Evaluation of the ISGLS Criteria for Post-hepatectomy Liver Failure: Insights from Consideration of the Comprehensive Complication Index as a Measure of Morbidity

Abstract

Purpose: We aimed to evaluate the International Study Group of Liver Surgery (ISGLS) definition and grading system for post-hepatectomy liver failure (PHLF) using the Comprehensive Complication Index (CCI), a standardized morbidity measure. Methods: Adult patients who underwent major hepatic resection between 2010-2020 were included from twelve international centers. We identified patients who met criteria for PHLF based on three definitions: 1) ISGLS, 2) INR >1.7 and serum bilirubin >3 mg/dL (Balzan), or 3) peak serum bilirubin >7 mg/dL (Mullen). We compared the 90-day mortality and major morbidity predicted by each definition. We then tabulated the distribution of CCI by ISGLS grade and used logistic regression to determine the odds of CCI>40 and 90-day mortality associated with ISGLS grade. Results: Among 1654 patients, 444 (26.8%) met ISGLS PHLF criteria. Of the three PHLF definitions, the ISGLS definition had the highest AUC (0.72) and sensitivity (69.4) for prediction of 90-day mortality. Patients with ISGLS PHLF grades B and C were at increased odds of CCI>40 (Grade B OR 3.7; 95% CI: 2.0-6.9; and Grade C OR 96.1; 95% CI: 45.8-201.3) and 90-day mortality (Grade B OR 2.8; 95% CI: 1.0-7.4; and Grade C OR 108.0; 95% CI: 53.3, 218.7). ISGLS grade A PHLF was not associated with CCI>40 or 90-day mortality (Table 1). Conclusions: In this diverse, international cohort of patients undergoing major hepatectomy, ISGLS grade A was not associated with significant morbidity or mortality, calling into question the current classification of patients in this group as having clinically significant PHLF.FP08.06_Table 1Comparison of Morbidity and Mortality by ISGLS Grade (n=1654)No ISGLS PHLF n=1210ISGLS A n=287ISGLS B n=103ISGLS C n=54CCI, median (IQR)0 (0-20.9)8.7 (0-26.2)27.6 (20.9-35.9)100 (44.9-100)P<0.001 CCI: 0672 (55.5)138 (48.1)0 (0)0 (0) CCI: 1-20110 (9.1)21 (7.3)12 (11.7)0 (0) CCI: 20-40375 (31.0)111 (38.7)76 (73.8)10 (18.5) CCI: 40-6032 (2.6)9 (3.1)14 (13.6)9 (16.7) CCI: 60-802 (0.2)0 (0)0 (0)1 (1.9) CCI: 80-10019 (1.6)8 (2.8)1 (0.97)34 (63.0)OR for CCI>40 (95% CI)-1.37 (0.78-2.41)3.72 (2.02-6.87)96.05 (45.84-201.27)AUC=0.72OR for 90-day mortality (95% CI)-1.75 (0.80-3.83)2.76 (1.02-7.43)108.00 (53.33-218.72)AUC=0.78 Open table in a new tab