Comparative study of indocyanine green (ICG)-R15 and Albumin-Indocyanine Green Evaluation (ALICE) grading system in the prediction of posthepatectomy liver failure and postoperative mortality in patients with hepatic alveolar echinococcosis.

BACKGROUND: A precise evaluation of liver reserve function in patients with hepatic alveolar echinococcosis (HAE) prior to hepatectomy could substantially increase the success rate of the operation and reduce the incidence of postoperative complications. The present study aimed to investigate the significance of the indocyanine green retention test at 15 min (ICG-R15) and the Albumin-Indocyanine Green Evaluation (ALICE) grading system in predicting severe posthepatectomy liver failure (PHLF) and postoperative mortality in HAE patients undergoing liver resection. METHODS: A total of 105 HAE patients undergoing hepatectomy were enrolled in this study. The value of each variable in predicting severe PHLF was evaluated by univariate and multivariate logistic regression analyses. The area under the receiver operating characteristic (ROC) curves (AUC) were calculated to evaluate the predictive ability of the Child-Pugh grade, ICG-R15, and ALICE grading system. Also, patients were classified using the optimal cutoff value for ICG-R15 and different ALICE grades, and the incidence of severe PHLF and postoperative mortality were compared with the predicted values. RESULTS: Out of the 105 HAE patients enrolled in this study, 34 patients (32.4%) developed severe PHLF. The ALICE grade and operative time were identified as independent predictors of severe PHLF. According to ROC analysis, the AUCs of the Child-Pugh grade, ICG-R15, and ALICE grade for predicting severe PHLF were 0.733 (95% confidence interval (CI), 0.637-0.814), 0.823 (95% CI, 0.737-0.891), 0.834 (95% CI, 0.749-0.900). The incidence of severe PHLF and postoperative 90-day mortality in patients with ICG-R15 > 7.2% were significantly higher than those with ICG-R15 ≤ 7.2% (P < 0.001; P = 0.008). Likewise, the incidence of severe PHLF and postoperative 90-day mortality in patients with ALICE grade 2 were higher than those with ALICE grade 1 within the Child-Pugh grade A (P < 0.001; P = 0.083). CONCLUSION: ICG-R15 and ALICE grading system are powerful predictors of severe PHLF and postoperative mortality among HAE patients undergoing hepatectomy. Furthermore, a combination of the preoperative Child-Pugh grade and ALICE grading system may provide an even more precise and objective guidance and facilitate surgical decision-making for HAE patients.

Comparison Between Liver Stiffness Measurement by Fibroscan and Splenic Volume Index as NonInvasive Tools for the Early Detection of Oxaliplatin-induced Hepatotoxicity.

Background: Oxaliplatin remains an essential component of many chemotherapy protocols for gastrointestinal cancers; however, neurotoxicity and hepatotoxicity may be dose-limiting. The gold standard for the diagnosis of oxaliplatin-induced hepatotoxicity is liver biopsy, which is invasive and costly. Splenomegaly has also been used as a surrogate for liver biopsy in detecting oxaliplatin-induced sinusoidal obstruction syndrome (SOS), but splenic measurement is not routine and can be inaccurate and complex. We investigated the correlation between increased liver elasticity assessed by Fibroscan and the increase in spleen volume on cross-sectional imaging after oxaliplatin as a noninvasive technique to assess liver stiffness associated with oxaliplatin-induced SOS. Methods: Forty-six patients diagnosed with gastrointestinal cancers and planned to take oxaliplatin containing regimens were included in this prospective study at the American University of Beirut Medical Center (AUBMC). Measurement of spleen volume using cross-sectional imaging and of liver elasticity using Fibroscan was performed at baseline, 3 and 6 months after starting oxaliplatin. Mean liver elasticity measurements were compared between patients stratified by the development of splenomegaly using the Student t-test. Splenomegaly was defined as 50% increase in spleen size compared with baseline. Results: Patients who developed splenomegaly after oxaliplatin use had significantly higher mean elasticity measurements as reported by Fibroscan at 3 (16.2 vs. 7.8 kPa, P = 0.036) and 6 (9.3 vs. 6.7 kPa, P = 0.03) months. Conclusion: Measurement of elasticity using Fibroscan could be potentially used in the future as a noninvasive test for predicting oxaliplatin-induced hepatotoxicity.

Comment on "Outcomes of curative liver resection for hepatocellular carcinoma in patients with cirrhosis".

The present letter to the editor is in response to the research "Outcomes of curative liver resection for hepatocellular carcinoma in patients with cirrhosis" by Elshaarawy et al in World J Gastroenterol 2021; 13(5): 424-439. The preoperative assessment of the liver reserve function in hepatocellular carcinoma (HCC) patients with cirrhosis is crucial, and there is no universal consensus on how to assess it. Based on a retrospective study, Elshaarawy et al investigated the impact of various classical clinical indicators on liver failure and the prognosis after hepatectomy in HCC patients with cirrhosis. We recommend that we should strive to explore new appraisal indicators, such as the indocyanine green retention rate at 15 min.

A Nomogram Based on Preoperative Lab Tests, BMI, ICG-R15, and EHBF for the Prediction of Post-Hepatectomy Liver Failure in Patients with Hepatocellular Carcinoma.

Background: Liver cancer is one of the most common malignant tumors, and worldwide, its incidence ranks sixth, and its morality third. Post-hepatectomy liver failure (PHLF) is the leading cause of death in patients who have undergone liver resection. This retrospective study investigated the risk factors for PHLF by predicting and constructing an index to evaluate the risk. This was achieved by combining the lab tests with an indocyanine green (ICG) clearance test. Methods: The study analyzed 1081 hepatocellular carcinoma (HCC) patients who had received liver resection at Sun Yat-sen University Cancer Center between 2005 and 2020. The patients were divided into a PHLF group (n = 113) and a non-PHLF group (n = 968), according to the International Study Group of Liver Surgery (ISGLS) criteria. Receiver operating characteristics (ROC) curves were then used to estimate the optimal cut-off values. Univariate and multivariate logistic regression analyses were performed to identify the independent risk factors. Finally, a nomogram was constructed where the calibration plot, the areas under the ROC curve (AUC), and the decision curve analysis (DCA) showed good predictive ability. Results: Correlation analysis revealed that body mass index (BMI) was positively correlated with ICG-R15 and with effective hepatic blood flow (EHBF). Univariate and multivariate logistics regression analysis revealed that BMI, ICG-R15, international normalized ratio (INR), tumor size, hepatic inflow occlusion (HIO) time, and operation method were independent predictive factors for PHLF. When these factors and EHBF were included in the nomogram, the nomogram showed a good predictive value, with a C-index of 0.773 (95% Confidence Interval [CI]: 0.729-0.818). The INR had the largest ROC areas (AUC INR = 0.661). Among the variables, ICG-R15 (AUC ICG-R15 = 0.604) and EHBF (AUC EHBF = 0.609) also showed good predictive power. Conclusions: The risk of PHLF in HCC patients can be precisely predicted by this model prior to the operation. By integrating EHBF into the model, HCC patients at higher risk for PHLF can be identified more effectively.

Rescue Partial ALPPS for Left Hemihepatectomy with Reconstruction of the Middle Hepatic Vein.

Major hepatectomy in patients with insufficient future liver remnant (FLR) volume and impaired liver functional reserve has considerable risks for posthepatectomy liver failure (PHLF). The patient was a male in his 70s with an intrahepatic cholangiocarcinoma in left hemiliver, involving the middle hepatic vein (MHV). Although FLR volume after left hemihepatectomy was estimated to be 64.4% of the total liver volume, an indocyanine green retention rate at 15 min (ICG-R15) value was 24.2%, thus the patient underwent left portal vein embolization. The FLR volume increased to 71.3%; however, the noncongestive FLR volume was re-estimated as 45.8% after resection of the MHV, the ICG-R15 value was 29.0%, and ICG-Krem was calculated as 0.037. We performed partial rescue Associating Liver Partition and Portal vein occlusion for Staged hepatectomy (ALPPS) for left hemihepatectomy with the MHV reconstruction. On the first stage, partial liver partition was done along Rex-Cantlie's line, preserving the MHV and sacrificing the remaining branches to segment 8. The FLR volume increased to 77.4% on day 14. The ICG-R15 value was 29.6%, but ICG-Krem after MHV reconstruction was estimated to be 0.059. The second-stage operation on day 21 was left hemihepatectomy with the MHV reconstruction using the left superficial femoral vein graft. The usage of rescue partial ALPPS may contribute to preventing PHLF by introducing occlusion of the portal and/or venous branches in the left hemiliver before curative hepatectomy.

A Nomogram Based on Preoperative Inflammatory Indices and ICG-R15 for Prediction of Liver Failure After Hepatectomy in HCC Patients.

OBJECTIVE: To establish a nomogram based on inflammatory indices and ICG-R15 for predicting post-hepatectomy liver failure (PHLF) among patients with resectable hepatocellular carcinoma (HCC). METHODS: A retrospective cohort of 407 patients with HCC hospitalized at Xiangya Hospital of Central South University between January 2015 and December 2020, and 81 patients with HCC hospitalized at the Second Xiangya Hospital of Central South University between January 2019 and January 2020 were included in the study. Totally 488 HCC patients were divided into the training cohort (n=378) and the validation cohort (n=110) by random sampling. Univariate and multivariate analysis was performed to identify the independent risk factors. Through combining these independent risk factors, a nomogram was established for the prediction of PHLF. The accuracy of the nomogram was evaluated and compared with traditional models, like CP score (Child-Pugh), MELD score (Model of End-Stage Liver Disease), and ALBI score (albumin-bilirubin) by using receiver operating characteristic (ROC) curve, calibration curve, and decision curve analysis (DCA). RESULTS: Cirrhosis (OR=2.203, 95%CI:1.070-3.824, P=0.030), prothrombin time (PT) (OR=1.886, 95%CI: 1.107-3.211, P=0.020), tumor size (OR=1.107, 95%CI: 1.022-1.200, P=0.013), ICG-R15% (OR=1.141, 95%CI: 1.070-1.216, P<0.001), blood loss (OR=2.415, 95%CI: 1.306-4.468, P=0.005) and AST-to-platelet ratio index (APRI) (OR=4.652, 95%CI: 1.432-15.112, P=0.011) were independent risk factors of PHLF. Nomogram was built with well-fitted calibration curves on the of these 6 factors. Comparing with CP score (C-index=0.582, 95%CI, 0.523-0.640), ALBI score (C-index=0.670, 95%CI, 0.615-0.725) and MELD score (C-ibasedndex=0.661, 95%CI, 0.606-0.716), the nomogram showed a better predictive value, with a C-index of 0.845 (95%CI, 0.806-0.884). The results were consistent in the validation cohort. DCA confirmed the conclusion as well. CONCLUSION: A novel nomogram was established to predict PHLF in HCC patients. The nomogram showed a strong predictive efficiency and would be a convenient tool for us to facilitate clinical decisions.

New frontiers in liver resection for hepatocellular carcinoma.

Liver resection is one of the main curative options for early hepatocellular carcinoma (HCC) in patients with cirrhosis and is the treatment of choice in non-cirrhotic patients. However, careful patient selection is required to balance the risk of postoperative liver failure and the potential benefit on long-term outcomes. In the last decades, improved surgical techniques and perioperative management, as well as better patient selection, have enabled the indications for liver resection to be expanded. In this review, we aim to describe the main indications for liver resection in the management of HCC, its role compared to percutaneous ablation and liver transplantation in the therapeutic algorithm, as well as the recent advances in liver surgery that could be used to improve the prognosis of patients with HCC.

Diffusion kurtosis imaging in the assessment of liver function: Its potential as an effective predictor of liver function.

OBJECTIVES:: We aimed to determine whether diffusion kurtosis imaging (DKI) analysis with the breath-hold technique can replace liver function results obtained from laboratory tests. METHODS:: Patients (n = 79) suspected of having a hepatobiliary disease, and control group without liver diseases (n = 15) were examined with non-Gaussian diffusion-weighted imaging using a 3.0 T magnetic resonance imaging unit. Based on the findings of DKI, various blood serum parameters, including the indocyanine green (ICG) retention rate 15 min after an intravenous injection of ICG (ICG-R15) and mean kurtosis values and Child-Pugh and albumin-bilirubin (ALBI) scores, were calculated. In total, 17 patients were tested using ICG-R15. For evaluating liver function, correlations between the mean kurtosis value and the Child-Pugh score, ALBI score, and ICG-R15 value as indicators of liver function obtained from blood data were assessed using Spearman's rank correlation. In apparent diffusion coefficient as well, we assessed correlations with these indicators. RESULTS:: The mean kurtosis value correlated with the Child-Pugh score (Spearman's rank-correlation coefficient, ρ = 0.3992; p < 0.0001). Moreover, the mean kurtosis value revealed a correlation with the ICG-R15 value (Spearman's rank-correlation coefficient, ρ = 0.5972; p = 0.00114). The correlation between the mean kurtosis value and the ALBI score was the poorest among these (Spearman's rank-correlation coefficient, ρ = 0.3395; p = 0.0008). CONCLUSION:: Liver function correlating with the Child-Pugh score and ICG-R15 value can be quantitatively estimated using the mean kurtosis value obtained from DKI analysis. DKI analysis with the breath-hold technique can be used to determine liver function instead of performing laboratory tests. ADVANCES IN KNOWLEDGE:: Previous studies have not evaluated liver function in vivo using DKI.

Comparison of the ability of Child-Pugh score, MELD score, and ICG-R15 to assess preoperative hepatic functional reserve in patients with hepatocellular carcinoma.

BACKGROUND: Assessing hepatic functional reserve before hepatectomy is beneficial to reduce the incidence of posthepatectomy liver failure (PHLF). This study aimed to compare the ability of the Child-Pugh score, model for end-stage liver disease (MELD) score, and retention test at 15 minutes (indocyanine green [ICG]-R15) to assess hepatic functional reserve. METHODS: A total of 185 patients with hepatocellular carcinoma (HCC) undergoing hepatectomy were enrolled in this study. The ability of Child-Pugh score, MELD score, and ICG-R15 predicting severe PHLF were compared. RESULTS: A total of 23 patients (12.4%) developed severe PHLF. Multivariate analyses identified that platelet count, ICG-R15, clinically significant portal hypertension, and major resection were independent factors for predicting severe PHLF. The area under the receiver operating characteristic curve of ICG-R15 for predicting severe PHLF was higher than that of both Child-Pugh score and MELD score. With an optimal cutoff value of 7.1%, the sensitivity and specificity of ICG-R15 for predicting severe PHLF were 52.2% and 89.5%, respectively. Both the incidence of severe PHLF and mortality in patients with ICG-R15 >7.1% were significantly higher than the figures for patients with ICG-R15 ≤7.1%. CONCLUSION: ICG-R15 is more accurate than the Child-Pugh score and MELD score in predicting hepatic functional reserve before hepatectomy.