs used the DeLong test.

RESULTS

CT-derived ECV, measured future liver remnant (mFLR) ratio, and serum albumin were independent predictors for PHLF in resectable HCC patients. The AUC of the model was significantly higher than that of the ALBI score in the training cohort, internal validation cohort, and external validation cohort (all p < 0.001). The calibration curve of the model showed good consistency in the training cohort and the internal and external validation cohorts.

CONCLUSIONS

The novel model contributes to the preoperative prediction of PHLF in resectable HCC patients.

CRITICAL RELEVANCE STATEMENT

The novel model combined CT-derived extracellular volume, measured future liver remnant ratio, and serum albumin outperforms the albumin-bilirubin score for predicting posthepatectomy liver failure in patients with resectable hepatocellular carcinoma.

KEY POINTS

• CT-derived ECV correlated well with the fibrosis stage of the background liver. • CT-derived ECV and mFLR ratio were independent predictors for PHLF in HCC. • The AUC of the model was higher than the CT-derived ECV and mFLR ratio. • The model showed a superior predictive performance than that of the ALBI score.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

KEY POINTS

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

Diagnostic accuracy of 3D imaging combined with intra-operative ultrasound in the prediction of post-hepatectomy liver failure

Background

The risk of post-hepatectomy liver failure (PHLF) is difficult to predict preoperatively. Accurate preoperative assessment of residual liver volume is critical in PHLF. Three-dimensional (3D) imaging and intra-operative ultrasound (IOUS) offer significant advantages in calculating liver volume and have been widely used in hepatectomy risk assessment. Our research aimed to explore the accuracy of 3D imaging technique combining IOUS in predicting PHLF after hepatectomy.

Methods

We used a retrospective study design to analyze patients who underwent hepatectomy with 3D imaging combined with IOUS between 2017 and 2020. Utilizing 3D reconstruction, the patient's residual liver volumes (PRLVs) and ratio of PRLV to standard liver volume (SLV) were calculated preoperatively. Hepatectomy were performed and actual hepatectomy volume (AHV) were measured. Consistency between preoperative planned hepatectomy volume (PPHV) and AHV was quantified postoperatively by Bland-Altman analysis. Multiple logistic regression and receiver-operating characteristic (ROC) curves were utilized to discuss the predictive value of PRLV/SLV in PHLF.

Results

Among the 214 included patients, 58 (27.1%) had PHLF. Patients with PHLF had significantly higher residual rates of ICG-R15 (%) (P=0.000) and a lower PRLV/SLV ratio (P=0.000). Bland-Altman analysis showed that PPHV was consistent with AHV (P=0.301). Multivariate analysis confirmed that PRLV/SLV ratio >60% (OR, 0.178; 95% CI: 0.084-0.378; P<0.01) was a protective factor for PHLF. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were 75.8% (95% CI: 64.5.3-87.2%), 66.6% (95% CI: 59.1-74.1%), 45.8%, and 88.1%, respectively. The area under the ROC curve (AUC) was 73.7% (95% CI: 65.7-85.8%) and the diagnostic accuracy of PRLV/SLV for PHLF was moderate (P<0.001). These results were validated in the validation cohort perfectly. The primary cohort included 214 patients with a PHLF rate of 27.1% (n=58, 28 grade B and 13 grade C). The validation cohort included 135 patients with a PHLF rate of 35.6% (n=48, 24 grade B and 11 grade C).

Conclusions

The calculation of PRLV/SLV has predictive value in PHLF and can be exploited as a predictive factor. The 3D imaging technique combined with IOUS may be useful for PHLF risk assessment in hepatectomy patients.

[Laparoscopic Posterolateral Sectionectomy in Hepatocellular Cacinoma - Increasing Oncological Precision by Combining the Glissonean Pedicle Approach and Fluorescence Guidance]

AIM

Minimally invasive procedures have been increasingly performed in liver surgery. Benefits include lower intraoperative blood loss, reduced postoperative morbidity and shorter lengths of hospital stay in comparison to open liver surgery. Exact resection margins seem advantageous in primary liver cancer but challenging to implement with minimally invasive techniques. In this case report, we aimed to increase surgical precision by combining the Glissonean pedicle approach and intraoperative fluorescence guidance.

INDICATION

A 73-year-old female patient with CHILD A liver cirrhosis with chronic hepatitis C virus infection was transferred to our hospital with high levels of alpha-fetoprotein (792 ng/ml). Sectional imaging confirmed the suspected diagnosis of a single hepatocellular carcinoma (HCC) with a size of 2.2 cm in segments VI/VII. In line with the local tumour board recommendation, an anatomical posterolateral sectionectomy using the Glissonean pedicle approach was planned.

METHODS

The patient was placed in the French position. After mobilisation of the right liver, the posterolateral pedicle was encircled and transected. 0.2 mg/kg of body mass indocyanine green (ICG) was then injected intravenously. The perfused parenchyma of segments I-V and VIII turned green, but the unperfused posterolateral segment VI and VII remained native. The transection line was marked under ICG-imaging to indicate the transition of the posterolateral to the anteromedial sector. Parenchymal transection was performed under intermittent ICG-guided imaging. Pathological workup confirmed R0 resection of a well differentiated HCC in a cirrhotic liver (grade 4). The patient was discharged from the hospital on the 6th postoperative day after an uncomplicated course and was confirmed to be tumour-free six months after surgery.

CONCLUSION

As an additional intraoperative tool, ICG-imaging may provide visualisation of segment and sector boundaries and thus may enable precise anatomical resection. Prospective studies are needed to evaluate the added value of this technique, especially with regard to the rate of R0 resections.