Nomogram based on liver stiffness and spleen area with ultrasound for posthepatectomy liver failure:A multicenter study

BACKGROUND Liver stiffness(LS)measurement with two-dimensional shear wave elastography(2D-SWE)correlates with the degree of liver fibrosis and thus indirectly reflects liver function reserve.The size of the spleen increases due to tissue proliferation,fibrosis,and portal vein congestion,which can indirectly reflect the situation of liver fibrosis/cirrhosis.It was reported that the size of the spleen was related to posthepatectomy liver failure(PHLF).So far,there has been no study combining 2D-SWE measurements of LS with spleen size to predict PHLF.This prospective study aimed to investigate the utility of 2D-SWE assessing LS and spleen area(SPA)for the prediction of PHLF in hepatocellular carcinoma(HCC)patients and to develop a risk prediction model.AIM To investigate the utility of 2D-SWE assessing LS and SPA for the prediction of PHLF in HCC patients and to develop a risk prediction model.METHODS This was a multicenter observational study prospectively analyzing patients who underwent hepatectomy from October 2020 to March 2022.Within 1 wk before partial hepatectomy,ultrasound examination was performed to measure LS and SPA,and blood was drawn to evaluate the patient’s liver function and other conditions.Least absolute shrinkage and selection operator logistic regression and multivariate logistic regression analysis was applied to identify independent predictors of PHLF and develop a nomogram.Nomogram performance was validated further.The diagnostic performance of the nomogram was evaluated with receiver operating charac-teristic curve compared with the conventional models,including the model for end-stage liver disease(MELD)score and the albumin-bilirubin(ALBI)score.RESULTS A total of 562 HCC patients undergoing hepatectomy(500 in the training cohort and 62 in the validation cohort)were enrolled in this study.The independent predictors of PHLF were LS,SPA,range of resection,blood loss,international normalized ratio,and total bilirubin.Better diagnostic performance of the nomogram was obtained in the training[area under receiver operating characteristic curve(AUC):0.833;95%confidence interval(95%CI):0.792-0.873;sensitivity:83.1%;specificity:73.5%]and validation(AUC:0.802;95%CI:0.684-0.920;sensitivity:95.5%;specificity:52.5%)cohorts compared with the MELD score and the ALBI score.CONCLUSION This PHLF nomogram,mainly based on LS by 2D-SWE and SPA,was useful in predicting PHLF in HCC patients and presented better than MELD score and ALBI score.

Exploring predictive markers for liver failure post-hepatectomy in hepatocellular carcinoma patients

This letter to the editor addresses the study titled“Predictive value of NLR,Fib4,and APRI in the occurrence of liver failure after hepatectomy in patients with hepatocellular carcinoma”by Kuang et al in the World Journal of Gastrointestinal Surgery.The study acknowledges the comprehensive patient data analysis while suggesting that there is a need for further discussion on the clinical applicability of these markers across diverse patient populations.This letter recommends prospective studies for validation and considers the influence of confounding factors.This finding underscores the significance of this study in improving hepatocellular carcinoma management.

Heparin is an effective treatment for preventing liver failure after hepatectomy

BACKGROUND Posthepatectomy liver failure(PHLF)is one of the most important causes of death following liver resection.Heparin,an established anticoagulant,can protect liver function through a number of mechanisms,and thus,prevent liver failure.AIM To look at the safety and efficacy of heparin in preventing hepatic dysfunction after hepatectomy.METHODS The data was extracted from Multiparameter Intelligent Monitoring in Intensive Care III(MIMIC-III)v1.4 pinpointed patients who had undergone hepatectomy for liver cancer,subdividing them into two cohorts:Those who were injected with heparin and those who were not.The statistical evaluations used were unpaired ttests,Mann-Whitney U tests,chi-square tests,and Fisher’s exact tests to assess the effect of heparin administration on PHLF,duration of intensive care unit(ICU)stay,need for mechanical ventilation,use of continuous renal replacement therapy(CRRT),incidence of hypoxemia,development of acute kidney injury,and ICU mortality.Logistic regression was utilized to analyze the factors related to PHLF,with propensity score matching(PSM)aiming to balance the preoperative disparities between the two groups.RESULTS In this study,1388 patients who underwent liver cancer hepatectomy were analyzed.PSM yielded 213 matched pairs from the heparin-treated and control groups.Initial univariate analyses indicated that heparin potentially reduces the risk of PHLF in both matched and unmatched samples.Further analysis in the matched cohorts confirmed a significant association,with heparin reducing the risk of PHLF(odds ratio:0.518;95%confidence interval:0.295-0.910;P=0.022).Additionally,heparin treatment correlated with improved short-term postoperative outcomes such as reduced ICU stay durations,diminished requirements for respiratory support and CRRT,and lower incidences of hypoxemia and ICU mortality.CONCLUSION Liver failure is an important hazard following hepatic surgery.During ICU care heparin administration has been proved to decrease the occurrence of hepatectomy induced liver failure.This indicates that heparin may provide a hopeful option for controlling PHLF.

Construction of a predictive model for acute liver failure after hepatectomy based on neutrophil-to-lymphocyte ratio and albuminbilirubin score

BACKGROUND Acute liver failure(ALF)is a common cause of postoperative death in patients with hepatocellular carcinoma(HCC)and is a serious threat to patient safety.The neutrophil-to-lymphocyte ratio(NLR)is a common inflammatory indicator that is associated with the prognosis of various diseases,and the albumin-bilirubin score(ALBI)is used to evaluate liver function in liver cancer patients.Therefore,this study aimed to construct a predictive model for postoperative ALF in HCC tumor integrity resection(R0)based on the NLR and ALBI,providing a basis for clinicians to choose appropriate treatment plans.AIM To construct an ALF prediction model after R0 surgery for HCC based on NLR and ALBI.METHODS In total,194 patients with HCC who visited The First People’s Hospital of Lianyungang to receive R0 between May 2018 and May 2023 were enrolled and divided into the ALF and non-ALF groups.We compared differences in the NLR and ALBI between the two groups.The risk factors of ALF after R0 surgery for HCC were screened in the univariate analysis.Independent risk factors were analyzed by multifactorial logistic regression.We then constructed a prediction model of ALF after R0 surgery for HCC.A receiver operating characteristic curve,calibration curve,and decision curve analysis(DCA)were used to evaluate the value of the prediction model.RESULTS Among 194 patients with HCC who met the standard inclusion criteria,46 cases of ALF occurred after R0(23.71%).There were significant differences in the NLR and ALBI between the two groups(P<0.05).The univariate analysis showed that alpha-fetoprotein(AFP)and blood loss volume(BLV)were significantly higher in the ALF group compared with the non-ALF group(P<0.05).The multifactorial analysis showed that NLR,ALBI,AFP,and BLV were independent risk factors for ALF after R0 surgery in HCC.The predictive efficacy of NLR,ALBI,AFP,and BLV in predicting the occurrence of ALT after R0 surgery for HCC was average[area under the curve(AUC)NLR=0.767,AUCALBI=0.755,AUCAFP=0.599,AUCBLV=0.718].The prediction model for ALF after R0 surgery for HCC based on NLR and ALBI had a better predictive efficacy(AUC=0.916).The calibration curve and actual curve were in good agreement.DCA showed a high net gain and that the model was safer compared to the curve in the extreme case over a wide range of thresholds.CONCLUSION The prediction model based on NLR and ALBI can effectively predict the risk of developing ALF after HCC R0 surgery,providing a basis for clinical prevention of developing ALF after HCC R0 surgery.

End-stage liver disease score and future liver remnant volume predict post-hepatectomy liver failure in hepatocellular carcinoma

BACKGROUND Hepatocellular carcinoma(HCC)is the world’s sixth most common malignant tumor and the third cause of cancer death.Although great progress has been made in hepatectomy,it is still associated with a certain degree of risk of posthepatectomy liver failure(PHLF),which extends the length of hospital stay and remains the leading cause of postoperative death.Studies have shown that assessment of hepatic functional reserve before hepatectomy is beneficial for reducing the incidence of PHLF.AIM To assess the value of model for end-stage liver disease(MELD)score combined with standardized future liver remnant(sFLR)volume in predicting PHLF in patients undergoing hepatectomy for HCC.METHODS This study was attended by 238 patients with HCC who underwent hepatectomy between January 2015 and January 2018.Discrimination of sFLR volume,MELD score,and sFLR/MELD ratio to predict PHLF was evaluated according to the area under the receiver operating characteristic curve.RESULTS The patients were divided into two groups according to whether PHLF occurred after hepatectomy.The incidence of PHLF was 8.4%in our research.The incidence of PHLF increased with the decrease in sFLR volume and the increase in MELD score.Both sFLR volume and MELD score were considered independent predictive factors for PHLF.Moreover,the cut-off value of the sFLR/MELD score to predict PHLF was 0.078(P<0.001).This suggests that an sFLR/MELD≥0.078 indicates a higher incidence of PHLF than an sFLR/MELD<0.078.CONCLUSION MELD combined with sFLR is a reliable and effective PHLF predictor,which is superior to MELD score or sFLR volume alone.

Delayed diagnosis of alpha-1-antitrypsin deficiency following post-hepatectomy liver failure: A case report

Post-hepatectomy liver failure(PHLF) is a leading cause of morbidity and mortality following major liver resection. The development of PHLF is dependent on the volume of the remaining liver tissue and hepatocyte function. Without effective pre-operative assessment, patients with undiagnosed liver disease could be at increased risk of PHLF. We report a case of a 60-year-old male patient with PHLF secondary to undiagnosed alpha-1-antitrypsin deficiency(AATD) following major liver resection. He initially presented with acute large bowel obstruction secondary to a colorectal adenocarcinoma, which had metastasized to the liver. There was no significant past medical history apart from mild chronic obstructive pulmonary disease. After colonic surgery and liver directed neo-adjuvant chemotherapy, he underwent a laparoscopic partially extended right hepatectomy and radio-frequency ablation. Post-operatively he developed PHLF. The cause of PHLF remained unknown, prompting reanalysis of the histology, which showed evidence of AATD. He subsequently developed progressive liver dysfunction, portal hypertension, and eventually an extensive parastomal bleed, which led to his death; this was ultimately due to a combination of AATD and chemotherapy. This case highlights that formal testing for AATD in all patients with a known history of chronic obstructive pulmonary disease, heavy smoking, or strong family history could help prevent the development of PHLF in patients undergoing major liver resection.

Pre-hepatectomy type Ⅳ collagen 7S predicts post-hepatectomy liver failure and recovery

BACKGROUND Liver resection is an effective treatment for benign and malignant liver tumors.However,a method for preoperative evaluation of hepatic reserve has not yet been established.Previously reported assessments of preoperative hepatic reserve focused only on liver failure in the early postoperative period and did not consider the long-term recovery of hepatic reserve.When determining eligibility for hepatectomy,the underlying pathophysiology needs to be considered to determine if the functional hepatic reserve can withstand both surgery and any postoperative therapy.AIM To identify pre-hepatectomy factors associated with both early postoperative liver failure and long-term postoperative liver function recovery.METHODS This study was a retrospective cohort study.We retrospectively investigated 215 patients who underwent hepatectomy at our hospital between May 2013 and December 2016.Early post-hepatectomy liver failure(PHLF)was defined using the International Study Group of Liver Surgery’s definition of PHLF.Long-term postoperative recovery of liver function was defined as the time taken for serum total bilirubin and albumin levels to return to levels of<2 mg/dL and>2.8 g/dL,respectively,and the time taken for Child-Pugh score to return to Child-Pugh class A.RESULTS Preoperative type IV collagen 7S was identified as a significant independent factor associated with both PHLF and postoperative long-term recovery of liver function.Further analysis revealed that the time taken for the recovery of Child-Pugh scores and serum total bilirubin and albumin levels was significantly shorter in patients with type IV collagen 7S≤6 ng/mL than in those with type IV collagen 7S>6 ng/mL.In additional analyses,similar results were observed in patients without chronic viral hepatitis associated with fibrosis.CONCLUSION Preoperative type IV collagen 7S is a preoperative predictor of PHLF and longterm postoperative liver function recovery.It can also be used in patients without chronic hepatitis virus.

Risk factors for post-hepatectomy liver failure in 80 patients

BACKGROUND Post-hepatectomy liver failure(PHLF)is a serious complication and a leading cause of death after hepatectomy,an accurate prediction of PHLF is important for improvement of prognosis after hepatectomy.AIM To retrospectively analyze the risk factors for postoperative liver failure in patients undergoing hepatectomy for liver tumors.METHODS The clinical data of 80 patients undergoing hepatectomy in our hospital from June 2018 to January 2020 were collected.With laboratory examination as well as preand post-operative abdominal three-dimensional reconstructive computed tomography,the demographic data,surgical data,biochemical indicators,coagulation index,routine blood tests,spleen and liver volumes,relative remnant liver volume,and other related indicators were obtained and compared between patients with PHLF and those without PHLF.RESULTS PHLF occurred in 19(23.75%)patients.Univariate logistic regression analysis showed that gender,history of hepatitis/cirrhosis,and preoperative bilirubin,albumin,coagulation function,albumin-bilirubin ratio,aspartate aminotransferase-to-platelet ratio index(APRI),Model for End-Stage Liver Disease score,spleen volume(SV),spleen volume/liver volume ratio(SV/LV),and relative remnant liver volume were statistically associated with the occurrence of PHLF(all P<0.05).Multivariate regression analysis showed that preoperative total bilirubin,platelets(PLT),APRI,and SV/LV were independent risk factors for PHLF(all P<0.05).The area under the curve and cut-off values were 0.787 and 18.6 mmol/L for total bilirubin,0.893 and 146×1012/L for PLT,0.907 and 0.416 for APRI,and 0.752 and 20.84%for SV/LV,respectively.CONCLUSION For patients undergoing liver resection,preoperative total bilirubin,PLT,APRI,and SV/LV are independent risk factors for PHLF.These findings may provide guidance to safely perform liver surgery in such patients.

An accurate predictor of liver failure and death after hepatectomy:A single institution's experience with 478 consecutive cases

AIM:To establish a reliable definition of postoperative liver failure(PLF)and allow the prediction of outcomes after hepatectomy.METHODS:The clinical data of 478 consecutive patients who underwent hepatectomy were retrospectively analyzed.The examined prognostic factors included the ratio of total bilirubin(TBIL)on postoperative day(POD)X to TBIL on POD 1(TBIL-r1)and the ratio of the international normalized ratio(INR)on POD X to the INR on POD 1(INR-r1)for PODs 3,5 and 7.Student’s t test,theχ2test,logistic regression,survival analysis and receiver operating curve analysis were used to evaluate risk factors and establish the definition of postoperative liver failure(PLF).RESULTS:Fourteen patients(2.9%)died of liver failure within 3 mo of surgery.Significant differences were found between patients who died of liver failure and the remaining patients in terms of TBIL-r1 and INR-r1on PODs 3,5 and 7.The combination of TBIL-r1 and INR-r1 on POD 5 showed strong predictive power for liver failure-related death(sensitivity 92.9%and specificity 90.1%).The hepatic damage score(HDs),which was derived from TBIL-r1 and INR-r1,was used to define the degree of metabolic functional impairment after resection as mild(HDs=0),reversible hepatic"dysfunction"(HDs=1)or fatal hepatic failure(HDs=2).Furthermore,the indocyanine green retention rate at 15 min(ICG-R15)and the number of resected segments(RSs)were identified as independent predictors of the HDs.A linear relationship was found between ICG-R15 and RSs in the HDs=2 group.The regression equation was:RSs=-0.168×ICG-R15+5.625(r2=0.613,F=14.257,P=0.004).CONCLUSION:PLF can be defined by the HDs,which accurately predicts liver failure-related death after liver resection.Furthermore,the ICG-R15 and RSs can be used as selection criteria for hepatectomy.

Subacute liver and respiratory failure after segmental hepatectomy for complicated hepatolithiasis with secondary biliary cirrhosis: A case report

BACKGROUND Despite being a benign disease, hepatolithiasis has a poor prognosis because of its intractable nature and frequent recurrence. Nonsurgical treatment is associated with high incidences of residual and recurrent stones. Consequently, surgery via hepatic lobectomy or segmental hepatectomy has become the main treatment modality. Clinical management and resolution of complicated hepatolithiasis with bilateral or diffuse intrahepatic stones remain very difficult and challenging. Repeated cholangitis and calculous obstruction may result in secondary biliary cirrhosis, a limiting factor in the treatment of hepatolithiasis.CASE SUMMARY A 53-year-old woman with a 5-year history of intermittent abdominal pain and fever was admitted to the hepatopancreatobiliary surgery department following worsening symptoms over a 3-d period. Blood tests revealed elevated transaminases, alkaline phosphatase, γ-glutamyl transpeptidase, and total bilirubin, as well as anemia. Magnetic resonance cholangiopancreatography showed dilatation of the intrahepatic, left and right hepatic, common hepatic, and common bile ducts, and multiple short T2 signals in the intrahepatic and common bile ducts. Abdominal computed tomography showed splenomegaly and splenic varices. The diagnosis was bilateral hepatolithiasis and choledocholithiasis with cholangitis. Surgical treatment included hepatectomy of segments Ⅱ and Ⅲ, cholangioplasty, left hepaticolithotomy, second biliary duct exploration, choledocholithotomy, T-tube drainage, and accretion lysis. Surgical and pathological findings confirmed secondary biliary cirrhosis. Liver-protective therapy and anti-infectives were administered. The patient developed liver and respiratory failure, severe abdominal infection, and septicemia. Eventually, her family elected to discontinue treatment.CONCLUSION Liver transplantation, rather than hepatectomy, might be a treatment option for complicated bilateral hepatolithiasis with secondary liver cirrhosis.

Experimental research on TECA-I bioartificial liver support system to treat canines with acute liver failure

AIM: To evaluate the efficacy and safety of the TECA-I bioartificial liver support system (BALSS) in treating canines with acute liver failure (ALF). METHODS: Ten canines with ALF induced by 80% liver resection received BALSS treatment (BALSS group). Blood was perfused through a hollow fiber tube containing 1X10(10) porcine hepatocytes.Four canines with ALF were treated with BALSS without porcine hepatocytes (control group), and five canines with ALF received drug treatment (drug group). Each treatment lasted 6 hours. RESULTS: BALSS treatment yielded beneficial effects for partial liver resection induced ALF canines with survival and decreased plasma ammonia, ALT, AST and BIL. There was an obvious decrease in PT level and increase in PA level, and there were no changes in the count of lymphocytes, immunoglobulins (IgA, IgG and IgM) and complement (C3 and C4) levels after BALSS treatment. In contrast, for the canines with ALF in non-hepatocyte BALSS group (control group) and drug group, there were no significant changes in ammonia, ALT, AST, BIL, PT and PA levels. ALF canines in BALSS group, control group and drug group lived respectively an average time of 108.0h +/- 12.0h, 24.0h +/- 6.0h and 20.4h +/- 6.4h,and three canines with ALF survived in BALSS group. CONCLUSION: TECA-I BALSS is efficacious and safe for ALF canines induced by partial liver resection.

Hypothermia predicts hepatic failure after extensive hepatectomy in mice

AIM:To investigate the effect of hypothermia on the function of the liver remnant(LR)after extended hepatectomy.METHODS:We performed a 75% partial hepatectomy(PH)in male C57BL/6J mice.Body temperature was measured with a rectal probe.The study mice were prospectively grouped as hypothermic(HT)or normothermic(NT)if their body temperature was < 34 ℃ vs≥ 34 ℃,respectively.Blood and liver samples were obtained at 24 and 48 h after 75% PH.Various factors during and after 75% PH were compared at each time point and the most important factor for a good outcome after 75% PH was determined.RESULTS:At 24 and 48 h after 75% PH,LR weight was decreased in HT mice compared with that in NT mice and the assay results in the HT mice were consistent with liver failure.NT mice had normal liver regeneration.Each intra-and post-operative factor which showed statistical significance in univariate analysis was evaluated by multivariate analysis.The most important factor for a good outcome after 75% PH was body temperature at both 24 and 48 h after surgery.CONCLUSION:Hypothermia after an extensive hepatectomy predicts impending liver failure and may be a useful clinical marker for early detection of liver failure after extended hepatectomy.

Predicting liver function after hemihepatectomy in patients with hepatocellular carcinoma using different modalities

In response to Dr.Yue et al's study on prognostic factors for post-hemihep-atectomy outcomes in hepatocellular carcinoma(HCC)patients,this critical review identifies methodological limitations and proposes enhancements for future research.While the study identifies liver stiffness measure and standard residual liver volume as potential predictors,concerns regarding small sample size,reliance on biochemical markers for safety assessment,and inadequate ad-justment for confounding variables are raised.Recommendations for rigorous methodology,including robust statistical analysis,consideration of confounding factors,and selection of outcome measures with clinical components,are proposed to strengthen prognostic assessments.Furthermore,validation of novel evaluation models is crucial for enhancing clinical applicability and advancing understanding of postoperative outcomes in patients with HCC undergoing hem-ihepatectomy.

A reliable graded acute liver failure model in rats: treatment with internal bioartificial liver

BACKGROUND: Appropriate animal models are impor- tant for studying acute liver failure. This study was to assess a new suitable rat model for acute liver failure. METHODS: After the right influent hepatic vessels were clamped for a period of time (45, 60 or 90 minutes respec- tively), the animal model was established by removal of the clamp for restoring blood flow of the right lobes while im- mediately removal of the median, left lateral and caudate lobes. Animal survival rate was observed in the following 14 days in each group. To study the pathophysiological chan- ges of the model, some biochemical parameters in 5 con- secutive days were evaluated in the 60-minute group. Inter- nal bioartificial liver was transplanted in the peritoneal cavi- ty to test the reversibility of the model. RESULTS: The survival rate of the models decreased, as the ischemia time of the right lobes prolonged to zero in the 90-minute group, to 50% in the 60-minute group and to 100% in the 45-minute group on the fifth day after opera- tion. The levels of ammonia, alanine aminotransferase, al- kaline phosphatase, total bilirubin and prothrombin were elevated dramatically 12 to 24 hours after operation in the 60-minute group. When internal bioartificial liver was transplanted, the survival rate increased significantly in ad- dition to the levels of ammonia and total bilirubin. CONCLUSION: A period time of ischemic injury in the right lobe followed by 70% liver resection can produce a graded acute hepatic failure model in rats.

A combined pre- and intra-operative nomogram in evaluation of degrees of liver cirrhosis predicts post-hepatectomy liver failure: a multicenter prospective study

Background:Adequate evaluation of degrees of liver cirrhosis is essential in surgical treatment of hepatocellular carcinoma(HCC)patients.The impact of the degrees of cirrhosis on prediction of post-hepatectomy liver failure(PHLF)remains poorly defined.This study aimed to construct and validate a combined pre-and intra-operative nomogram based on the degrees of cirrhosis in predicting PHLF in HCC patients using prospective multi-center’s data.Methods:Consecutive HCC patients who underwent hepatectomy between May 18,2019 and Dec 19,2020 were enrolled at five tertiary hospitals.Preoperative cirrhotic severity scoring(CSS)and intra-operative direct liver stiffness measurement(DSM)were performed to correlate with the Laennec histopathological grading system.The performances of the pre-operative nomogram and combined pre-and intra-operative nomogram in predicting PHLF were compared with conventional predictive models of PHLF.Results:For 327 patients in this study,histopathological studies showed the rates of HCC patients with no,mild,moderate,and severe cirrhosis were 41.9%,29.1%,22.9%,and 6.1%,respectively.Either CSS or DSM was closely correlated with histopathological stages of cirrhosis.Thirty-three(10.1%)patients developed PHLF.The 30-and 90-day mortality rates were 0.9%.Multivariate regression analysis showed four pre-operative variables[HBV-DNA level,ICG-R15,prothrombin time(PT),and CSS],and one intra-operative variable(DSM)to be independent risk factors of PHLF.The pre-operative nomogram was constructed based on these four pre-operative variables together with total bilirubin.The combined pre-and intra-operative nomogram was constructed by adding the intra-operative DSM.The pre-operative nomogram was better than the conventional models in predicting PHLF.The prediction was further improved with the combined pre-and intra-operative nomogram.Conclusions:The combined pre-and intra-operative nomogram further improved prediction of PHLF when compared with the pre-operative nomogram.

Liver resection, and technical advances to mitigate post-hepatectomy liver failure

The liver is the chemical factory in human body and a unique organ in five ways:(Ⅰ)it is the largest internal human viscera;(Ⅱ)anatomically it is unique due to the duality of blood and oxygen supply;(Ⅲ)among all abdominal viscera,liver receives the highest amount of blood supply in resting state;(Ⅳ)physiologically liver is unique as pathology management decisions are not only determined by pathology but also by inherent liver function;and(Ⅴ)clinically it is unique as it is the commonest site of metastatic disease from solid organ primaries.These unique characteristics increase the challenges in managing liver conditions,especially liver resection.In addition to general operative risks,and liver-specific operative risks;one unique risk of liver resection is an insufficient future liver remnant(FLR)resulting in post-hepatectomy liver failure(PHLF);as unlike renal dialysis,liver dialysis is not a practical standard of care.

Preoperative assessment of liver function and perioperative management of posthepatectomy liver failure

PHLF is the status of disfunction in synthesis,excretion and detoxication.According to International Study Group of Liver Surgery(ISGLS),PHLF is defined by an increased bilirubin level and international normalized ratio(INR)on or after postoperative 5 days,and is graded by clinical severity from grades A to C(1,2).Grade A is the condition without any treatment.Grade B deviates from normal postoperative management and requires blood products,diuretics,oxygen administration,and so on.Grade C is the status with multiple organ failure which requires intensive management including respirator,dialysis,and liver transplantation,etc.Perioperative mortality rates in A,B and C were estimated 0%,12%,and 54%,respectively(1).Although PHLF has decreased due to extensive studies of risk factors for PHLF and improvements in surgical techniques,it remains high for several types of procedures.According to a nationwide survey of board-certified training institutions by the Japanese Society of Hepato-Biliary-Pancreatic Surgery,90-day mortality rates is 10.3%and 6.7%after left trisectionectomy and hepatopancreatectomy,respectively(3).Further,the mortality rates after associating liver partition and portal vein ligation for staged hepatectomy(ALPPS)was reported over 5%(4).

Risk predictors of post-hepatectomy liver failure: unraveling complexities and navigating challenges in clinical application

Studies related to the prediction of post-hepatectomy liver failure(PHLF)have seen a surge in recent literature.A PubMed search using the terms((“pred*”OR“nomogra*”OR“model*”)AND(“mortality”OR“liver failure”OR“PHLF”)AND(“hepatect*”OR“liver resect*”))revealed 29 relevant studies on PHLF prediction between January 2020 and November 2023,with 20 adhering to grade B/C International Study Group of Liver Surgery(ISGLS)definitions(Table 1).These studies are primarily enrolling patients with hepatocellular carcinoma(HCC).This underscores the growing interest in applying such predictive scores in routine clinical practice.However,the extent to which these predictive models can be effectively implemented in clinical settings remains unclear(21,22).Indeed,all studies are retrospective,and only a limited number underwent external validation.It is crucial to recognize that these scores predominantly emerge within surgical cohorts,where patients underwent prior meticulous selection,leading to tailored surgical strategies and the exclusion of specific candidates(21).

Critical appraisal of novel prediction models and risk calculators for post-hepatectomy liver failure and complications: practicability and generalisability in the real-world setting

Over the last few decades,the evolution of liver resection has progressed through numerous milestones in peri-operative management,operative techniques and novel technologies that have dramatically improved patient safety and outcomes(1).Consequently,such developments have enabled surgeons to embark on liver resections of lesions in technically challenging locations,whereby extended resection or bilovascular reconstruction may be required to ensure oncologic clearance.In the context of extended resections or resection of lesions from heavily diseased livers,concerns remain regarding the adequacy of the remnant future liver remnant(FLR)and liver function,placing patients at risk of the clinical phenomenon known as post-hepatectomy liver failure(PHLF).Although relatively uncommon,PHLF has a reported incidence of up to 32%in the literature and remains an important cause of post-hepatectomy morbidity and mortality(2).Presently,several definitions have been proposed to describe PHLF,the most recent of which was proposed by the International Study Group of Liver Surgery(ISGLS).In this definition,PHLF was defined as an increased international normalized ratio(INR)or hyperbilirubinemia on or after post-operative day 5,with further stratification of severity grades(A,B or C)based on the extent of clinical management(3).While definitions in PHLF assist in providing a common diagnostic framework among physicians,establishing predictors in PHLF is conceivably more helpful as it allows surgeons to have important decision-making details prior to planned liver resection.

Pure laparoscopic hepatectomy for hepatocellular carcinoma with chronic liver disease

Pure laparoscopic hepatectomy is a less invasive procedure than conventional open hepatectomy for the resection of hepatic lesions. Increases in experiences with the technique, in combination with advances in technology, have promoted the popularity of pure laparoscopic hepatectomy. However, indications for usage and potential contraindications of the procedure remain unresolved. The characteristics and specific advantages of the procedure, especially for hepatocellular carcinoma(HCC) patients with chronic liver diseases,are reviewed and discussed in this paper. For cirrhotic patients with liver tumors, pure laparoscopic hepatectomy minimizes destruction of the collateral blood and lymphatic flow from laparotomy and mobilization, and mesenchymal injury from compression. Therefore, pure laparoscopic hepatectomy has the specific advantage of minimal postoperative ascites production that leads to lowering the risk of disturbance in water or electrolyte balance and hypoproteinemia. It minimizes complications that routinely trigger postoperative serious liver failure. Under adequate patient positioning and port arrangement, the partial resection of the liver in the area of subphrenic space, peri-inferior vena cava area or next to the attachment of retro-peritoneum is facilitated in pure laparoscopic surgery by providing good vision and manipulation in the small operative field.Furthermore, the features of reduced post-operative adhesion, good vision, and manipulation within the small area between the adhesions make this procedure safer in the context of repeat hepatectomy procedures.These improved features are especially advantageous for patients with liver cirrhosis and multicentric and/or metachronous HCCs.