Prediction Of Posthepatectomy Liver Failure Research Articles

Albumin-bilirubin score versus Child-Pugh score as predictors of post-hepatectomy liver failure in hepatocellular carcinoma patients

Objective To compare the discriminatory power of the Albumin-bilirubin score (ALBI) and the Child-Pugh score (CP) in predicting post-hepatectomy liver failure (PHLF) in patients with hepatocellular carcinoma (HCC) after curative liver resection, and to explore the clinical value of ALBI score. Methods The clinical data of HCC patients who underwent curative hepatectomy in Nanfang Hospital, Southern Medical University from January 2011 to December 2016 were retrospectively reviewed. The risk factors of PHLF were identified through logistic regression. The areas under the receiver operating characteristic (ROC) curve were calculated to measure the ALBI and CP scores in the prediction of PHLF. Results A total of 1 013 patients were enrolled. The incidence of PHLF was 17.7% (179/1 013). Both CP score (OR=1.94, P<0.05) and ALBI score (OR=3.85, P<0.05) were identified as independent predictors of PHLF on multivariable analysis. The incidence of PHLF in patients with CP grade A was significantly lower than those with CP grade B(16.4%, 158/963 vs. 42%, 21/50; P<0.05). The incidences of PHLF in patients with AIBI 1, 2 and 3 were 9.9%(50/504), 24.8%(124/501) and 62.5%(5/8), respectively (P<0.05), indicating that the incidences of PHLF increased significantly with increasing ALBI grades. Moreover, when the ALBI score further classified patients of the CP grade A into the ALBI 1-A and ALBI 2-A subgroups, the incidence of PHLF in patients with ALBI 1-A was significantly lower than that with ALBI 2-A (9.9%, 50/504 vs. 23.5%, 108/459; P<0.05). The area under the ROC curve for the ALBI score in predicting PHLF was greater than that of the CP score (0.705 vs. 0.630; P<0.05). Conclusions The prognostic power of the ALBI score was greater than that of the CP score in predicting PHLF. Even in patients with CP grade A, the ALBI score was more sensitive in identifying patients with a high risk of PHLF. The ALBI score is a useful tool to predict PHLF after hepatectomy in HCC patients. Key words: Carcinoma, hepatocellular; Post-hepatectomy liver failure; Albumin-bilirubin score; Child-Pugh score

A Comparative Study of Albumin-Bilirubin Score with Child-Pugh Score, Model for End-Stage Liver Disease Score and Indocyanine Green R15 in Predicting Posthepatectomy Liver Failure for Hepatocellular Carcinoma Patients

Background: The albumin-bilirubin (ALBI) grade is a newly proposed model for assessing the hepatic function. This study aimed to compare the value of the ALBI score with Child-Pugh score, model for end-stage liver disease (MELD) score and indocyanine green (ICG) R15 in predicting posthepatectomy liver failure (PHLF). Methods: Patients undergoing curative resection for hepatocellular carcinoma (HCC) between January 2014 and June 2017 were enrolled. The values of the Child-Pugh score, MELD score, ICG R15 and ALBI score in predicting PHLF were evaluated. Results: A total of 473 HCC patients were enrolled. The ALBI score was identified as an independent predictor of PHLF. The AUCs for the Child-Pugh score, MELD score, ICG R15 and ALBI score in predicting PHLF were 0.665, 0.649, 0.668, and 0.745 respectively. Multivariable analyses revealed that the ALBI score was an independent predictor of PHLF regardless of the hepatectomy subgroups, but the Child-Pugh score and MELD score were not significant predictors of PHLF both in major and minor hepatectomy subgroups, and ICG R15 was only a significant predictor of PHLF in minor hepatectomy subgroup. Conclusion: The ALBI score showed superior predictive value of PHLF over Child-Pugh score, MELD score and ICG R15. We propose to use the ALBI score to evaluate surgical risk for HCC patients undergoing hepatic resection.

Prediction of Posthepatectomy Liver Failure Proposed by the International Study Group of Liver Surgery: Residual Liver Function Estimation With 99mTc-Galactosyl Human Serum Albumin Scintigraphy.

The International Study Group of Liver Surgery (ISGLS) proposed a definition and grading system for posthepatectomy liver failure (PHLF). We evaluated the usefulness of residual liver function estimation using Tc-galactosyl human serum albumin (Tc-GSA) for the prediction of PHLF. Patients with liver tumors (n = 136) and scheduled for hepatectomy underwent Tc-GSA scintigraphy. Based on their imaging data, the maximal GSA removal rate (GSA-Rmax)was calculated using multicompartment analysis. We also calculated GSA-Rmax in the predicted residual liver (GSA-RL) whose volume was determined on computed tomography (CT) scans. We compared the age, sex, 15-minute indocyanine green retention rate; albumin, bilirubin, hyaluronic acid, and type 4 collagen levels; the Child-Pugh classification; residual liver volume; residual liver percentage; GSA-Rmax; and GSA-RL in patients with and without PHLF. Univariate and multivariate logistic analyses were used for statistical assessments. Of 136 patients, 17 (12.5%) met the ISGLS criteria for PHLF (ISGLS-PHLF). There was a statistically significant difference in the age, albumin level, Child-Pugh classification, residual liver volume, residual liver percentage, GSA-Rmax, and GSA-RL between patients with and without PHLF. Based on multivariate analysis, GSA-RL and the residual liver volume were significant independent predictors of ISGLS-PHLF (P = 0.004 and P = 0.038, respectively). The odds ratio was 149423 for GSA-RL and 1.003 for the residual liver volume. GSA-RL calculated using Tc-GSA scintigraphy was the most useful independent predictor for ISGLS-PHLF.

Risk prediction of post-hepatectomy liver failure in patients with perihilar cholangiocarcinoma.

In most patients with perihilar cholangiocarcinoma (PHCC), major hepatectomy and extrahepatic bile duct resection are needed for surgical radicality, and a high risk of hepatic insufficiency exists. This study aims to develop a prediction model for post-hepatectomy liver failure (PHLF) in patients with PHCC. A total of 143 patients who underwent major liver resection and extrahepatic bile duct resection for PHCC between October 2001 and December 2013 were included. Clinically relevant PHLF was defined as liver failure corresponding to grade B or C of the International Study Group of Liver Surgery criteria. Multivariate logistic regression was used to develop the PHLF risk model. Model performance was evaluated internally using the area under the curve analysis (discrimination) after 1000 bootstrap resampling and the Hosmer-Lemeshow goodness-of-fit test (calibration). Post-hepatectomy liver failure occurred in 43.4% of patients (n=62). In multivariate analysis, PHLF was significantly associated with future liver remnant ratio (odds ratio [OR] per 10%=0.68, 95% confidence interval [CI] 0.51-0.88), intraoperative blood loss (OR per 1L=1.82, 95% CI 1.11-3.17), and preoperative prothrombin time>1.20 (OR=3.22, 95% CI 1.15-9.97). The PHLF risk score model showed good discrimination (area under the curve=0.708, 95% CI 0.623-0.793) and calibration (P=0.227). The risk model proposed in this study accurately predicted PHLF in patients with PHCC. This offers surgeons a practical guide to quantitative risk assessment of hepatic insufficiency and aids decision-making in surgical treatment and perioperative management.

Predictors of post-hepatectomy liver failure in patients undergoing extensive liver resections for hepatocellular carcinoma.

Backgrounds/AimsTo determine the prevalence of post-hepatectomy liver failure/insufficiency (PHLF/I) in patients undergoing extensive hepatic resections for hepatocellular carcinoma (HCC) and to assess the predictive value of preoperative factors for post-hepatectomy liver failure or insufficiency (PHLF/I).MethodsA retrospective review of patients who underwent liver resections for HCC between 2001 and 2013 was conducted. Preoperative parameters were assessed and analyzed for their predictive value of PHLF/I. Definitions used included the 50–50, International Study Group of Liver Surgery (ISGLS) and Memorial Sloan Kettering Cancer Centre (MSKCC) criteria.ResultsAmong the 848 patients who underwent liver resections for HCC between 2001 and 2013, 157 underwent right hepatectomy (RH) and extended right hepatectomy (ERH). The prevalence of PHLF/I was 7%, 41% and 28% based on the 50–50, ISGLS and MSKCC criteria, respectively. There were no significant differences in PHLF/I between RH and ERH. Model for End-Stage Liver Disease (MELD) score and bilirubin were the strongest independent predictors of PHLF/I based on the 50–50 and ISGLS/MSKCC criteria, respectively. Predictive models were developed for each of the criteria with multiple logistic regression.ConclusionsMELD score, bilirubin, alpha-fetoprotein and platelet count showed significant predictive value for PHLF/I (all p<0.05). A composite score based on these factors serves as guideline for physicians to better select patients undergoing extensive resections to minimize PHLF.

Preoperative thrombocytopenia may predict poor surgical outcome after extended hepatectomy

Background. It is a novel idea that platelet counts may be associated with postoperative outcome following liver surgery. This may help in planning an extended hepatectomy (EH), which is a surgical procedure with high morbidity and mortality. Aim. The aim of this study was to evaluate the predictive potential of platelet counts on the outcome of EH in patients without portal hypertension, splenomegaly, or cirrhosis. Methods. A series of 213 consecutive patients underwent EH (resection of ≥ five liver segments) between 2001 and 2016. The association of preoperative platelet counts with posthepatectomy liver failure (PHLF), morbidity (based on Clavien-Dindo classification), and 30-day mortality was evaluated using multivariate analysis. Results. PHLF was detected in 26.3% of patients, major complications in 26.8%, and 30-day mortality in 11.3% of patients. Multivariate analysis revealed that the preoperative platelet count is an independent predictor of PHLF (odds ratio [OR] 4.4, 95% confidence interval [CI] 1.3–15.0, p=0.020) and 30-day mortality (OR 4.4, 95% CI 1.1–18.8, p=0.043). Conclusions. Preoperative platelet count is associated with PHLF and mortality following extended liver resection. This association was independent of other related parameters. Prospective studies are needed to evaluate the predictive role and to determine the impact of preoperative correction of platelet count on postoperative outcomes after EH.

Prediction of posthepatectomy liver failure using transient elastography in patients with hepatitis B related hepatocellular carcinoma

BackgroundIt is essential to accurately predict Postoperative liver failure (PHLF) which is a life-threatening complication. Liver hardness measurement (LSM) is widely used in non-invasive assessment of liver fibrosis. The aims of this study were to explore the application of preoperative liver stiffness measurements (LSM) by transient elastography in predicting postoperative liver failure (PHLF) in patients with hepatitis B related hepatocellular carcinoma.MethodsThe study included 247 consecutive patients with hepatitis B related hepatocellular carcinoma who underwent hepatectomy between May 2015 and September 2015. Detailed preoperative examinations including LSM were performed before hepatectomy. The endpoint was the development of PHLF.ResultsAll of the patients had chronic hepatitis B defined as the presence of hepatitis B surface antigen (HBsAg) for more than 6 months and 76 (30.8%) had cirrhosis. PHLF occurred in 37 (14.98%) patients. Preoperative LSM (odds ratio, OR, 1.21; 95% confidence interval, 95% CI: 1.13–1.29; P < 0.001) and international normalized ratio (INR) (OR, 1.07; 95% CI: 1.01–1.12; P < 0.05) were revealed to be independent risk factors for PHLF, and a new model was defined as LSM-INR index (LSM-INR index = 0.191*LSM + 6.317*INR-11.154). The optimal cutoff values of LSM and LSM-INR index for predicting PHLF were 14 kPa (AUC 0.86, 95% CI: 0.811–0.901, P < 0.001) and −1.92 (AUC 0.87, 95% CI: 0.822–0.909, P < 0.001), respectively.ConclusionsLSM can be helpful for surgeons to make therapeutic decisions in patients with hepatitis B related hepatocellular carcinoma.

Value of Preoperative Indocyanine Green Clearance Test for Predicting Post-Hepatectomy Liver Failure in Noncirrhotic Patients.

BackgroundLiver failure is the most feared complication following hepatectomy. Post-hepatectomy liver failure (PHLF) is closely related to the remnant liver volume, and functional reserve. There are several methods for predicting PHLF prior to liver resection. The indocyanine green (ICG) clearance test was popularized in patients with hepatocellular cancer (HCC). We aim to demonstrate the value of preoperative ICG clearance measurement via pulse spectrophotometer (LIMON®) in prediction of PHLF in noncirrhotic patients prior to liver resection.Material/MethodsFifty-three noncirrhotic patients who underwent liver resection due to different pathologies were included. Retrospectively collected clinical data, including the preoperative ICG clearance measurements and remnant liver volumes of the patients, were statistically evaluated according to the PHLF criteria of the International Study Group of Liver Surgery.ResultsFour (7.5%) patients with PHLF were observed. There was no significant difference between PHLF and non-PHLF groups regarding ICG clearance measurements with cut-off values of 5% and 9.5%.ConclusionsThe ICG clearance test does not satisfy our expectations in noncirrhotic patients in predicting PHLF. We believe that the ICG clearance test should be reserved for patients with cirrhosis and/or HCC. This test could be an option for noncirrhotic patients with chronic active hepatitis, advanced-grade fatty livers, or for patients who received long-term preoperative chemotherapy, and also for patients who underwent single or multiple sessions of TACE or TARE prior to liver resection. If the routine selection criteria have been fulfilled, there is no further need to perform the ICG clearance test for living liver donors.

Estimation of the future remnant liver function is a better tool to predict post-hepatectomy liver failure than platelet-based liver scores

IntroductionRecently, there has been increasing interest in the preoperative prediction and prevention of post-hepatectomy liver failure (PHLF). This is a particular concern in colorectal liver metastases (CRLM), when surgery follows potentially hepatotoxic chemotherapy. Platelet-based liver scores (PBLS) such as APRI and FIB-4 are predictive of chemotherapy-associated liver injury (CALI) and PHLF. Estimation of the future liver remnant function (eFLRF) by combining 99mTc-Mebrofenin Hepatobiliary Scintigraphy (HBSBSA) with future liver remnant volume ratio (FLRV%), is predictive of PHLF and related mortality. We hypothesized that a HBSBSA based formula was a better predictor for PHLF than PBLS in chemotherapy-pretreated CRLM. MethodsBetween 2012 and 2016, 140 patients underwent liver resection for CRLM following systemic therapy. HBSBSA, FLRV%, eFLRF and PBLS were calculated and compared for their value in predicting PHLF. ResultseFLRF and FLRV% had a better predictive value for PHLF than HBSBSA alone and APRI and FIB-4 (AUC = 0.800, 0.843 versus 0.652, 0.635 and 0.658 respectively). In a subgroup analysis (Oxaliplatin all, Oxaliplatin ≥ 6 cycles, Irinotecan all and Irinotecan ≥ 6 cycles), eFLRF was the only factor predictive for PHLF in all subgroups (all: p ≤ 0.05). Prediction of HBSBSA for chemotherapy associated steato-hepatitis (CASH) reached almost significance (p = 0.06). FIB-4 was predictive for sinusoidal obstruction syndrome (SOS) (p = 0.011). Only weak correlation was found between HBSBSA and PBLS. ConclusioneFLRF is a better predictor of PHLF than PBLS or HBSBSA alone. PBLS seem to measure other aspects of liver function or damage than HBSBSA.

Nomogram for individualised prediction of liver failure risk after hepatectomy in patients with resectable hepatocellular carcinoma: the evidence from ultrasound data.

This study sought to develop a clinical nomogram for predicting post-hepatectomy liver failure (PHLF) among patients with resectable hepatocellular carcinoma (HCC). The nomogram was established based on data obtained from a prospective study on 136 consecutive patients with resectable HCC undergoing hepatectomy from January 2015 to December 2015 in our centre. Another 80 patients in our centre served as an independent internal validation set. The predictive accuracy and discriminative ability of the nomogram were determined by concordance index (C-index), calibration curve and compared with commonly predictive systems. PHLF occurred in 30.9% of patients in the derivation set, including 36 and six patients with Grades A and B, respectively. The statistical nomogram built on the basis of platelet count, serum bilirubin, serum GGT, clinical signs of portal hypertension and shear wave elastography had good calibration and discriminatory abilities, with C-indices of 0.85. These models showed satisfactory goodness-of-fit and discrimination abilities in the independent validation set with C-indices of 0.824 for PHLF. The areas under the receiver-operator characteristic (ROC) curve using our methods were greater than those of conventional predictive systems in the validation patients (corresponding C-indices, 0.572-0.701). This novel nomogram provides good preoperative prediction of PHLF in patients with resectable HCC. • The nomogram was built by platelet count, bilirubin, GGT, CSPH and SWE. • The nomogram showed good calibration and discriminatory abilities in the different sets. • Compared with other models, the nomogram indicated better discriminatory capability.

Usefulness of Mac-2 Binding Protein Glycosylation Isomer for Prediction of Posthepatectomy Liver Failure in Patients With Hepatocellular Carcinoma

The aim of this study was to evaluate the usefulness of the Mac-2 binding protein glycosylation isomer (M2BPGi) for the prediction of posthepatectomy liver failure (PHLF) in hepatocellular carcinoma (HCC) patients. M2BPGi is a novel serum marker of liver fibrosis. The usefulness of M2BPGi for the prediction of PHLF has not been evaluated. Clinicopathological data were analyzed in 138 HCC patients who underwent liver resection between August 2011 and November 2014. PHLF was evaluated according to the definition of the International Study Group of Liver Surgery. Performance of preoperative parameters in predicting PHLF was determined using receiver operating characteristic (ROC) analysis. Serum M2BPGi level correlated with the METAVIR fibrosis score. M2BPGi levels of hepatitis C virus (HCV)-positive patients were significantly higher than those of HCV-negative patients, even in the same fibrosis stage. PHLF ≥ Grade B developed in 19 patients (13.8%). The area under the ROC curve (AUROC) of M2BPGi for the prediction of PHLF ≥ Grade B was 0.71. In multivariate analysis, M2BPGi [odds ratio (OR): 2.08, 95% confidence interval (CI) 1.28-3.55], platelet count (OR: 0.39, 95% CI 0.18-0.80), and resection rate (OR: 2.71, 95% CI 1.46-5.40) were the significant factors associated with PHLF ≥ Grade B. The AUROC of the PHLF index defined by these factors was 0.81. Notably, in patients with HCV infection, the predictive ability of M2BPGi for PHLF (AUROC 0.85) was the best among the preoperative parameters. M2BPGi is a useful predictor of PHLF, especially in patients with HCV infection.

Interstage assessment of remnant liver function in ALPPS using hepatobiliary scintigraphy: prediction of posthepatectomy liver failure and introduction of the HIBA index

Interstage assessment of remnant liver function in ALPPS using hepatobiliary scintigraphy: prediction of posthepatectomy liver failure and introduction of the HIBA index

Can contrast-enhanced MRI with gadoxetic acid predict liver failure and other complications after major hepatic resection?

To determine whether a combination of clinical factors, the future liver remnant (FLR) ratio, and hepatic uptake of gadoxetic acid can be used to predict post-hepatectomy liver failure (PHLF) and other major complications (OMC). Sixty-five consecutive patients who underwent pre-hepatectomy gadoxetic acid-enhanced magnetic resonance imaging (MRI) between October 2010 and December 2013 were included. The relative liver enhancement (RLE) of gadoxetic acid was calculated from regions of interest on MRI, and FLR ratios were obtained from computed tomography (CT). PHLF and OMC were defined by the International Study Group of Liver Surgery criteria and Clavien-Dindo grade of ≥3, respectively. Multivariate logistic regression modelling was performed to identify predictors of PHLF and OMC, including RLE, FLR ratio, age, sex, chemotherapy history, intra-operative blood loss, and intra-operative transfusion. Nine patients experienced PHLF and another nine patients experienced OMC. RLE was comparable to the FLR ratio in predicting PHLF (areas under the receiver operating characteristic [AUROC] curves, 0.665 and 0.705), but performed poorly in predicting OMCs (AUROCs, 0.556 and 0.702). Combining all clinical and imaging parameters as predictors yielded the best performing predictive models (AUROCs, 0.875 and 0.742 for PHLF and OMC, respectively). A model based on clinical parameters, the FLR ratio, and RLE of gadoxetic acid may improve pre-hepatectomy risk assessment.

Measuring future liver remnant function prior to hepatectomy may guide the indication for portal vein occlusion and avoid posthepatectomy liver failure: a prospective interventional study

BackgroundEstimation of the future liver remnant function (eFLRF) can avoid post-hepatectomy liver failure (PHLF). In a previous study, a cutoff value of 2.3%/min/m2 for eFLRF was a better predictor of PHLF than future liver remnant volume (FLRV%). In this prospective interventional study, investigating a management strategy aimed at avoiding PHLF, this cutoff value was the sole criterion assessing eligibility for hepatectomy, with or without portal vein occlusion (PVO). MethodsIn 100 consecutive patients, eFLRF was determined using the formula: eFLRF = FLRV% × total liver function (TLF). Group 1 (eFLRF >2.3%/min/m2) underwent hepatectomy without preoperative intervention. Group 2 (eFLRF <2.3%/min/m2) underwent PVO and re-evaluation of eFLRF at 4–6 weeks. Hepatectomy was performed if eFLRF had increased to >2.3%/min/m2, but was considered contraindicated if the value remained lower. ResultsIn group 1 (n = 93), 1 patient developed grade B PHLF. In group 2 (n = 7) no PHLF was recorded. Postoperative recovery of TLF in patients with preoperative eFLRF <2.3%/min/m2 occurred more rapidly when PVO had been performed. ConclusionA predefined cutoff for preoperatively calculated eFLRF can be used as a tool for selecting patients prior to hepatectomy, with or without PVO, thus avoiding PHLF and PHLF-related mortality.

Liver failure after hepatectomy: A risk assessment using the pre-hepatectomy shear wave elastography technique

ObjectiveTo determine the efficacy of liver stiffness (LS) measurements utilizing the Shear Wave Elastography (SWE) technique for predicting post-hepatectomy liver failure (PHLF) among patients with hepatocellular carcinoma (HCC). MethodsData from eighty consecutive patients who were undergoing hepatectomy for HCC were prospectively identified and evaluated with preoperative SWE. The SWE was measured with advanced ultrasound equipment (Philips EPIQ7; Philips Healthcare, Seattle, WA, USA). PHLF classification was defined according to the International Study Group of Liver Surgery Recommendations (ISGLS). ResultsSWE was successfully performed in 77 patients. According to the ISGLS criteria, PHLF occurred in 35.1% of patients (27 patients), including 2/25 patients with Grade A/B, respectively. Elevated SWE values (P=0.002) and histological cirrhosis (P=0.003) were independent predictors of PHLF according to the multivariate analysis. Patients with SWE values higher than or equal to 6.9kPa were identified at higher risk of PHLF (area under the curve: 0.843, sensitivity: 77.8% and specificity: 78.0%). Postoperative dynamic course of the median the Model For End-stage Liver Disease (MELD) score showed irregular changes among patients with an SWE >6.9kPa. Patients with an SWE <6.9kPa, postoperative dynamic course of the median MELD score gradually decreased. ConclusionLS measured with SWE is a valid and reliable method for the prediction of PHLF grade A/B among patients with HCC. SWE could become a routine examination for the preoperative evaluation of PHLF.

Portal Vein Pressure Change Predicts Posthepatectomy Liver Failure Following Right Lobectomy

The aim of this study was to evaluate the usefulness of intraoperative portal venous pressure (PVP) as a predictor of posthepatectomy liver failure (PHLF). Hepatic functional reserve is typically evaluated by using parameters such as albumin level, platelet count, prothrombin activity level, or indocyanine green retention rate at 15 minutes. Low hepatic functional reserve can enhance the risk of PHLF. We retrospectively analyzed the outcomes of 35 patients who underwent right lobectomy and intraoperative PVP measurements between April 2004 and August 2012. According to preoperative prediction scores, all patients were within a safe limit for right lobectomy. The patients were grouped into uncomplicated (n = 22) and PHLF (n = 13) groups by postoperative course. PHLF was defined as grade B or C according to International Study Group of Liver Surgery criteria. Patient background, intraoperative bleeding, operative time, and PVP elevation after hepatectomy (ΔPVP) grade were compared between the groups. No cases of in-hospital death occurred. Univariate analysis revealed significant differences in preoperative white blood counts, intraoperative bleeding, and ΔPVP between the groups (P &amp;lt; 0.05). The ΔPVP was an independent risk factor on multivariate analysis. A ΔPVP &amp;gt;3 cmH2O was associated with PHLF at 69.2% sensitivity and 90.9% specificity. Following right lobectomy, a ΔPVP &amp;gt;3 cmH2O indicates a risk of PHLF and warrants careful postoperative management.

MAC 2 binding protein gi for the prediction of posthepatectomy liver failure in hepatocellular carcinoma patients

Introduction: Posthepatectomy liver failure (PHLF) is a serious postoperative state, and the precise prediction of PHLF is essential. Recently, Mac 2 binding protein Gi (M2BPGi) has been reported as a useful predictor of liver fibrosis. We aimed to evaluate the usefulness of M2BPGi in predicting PHLF in hepatocellular carcinoma (HCC) patients. Methods: We retrospectively collected and analyzed the data of liver function tests, fibrotic markers, shear wave velocity (SWV) by acoustic radiation force impulse imaging, and resection rate (RR) of 138 patients with HCC who underwent liver resection. M2BPGi values were measured using frozen serum samples. RR was calculated by computed tomography volumetry. PHLF was diagnosed based on the International Study Group of Liver Surgery definition. Results: PHLF grade≧B occurred in 19 patients (13.7%: grade B, n = 14; grade C, n = 5). The area under the receiver operating characteristic curve (AUROC) of M2BPGi, SWV and platelet count (Plt) in predicting PHLF grade≧B was high (0.705, 0.769 and 0.720, respectively). Multivariate analysis identified M2BPGi (odds ratio [OR]: 2.08, 95% confidence interval [CI]: 1.28 to 3.55, p < 0.01), Plt (OR: 0.39, 95% CI: 0.18 to 0.80, p = 0.02) and RR (OR: 2.71, 95% CI: 1.46 to 5.40, p < 0.01) as the significant factors associated with PHLF grade≧B, and the logistic model that included these factors resulted in an AUROC of 0.81. Conclusion: In HCC patients, M2BPGi was useful in predicting PHLF, and the predictive power was improved in combination with Plt and RR.

The Results of СТ-Volumetry and Clearance Test with Indocyanine Green as Indications for Preoperative Portal Vein Embolization

Aim. To clarify the indications for preoperative portal vein embolization using CT-volumetry and indocyanine green clearance as predictors of post-resection liver failure. Material and Methods. The results of 179 liver resections were analyzed. There were 128 hemihepatectomies and 51 partial resections. In 24 cases preoperative portal vein embolization was used. Indocyanine green clearance test was applied for a quantitative assessment of liver function. Plasma disappearance rate and residual concentration of indocyanine green during the first 15 minutes were determined. CT-volumetry was used to calculate the future remnant liver volume. Posthepatectomy liver failure severity was evaluated in accordance with the recommendations of the International Study Group of Liver Surgery (ISGLS) and taking into account “50–50" criteria. Results. The frequency of posthepatectomy liver failure after extensive resections was 42.5%: grade A – 38.7%; grade B –41.9%, grade C – 19.4%. The future remnant liver volume as a predictor of posthepatectomy liver failure had moderate predictive power (c-statistic = 0.71, p = 0.04) with sensitivity and specificity about 84.6% and 61%, respectively. Indocyanine green elimination was significantly worse in patients with chronic liver disease or after previous repeated courses of chemotherapy (plasma disappearance rate 15.6%/min vs 18.6%/min, p = 0.004; indocyanine green residual concentration after 15 minutes 19.6% vs 6,1%, p = 0.003). Clearance test with indocyanine green was characterized by high sensitivity (92.3%) and specificity (71.4%) in the definition of liver function and excellent predictive power (c-statistic = 0.82, p = 0.0001) in determining of posthepatectomy liver failure. Risk factors of posthepatectomy liver failure were future remnant liver volume &lt;372 cm3/m2 and plasma disappearance rate of indocyanine green &lt;10%/min. The indications for preoperative portal vein embolization are future remnant liver volume &lt;372 cm3/m2 at plasma disappearance rate of indocyanine green &gt;15%/min or plasma disappearance rate of indocyanine green &gt;10%/min but &lt;15%/min and future remnant liver volume &lt;550 cm3/m2. These criteria allowed to reduce the incidence of posthepatectomy liver failure (25.6%) and to avoid the development of severe liver dysfunction. Conclusion. The future remnant liver volume and indocyanine green clearance test are highly sensitive methods to predict posthepatectomy liver failure. Application of the developed diagnostic and treatment algorithm with updated indications for preoperative portal vein embolization can reduce the frequency of posthepatectomy liver failure.

Prediction of posthepatectomy liver failure based on liver stiffness measurement in patients with hepatocellular carcinoma

Posthepatectomy liver failure (PHLF) is a potentially fatal complication, and the accurate prediction of PHLF is essential. Liver stiffness measurement (LSM) has been accepted widely as a noninvasive assessment for liver fibrosis. We aimed to evaluate the usefulness of LSM in predicting PHLF. One hundred seventy-seven patients with hepatocellular carcinoma who underwent liver resection between August 2011 and October 2014 were analyzed prospectively. LSM was performed by Virtual Touch Tissue Quantification based on acoustic radiation force impulse imaging, and its value was expressed as the shear wave velocity (Vs) [m/s]. The remnant liver volume rate (Rem) was calculated by computed tomography volumetry. PHLF was diagnosed on the basis of the definition from the International Study Group of Liver Surgery. PHLF occurred in 38 patients (21.5%): grade A, 17 patients (9.6%); grade B, 15 patients (8.5%); and grade C, 6 patients (3.4%). The area under the receiver operating characteristic curve of the Vs for predicting PHLF was 0.67 for grade ≥A, 0.78 for grade ≥B, and 0.74 for grade C, which was greater than any other preoperative factor for each grade. Multivariate stepwise selection identified 2 significant factors associated with PHLF grade ≥B: Vs (odds ratio, 2.66; 95% confidence interval, 1.69-4.41, P<.01) and Rem (odds ratio, 0.47; 95% confidence interval, 0.27-0.79, P<.01). The logistic model that included the Vs and Rem resulted in an area under the receiver operating characteristic curve of 0.80 for predicting PHLF grade ≥B. LSM was useful for the prediction of PHLF and the estimation of the safe Rem range.

Liver failure after hepatocellular carcinoma surgery.

The aim of this study was to construct a prediction model for posthepatectomy liver failure (PHLF), as defined by the International Study Group of Liver Surgery, and evaluate its accuracy in hepatocellular carcinoma (HCC) patients with cirrhosis or chronic hepatitis. A total of 277 consecutive hepatectomies for HCC between 2005 and 2013 were analyzed retrospectively. Multivariate logistic regression analysis was used to develop a predictive model for PHLF. The sensitivity, specificity, and area under the receiver operating characteristic (AUROC) curve were evaluated. The Hosmer-Lemeshow goodness-of-fit test was used to assess the model calibration. The constructed model was internally validated by k-fold cross-validation (k=5). PHLF developed in 12.6% of hepatectomies. Multivariate analysis identified the following variables as predictors of PHLF: elevated preoperative serum bilirubin level, elevated preoperative international normalized ratio, and intraoperative packed red blood cell transfusion. The predictive model allowed discrimination between patients who developed PHLF and those who did not, with a sensitivity of 82.9%, specificity of 72.3%, and AUROC curve of 0.81 (95% CI, 0.74 to 0.89). The Hosmer-Lemeshow test indicated a good fit (P=0.545). The AUROC curve of the developed model was significantly greater than that of the model for end-stage liver disease (MELD) score (P=0.014), suggesting that the former model is better at predicting the PHLF than the latter one. The developed model could be useful for predicting the occurrence of PHLF in HCC patients with underlying liver disease.