Impact of Aspartate Aminotransferase–to–platelet Ratio Index Based Score to Assess Posthepatectomy Liver Failure in Patients With Hepatocellular Carcninoma

Background: Posthepatectomy liver failure (PHLF) is a life-threatening complication following hepatic resection. The aspartate aminotransferase-to-platelet ratio index (APRI) is a noninvasive model for assessing the liver functional reserve in patients with hepatocellular carcinoma (HCC). This study aimed to establish a scoring model to stratify patients with HCC at risk for PHLF.Methods: This single-center retrospective study included 451 patients who underwent hepatic resection for HCC between 2004 and 2017. Preoperative factors, including noninvasive liver fibrosis markers and intraoperative factors, were evaluated. The predictive impact for PHLF was evaluated using receiver operating characteristic (ROC) curves of these factors.Results: Of 451 patients, 30 (6.7%) developed severe PHLF (grade B/C). Multivariate logistic analysis indicated that APRI, model for end-stage liver disease (MELD) score, operating time, and intraoperative blood loss were significantly associated with severe PHLF. A scoring model (over 0–4 points) was calculated using these optimal cutoff values. The area under the ROC curve of the established score for severe PHLF was 0.88, which greatly improved the predictive accuracy compared with these factors alone (p < 0.05 for all). Conclusions: The scoring model-based APRI, MELD score, operating time, and intraoperative blood loss can predict severe PHLF in patients with HCC.

Extensive liver resection in a child with an extremely low future liver remnant volume

The incidence of posthepatectomy liver failure in adult patients and a large number of complications of two-stage liver resections require a search for criteria that allow highly accurate assessment of the risk of liver failure. For this purpose, the study of the future liver remnant volume and function have been widely introduced among adult patients, and the future liver remnant function measurement reflects the greater sensitivity. The absence of references to posthepatectomy liver failure, as well as the experience of determining the functional reserve of the future liver remnant in children, let us to suggest the possibility of a wider using one-stage liver resections when the future liver remnant volume is below the generally accepted threshold (25% of the healthy liver parenchyma volume) in the case of the functional reserve sufficient value. This clinical case describes the successful extended right hemihepatectomy and segmentectomy 1 in a 3-year patient with a future liver remnant volume of 16.5% without clinical signs of postresection hepatic failure, which confirms the thesis of the need to assess the functional liver reserve in pediatric oncology to reduce the frequency of two-stage resections and liver transplants. The patient’s parents gave consent to the use of their child’s data, including photographs, for research purposes and in publications.

Predictive value of gadoxetic acid–enhanced MRI for posthepatectomy liver failure: a systematic review

Objectives Effective and non-invasive biomarkers to predict and avoid posthepatectomy liver failure (PHLF) are urgently needed. This systematic review aims to evaluate the efficacy of gadoxetic acid–enhanced MRI-derived parameters as an imaging biomarker in preoperative prediction of PHLF. Methods A systematic literature search was performed in the databases of PubMed/Medline, Web of Science, Embase, and Cochrane Library up to 11 December 2020. Studies evaluating the incidence of PHLF on patients who underwent hepatectomy with preoperative liver function assessment using gadoxetic acid–enhanced MRI were included. Data was extracted using pre-designed tables. The Quality In Prognostic Studies (QUIPS) tool was adopted to evaluate the risk of bias. Results A total of 15 studies were identified for qualitative synthesis and most studies were marked as low to moderate risk of bias in each domain of QUIPS. The most commonly used parameter was relative liver enhancement or its related parameters. The reported incidence of PHLF ranged from 3.9 to 40%. The predictive sensitivity and specificity of gadoxetic acid–enhanced MRI parameters varied from 75 to 100% and from 54 to 93% in ten reported studies. A majority of the studies revealed that the gadoxetic acid–enhanced MRI parameter was a predictor for PHLF. Conclusions Gadoxetic acid–enhanced MRI showed a high predictive capacity for PHLF and represents a promising imaging biomarker in prediction of PHLF. Multicenter, prospective trials with large sample size and reliable, unified liver function parameters are required to validate the efficacy of individual liver function parameters. Key Points • There is an obvious heterogeneity of the published studies, not only in variance of MRI liver function parameters but also in indication and extent of the liver resection. • Signal intensity (SI)–based parameters derived from gadoxetic acid–enhanced MRI are the commonly used method for PHLF prediction. • Gadoxetic acid–enhanced MRI-derived parameters showed high predictive efficacy for PHLF and can potentially serve as a predictor for the incidence of PHLF.

Search threshold values of future liver remnant function and volume for extensive resections in children

Aim. To evaluate the relationship between the future liver remnant volume and function and determine the possible threshold values of these parameters for predicting posthepatectomy liver failure in children.Methods. Data of 57 patients who underwent major hepatectomy from July 2017 to February 2021 were retrospectively analyzed. Before surgery all children underwent the CT-volumetry and 99mTc-Mebrofenin hepatobiliary scintigraphy. The threshold values for the future liver volume and function were considered 25%, and 2.7%/min/m2 , respectively. After surgery the ISGLS and 50–50 criteria for posthepatectomy liver failure were assessed. The principal components method was used to identify risk factors for its development. The correlation analysis included the maximum value of total bilirubin after hepatectomy, as well as the values of total bilirubin, albumin, urea, prothrombin index, international normalized ratio and platelets on the postoperative day 5.Results. The posthepatectomy liver failure was observed in 2 patients: grade B developed in a patient with FLR-V 43%, FLR-F 1.8%/min/m2 , grade A in a patient with FLR-V 16.5% and FLR-F 4.78%/min/m2 . A significant statistical relationship of average strength was revealed between the indicators of FLR-F and FLR-V (Pearson η = 0.409; p < 0.01). However, direct pairwise comparison did not reveal the relationship between future liver remnant volume, function and the laboratory parameters. The principal components analysis showed that during the postoperative period, the prothrombin index and international normalized ratio value were the most sensitive to the large volume of the liver parenchyma loss. The threshold value of FLR-F (3%/min/m2 ) was calculated. The decrease below this value can lead to posthepatectomy liver failure, which will manifest as a hemostasis disorder.Conclusion. Planning a one-staged hepatectomy not only the future liver remnant volume should be taken into account, but also its function. The threshold for future liver remnant volume in children is below the generally accepted level 25%. To perform one-stage hepatectomies in such patients, the FLR-F must be at least 2.7%/min/m2 . The future investigations in this field is waranteed.