Postoperative Liver Dysfunction Research Articles

Novel use of the Nathanson liver retractor to prevent postoperative transient liver dysfunction during laparoscopic gastrectomy.

IntroductionThe Nathanson liver retractor (N) has been known to cause postoperative transient liver dysfunction (POTLD) in laparoscopic gastrectomy (LG). To reduce the incidence of POTLD, specifically we added to the retractor the use of a disk (N + D) to reduce the localized pressure, and furthermore repositioned the retractor every 30 minutes (N + D TM) to reduce the liver retraction time. Before and after introducing this retractor, we assessed four consecutive retraction procedures. These included the following disk suspension methods (D), N, N + D, and N + D TM.MethodsWe retrospectively enrolled 85 patients who underwent an LG. In the D, N, N + D, and N + D TM groups, we evaluated the postoperative serum aspartate aminotransferase (AST) and alanine aminotransferase (ALT) values.ResultsFor the D and N groups, the AST value significantly increased from the immediate post‐operation time point (IPOT) to the third postoperative day (POD3). Additionally, the ALT value increased from IPOT to POD7. In the N + D group, the only decrease was in the ALT value at IPOT compared to the N group. The N + D TM group decreased in both the AST value from IPOT to POD3 and in the ALT value from IPOT to POD7, compared to the N group.ConclusionsOur findings demonstrate the importance of reducing both the localized pressure and liver retraction time when using the Nathanson retractor to prevent POTLD during an LG. To make this possible, we successfully introduced the use of both a disk and the repositioning of the retractor at 30 minute intervals.

The value of indocyanine green clearance assessment to predict postoperative liver dysfunction in patients undergoing liver resection

Postoperative liver dysfunction remains a major concern following hepatic resection. In order to identify patients who are at risk of developing liver dysfunction, indocyanine green (ICG) clearance has been proposed to predict postoperative liver function. All patients who underwent liver resection at the Medical University Vienna, Austria between 2006 and 2015 with preoperative ICG clearance testing (PDR, R15) were analyzed in this study. Postoperative liver dysfunction was analyzed as defined by the International Study Group of Liver Surgery. Overall, 698 patients (male: 394 (56.4%); female: 304 (43.6%)) with a mean age of 61.3 years (SD: 12.9) were included in this study, including 313 minor liver resections (44.8%) and 385 major liver resections (55.2%). One hundred and seven patients developed postoperative liver dysfunction after liver resection (15.3%). Factors associated with liver dysfunction were: male sex (p = 0.043), major liver resection (p < 0.0001), and preoperative ICG clearance (PDR (p = 0.002) and R15 (p < 0.0001)). Notably ICG clearance was significantly associated with liver dysfunction in minor and major liver resections respectively and remained a predictor upon multivariable analysis. An optimal cut-off for preoperative ICG clearance to accurately predict liver dysfunction was PDR < 19.5%/min and R15 > 5.6%. To the best of our knowledge, this is the largest study analyzing the predictive value of preoperative ICG clearance assessment in patients undergoing liver resection. ICG clearance is useful to identify patients at risk of postoperative liver dysfunction.

Predicting Postoperative Liver Dysfunction Based on Blood-Derived MicroRNA Signatures.

There is an urgent need for an easily assessable preoperative test to predict postoperative liver function recovery and thereby determine the optimal time point of liver resection, specifically as current markers are often expensive, time consuming, and invasive. Emerging evidence suggests that microRNA (miRNA) signatures represent potent diagnostic, prognostic, and treatment‐response biomarkers for several diseases. Using next‐generation sequencing as an unbiased systematic approach, 554 miRNAs were detected in preoperative plasma of 21 patients suffering from postoperative liver dysfunction (LD) after liver resection and 27 matched controls. Subsequently, we identified a miRNA signature—consisting of miRNAs 151a‐5p, 192‐5p, and 122‐5p—that highly correlated with patients developing postoperative LD after liver resection. The predictive potential for postoperative LD was subsequently confirmed using real‐time PCR in an independent validation cohort of 98 patients. Ultimately, a regression model of the two miRNA ratios 151a‐5p to 192‐5p and 122‐5p to 151a‐5p was found to reliably predict postoperative LD, severe morbidity, prolonged intensive care unit and hospital stays, and even mortality before an operation with a remarkable accuracy, thereby outperforming established markers of postoperative LD. Ultimately, we documented that miRNA ratios closely followed liver function recovery after partial hepatectomy. Conclusion: Our data demonstrate the clinical utility of an miRNA‐based biomarker to support the selection of patients undergoing partial hepatectomy. The dynamical changes during liver function recovery indicate a possible role in individualized patient treatment. Thereby, our data might help to tailor surgical strategies to the specific risk profile of patients.

The 3-60 criteria challenge established predictors of postoperative mortality and enable timely therapeutic intervention after liver resection.

To date, definitions of liver dysfunction (LD) after hepatic resection rely on late postoperative time points. Further, the used parameters are markedly influenced by perioperative management. Thus, we aimed to establish a very early postoperative score to predict postoperative mortality. Liver related parameters were evaluated after liver resection in a retrospective evaluation cohort of 228 colorectal cancer patients with liver metastasis (mCRC) and subsequent validation in a prospective set of 482 consecutive patients from 4 independent institutions undergoing hepatic resection was performed. C-reactive protein (CRP, AUC =0.739, P<0.001) and antithrombinIII-activity (ATIII, AUC =0.844, P<0.001) on the first postoperative day (POD) were found to be elevated in patients with LD. Cut-off values for CRP at 3 mg/dL and for ATIII at 60% significantly identified high-risk patients for postoperative LD and mortality (P<0.001) and thus defined the 3-60 criteria on POD1. The 3-60 criteria showed superior sensitivity and specificity compared to established criteria for LD [3-60 criteria: total positive patients: 26 patients (70% mortality detected), odds ratio (OR): 48.8; International Study Group for Liver Surgery: total positive patients: 43 (70% mortality detected), OR: 23.3; Peak7: total positive patients: 9 (30% mortality detected), OR: 27.8; 50-50: total positive patients: 9 (30% mortality detected), OR: 27.8]. These results could be validated in a multi-center analysis and ultimately the 3-60 criteria remained an independent predictor of postoperative mortality upon multivariable analysis. The 3-60 criteria on POD1 predict postoperative LD and mortality early after liver resection with a comparable or better accuracy than established criteria, allowing for immediate identification of high-risk patients.

Perioperative Antiviral Treatment Facilitate the Postoperative Recovery for Patients with HBV Related to Hepatocellular Carcinoma

Objective: This study aimed to determine whether perioperative antiviral treatment is facilitate for patients with hepatitis B virus (HBV)-related hepatocellular carcinoma (HCC) and Child-Pugh grade A cirrhosis in perioperative recovery of liver function and HBV activation. Methods: The study included 115 patients with HBV-related HCC and Child-Pugh grade A cirrhosis who underwent resection. Patients were prospectively assigned to a preoperative antiviral treatment group (n = 51) or postoperative antiviral treatment group (n = 52); twelve patients who had not received antiviral treatment before and after surgery were designated a non-treatment group (n = 12). HBV reactivation during a month after the operation was defined as a HBV DNA value tenfold over preoperative values. Postoperative liver dysfunction was defined as prothrombin activity 50 mmol/L on postoperative day 5. Results: Postoperatively, liver dysfunction was present in 1 of 51 (1.96%) patients who received preoperative antiviral therapy, 1 of 52 (1.92%) who received postoperative therapy, and 3 of 12 (25%) who received no antiviral therapy. HBV reactivation postoperatively occurred at similar rates. Conclusions: Preoperative and postoperative antiviral treatment of patients with Child-Pugh grade A cirrhosis and high levels of HBV DNA undergoing hepatic resection for HCC are both facilitate in preventing perioperative liver dysfunction and reactivation of HBV. Thus, in this population with high levels of HBV DNA, perioperative antiviral treatment is important.

Timely identification of patients at risk for development of postoperative liver dysfunction via CRP and ATIII - the 3-60 criteria

Background: Commonly, liver dysfunction (LD) after liver resection is defined based on levels of bilirubin and prothrombin time on or after the fifth postoperative day. While patients with abnormal levels of these parameters at the mentioned time point were shown to have a higher incidence of morbidity and even mortality, these current definitions of LD do not allow supportive interventions due to the late time point. Further, both bilirubin and prothrombin time were found to be potentially influenced by the postoperative management of patients undergoing liver resection. Thus, the present study aimed to evaluate an early and stable definition of postoperative LD.

Comparison of dexmedetomidine vs. remifentanil combined with sevoflurane during radiofrequency ablation of hepatocellular carcinoma: a randomized controlled trial

BackgroundRemifentanil is widely used for ultrasound-guided percutaneous radiofrequency ablation (RFA) of small hepatocellular carcinoma (HCC). We determined whether dexmedetomidine could be an alternative to remifentanil for RFA of HCC under general anesthesia with sevoflurane.MethodsWe prospectively randomized patients scheduled to undergo RFA for HCC to a dexmedetomidine (DEX) group or remifentanil (REMI) group (47 patients each). In the DEX group, a bolus infusion (0.4 μg kg− 1) was started 15 min before anesthesia induction and continued at 0.2 μg kg− 1 h− 1 until 10 min before the end of surgery. In the REMI group, 3 μg kg− 1 h− 1 of remifentanil was administered from 15 min before anesthesia induction to the end of the surgery. The primary endpoint was postoperative pain intensity. Secondary endpoints included analgesic requirement, postoperative liver function, patient comfort, and hemodynamic changes. Group allocation was concealed from patients and data analysts but not from anesthesiologists.ResultsPostoperative pain intensity, analgesic consumption, comfort, liver function, and time to emergence and extubation did not differ between the two groups. Heart rate, but not mean arterial pressure, was significantly lower in the DEX group than in the REMI group, at 1 min after intubation and from 30 min after the start of the surgery until anesthesia recovery. Sevoflurane concentration and dosage were significantly lower in the DEX group than in the REMI group.ConclusionDuring RFA for HCC, low-dose dexmedetomidine reduced the heart rate and need for inhalational anesthetics, without exacerbating postoperative discomfort or liver dysfunction. Although it did not exhibit outstanding advantages over remifentanil in terms of pain management, dexmedetomidine could be a safe alternative adjuvant for RFA under sevoflurane anesthesia.Trial registrationChinese Clinical Trial Registry, ChiCTR-OPC-15006613. Registered on 16 June 2015.

The Combination of APRI and ALBI Facilitates Preoperative Risk Stratification for Patients Undergoing Liver Surgery After Neoadjuvant Chemotherapy

BackgroundNeoadjuvant chemotherapy (NeoCTx) is performed for most patients with colorectal cancer liver metastases (CRCLM). However, chemotherapy-associated liver injury (CALI) has been associated with poor postoperative outcome. To date, however, no clinically applicable and noninvasive tool exists to assess CALI before liver resection.MethodsRoutine blood parameters were assessed in 339 patients before and after completion of NeoCTx and before surgery. The study assessed the prognostic potential of the aspartate aminotransferase (AST)-to-platelet ratio index (APRI), the albumin-bilirubin grade (ALBI), and their combinations. Furthermore, an independent multi-center validation cohort (n = 161) was included to confirm the findings concerning the prediction of postoperative outcome.ResultsHigher ALBI, APRI, and APRI + ALBI were found in patients with postoperative morbidity (P = 0.001, P = 0.064, P = 0.001, respectively), liver dysfunction (LD) (P = 0.009, P = 0.012, P < 0.001), or mortality (P = 0.037, P = 0.045, P = 0.016), and APRI + ALBI had the highest predictive potential for LD (area under the curve [AUC], 0.695). An increase in APRI + ALBI was observed during NeoCTx (P < 0.001). Patients with longer periods between NeoCTx and surgery showed a greater decrease in APRI + ALBI (P = 0.006) and a trend for decreased CALI at surgery. A cutoff for APRI + ALBI at − 2.46 before surgery was found to identify patients with CALI (P = 0.002) and patients at risk for a prolonged hospital stay (P = 0.001), intensive care (P < 0.001), morbidity (P < 0.001), LD (P < 0.001), and mortality (P = 0.021). Importantly, the study was able to confirm the predictive potential of APRI + ALBI for postoperative LD and mortality in a multicenter validation cohort.ConclusionDetermination of APRI + ALBI before surgery enables identification of high-risk patients for liver resection. The combined score seems to dynamically reflect CALI. Thus, APRI + ALBI could be a clinically relevant tool for optimizing timing of surgery in CRCLM patients after NeoCTx.

Complex major hepatectomy by thunderbeat with the pringle maneuver and infra-hepatic inferior vena cava clamping

Introduction: Complex major hepatectomy (CMH) equivalent to major liver resection with high complexity classification is a demanding operation. Parenchymal transection represents a crucial step during liver resection and the use of energy devices has gained popularity for faster and safer hepatectomy. Thunderbeat (TB) is a novel device that uses both ultrasonic and advanced bipolar energies. We report the CMH with TB assisted by the Pringle maneuver and infra-hepatic inferior vena cava (IVC) clamping. Method: During parenchymal transection, only the pedicles equal or larger than 3rd branches of Glissonian pedicles or main branches of major hepatic veins were ligated, the other vessels were sealed with TB. Parenchymal transection time was defined as the duration recorded from the beginning of the parenchymal resection to the removal of the en-bloc specimen of the liver. Clavien-Dindo (CD) classification ≥3a was applied to define postoperative complication. The postoperative liver dysfunction was assessed on the basis of Balzan 50-50 criteria. Result: Four patients underwent CMH with TB assisted by the Pringle maneuver and infra-hepatic IVC clamping, including extended right hepatectomy with caudate resection and hepaticojejunostomy for perihilar chalangiocarcinoma (n=2) and colon cancer liver metastasis with central biliary invasion (n=1), and anatomic middle hepatectomy for hepatocellular carcinoma (n=1). The median parenchymal transection time, operation time, and estimated blood loss was 16.5 (range: 13-45) min, 415 (range: 260-596) min, and 1,928 (range: 1,380-2,730) mL, respectively Postoperative complications were hepaticojejunostomy failure in one (CD 3a) and heparin-induced postoperative bleeding (CD 3b) in one. There were no postoperative liver dysfunction, pulmonary embolism, and hospital mortality. Conclusion: TB assisted by the Pringle maneuver and infra-hepatic IVC clamping can be feasible and offer the combination of simplicity and rapidity during CMH.

Risk factors of liver dysfunction for donor after extended right lobe graft donation

Introduction: Extended right lobe graft are often used in living donor liver transplantation(LDLT), in the donors with sufficient future liver remnant (FLR) volume. The aim of this study is to review retrospectively and to find risk factors of liver dysfunction for donor after extended right lobe graft donation. Method: From November 2005 to May 2018, a total of 52 living liver donors who underwent extended right lobectomy were included in this study.The subjects were divided into 2 groups.The hazard group was defined as the donors showing at least one of the following criteria:(1)postoperative serum peak bilirubin > 3.0mg/dL; (2) postoperative peak INR > 2.0, (3) posthepatectomy liver failure(PHLF) grade B or C of International Study Group of Liver Surgery(ISGLS), (4) ascites > 500cc on or after pod 5. Other donors with no criteria mentioned above were included in the safety group. Result: In hazard group, they had smaller volume of left lateral section(LLS) compared to safety group and the ratio of left liver volume(LLV) and left lateral section volume(LLSV) to total liver volume (TLV) in hazard group were smaller than in safety group. The mean and median values of the ratio of LLV to TLV(LLV/TLV); 38%, and the ratio of LLSV to TLV(LLSV/TLV); 20%, were used as the cut-off value. In hazard group, there were more patients whose LLV/TLV was less than 38% and whose LLSV/TLV was less than 20%. Using each cut-off values regarded as risk factors, three groups were categorized. This indicates that donors with smaller LLV/TLV or/and LLSV/TLV are more prone to liver dysfunction. Conclusion: The extent of donor hepatectomy must be contemplated based on a careful preoperative evaluation, including the volumetry. In this study, the LLV/TLV less than 38% and/or LLSV/TLV less than 20% were the major risk factors for postoperative liver dysfunction.

An Easy and Safe Method of Liver Retraction Using a Silicone Disc and Needle Forceps for Laparoscopic Gastrectomy

For safe laparoscopic gastrectomy, it is essential to secure a good visual field by employing liver retraction. We have developed a safe and easy method for liver retraction using a silicone disc, and evaluated its feasibility. We analyzed retrospectively 36 patients with gastric cancer, who underwent laparoscopic distal gastrectomy employing liver retraction by a silicone disc and needle forceps (Silicone group) or by the Penrose drain method (Penrose group) between January 2013 and July 2016. The time needed for liver retraction, complications resulting from it, and postoperative liver dysfunction were compared between the two groups. In all patients in both groups, the operation was performed successfully, obtaining an appropriate visual field. The mean time required for liver retraction was 633.8 ± 286.6 seconds in the Silicone group and 639.8 ± 328.6 seconds in the Penrose group (P = .954). Postoperative elevation of either aspartate transaminase (AST) or alanine aminotransferase (ALT) level was recognized in 13 (72.2%) of the Silicone group patients and 18 (100%) of the Penrose group patients (P = .0160). The mean AST and ALT levels in the Silicone group were significantly lower than those in the Penrose group on postoperative days 0, 1, and 3. Among intraoperative complications related to liver retraction, hemorrhage from the abdominal wall occurred in one Silicone group case and hemorrhage from liver occurred in one Penrose group case. Liver retraction using a silicone disc and needle forceps in laparoscopic gastrectomy is easy and safe, offering a good visual field and a reduced degree of liver dysfunction.

Elevated ADAMTS13 Activity is Associated with Poor Postoperative Outcome in Patients Undergoing Liver Resection

Recently, von-Willebrand-Factor (vWF) has been shown to correlate with postoperative liver dysfunction (LD). Accordingly, “disintegrin-like metalloprotease with thrombospondin type1 motif” (ADAMTS13) is known to cleave vWF in less active fragments. Thus, we aimed to evaluate the diagnostic potential of ADAMTS13-activity (ADAMTS13-AC) to identify patients with postoperative LD after hepatectomy. Accordingly 37 patients undergoing hepatectomy for different neoplastic entities were included in this study. Plasma ADAMTS13-AC and vWF-Ag were measured 1 day prior to (preOP), 1 and 5 days (POD1/5) after hepatectomy. In accordance to the ISGLS-criteria LD was prospectively recorded. In this context, perioperative ADAMTS13-AC- and vWF-Ag/ADAMTS13-AC-ratio- levels revealed a significant increase after hepatectomy. Accordingly, elevated vWF-Ag/ADAMTS13-AC-ratio significantly predicted LD (preOP AUC: 0.75, p = 0.02; POD1 AUC: 0.80, p = 0.03). Patients who fulfilled our perioperative vWF-Ag/ADAMTS13-AC-ratio cut-off-levels (preOP: ≥116, POD1: ≥165) suffered from significantly higher incidences of LD (preOP: 70% vs. 30%, p = 0.01; POD1: 83% vs. 17%, p = 0.001). In conclusion, perioperative ADAMTS13-AC measurement may serve as a useful parameter to early detect high-risk patients developing postoperative LD prior to liver resection in patients suffering from hepatic malignancies. Indeed, further investigations have to be performed to consolidate its role as a predictive marker for LD.

Adipose-derived stem cells reduce liver oxidative stress and autophagy induced by ischemia-reperfusion and hepatectomy injury in swine

AimsHepatic ischemia-reperfusion (I/R) injury is an unavoidable complication of liver surgery, often resulting in postoperative complications and liver dysfunction. Adipose-derived stem cells (ADSCs) have been recognized as a potential tool to be exploited in the field of regenerative medicine for the treatment of a variety of diseases. In the present study, the efficacy of ADSCs in a porcine I/R model of laparoscopic hepatectomy was evaluated. Main methodsTwelve Bama miniature pigs were randomly divided into IRI and ADSCs group. ADSCs were injected through the liver parenchyma following a partial laparoscopic hepatectomy. The roles of ADSCs on oxidative stress and autophagy were analyzed. Key findingsIt was observed that serum levels of aspartate aminotransferase (AST), alanine aminotransferase (ALT), total bilirubin (T-BIL) and lactate dehydrogenase (LDH) was significantly decreased in response to the ADSC treatment. The data were suggestive of the mechanism of action through which ADSCs exert their attenuating effects on oxidative stress by increasing the activity of superoxide dismutase (SOD), and by suppressing the generation of both myeloperoxidase (MPO) and malondialdehyde (MDA). Moreover, the expression of the critical markers of autophagy including Beclin1, ATG5, ATG12 and LC3II all decreased, whereas expression of P62 increased during phagophore expansion. SignificanceIn conclusion, ADSCs attenuate hepatic I/R and hepatectomy-induced liver damage by reducing oxidative stress and inhibiting autophagy.

Value of Indocyanine Green Clearance Assessment to Predict Postoperative Liver Dysfunction in Patients Undergoing Liver Resection

Schwarz, Christoph C. MD, PhD; Plass, Immanuel CM; Fitschek, Fabian CM; Mittlböck, Martina PhD; Kampf, Stephanie MD; Asenbaum, Ulrika MD; Starlinger, Patrick MD, PhD; Stremitzer, Stefan MD; Bodingbauer, Martin MD; Kaczirek, Klaus MD, FACS Author Information

Metabolomic profiling of liver tumors and its impact on liver regeneration

Postoperative liver dysfunction (LD) still represents a severe complication in patients undergoing liver resection and its incidence is estimated at 10–20%. As postoperative LD commonly develops as a result of delayed liver regeneration, it is most relevant to reach a comprising understanding of this process. Thus, we aimed to investigate the perioperative dynamic of circulating metabolites, as well as differences in the metabolic profile of patients with and without postoperative LD using an unbiased metabolomics approach. Plasma from 95 prospectively included patients was collected preoperatively and on the first and fifth postoperative day (POD5). Per patient and time point 180 metabolites were assessed using the Biocrates p180-kit. Development of LD was prospectively recorded. 21 patients (19.95%) suffered from postoperative LD. We observed significant dynamics in the metabolic profile after liver surgery, that tended to normalize upon POD5. Further, we were able to document differences in the concentration of 120 metabolites between patients with and without postoperative LD. Interestingly, the family of sphingolipids showed an evident accumulation of differentially abundant metabolites in patients with LD at several time points, while the total amount of sphingolipids did not differ. Within this study we present the first data on the metabolic profile in patients undergoing liver resection and in patients with delayed liver regeneration. While we found a plethora of potential markers for postoperative LD at various time points, we also present hypothesis generating data and the opportunity to characterize potentially targetable pathways for improvement of postoperative liver regeneration.

Long-term outcome and recurrence of hepatitis B virus following liver transplantation from hepatitis B surface antigen-positive donors in a Chinese population.

Due to the severe shortage of the donor pool in China, a large number of patients are waiting for a suitable liver, or even worse lose the opportunity of transplantation. Reasonable use of hepatitis B surface antigen-positive (HBsAg-positive) donors is one possible strategy to increase the donor pool but the long-term outcome in a Chinese population is unknown. To evaluate the safety of using of HBsAg-positive donor for liver transplantation, we set up a multicentric retrospective study from 1 January 2007 to 31 December 2012. A total of 8632 patients underwent liver transplantation during the period and 282 (2.97%) received a liver from a HBsAg-positive donor. A total of 259 cases in both the case and control groups were matched. The incidence of postoperative liver dysfunction, early-stage and long-term complications and the 1-, 3- and 5-year patient survival (78.92% vs 85.65%, 60.41% vs 69.14%, 58.08% vs 69.14%, respectively) showed no difference between the two groups (P value>0.05). However, the 1-, 3- and 5-year HBV recurrence for patients received the HBsAg-positive donor was higher compared with controls (5.85% vs 1.97%, 11.63% vs 4.46%, 17.94% vs 4.46%, respectively, P value=0.016). Our results showed the use of HBsAg-positive donors is feasible and postoperative antiviral therapy should be managed.

Transient liver dysfunction increases surgical site infections after coronary surgery.

Background Surgical site infections can have a significant impact on cardiac surgical outcome. The liver plays an important role in infection prevention. This study aimed to retrospectively determine whether transient postoperative liver dysfunction after coronary bypass surgery increased surgical site infections. Methods A modified version of the Schindl scoring scale for liver dysfunction was adapted to objectively quantify transient liver dysfunction in the first 7 days after on-pump coronary artery bypass grafting. A retrospective analysis of clinical outcomes at 30 months postoperatively was performed on data of 575 patients who underwent coronary artery bypass between 2014 and 2016. The patients were categorized into a liver dysfunction group (Schindl score ≥ 4) and a non-liver dysfunction group (Schindl score < 4). Results The liver dysfunction group (47.3%) had significantly more patients who were obese, current smokers, and had diabetes, renal impairment, and peripheral vascular disease. Surgical site infections occurred predominantly in the liver dysfunction group (12.1% vs. 0.3%, p < 0.001). The independent predictors of surgical site infection were liver dysfunction, body mass index > 30 kg m-2, and coronary bypass surgery combined with other cardiac procedures. Conclusions Surgical wound infections can be precipitated by multiple factors before, during, and after coronary bypass surgery. Transient liver dysfunction in the perioperative period is associated with an increased rate of surgical infections even after adjusting for known risk factors. Considering this factor as well as other known risks may help to identify and stratify patients with a potentially higher risk of surgical site infections.

Shaping the future of liver surgery: Implementation of experimental insights into liver regeneration.

SummaryBackgroundWhile liver surgery has become a safe and feasible operation technique, the incidence of postoperative liver dysfunction still remains a central problem. Approximately 10% of patients undergoing liver resection were shown to develop liver dysfunction, which is associated with an increased risk of morbidity and mortality. Yet, to date there is no effective treatment option for postoperative liver dysfunction available. The development of postoperative liver dysfunction was linked to a disruption in the liver’s potential to regenerate. Thus, it is importance to elucidate the underlying mechanisms of liver regeneration and to find potential therapeutic targets for the treatment of patients with postoperative liver dysfunction.MethodsA review of the literature was carried out.ResultsWe report on potential future interventions for improvement of liver regeneration after surgical resection. Moreover, we evaluate the benefits and drawbacks of hepatic progenitor cell therapy and hematopoietic stem cell therapy. However, the most significant improvement seems to come from molecular targets. Indeed, von Willebrand factor and its pharmacologic manipulation are among the most promising therapeutic targets to date. Furthermore, using the example of platelet-based therapy, we stress the potentially adverse effects of treatments for postoperative liver dysfunction.ConclusionThe present review reports on the newest advances in the field of regenerative science, but also underlines the need for more research in the field of postoperative liver regeneration, especially in regard to translational studies.

Clinical value of the conventional liver function test in liver reserve function assessment for large hepatocellular carcinoma

Objective To study the clinical value of the conventional liver function tests in liver reserve function assessment for large hepatocellular carcinoma. Methods The clinicopathological data of 113 patients with Child-Pugh A hepatocellular carcinoma who underwent radical resection with large hepatocellular carcinoma in the Department of Hepatobiliary Surgery of Fuzhou General Hospital of People′s Liberation Army from January 2014 to December 2016 were retrospectively analyzed. The patients were divided into two groups according to the recovery of postoperative liver function, which 105 patients recovered well and 8 patients had hepatic decompensation among them. The liver function index of two groups were analyzed. Measurement data with approximately normal distribution were represented by and groups were compared using t test; measurement data with skewed or uneven disstribution were represented by M (range)and group werecompared using Man-Whitney U test; count data were compared using Fisher exact test; risk factors for postoperative liver dysfunction were analyzed using Logistic single factor and multivariate and ROC curve were drawn. Results Preoperative prothrombin time, international standardization ratio, platelet, prealbumin, total bilirubin, alkaline phosphatase, γ-glutamyl transpeptidase comparison between the two groups were statistically significant (Z=-1.983, -2.180, -2.608, -2.007, -3.577, -2.228, -2.575, P<0.05). Logistic univariate analysis showed that platelet, total bilirubin and prealbumin were the risk factors for the recovery of liver function of radical resection hepatic decompensation with large hepatocellular carcinoma. Logistic multivariate regression analysis showed that preoperative high total bilirubin and low preabumin were independent risk factors of radical resection hepatic decompensation with large hepatocellular carcinoma. Logistic univariate analysis showed that preoperative high total bilirubin and low prealbumin were not risk factors of radical resection liver failure with large hepatocellular carcinoma. The area under the curve of total bilirubin was 0.880, P=0.000, 95%CI: 0.808-0.953, the sensitivity was 87.5%, specificity was 84.8% and the area under prealbumin curve was 0.769, P=0.011, 95%CI: 0.648-0.891, sensitivity was 75.2%, specificity was 77.5% by the ROC curve. The best threshold of total bilirubin and prealbumin after radical resection with large hepatocellular carcinoma were 17.55 μmol/L and 0.18 g/L respectively by the ROC curve. Conclusion The Child-Pugh A patients in radical resection hepatic decompensation with large hepatocellular carcinoma recover well when the preoperative liver function is as follows: total bilirubin<17.55 μmol/L and prealbumin≥0.18 g/L. Key words: Large hepatocellular carcinoma; Prealbumin; Hepatic reserve; Hepatic decompensation; Liver failure

Higher Transaminase Levels in the Postoperative Period After Orthotopic Heart Transplantation Are Associated With Worse Survival

Preoperative liver function in heart failure patients is associated with extensive functional, structural, and hemodynamic abnormalities. The authors hypothesized that perioperative liver dysfunction is associated with worse 2-year survival after orthotopic heart transplantation. Retrospective study. Single-center, university hospital. The study comprised 209 consecutive patients undergoing heart transplantation. No interventions. Hepatobiliary markers, hemodynamic parameters, echocardiographic parameters, the need for mechanical cardiac support, demographic parameters, and United Network for Organ Sharing and Model for End-Stage Liver Disease (MELD) scores were investigated. Fifty-five patients (26.3%) died, and the mean survival time was 3.61 years after transplantation. In multivariate Cox regression analysis, in addition to the preoperative modified MELD score, the 4th quartiles of the maximum aspartate transaminase (AST) and alanine transaminase levels on the 4th through 7th postoperative days were independently associated with mortality (odds ratio [OR] 2.46, 95% confidence interval [CI] 1.09-5.55; p = 0.031 and OR 2.41, 95% CI 1.13-5.18; p = 0.024, respectively). By expressing the transaminase values as the multiplier of the sex-specific top normal value, the maximum AST and alanine transaminase levels (OR 1.02, 95% CI 1.01-1.02; p < 0.001 and OR 1.02, 95% CI 1.01-1.03; p = 0.001, respectively) were linked to worse survival. Among the postdischarge parameters, the modified MELD score (OR 1.17, 95% CI 1.09-1.27; p < 0.001) and the AST level were associated with postdischarge mortality (OR 1.002, 95% CI 1.001-1.003; p < 0.001 as a continuous variable; OR 1.07, 95% CI 1.05-1.10; p < 0.001, expressed as the multiplier of the sex-specific normal value, respectively). The severity of postoperative liver dysfunction negatively influences survival after heart transplantation, and liver function should be closely assessed in these patients.