Background: Post-hepatectomy liver failure(PHLF) is a leading cause of postoperative mortality after liver surgery. Due to its significant impact, it is imperative to understand the risk stratification and preventativ...Background: Post-hepatectomy liver failure(PHLF) is a leading cause of postoperative mortality after liver surgery. Due to its significant impact, it is imperative to understand the risk stratification and preventative strategies for PHLF. The main objective of this review is to highlight the role of these strategies in a timeline centered way around curative resection. Data sources: This review includes studies on both humans and animals, where they addressed PHLF. A literature search was conducted across the Cochrane Library, Embase, MEDLINE/Pub Med, and Web of Knowledge electronic databases for English language studies published between July 1997 and June 2020. Studies presented in other languages were equally considered. The quality of included publications was assessed using Downs and Black’s checklist. The results were presented in qualitative summaries owing to the lack of studies qualifying for quantitative analysis. Results: This systematic review with 245 studies, provides insight into the current prediction, prevention, diagnosis, and management options for PHLF. This review highlighted that liver volume manipulation is the most frequently studied preventive measure against PHLF in clinical practice, with modest improvement in the treatment strategies over the past decade. Conclusions: Remnant liver volume manipulation is the most consistent preventive measure against PHLF.展开更多
BACKGROUND Post-hepatectomy liver failure(PHLF)is one of the main causes of postoperative mortality and is challenging to predict early in patients after liver resection.Some studies suggest that the postoperative ser...BACKGROUND Post-hepatectomy liver failure(PHLF)is one of the main causes of postoperative mortality and is challenging to predict early in patients after liver resection.Some studies suggest that the postoperative serum phosphorus might predict outcomes in these patients.AIM To perform a systematic literature review on hypophosphatemia and evaluate it as a prognostic factor for PHLF and overall morbidity.METHODS This systematic review was performed according to preferred reporting items for systematic reviews and meta-analyses statement.A study protocol for the review was registered in the International Prospective Register of Systematic Reviews database.PubMed,Cochrane and Lippincott Williams&Wilkins databases were systematically searched up to March 31,2022 for studies analyzing postoperative hypophosphatemia as a prognostic factor for PHLF,overall postoperative morbidity and liver regeneration.The quality assessment of the included cohort studies was performed according to the Newcastle-Ottawa Scale.RESULTS After final assessment,nine studies(eight retrospective and one prospective cohort study)with 1677 patients were included in the systematic review.All selected studies scored≥6 points according to the Newcastle-Ottawa Scale.Cutoff values of hypophosphatemia varied from<1 mg/dL to≤2.5 mg/dL in selected studies with≤2.5 mg/dL being the most used defining value.Five studies analyzed PHLF,while the remaining four analyzed overall complications as a main outcome associated with hypophosphatemia.Only two of the selected studies analyzed postoperative liver regeneration,with reported better postoperative liver regeneration in cases of postoperative hypophosphatemia.In three studies hypophosphatemia was associated with better postoperative outcomes,while six studies revealed hypophosphatemia as a predictive factor for worse patient outcomes.CONCLUSION Changes of the postoperative serum phosphorus level might be useful for predicting outcomes after liver resection.However,routine measurement of perioperative serum phosphorus levels remains questionable and should be evaluated individually.展开更多
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 ...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.展开更多
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 funct...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.展开更多
<strong>Background:</strong><span><span><span style="font-family:""><span style="font-family:Verdana;"> Treatment strategy for recurrent hepatocellular carc...<strong>Background:</strong><span><span><span style="font-family:""><span style="font-family:Verdana;"> Treatment strategy for recurrent hepatocellular carcinoma (HCC) remains scantily defined. This study was aimed to establish a treatment strategy to manage post-hepatectomy recurrent HCC and report the clinical outcomes. </span><b><span style="font-family:Verdana;">Methods: </span></b><span style="font-family:Verdana;">From January 2006 to December 2016, 556 consecutive patients who developed post-hepatectomy HCC recurrence were enrolled in the study. The patients were clinically stratified and treated according to a strategy established by a multi-disciplinary team. Clinical data and survival times were collected prospectively and analyzed retrospectively. </span><b><span style="font-family:Verdana;">Results: </span></b><span style="font-family:Verdana;">According to the strategy, there were 298 (53.6%), 214 (38.5%), 32 (5.7%) and 12 (2.2%) patients stratified into Early, Intermediate, Advanced and Terminal stages, respectively. In Early stage patients, 164 (55.0%) received curative treatment in the form of repeat resection or local ablation, 134 (45.0%) received transarterial chemoe</span><span style="font-family:Verdana;">mbolization (TACE), and the 1-, 3-, and 5-year overall survival (OS) rates were 82.0%, 46.8% and 37.3%, respectively. In Intermediate stage patients, 207 (96.7%) received TACE, 7 (3.3%) radiotherapy, and the 1-, 3-, and 5-year OS rates were 73.2%, 31.8% and 15.9%, respectively. In Advanced stage patients, 22 patients received sorafenib, 10 radiotherapy, and the mean survival time (MST) was 25.1 ± 3.1 months. All the 12 patients in Terminal stage rece</span><span style="font-family:Verdana;">ived the best supportive treatment, and the MST was 6.5 ± 3.4 months. Clinical stages and duration of disease-free interval were independent factors relating to overall survival. </span><b><span style="font-family:Verdana;">Conclusions: </span></b><span style="font-family:Verdana;">A treatment strategy derived from the Barcelona Clinic Liver Cancer staging system, with some modifications, has been successfully established to manage post-hepatectomy recurrent HCC, and the clinical outcomes were commendable.</span></span></span></span>展开更多
The fame of regeneration has been attributed to the liver ever since the era of Greek mythology,in which Prometheus’liver could grow back overnight against the daily predation of Zeus’eagle.Hepatectomy is the very b...The fame of regeneration has been attributed to the liver ever since the era of Greek mythology,in which Prometheus’liver could grow back overnight against the daily predation of Zeus’eagle.Hepatectomy is the very basis of liver surgery including liver transplantation,and post-hepatectomy liver regeneration remains the center of interest for both clinicians and scientists.Novel tools for structural and functional assessment of liver regeneration have been constantly developed and validated,laying the groundwork for clinical management and scientific analysis(1).展开更多
(PHLF)is a severe complication and main cause of death in patients undergoing hepatectomy.The aim of this study was to build a predictive model of PHLF in patients undergoing hepatectomy.Methods:We retrospectively ana...(PHLF)is a severe complication and main cause of death in patients undergoing hepatectomy.The aim of this study was to build a predictive model of PHLF in patients undergoing hepatectomy.Methods:We retrospectively analyzed patients undergoing hepatectomy at Zhongshan Hospital,Fudan University from July 2015 to June 2018,and randomly divided them into development and internal validation cohorts.External validation was performed in an independent cohort.Least absolute shrinkage and selection operator(commonly referred to as LASSO)logistic regression was applied to identify predictors of PHLF,and multivariate binary logistic regression analysis was performed to establish the predictive model,which was visualized with a nomogram.Results:A total of 492 eligible patients were analyzed.LASSO and multivariate analysis identified three preoperative variables,total bilirubin(p=0.001),international normalized ratio(p<0.001)and platelet count(p=0.004),and two intraoperative variables,extent of resection(p=0.002)and blood loss(p=0.004),as independent predictors of PHLF.The area under receiver operating characteristic curve(referred to as AUROC)of the predictive model was 0.838 and outperformed the model for end-stage liver disease score,albumin-bilirubin score and platelet-albumin-bilirubin score(AUROCs:0.723,0.695 and 0.663,respectively;p<0.001 for all).The optimal cut-off value of the predictive model was 14.7.External validation showed the model could predict PHLF accurately and distinguish high-risk patients.Conclusions:PHLF can be accurately predicted by this model in patients undergoing hepatectomy,which may significantly contribute to the postoperative care of these patients.展开更多
Post-hepatectomy liver failure(PHLF)is associated with great morbidity and mortality after resection of hepatocellular carcinoma.Previous studies have underlined that advanced age could be a potential factor influenci...Post-hepatectomy liver failure(PHLF)is associated with great morbidity and mortality after resection of hepatocellular carcinoma.Previous studies have underlined that advanced age could be a potential factor influencing post-operative complications and long-term survival.In the past,candidates for resection were based on the Child-Pugh classification,the predictive value of which was rather low.The selection of patients undergoing resection in Western countries is based on the assessment of portal hypertension(PH),which is clinically assessed by measurement of the hepatic venous pressure gradient,an invasive and costly process.Thus,there have been several attempts to identify the best non-invasive test(NIT)to accurately predict PHLF.Most biochemical NITs for the prediction of PHLF are focused on evaluation of underlying liver cirrhosis and PH.Amongst them,FIB-4,which also includes the patient's age,seems to have more robust supporting results.In Europe and the USA.,the most tested and reliable NIT for predicting PHLF is the evaluation of liver stiffness measurement,which is also influenced by age.Imaging parameters are promising tools which are used only in specialized centers however,and when available.Liver volume parameters,as well as contrast-enhanced data,demonstrate good accuracy in predicting PHLF.In this scenario,the evaluation of sarcopenia and bone mineral density through contextual imaging allows the delineation of PHLF in at-risk elderly patients.Further studies focused on parameters for the evaluation of PHLF in elderly patients are needed.展开更多
Background:The upper limit for liver resections in rats is approximately 90%.In the early postoperative phase,mortality increases.The aim of the present study was to validate the rat model of 90%partial hepatectomy(PH...Background:The upper limit for liver resections in rats is approximately 90%.In the early postoperative phase,mortality increases.The aim of the present study was to validate the rat model of 90%partial hepatectomy(PH)as a model of post-hepatectomy liver failure(PHLF).Further,we wanted to test a quantitative scoring system as a detector of lethal outcomes caused by PHLF in rats.Methods:Sixty-eight rats were randomized to 90%PH,sham operation,or no sur-gery.Further,block randomization was performed based on time of euthanization:12,24,or 48 h after surgery.A general distress score(GDS)≥10 during the day or≥6 at midnight prompted early euthanization and classification as nonsurvivor.Animals euthanized as planned were classified as survivors.During euthanization,blood and liver tissue were collected,and liver-specific biochemistry was evaluated.Results:Based on the biochemical results,all animals subjected to 90%PH expe-rienced PHLF.Seventeen rats were euthanized due to irreversible PHLF.The GDS increased for nonsurvivors within 12–18 h after surgery.The mean time for euthaniza-tion was 27 h after surgery.Conclusion:Based on the GDS and liver-specific biochemistry,we concluded that the model of 90%PH seems to be a proper model for investigating PHLF in rats.As a high GDS is associated with increased mortality,the GDS appears to be valuable in detect-ing lethal outcomes caused by PHLF in rats.展开更多
BACKGROUND Post-hepatectomy liver failure(PHLF)increases morbidity and mortality after liver resection for patients with advanced liver fibrosis and cirrhosis.Preoperative liver stiffness using two-dimensional shear w...BACKGROUND Post-hepatectomy liver failure(PHLF)increases morbidity and mortality after liver resection for patients with advanced liver fibrosis and cirrhosis.Preoperative liver stiffness using two-dimensional shear wave elastography(2D-SWE)is widely used to evaluate the degree of fibrosis.However,the 2D-SWE results were not accurate.A durometer measures hardness by quantifying the ability of a material to locally resist the intrusion of hard objects into its surface.However,the durometer score can only be obtained during surgery.To measure correlations among 2D-SWE,palpation by surgeons,and durometermeasured objective liver hardness and to construct a liver hardness regression model.METHODS We enrolled 74 hepatectomy patients with liver hardness in a derivation cohort.Tactile-based liver hardness scores(0-100)were determined through palpation of the liver tissue by surgeons.Additionally,liver hardness was measured using a durometer.Correlation coefficients for durometer-measured hardness and preoperative parameters were calculated.Multiple linear regression models were constructed to select the best predictive durometer scale.Receiver operating characteristic(ROC)curves and univariate and multivariate analyses were used to calculate the best model’s prediction of PHLF and risk factors for PHLF,respectively.A separate validation cohort(n=162)was used to evaluate the model.RESULTS The stiffness measured using 2D-SWE and palpation scale had good linear correlation with durometer-measured hardness(Pearson rank correlation coefficient 0.704 and 0.729,respectively,P<0.001).The best model for the durometer scale(hardness scale model)was based on stiffness,hepatitis B virus surface antigen,and albumin level and had an R2 value of 0.580.The area under the ROC for the durometer and hardness scale for PHLF prediction were 0.807(P=0.002)and 0.785(P=0.005),respectively.The optimal cutoff value of the durometer and hardness scale was 27.38(sensitivity=0.900,specificity=0.660)and 27.87(sensitivity=0.700,specificity=0.787),respectively.Patients with a hardness scale score of>27.87 were at a significantly higher risk of PHLF with hazard ratios of 7.835(P=0.015).The model’s PHLF predictive ability was confirmed in the validation cohort.CONCLUSION Liver stiffness assessed by 2D-SWE and palpation correlated well with durometer hardness values.The multiple linear regression model predicted durometer hardness values and PHLF.展开更多
BACKGROUND Liver reduction is the main curative treatment for primary liver cancer,but its use remains limited as liver regeneration requires a minimum of 30%functional parenchyma.AIM To study the dynamics of the live...BACKGROUND Liver reduction is the main curative treatment for primary liver cancer,but its use remains limited as liver regeneration requires a minimum of 30%functional parenchyma.AIM To study the dynamics of the liver regeneration process and consequent behavior of cell cycle regulators in rats after extended hepatectomy(90%)and postoperative glucose infusions.METHODS Post-hepatectomy liver failure was triggered in 84 Wistar rats by reducing their liver mass by 90%.The animals received a post-operative glucose infusion and were randomly assigned to two groups:One to investigate the survival rate and the other for biochemical analyses.Animals that underwent laparotomy or 70%hepatectomy were used as controls.Blood and liver samples were collected on postoperative days 1 to 7.Liver morphology,function,and regeneration were studied with histology,immunohistochemistry,and western blotting.RESULTS Postoperative mortality after major resection reached 20%and 55%in the first 24 h and 48 h,respectively,with an overall total of 70%7 d after surgery.No apparent signs of apoptotic cell death were detected in the extended hepatectomy rat livers,but hepatocytes displaying a clear cytoplasm and an accumulation of hyaline material testified to changes affecting their functional activities.Liver regeneration started properly,as early events initiating cell proliferation occurred within the first 3 h,and the G1 to S transition was detected in less than 12 h.However,a rise in p27(Kip1)followed by p21(Waf1/Cip1)cell cycle inhibitor levels led to a delayed S phase progression and mitosis.Overall,liver regeneration in rats with a 90%hepatectomy was delayed by 24 h and associated with a delayed onset and lower peak magnitude of hepatocellular deoxyribonucleic acid synthesis.CONCLUSION This work highlights the critical importance of the cyclin/cyclin-dependent kinase inhibitors of the Cip/Kip family in regulating the liver regeneration timeline following extended hepatectomy.展开更多
Background:Surgery for perihilar cholangiocarcinoma(PHCC)remains a challenging procedure with high morbidity and mortality.The Academic Medical Center(Amsterdam UMC)and Memorial Sloan Kettering Cancer Center proposed ...Background:Surgery for perihilar cholangiocarcinoma(PHCC)remains a challenging procedure with high morbidity and mortality.The Academic Medical Center(Amsterdam UMC)and Memorial Sloan Kettering Cancer Center proposed a postoperative mortality risk score(POMRS)and post-hepatectomy liver failure score(PHLFS)to predict patient outcomes.This study aimed to validate the POMRS and PHLFS for PHCC patients at Hokkaido University.Methods:Medical records of 260 consecutive PHCC patients who had undergone major hepatectomy with extrahepatic bile duct resection without pancreaticoduodenectomy at Hokkaido University between March 2001 and November 2018 were evaluated to validate the PHLFS and POMRS.Results:The observed risks for PHLF were 13.7%,24.5%,and 39.8%for the low-risk,intermediate-risk,and high-risk groups,respectively,in the study cohort.A receiver-operator characteristic(ROC)analysis revealed that the PHLFS had moderate predictive value,with an analysis under the curve(AUC)value of 0.62.Mortality rates based on the POMRS were 1.7%,5%,and 5.1%for the low-risk,intermediate-risk,and high-risk groups,respectively.The ROC analysis demonstrated an AUC value of 0.58.Conclusions:This external validation study showed that for PHLFS the threshold for discrimination in an Eastern cohort was reached(AUC>0.6),but it would require optimization of the model before use in clinical practice is acceptable.The POMRS were not applicable in the eastern cohort.Further external validation is recommended.展开更多
Background:Obesity and associated steatosis is an increasing health problem worldwide.Its influence on post-hepatectomy liver failure(PHLF)and after liver resection(LR)is still unclear.Methods:Patients who underwent L...Background:Obesity and associated steatosis is an increasing health problem worldwide.Its influence on post-hepatectomy liver failure(PHLF)and after liver resection(LR)is still unclear.Methods:Patients who underwent LR were investigated and divided into three groups[normal weight:body mass index(BMI)18.5-24.9 kg/m2,overweight:BMI 25.0-29.9 kg/m2,obese:BMI≥30 kg/m2]in this retrospective study.Primary aim of this study was to assess the influence of BMI and nonalcoholic steatohepatitis(NASH)on PHLF and morbidity.Results:Of 888 included patients,361(40.7%)had normal weight,360(40.5%)were overweight,167(18.8%)were obese.Median age was 62.5 years(IQR,54-69 years).The primary indication for LR was colorectal liver metastases(CLM)(n=366,41.2%).NASH was present in 58(16.1%)of normal weight,84(23.3%)of overweight and 69(41.3%)of obese patients(P<0.001).PHLF occurred in 16.3%in normal weight,15.3%in overweight and 11.4%in obese patients(P=0.32).NASH was not associated with PHLF.There was no association between patients’weight and the occurrence of postoperative complications(P=0.45).At multivariable analysis,solely major LR[odds ratio(OR):2.7,95%confidence interval(CI):1.83-4.04;P<0.001]remained a significant predictor for PHLF.Conclusions:Postoperative complications and PHLF are comparable in normal weight,overweight and obese patients and LRs using modern techniques can be safely performed in these patients.展开更多
文摘Background: Post-hepatectomy liver failure(PHLF) is a leading cause of postoperative mortality after liver surgery. Due to its significant impact, it is imperative to understand the risk stratification and preventative strategies for PHLF. The main objective of this review is to highlight the role of these strategies in a timeline centered way around curative resection. Data sources: This review includes studies on both humans and animals, where they addressed PHLF. A literature search was conducted across the Cochrane Library, Embase, MEDLINE/Pub Med, and Web of Knowledge electronic databases for English language studies published between July 1997 and June 2020. Studies presented in other languages were equally considered. The quality of included publications was assessed using Downs and Black’s checklist. The results were presented in qualitative summaries owing to the lack of studies qualifying for quantitative analysis. Results: This systematic review with 245 studies, provides insight into the current prediction, prevention, diagnosis, and management options for PHLF. This review highlighted that liver volume manipulation is the most frequently studied preventive measure against PHLF in clinical practice, with modest improvement in the treatment strategies over the past decade. Conclusions: Remnant liver volume manipulation is the most consistent preventive measure against PHLF.
文摘BACKGROUND Post-hepatectomy liver failure(PHLF)is one of the main causes of postoperative mortality and is challenging to predict early in patients after liver resection.Some studies suggest that the postoperative serum phosphorus might predict outcomes in these patients.AIM To perform a systematic literature review on hypophosphatemia and evaluate it as a prognostic factor for PHLF and overall morbidity.METHODS This systematic review was performed according to preferred reporting items for systematic reviews and meta-analyses statement.A study protocol for the review was registered in the International Prospective Register of Systematic Reviews database.PubMed,Cochrane and Lippincott Williams&Wilkins databases were systematically searched up to March 31,2022 for studies analyzing postoperative hypophosphatemia as a prognostic factor for PHLF,overall postoperative morbidity and liver regeneration.The quality assessment of the included cohort studies was performed according to the Newcastle-Ottawa Scale.RESULTS After final assessment,nine studies(eight retrospective and one prospective cohort study)with 1677 patients were included in the systematic review.All selected studies scored≥6 points according to the Newcastle-Ottawa Scale.Cutoff values of hypophosphatemia varied from<1 mg/dL to≤2.5 mg/dL in selected studies with≤2.5 mg/dL being the most used defining value.Five studies analyzed PHLF,while the remaining four analyzed overall complications as a main outcome associated with hypophosphatemia.Only two of the selected studies analyzed postoperative liver regeneration,with reported better postoperative liver regeneration in cases of postoperative hypophosphatemia.In three studies hypophosphatemia was associated with better postoperative outcomes,while six studies revealed hypophosphatemia as a predictive factor for worse patient outcomes.CONCLUSION Changes of the postoperative serum phosphorus level might be useful for predicting outcomes after liver resection.However,routine measurement of perioperative serum phosphorus levels remains questionable and should be evaluated individually.
基金Supported by the National Natural Science Foundation of China,No.81970569,No.81773293,and No.31660266Natural Science Foundation of Hunan Province,No.2015JJ4083,No.2019JJ50874,and No.2018JJ3758
文摘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.
文摘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.
文摘<strong>Background:</strong><span><span><span style="font-family:""><span style="font-family:Verdana;"> Treatment strategy for recurrent hepatocellular carcinoma (HCC) remains scantily defined. This study was aimed to establish a treatment strategy to manage post-hepatectomy recurrent HCC and report the clinical outcomes. </span><b><span style="font-family:Verdana;">Methods: </span></b><span style="font-family:Verdana;">From January 2006 to December 2016, 556 consecutive patients who developed post-hepatectomy HCC recurrence were enrolled in the study. The patients were clinically stratified and treated according to a strategy established by a multi-disciplinary team. Clinical data and survival times were collected prospectively and analyzed retrospectively. </span><b><span style="font-family:Verdana;">Results: </span></b><span style="font-family:Verdana;">According to the strategy, there were 298 (53.6%), 214 (38.5%), 32 (5.7%) and 12 (2.2%) patients stratified into Early, Intermediate, Advanced and Terminal stages, respectively. In Early stage patients, 164 (55.0%) received curative treatment in the form of repeat resection or local ablation, 134 (45.0%) received transarterial chemoe</span><span style="font-family:Verdana;">mbolization (TACE), and the 1-, 3-, and 5-year overall survival (OS) rates were 82.0%, 46.8% and 37.3%, respectively. In Intermediate stage patients, 207 (96.7%) received TACE, 7 (3.3%) radiotherapy, and the 1-, 3-, and 5-year OS rates were 73.2%, 31.8% and 15.9%, respectively. In Advanced stage patients, 22 patients received sorafenib, 10 radiotherapy, and the mean survival time (MST) was 25.1 ± 3.1 months. All the 12 patients in Terminal stage rece</span><span style="font-family:Verdana;">ived the best supportive treatment, and the MST was 6.5 ± 3.4 months. Clinical stages and duration of disease-free interval were independent factors relating to overall survival. </span><b><span style="font-family:Verdana;">Conclusions: </span></b><span style="font-family:Verdana;">A treatment strategy derived from the Barcelona Clinic Liver Cancer staging system, with some modifications, has been successfully established to manage post-hepatectomy recurrent HCC, and the clinical outcomes were commendable.</span></span></span></span>
文摘The fame of regeneration has been attributed to the liver ever since the era of Greek mythology,in which Prometheus’liver could grow back overnight against the daily predation of Zeus’eagle.Hepatectomy is the very basis of liver surgery including liver transplantation,and post-hepatectomy liver regeneration remains the center of interest for both clinicians and scientists.Novel tools for structural and functional assessment of liver regeneration have been constantly developed and validated,laying the groundwork for clinical management and scientific analysis(1).
基金This work was supported by the Leading Investigator Program of the Shanghai municipal government(17XD1401100)the National Key Basic Research Program(973 Program+1 种基金2015CB554005)from the Ministry of Science and Technology of Chinathe National Natural Science Foundation of China(81672326 and 81871928,and 81871929).
文摘(PHLF)is a severe complication and main cause of death in patients undergoing hepatectomy.The aim of this study was to build a predictive model of PHLF in patients undergoing hepatectomy.Methods:We retrospectively analyzed patients undergoing hepatectomy at Zhongshan Hospital,Fudan University from July 2015 to June 2018,and randomly divided them into development and internal validation cohorts.External validation was performed in an independent cohort.Least absolute shrinkage and selection operator(commonly referred to as LASSO)logistic regression was applied to identify predictors of PHLF,and multivariate binary logistic regression analysis was performed to establish the predictive model,which was visualized with a nomogram.Results:A total of 492 eligible patients were analyzed.LASSO and multivariate analysis identified three preoperative variables,total bilirubin(p=0.001),international normalized ratio(p<0.001)and platelet count(p=0.004),and two intraoperative variables,extent of resection(p=0.002)and blood loss(p=0.004),as independent predictors of PHLF.The area under receiver operating characteristic curve(referred to as AUROC)of the predictive model was 0.838 and outperformed the model for end-stage liver disease score,albumin-bilirubin score and platelet-albumin-bilirubin score(AUROCs:0.723,0.695 and 0.663,respectively;p<0.001 for all).The optimal cut-off value of the predictive model was 14.7.External validation showed the model could predict PHLF accurately and distinguish high-risk patients.Conclusions:PHLF can be accurately predicted by this model in patients undergoing hepatectomy,which may significantly contribute to the postoperative care of these patients.
文摘Post-hepatectomy liver failure(PHLF)is associated with great morbidity and mortality after resection of hepatocellular carcinoma.Previous studies have underlined that advanced age could be a potential factor influencing post-operative complications and long-term survival.In the past,candidates for resection were based on the Child-Pugh classification,the predictive value of which was rather low.The selection of patients undergoing resection in Western countries is based on the assessment of portal hypertension(PH),which is clinically assessed by measurement of the hepatic venous pressure gradient,an invasive and costly process.Thus,there have been several attempts to identify the best non-invasive test(NIT)to accurately predict PHLF.Most biochemical NITs for the prediction of PHLF are focused on evaluation of underlying liver cirrhosis and PH.Amongst them,FIB-4,which also includes the patient's age,seems to have more robust supporting results.In Europe and the USA.,the most tested and reliable NIT for predicting PHLF is the evaluation of liver stiffness measurement,which is also influenced by age.Imaging parameters are promising tools which are used only in specialized centers however,and when available.Liver volume parameters,as well as contrast-enhanced data,demonstrate good accuracy in predicting PHLF.In this scenario,the evaluation of sarcopenia and bone mineral density through contextual imaging allows the delineation of PHLF in at-risk elderly patients.Further studies focused on parameters for the evaluation of PHLF in elderly patients are needed.
基金Arvid Nilssons FoundationFabrikant Einar Willumsen Foundation+1 种基金Familien Hede Nielsen FoundationKobmand Sven Hansen og Hustru Ina Hansen Foundation
文摘Background:The upper limit for liver resections in rats is approximately 90%.In the early postoperative phase,mortality increases.The aim of the present study was to validate the rat model of 90%partial hepatectomy(PH)as a model of post-hepatectomy liver failure(PHLF).Further,we wanted to test a quantitative scoring system as a detector of lethal outcomes caused by PHLF in rats.Methods:Sixty-eight rats were randomized to 90%PH,sham operation,or no sur-gery.Further,block randomization was performed based on time of euthanization:12,24,or 48 h after surgery.A general distress score(GDS)≥10 during the day or≥6 at midnight prompted early euthanization and classification as nonsurvivor.Animals euthanized as planned were classified as survivors.During euthanization,blood and liver tissue were collected,and liver-specific biochemistry was evaluated.Results:Based on the biochemical results,all animals subjected to 90%PH expe-rienced PHLF.Seventeen rats were euthanized due to irreversible PHLF.The GDS increased for nonsurvivors within 12–18 h after surgery.The mean time for euthaniza-tion was 27 h after surgery.Conclusion:Based on the GDS and liver-specific biochemistry,we concluded that the model of 90%PH seems to be a proper model for investigating PHLF in rats.As a high GDS is associated with increased mortality,the GDS appears to be valuable in detect-ing lethal outcomes caused by PHLF in rats.
基金National Natural Science Foundation of China,No.81372626Key Research and Development Project of Science and Technology Department of Zhejiang,China,No.2015C03053Zhejiang Provincial Program for the Cultivation of High-level Innovative Health Talents.
文摘BACKGROUND Post-hepatectomy liver failure(PHLF)increases morbidity and mortality after liver resection for patients with advanced liver fibrosis and cirrhosis.Preoperative liver stiffness using two-dimensional shear wave elastography(2D-SWE)is widely used to evaluate the degree of fibrosis.However,the 2D-SWE results were not accurate.A durometer measures hardness by quantifying the ability of a material to locally resist the intrusion of hard objects into its surface.However,the durometer score can only be obtained during surgery.To measure correlations among 2D-SWE,palpation by surgeons,and durometermeasured objective liver hardness and to construct a liver hardness regression model.METHODS We enrolled 74 hepatectomy patients with liver hardness in a derivation cohort.Tactile-based liver hardness scores(0-100)were determined through palpation of the liver tissue by surgeons.Additionally,liver hardness was measured using a durometer.Correlation coefficients for durometer-measured hardness and preoperative parameters were calculated.Multiple linear regression models were constructed to select the best predictive durometer scale.Receiver operating characteristic(ROC)curves and univariate and multivariate analyses were used to calculate the best model’s prediction of PHLF and risk factors for PHLF,respectively.A separate validation cohort(n=162)was used to evaluate the model.RESULTS The stiffness measured using 2D-SWE and palpation scale had good linear correlation with durometer-measured hardness(Pearson rank correlation coefficient 0.704 and 0.729,respectively,P<0.001).The best model for the durometer scale(hardness scale model)was based on stiffness,hepatitis B virus surface antigen,and albumin level and had an R2 value of 0.580.The area under the ROC for the durometer and hardness scale for PHLF prediction were 0.807(P=0.002)and 0.785(P=0.005),respectively.The optimal cutoff value of the durometer and hardness scale was 27.38(sensitivity=0.900,specificity=0.660)and 27.87(sensitivity=0.700,specificity=0.787),respectively.Patients with a hardness scale score of>27.87 were at a significantly higher risk of PHLF with hazard ratios of 7.835(P=0.015).The model’s PHLF predictive ability was confirmed in the validation cohort.CONCLUSION Liver stiffness assessed by 2D-SWE and palpation correlated well with durometer hardness values.The multiple linear regression model predicted durometer hardness values and PHLF.
文摘BACKGROUND Liver reduction is the main curative treatment for primary liver cancer,but its use remains limited as liver regeneration requires a minimum of 30%functional parenchyma.AIM To study the dynamics of the liver regeneration process and consequent behavior of cell cycle regulators in rats after extended hepatectomy(90%)and postoperative glucose infusions.METHODS Post-hepatectomy liver failure was triggered in 84 Wistar rats by reducing their liver mass by 90%.The animals received a post-operative glucose infusion and were randomly assigned to two groups:One to investigate the survival rate and the other for biochemical analyses.Animals that underwent laparotomy or 70%hepatectomy were used as controls.Blood and liver samples were collected on postoperative days 1 to 7.Liver morphology,function,and regeneration were studied with histology,immunohistochemistry,and western blotting.RESULTS Postoperative mortality after major resection reached 20%and 55%in the first 24 h and 48 h,respectively,with an overall total of 70%7 d after surgery.No apparent signs of apoptotic cell death were detected in the extended hepatectomy rat livers,but hepatocytes displaying a clear cytoplasm and an accumulation of hyaline material testified to changes affecting their functional activities.Liver regeneration started properly,as early events initiating cell proliferation occurred within the first 3 h,and the G1 to S transition was detected in less than 12 h.However,a rise in p27(Kip1)followed by p21(Waf1/Cip1)cell cycle inhibitor levels led to a delayed S phase progression and mitosis.Overall,liver regeneration in rats with a 90%hepatectomy was delayed by 24 h and associated with a delayed onset and lower peak magnitude of hepatocellular deoxyribonucleic acid synthesis.CONCLUSION This work highlights the critical importance of the cyclin/cyclin-dependent kinase inhibitors of the Cip/Kip family in regulating the liver regeneration timeline following extended hepatectomy.
基金the institutional review board of Hokkaido University(No.018-0429).
文摘Background:Surgery for perihilar cholangiocarcinoma(PHCC)remains a challenging procedure with high morbidity and mortality.The Academic Medical Center(Amsterdam UMC)and Memorial Sloan Kettering Cancer Center proposed a postoperative mortality risk score(POMRS)and post-hepatectomy liver failure score(PHLFS)to predict patient outcomes.This study aimed to validate the POMRS and PHLFS for PHCC patients at Hokkaido University.Methods:Medical records of 260 consecutive PHCC patients who had undergone major hepatectomy with extrahepatic bile duct resection without pancreaticoduodenectomy at Hokkaido University between March 2001 and November 2018 were evaluated to validate the PHLFS and POMRS.Results:The observed risks for PHLF were 13.7%,24.5%,and 39.8%for the low-risk,intermediate-risk,and high-risk groups,respectively,in the study cohort.A receiver-operator characteristic(ROC)analysis revealed that the PHLFS had moderate predictive value,with an analysis under the curve(AUC)value of 0.62.Mortality rates based on the POMRS were 1.7%,5%,and 5.1%for the low-risk,intermediate-risk,and high-risk groups,respectively.The ROC analysis demonstrated an AUC value of 0.58.Conclusions:This external validation study showed that for PHLFS the threshold for discrimination in an Eastern cohort was reached(AUC>0.6),but it would require optimization of the model before use in clinical practice is acceptable.The POMRS were not applicable in the eastern cohort.Further external validation is recommended.
文摘Background:Obesity and associated steatosis is an increasing health problem worldwide.Its influence on post-hepatectomy liver failure(PHLF)and after liver resection(LR)is still unclear.Methods:Patients who underwent LR were investigated and divided into three groups[normal weight:body mass index(BMI)18.5-24.9 kg/m2,overweight:BMI 25.0-29.9 kg/m2,obese:BMI≥30 kg/m2]in this retrospective study.Primary aim of this study was to assess the influence of BMI and nonalcoholic steatohepatitis(NASH)on PHLF and morbidity.Results:Of 888 included patients,361(40.7%)had normal weight,360(40.5%)were overweight,167(18.8%)were obese.Median age was 62.5 years(IQR,54-69 years).The primary indication for LR was colorectal liver metastases(CLM)(n=366,41.2%).NASH was present in 58(16.1%)of normal weight,84(23.3%)of overweight and 69(41.3%)of obese patients(P<0.001).PHLF occurred in 16.3%in normal weight,15.3%in overweight and 11.4%in obese patients(P=0.32).NASH was not associated with PHLF.There was no association between patients’weight and the occurrence of postoperative complications(P=0.45).At multivariable analysis,solely major LR[odds ratio(OR):2.7,95%confidence interval(CI):1.83-4.04;P<0.001]remained a significant predictor for PHLF.Conclusions:Postoperative complications and PHLF are comparable in normal weight,overweight and obese patients and LRs using modern techniques can be safely performed in these patients.
