Functional assessment of liver regeneration after major hepatectomy

Background: Liver regeneration is crucial to restore the functional liver mass after liver resection. The aim of this study was to evaluate the early postoperative changes in remnant liver function, volume and liver stiffness after major liver resection and their correlation with postoperative outcomes. Methods: Patients undergoing major liver resection (≥3 segments) between February and November 2018 underwent both functional assessment using technetium-99m mebrofenin hepatobiliary scintigraphy (HBS) and CT-volumetry of the (future) remnant liver on preoperative day 1, the 5th postoperative day, and 4-6 weeks after resection. At the same time points, patients underwent transient elastography (TE) for the assessment of liver stiffness. Severe postoperative complications (Clavien-Dindo ≥ 3A) and mortality were correlated with the functional and volumetric increases of the remnant liver. Liver failure was graded according to the International Study Group of Liver Surgery (ISGLS) criteria. Results: A total of 18 patients were included of whom 10 (56%) had severe complications and one patient (5%) developed liver failure. Function and volume of the remnant liver had increased by the 5th postoperative day from 6.9 (5.4-10.9) to 9.6 (6.7-13.8) %/min/m2, P=0.004 and from 795.5 (538.3-1,037.5) to 1,080.0 (854.0-1,283.3) mL, P<0.001, respectively. After 4-6 weeks, remnant liver volume had further increased [from 1,080.0 (854.0-1,283.3) to 1,222.0 (1,016.0-1,380.5) mL, P=0.035], however, liver function did not show any significant, further increase [from 9.6 (6.7-13.8) to 10.9 (8.8-13.6) %/min/m2, P=0.177]. Liver elasticity of the future remnant liver (FRL) increased [from 10.8 (5.7-18.7) to 17.5 (12.4-22.6) kPa, P=0.018] and gradually recovered after 4-6 weeks to a median of 10.9 (5.7-18.8) kPa (T3 vs. T4, P=0.079). Patients who had severe postoperative complications did not show a significant increase in liver function on the 5th postoperative day (P=0.203), despite increase of volume (P<0.01). Conclusions: Functional regeneration of the remnant liver predominantly occurs during the first 5 days after resection. In case of severe complications, functional regeneration is delayed, in contrast to volume increase.

Development and internal validation of the Comprehensive ALPPS Preoperative Risk Assessment(CAPRA)score:is the patient suitable for Associating Liver Partition and Portal vein ligation for Staged hepatectomy(ALPPS)?

Background:Preoperative patient selection in Associating Liver Partition and Portal vein ligation for Staged hepatectomy(ALPPS)is not always reliable with currently available scores,particularly in patients with primary liver tumor.This study aims to(I)to determine whether comorbidities and patients characteristics are a risk factor in ALPPS and(II)to create a score predicting 90-day mortality preoperatively.Methods:Thirteen high-volume centers participated in this retrospective multicentric study.A risk analysis based on patient characteristics,underlying disease and procedure type was performed to identify risk factors and model the Comprehensive ALPPS Preoperative Risk Assessment(CAPRA)score.A nonparametric receiver operating characteristic analysis was performed to estimate the predictive ability of our score against the Charlson Comorbidity Index(CCI),the age-adjusted CCI(aCCI),the ALPPS risk score before Stage 1(ALPPS-RS1)and Stage 2(ALPPS-RS2).The model was internally validated applying bootstrapping.Results:A total of 451 patients were included.Mortality was 14.4%.The CAPRA score is calculated based on the following formula:(0.1×age)−(2×BSA)+1(in the presence of primary liver tumor)+1(in the presence of severe cardiovascular disease)+2(in the presence of moderate or severe diabetes)+2(in the presence of renal disease)+2(if classic ALPPS is planned).The predictive ability was 0.837 for the CAPRA score,0.443 for CCI,0.519 for aCCI,0.693 for ALPPS-RS1 and 0.807 for ALPPS-RS2.After 1,000 cycles of bootstrapping the C statistic was 0.793.The accuracy plot revealed a cut-off for optimal prediction of postoperative mortality of 4.70.Conclusions:Comorbidities play an important role in ALPPS and should be carefully considered when planning the procedure.By assessing the patient’s preoperative condition in relation to ALPPS,the CAPRA score has a very good ability to predict postoperative mortality.

Short-and long-term outcomes after hemihepatectomy for perihilar cholangiocarcinoma:does left or right side matter?

Background:The only potentially curative option for patients with perihilar cholangiocarcinoma(PHC)is resection,typically an extrahepatic bile duct resection in combination with(extended)liver resection.Complications such as bile leakage and liver failure have been suggested to be more common after right-sided resections compared to left-sided resections,whilst superior oncological outcomes have been reported after right-sided resections.However,data on outcomes after right-sided or left-sided liver resections in PHC are scarce.Therefore,we aimed to investigate short-and long-term outcomes after left and right hemihepatectomy in patients with PHC.Methods:In this retrospective study,patients undergoing major liver resection for suspected PHC in a tertiary center between 2000-2018 were included.Patients who had undergone left-sided resections were compared to patients with right-sided resections in terms of complications(90-day mortality,overall and severe morbidity and specific complications).For long-term outcomes,only patients with pathologically proven PHC were included in the survival analysis.Results:A total of 178 patients undergoing hemihepatectomy for suspected PHC were analysed,including 76 left-sided and 102 right-sided resections.Overall 90-day mortality was 14%(24 out of 178),with no significant difference after left-sided resection(11%;8 out of 76)versus right-sided resection(16%;16 out of 102)(P=0.319).Severe morbidity(Clavein Dindo≥3)was also comparable in both groups:54%versus 61%(P=0.361).No differences in specific complications including bile leakage were observed,although liver failure appeared to occur more frequently after right hemihepatectomy(22%versus 11%,P=0.052).Five-year overall survival for pathologically proven PHC,excluding in-hospital mortality,did not differ;43.7%after left-sided resection vs.and 38.2%after right-sided resection(P=0.553).Conclusions:Both short-and long-term outcomes between patients undergoing left and right hemihepatectomy for PHC were comparable.Post-hepatectomy liver failure was more common after right-sided resection.