A novel surgical scheme for hepatectomy in hepatocellular carcinoma patients with clinically significant portal hypertension.

Clinically significant portal hypertension (CSPH) seriously affects the feasibility and safety of surgical treatment for hepatocellular carcinoma (HCC) patients. The aim of this study was to establish a new surgical scheme defining risk classification of post-hepatectomy liver failure (PHLF) to facilitate the surgical decision-making and identify suitable candidates for individual hepatectomy among HCC patients with CSPH. Hepatectomy is the preferred treatment for HCC. Surgeons must maintain a balance between the expected oncological outcomes of HCC removal and short-term risks of severe PHLF and morbidity. CSPH aggravates liver decompensation and increases the risk of severe PHLF thus complicating hepatectomy for HCC. Multivariate logistic regression and stochastic forest algorithm were performed, then the independent risk factors of severe PHLF were included in a nomogram to determine the risk of severe PHLF. Further, a conditional inference tree (CTREE) through recursive partitioning analysis validated supplement the misdiagnostic threshold of the nomogram. This study included 924 patients, of whom 137 patients (14.8%) suffered from mild-CSPH and 66 patients suffered from (7.1%) with severe-CSPH confirmed preoperatively. Our data showed that preoperative prolonged prothrombin time, total bilirubin, indocyanine green retention rate at 15 min, CSPH grade, and standard future liver remnant volume were independent predictors of severe PHLF. By incorporating these factors, the nomogram achieved good prediction performance in assessing severe PHLF risk, and its concordance statistic was 0.891, 0.850 and 0.872 in the training cohort, internal validation cohort and external validation cohort, respectively, and good calibration curves were obtained. Moreover, the calculations of total points of diagnostic errors with 95% CI were concentrated in 110.5 (range 76.9-178.5). It showed a low risk of severe PHLF (2.3%), indicating hepatectomy is feasible when the points fall below 76.9, while the risk of severe PHLF is extremely high (93.8%) and hepatectomy should be rigorously restricted at scores over 178.5. Patients with points within the misdiagnosis threshold were further examined using CTREE according to a hierarchic order of factors represented by the presence of CSPH grade, ICG-R15, and sFLR. This new surgical scheme established in our study is practical to stratify risk classification in assessing severe PHLF, thereby facilitating surgical decision-making and identifying suitable candidates for individual hepatectomy.

Ye JZ ，Lu HZ ，Zeng C ，Lei G ，Wang XB ，Chen J ，Bai T ，Wu FX ，Mai RY ，Guo WX ，Li LQ ... -  《BMC CANCER》

Predicting symptomatic post-hepatectomy liver failure in patients with hepatocellular carcinoma: development and validation of a preoperative nomogram.

To develop and validate a nomogram based on liver stiffness (LS) for predicting symptomatic post-hepatectomy (PHLF) in patients with hepatocellular carcinoma (HCC). A total of 266 patients with HCC were enrolled prospectively from three tertiary referral hospitals from August 2018 to April 2021. All patients underwent preoperative laboratory examination to obtain parameters of liver function. Two-dimensional shear wave elastography (2D-SWE) was performed to measure LS. Three-dimensional virtual resection obtained the different volumes including future liver remnant (FLR). A nomogram was developed by using logistic regression and determined by receiver operating characteristic (ROC) curve analysis and calibration curve analysis, which was validated internally and externally. A nomogram was constructed with the following variables: FLR ratio (FLR of total liver volume), LS greater than 9.5 kPa, Child-Pugh grade, and the presence of clinically significant portal hypertension (CSPH). This nomogram enabled differentiation of symptomatic PHLF in the derivation cohort (area under curve [AUC], 0.915), internal fivefold cross-validation (mean AUC, 0.918), internal validation cohort (AUC, 0.876) and external validation cohort (AUC, 0.845). The nomogram also showed good calibration in the derivation, internal validation, and external validation cohorts (Hosmer-Lemeshow goodness-of-fit test, p = 0.641, p = 0.06, and p = 0.127, respectively). Accordingly, the safe limit of the FLR ratio was stratified using the nomogram. An elevated level of LS was associated with the occurrence of symptomatic PHLF in HCC. A preoperative nomogram integrating LS, clinical and volumetric features was useful in predicting postoperative outcomes in patients with HCC, which might help surgeons in the management of HCC resection. A serial of the safe limit of the future liver remnant was proposed by a preoperative nomogram for hepatocellular carcinoma, which might help surgeons in 'how much remnant is enough in liver resection'. • An elevated liver stiffness with the best cutoff value of 9.5 kPa was associated with the occurrence of symptomatic post-hepatectomy liver failure in hepatocellular carcinoma. • A nomogram based on both quality (Child-Pugh grade, liver stiffness, and portal hypertension) and quantity of future liver remnant was developed to predict symptomatic post-hepatectomy liver failure for HCC, which enabled good discrimination and calibration in both derivation and validation cohorts. • The safe limit of future liver remnant volume was stratified using the proposed nomogram, which might help surgeons in the management of HCC resection.

Long H ，Peng C ，Ding H ，Zheng Y ，Zhou J ，Chen W ，Zhong X ，Shi Y ，Duan Y ，Xie X ，Kuang M ，Xie X ，Lin M ... -  《-》

Nomogram for prediction of the international study Group of Liver Surgery (ISGLS) grade B/C Posthepatectomy liver failure in HBV-related hepatocellular carcinoma patients: an external validation and prospective application study.

Ye JZ ，Mai RY ，Guo WX ，Wang YY ，Ma L ，Xiang BD ，Cheng SQ ，Li LQ ... -  《BMC CANCER》

Severity of portal hypertension and prediction of postoperative liver failure after liver resection in patients with Child-Pugh grade A cirrhosis.

Patients with Child-Pugh grade A cirrhosis and clinical evidence of portal hypertension are likely to develop posthepatectomy liver failure (PHLF). Whether such patients are suitable candidates for partial hepatectomy is controversial. This study explored the impact of portal venous pressure (PVP) on PHLF and the possibility of stratifying patients with Child-Pugh grade A cirrhosis for risk of PHLF using clinical data alone. Between April 2009 and May 2011, consecutive patients who underwent partial hepatectomy for hepatocellular carcinoma and intraoperative measurement of PVP were included in this prospective study. Using signs of clinically significant portal hypertension (CSPH), patients with Child-Pugh grade A cirrhosis were subclassified into three groups: no, mild and severe CSPH. Risk factors for PHLF were subjected to univariable and multivariable analysis, and receiver operating characteristic (ROC) curve analysis. Sixty-seven (35·3 per cent) of 190 patients developed PHLF, which was persistent in 12 patients (6·3 per cent). Four patients (2·1 per cent) died from PHLF within 3 months of surgery. Multivariable analysis showed both PVP and CSPH to be independent predictors of PHLF (P < 0·001). PVP values, incidence of PHLF and persistent PHLF were significantly higher in the severe CSPH group than in the other two groups (P < 0·001). Severe CSPH (odds ratio 27·68, P = 0·005) and a preoperative neutrophil : lymphocyte ratio (NLR) of 2·8 or above (odds ratio 49·75, P = 0·002) were independent factors affecting the incidence of persistent PHLF. The severity of CSPH, corresponding to different PVP levels, could be used to stratify patients with Child-Pugh grade A cirrhosis and to predict the incidence of PHLF. Patients with severe CSPH or a NLR of 2·8 or above were more likely to develop persistent PHLF after partial hepatectomy.

Chen X ，Zhai J ，Cai X ，Zhang Y ，Wei L ，Shi L ，Wu D ，Shen F ，Lau WY ，Wu M ... -  《-》

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

Hu H ，Han H ，Han XK ，Wang WP ，Ding H ... -  《-》