Joint EANM/SNMMI/IHPBA procedure guideline for [99mTc]Tc-mebrofenin hepatobiliary scintigraphy SPECT/CT in the quantitative assessment of the future liver remnant function.

PURPOSE: The aim of this joint EANM/SNMMI/IHPBA procedure guideline is to provide general information and specific recommendations and considerations on the use of [99mTc]Tc-mebrofenin hepatobiliary scintigraphy (HBS) in the quantitative assessment and risk analysis before surgical intervention, selective internal radiation therapy (SIRT) or before and after liver regenerative procedures. Although the gold standard to estimate future liver remnant (FLR) function remains volumetry, the increasing interest in HBS and the continuous request for implementation in major liver centers worldwide, demands standardization. METHODS: This guideline concentrates on the endorsement of a standardized protocol for HBS elaborates on the clinical indications and implications, considerations, clinical appliance, cut-off values, interactions, acquisition, post-processing analysis and interpretation. Referral to the practical guidelines for additional post-processing manual instructions is provided. CONCLUSION: The increasing interest of major liver centers worldwide in HBS requires guidance for implementation. Standardization facilitates applicability of HBS and promotes global implementation. Inclusion of HBS in standard care is not meant as substitute for volumetry, but rather to complement risk evaluation by identifying suspected and unsuspected high-risk patients prone to develop post-hepatectomy liver failure (PHLF) and post-SIRT liver failure.

The Assessment of Regional Liver Function Before Major Hepatectomy Using Magnetic Resonance Imaging.

BACKGROUND: The liver-to-spleen signal intensity ratio (LSR) on magnetic resonance imaging with gadolinium-ethoxybenzyl-diethylenetriamine pentaacetic acid has been used as a parameter to assess liver function. LSR of the future remnant liver region (FR-LSR) is included in preoperative assessment of regional liver function. The aim of this study was to investigate the predictability of post-hepatectomy liver failure (PHLF) by FR-LSR. METHODS: Between May 2013 and May 2019, 127 patients underwent standardized EOB-MRI for diagnosis of liver tumor before major hepatectomy. The FR-LSR on EOB-MRI was calculated by a semiautomated three-dimensional volumetric analysis system. The cutoff value of FR-LSR in association with clinically relevant PHLF was determined according to the areas under the receiver operating characteristic curves. Then, FR-LSR and clinical variables were analyzed to assess the risk of clinically relevant PHLF. RESULTS: In patients with preoperative biliary drainage, metastatic liver tumor, estimated future remnant liver volume <50%, biliary reconstruction, operation time ≥ 480 min, estimated blood loss ≥ 1000 g, blood transfusion and a FR-LSR < 2.00 were associated with clinically relevant PHLF (P < .05 for all) in univariable analysis. The liver-to-spleen signal intensity ratio of the future remnant liver region < 2.00 was the only independent risk factor for clinically relevant PHLF in multivariable risk analysis (OR, 27.90; 95% CI: 7.99-136.40; P < .05). DISCUSSION: The present study revealed that FR-LSR calculated using a 3-dimensional volumetric analysis system was an independent risk factor for clinically relevant PHLF. The liver-to-spleen signal intensity ratio of the future remnant liver region might be a reliable preoperative parameter in liver functional assessment, enabling safe performance of major hepatectomy.

Appropriate and Potentially Inappropriate Medication Use in Decompensated Cirrhosis.

BACKGROUND AND AIMS: Patients with decompensated cirrhosis are prescribed numerous medications. Data are limited as to whether patients are receiving medications they need and avoiding those they do not. We examined a large national claims database (2010-2015) to characterize the complete medication profile as well as the factors associated with appropriate and potentially inappropriate medication use in 12,621 patients with decompensated cirrhosis. APPROACH AND RESULTS: Clinical guidelines and existing literature were used to determine appropriate and potentially inappropriate medications in decompensated cirrhosis. The total medication days' supply was calculated from pharmacy data and divided by the follow-up period for each decompensation. Ascites was the most common (86.5%), followed by hepatic encephalopathy (HE; 37.8%), variceal bleeding (VB; 17.5%), hepatorenal syndrome (6.3%), and spontaneous bacterial peritonitis (SBP; 6.1%). For patients with ascites, 55.8% filled a diuretic. For patients with HE, 32.4% and 63.3% filled rifaximin and lactulose, respectively. After VB, 60.3% of patients filled a nonselective beta blocker, and after an episode of SBP, 48.0% of patients filled an antibiotic for prophylaxis. The minority (4.5%-17.3%) had enough medication to cover >50% follow-up days. Potentially inappropriate medication use was common: 53.2% filled an opiate, 46.0% proton pump inhibitors, 14.2% benzodiazepines, and 10.1% nonsteroidal anti-inflammatory drugs. Disease severity markers were associated with more appropriate mediation use but not consistently associated with less inappropriate medication use. CONCLUSIONS: Patients with decompensated cirrhosis are not filling indicated medications as often or as long as is recommended and are also filling medications that are potentially harmful. Future steps include integrating pharmacy records with medical records to obtain a complete medication list and counseling on medication use with patients at each visit.

Perioperative assessment of indocyanine green elimination rate accurately predicts postoperative liver failure in patients undergoing hepatectomy.

BACKGROUND: This study aimed to evaluate the usefulness of perioperative indocyanine green elimination rate (ICG-K) as a predictive factor of posthepatectomy liver failure (PHLF). METHODS: This study enrolled 193 patients who underwent hepatectomy between 2013 and 2019. We analyzed the relationship between estimated ICG-K (ICG-Krem) calculated by the preoperative ICG-K and the residual liver volume ratio, ICG-K at days 1 and 7 after hepatectomy (ICG-Kpod1, ICG-Kpod7), and grade B or C PHLF. RESULTS: Grade B and C PHLF were observed in eight and two patients, respectively. ICG-Krem and ICG-Kpod1 were highly correlated (correlation coefficient [CC] 0.715), and ICG-Krem and ICG-Kpod7 were moderately correlated (CC 0.653). Receiver-operating characteristic curve analyses indicated that ICG-Krem and ICG-Kpod1 had moderate diagnostic value, while ICG-Kpod7 had high diagnostic value (area under the curve 0.703, 0.845 and 0.937, respectively). Multivariate analysis demonstrated that ICG-Kpod7 (relative risk [RR] 26.04, P = .012) and postoperative bile leakage (PBL) (RR 226.0, P < .001) were independent predictive factors for PHLF. PBL induced PHLF in seven patients, respectively. CONCLUSIONS: ICG-Krem correlated well with postoperative ICG-K, having moderate accuracy as a predictor of PHLF. However, the clinical relevance of postoperatively measuring ICG-K is limited because PHLF is greatly affected by surgical and postoperative factors.

Comparison of Quality of Life and Caregiving Burden of 2- to 4-Year-Old Children Post Liver Transplant and Their Parents.

A literature search determined there are no studies on children between 2 and 4 years of age who have had a liver transplant and their parents. For this reason, this study aimed to compare the quality of life of children between 2 and 4 years of age who have had a liver transplant, and the caregiving burden of their parents. The study was carried out as a descriptive cross-sectional study on 47 children who visited Inonu University Liver Transplant Institute outpatient clinic between March 2017 and March 2018. This study found that 59.6% of the children with transplants were male and 38.3% had their organ donated by their mother. There was a positive relationship between the quality of life of the parents and the quality of life and subdimensions of the children. There was a negative relationship between parental quality of life and care burden. This study found that the quality of life of children with liver transplants and their parents was low and, as the quality of life of children was impaired, the caregiving burden of parents increased. Healthcare professionals' awareness of the effect of caregivers' care load on quality of life after liver transplantation can positively affect the healing process.

Hepatic function assessment to predict post-hepatectomy liver failure: what can we trust? A systematic review.

Post hepatectomy liver failure (PHLF) could occur even though an adequate liver volume is preserved. Liver function is not strictly related to the volume and the necessity to pre-operatively predict the future liver remnant (FLR) function is emerging, together with the wide spreading of techniques, aiming to optimize the FLR. The aim of this study was to systematically review all the available tests, to pre-operatively assess the liver function and to estimate the risk of PHLF. A systematic literature research of Medline, Embase, Scopus was performed in accordance to the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines, to identify all the studies available for pre-operative liver function tests to assess the risk of PHLF and/or complications. From the 1122 references retrieved, 79 were included in the review. Dynamic functional tests, such as indocyanine green test (ICG), could evaluate only global liver function, with no definition of functional capacity of the remnant. Magnetic resonance imaging (MRI) with liver-specific contrast agents enables both liver function and volume evaluation; the absence of ionizing radiation showed a better patient's compliance. Nuclear imaging studies as hepatobiliary scintigraphy (HBS) present the unique ability to allow a precise evaluation of the segmental liver function of the remnant liver. Liver volume could overestimate liver function. Several liver function tests are available to evaluate the risk of PHLF in the pre-operative setting. However, no single test alone could accurately predict PHLF. Pre-operative combination between a dynamic quantitative test, such as ICG, with MRI or HBS, should enable a more complete functional evaluation. Functional tests to predict PHLF should be chosen according to patient's characteristics, disease, and center experience.

Relevance of liver surface nodularity for preoperative risk assessment in patients with resectable hepatocellular carcinoma.

BACKGROUND: Quantification of liver surface nodularity (LSN) on routine preoperative CT images allows detection of cirrhosis and clinically significant portal hypertension. This study aimed to assess the relevance of LSN in preoperative assessment of operative risks for patients with resectable hepatocellular carcinoma (HCC). METHODS: All patients undergoing hepatectomy for HCC between 2012 and 2017 were analysed retrospectively. LSN was assessed at the liver-fat interface on the left liver lobe on preoperative CT images. The feasibility of LSN quantification was assessed. The association between LSN and outcomes (severe complications and posthepatectomy liver failure (PHLF)) was evaluated by multivariable analysis and after propensity score matching. RESULTS: Among 210 patients, LSN measurement was successful in 187 (89·0 per cent). Among these, the median LSN score was 2·42 (i.q.r. 2·21-2·66) and 52·9 per cent had severe fibrosis, including 33·7 per cent with cirrhosis. LSN score increased with hepatic venous pressure gradient (P = 0·048), severity of steatosis (P = 0·011) and fibrosis grade (P = 0·001). LSN score was independently associated with severe complications (odds ratio (OR) 5·25; P = 0·006) and PHLF (OR 6·78; P = 0·003). After matching with respect to model for end-stage liver disease, aspartate aminotransferase-to-platelet ratio index and fibrosis-4 score, patients with a LSN score of 2·63 or higher retained an increased risk of PHLF (OR 5·81; P = 0·018). In the subgroup of patients without severe fibrosis, LSN was accurate in predicting severe complications (P = 0·005). Patients with (P = 0·039) or without (P = 0·018) severe fibrosis with increased LSN score had a higher comprehensive complication index score. Among patients with cirrhosis who had clinically significant portal hypertension, a LSN value below 2·63 ruled out the risk of PHLF. CONCLUSION: LSN measurement represents a practical tool that may allow improvement in the preoperative evaluation and management of patients with HCC.

ANTECEDENTES: La cuantificación de la nodularidad de la superficie hepática (liver surface nodularity, LSN) en las imágenes de la tomografía computarizada (TC) de rutina preoperatoria permite detectar la cirrosis y la hipertensión portal clínicamente significativa (clinically significant portal hypertension, CSPH). Este estudio tuvo como objetivo evaluar la relevancia de la LSN en la evaluación preoperatoria del riesgo quirúrgico en pacientes con carcinoma hepatocelular resecable (hepatocellular carcinoma, HCC). MÉTODOS: Todos los pacientes sometidos a hepatectomía por HCC entre 2012 y 2017 fueron analizados de forma retrospectiva. La LSN se evaluó en la interfase hígado-grasa en el lóbulo hepático izquierdo en la TC preoperatoria. Se evaluó la viabilidad de la cuantificación de la LSN. La asociación entre la LSN y los resultados (complicaciones graves e insuficiencia hepática poshepatectomía (post-hepatectomy liver failure, PHLF) se analizó en un análisis multivariable y después del método de emparejamiento por puntaje de propensión. RESULTADOS: Del total de 210 pacientes, la medición de la LSN fue exitosa en 187 (89,0%). En estos pacientes, la mediana de LSN fue de 2,42 (rango intercuartílico 2,21-2,66) y el 53,0% tenía fibrosis severa, incluyendo un 33,7% con cirrosis. La LSN aumentó con el gradiente de presión venosa hepática (P = 0,048), la gravedad de la esteatosis (P = 0,011) y el grado de fibrosis (P = 0,001). La LSN se asoció de forma independiente con complicaciones graves (razón de oportunidades, odds ratio, OR = 5,25; P = 0,006) y PHLF (OR = 6,78; P = 0,003). Después de emparejar para el modelo de enfermedad hepática terminal, el índice de relación aspartato amino transferase-plaquetas y el grado de fibrosis-4, los pacientes con LSN ≥ 2,63 mantuvieron un mayor riesgo de PHLF (OR = 5,81; P = 0,018). Dentro del subgrupo de pacientes sin fibrosis severa, la LSN fue precisa en predecir complicaciones graves (P = 0,005). Los pacientes con (P = 0,039) y sin (P = 0,018) fibrosis severa con aumento de la LSN tuvieron un índice de complicación global más alto. De los pacientes cirróticos con CSPH, un valor de LSN de 2,63 descartó el riesgo de PHLF. CONCLUSIÓN: La LSN representa una herramienta práctica, que puede permitir mejorar la evaluación preoperatoria y el manejo de pacientes con HCC.

Nonalcoholic fatty liver disease burden: Australia, 2019-2030.

BACKGROUND AND AIM: Nonalcoholic fatty liver disease (NAFLD) and nonalcoholic steatohepatitis (NASH) account for a large and growing proportion of liver disease burden globally. The burden of NAFLD/NASH manifests in increasing levels of advanced liver disease and primary liver cancer in Australia. A Markov model was used to forecast NAFLD burden in Australia through 2030. METHODS: A model was used to estimate fibrosis progression, primary liver cancer, and liver deaths among the Australian NAFLD population, with changes in incident NAFLD cases based on long-term trends for changes in the prevalence of obesity. Published estimates and surveillance data were applied to build and validate the model projections, including surveillance data for the incidence of liver cancer. RESULTS: Prevalent NAFLD cases were projected to increase 25% from the current burden (5 551 000 [4 748 000-6 306 000] cases in 2019) to 7 024 000 [5 838 000-7 886 000] cases in 2030. The projected increase in the number of NASH cases (40%) was greater than that of NAFLD cases. Incident cases of advanced liver disease are projected to increase up to 85% by 2030, and incident NAFLD liver deaths are estimated to increase 85% from 1900 (1100-3300) deaths in 2019 to 3500 (2100-6100) deaths in 2030. CONCLUSIONS: Restraining growth of the obese and diabetic populations, along with potential therapeutic options, will be essential for mitigating disease burden.

Validation of Functional Assessment for Liver Resection Considering Venous Occlusive Area after Extended Hepatectomy.

BACKGROUND: Previous studies demonstrated that liver function in a veno-occlusive region is approximately 40% of that in a non-veno-occlusive region after hepatectomy with excision of major hepatic vein. We validated the preoperative assessment of future remnant liver (FRL) function based on 40% decreased function of the veno-occlusive region. METHODS: Sixty patients who underwent hepatectomy with excision of major hepatic vein were analyzed. The FRL functions of the veno-occlusive and non-veno-occlusive regions were calculated with 99mTc-galactosyl human serum albumin scintigraphy single-proton emission computed tomography fusion system and SYNAPSE VINCENT® preoperatively. Risk assessment for hepatectomy was evaluated based on indocyanine green retention at 15 min, and patients with insufficient FRL function were described as marginal. RESULTS: The median volume and function of the veno-occlusive region per whole liver were 111 ml and 11.0%, respectively. When the function of the veno-occlusive region was presumed as 0%, 40%, and 100%, the FRL function was 62.5%, 68.4%, and 75.0% and 21, 15, and 7 patients were classified as marginal, respectively. When the function of the veno-occlusive region was presumed as 40%, the posthepatectomy liver failure (PHLF) rate of marginal patients was significantly higher than that of safe patients (46.7% vs 8.9%, P = 0.002). Multivariable analysis indicated that marginal FRL function based on 40% decreased function of the veno-occlusive region was the only independent risk factor for PHLF (odds ratio 8.97, P = 0.002) after extended hepatectomy. CONCLUSION: Assessment of preoperative FRL function based on 40% decreased function of the veno-occlusive region may have high validity.

A Multicenter Network Assessment of Three Inflammation Phenotypes in Pediatric Sepsis-Induced Multiple Organ Failure.

OBJECTIVES: Ongoing adult sepsis clinical trials are assessing therapies that target three inflammation phenotypes including 1) immunoparalysis associated, 2) thrombotic microangiopathy driven thrombocytopenia associated, and 3) sequential liver failure associated multiple organ failure. These three phenotypes have not been assessed in the pediatric multicenter setting. We tested the hypothesis that these phenotypes are associated with increased macrophage activation syndrome and mortality in pediatric sepsis. DESIGN: Prospective severe sepsis cohort study comparing children with multiple organ failure and any of these phenotypes to children with multiple organ failure without these phenotypes and children with single organ failure. SETTING: Nine PICUs in the Eunice Kennedy Shriver National Institutes of Child Health and Human Development Collaborative Pediatric Critical Care Research Network. PATIENTS: Children with severe sepsis and indwelling arterial or central venous catheters. INTERVENTIONS: Clinical data collection and twice weekly blood sampling until PICU day 28 or discharge. MEASUREMENTS AND MAIN RESULTS: Of 401 severe sepsis cases enrolled, 112 (28%) developed single organ failure (0% macrophage activation syndrome 0/112; < 1% mortality 1/112), whereas 289 (72%) developed multiple organ failure (9% macrophage activation syndrome 24/289; 15% mortality 43/289). Overall mortality was higher in children with multiple organ and the phenotypes (24/101 vs 20/300; relative risk, 3.56; 95% CI, 2.06-6.17). Compared to the 188 multiple organ failure patients without these inflammation phenotypes, the 101 multiple organ failure patients with these phenotypes had both increased macrophage activation syndrome (19% vs 3%; relative risk, 7.07; 95% CI, 2.72-18.38) and mortality (24% vs 10%; relative risk, 2.35; 95% CI, 1.35-4.08). CONCLUSIONS: These three inflammation phenotypes were associated with increased macrophage activation syndrome and mortality in pediatric sepsis-induced multiple organ failure. This study provides an impetus and essential baseline data for planning multicenter clinical trials targeting these inflammation phenotypes in children.

Assessment and optimization of liver volume before major hepatic resection: Current guidelines and a narrative review.

Post hepatectomy liver failure (PHLF) remains a significant cause of morbidity and mortality after major liver resection. Although the etiology of PHLF is multifactorial, an inadequate functional liver remnant (FLR) is felt to be the most important modifiable predictor of PHLF. Pre-operative evaluation of FLR function and volume is of paramount importance before proceeding with any major liver resection. Patients with inadequate or borderline FLR volume must be considered for volume optimization strategies such as portal vein embolization (PVE), two stage hepatectomy with portal vein ligation (PVL), Yttrium-90 radioembolization, and associating liver partition and portal vein ligation for staged hepatectomy (ALPPS). This paper provides an overview of assessing FLR volume and function, and discusses indications and outcomes of commonly used volume optimization strategies.

Interstage Assessment of Remnant Liver Function in ALPPS Using Hepatobiliary Scintigraphy: Prediction of Posthepatectomy Liver Failure and Introduction of the HIBA Index.

OBJECTIVE: The aim of this study was to evaluate interstage liver function in associating liver partition and portal vein occlusion for staged hepatectomy (ALPPS) using hepatobiliary scintigraphy (HBS) and whether this may help to predict posthepatectomy liver failure (PHLF). BACKGROUND: ALPPS remains controversial given the high rate of liver-related mortality after stage 2. HBS combined with single photon emission computed tomography (SPECT) accurately estimates future liver remnant function and may be useful to predict PHLF. METHODS: Between 2011 and 2016, 20 of 39 patients (51.3%) underwent SPECT-HBS before ALPPS stage 2 for primary (n = 3) or secondary liver tumors (n = 17) at the Hospital Italiano de Buenos Aires (HIBA). PHLF was defined by the International Study Group of Liver Surgery criteria, 50-50 criteria, or peak bilirubin >7 mg/dL. Grade A PHLF was excluded, as it requires no change in clinical management. Receiver-operating characteristic curves were used to determine cutoff for HBS parameters. RESULTS: Interstagely, 3 HBS parameters differed significantly between patients with (n = 4) and without PHLF (n = 16) after stage 2. Among these, the HIBA-index best predicted PHLF, with a cutoff value of 15%. The risk of PHLF in patients with cutoff <15% was 80%, whereas no patient with cutoff ≥15% developed PHLF. CONCLUSIONS: Interstage HBS could help to predict clinically significant PHLF after ALPPS stage 2. An HIBA-index cutoff of 15% seemed to give the best diagnostic performance. Although further studies are needed to confirm our findings, the routine application of this noninvasive low-cost examination could facilitate decision-making in institutions performing ALPPS.

Greater hypertrophy can be achieved with associating liver partition with portal vein ligation for staged hepatectomy compared to conventional staged hepatectomy, but with a higher price to pay?

BACKGROUND: Associating liver partition with portal vein ligation for staged hepatectomy (ALPPS) and conventional staged hepatectomy (CSH) are options for patients with unresectable liver tumors due to insufficient future liver remnant (FLR). METHODS: A retrospective comparison of clinical data, liver volumetry and surgical outcomes between 10 ALPPS and 29 CSH patients was performed. RESULTS: Patient demographics and disease characteristics were similar between both groups. ALPPS induced superior FLR growth (ALPPS vs. CSH, 48.1% (IQR 39.4-96.9%) vs. 11.8% (IQR 4.3-41.9%), p = 0.013). However, post-operative day 5 international normalized ratio (INR) (ALPPS vs. CSH, 1.6 (IQR 1.5-1.8) vs. 1.4 (IQR 1.3-1.6), p = 0.015) and rate of post-hepatectomy liver failure (ALPPS vs. CSH, 25 vs. 0%, p = 0.032) was higher in the ALPPS group. 90-day mortality (ALPPS vs. CSH, 12.5% vs. 0%, p = 0.320) was similar in both groups. CONCLUSION: ALPPS was superior in inducing FLR growth but associated with increased post-hepatectomy liver failure compared to CSH.

Quick chronic liver failure-sequential organ failure assessment: an easy-to-use scoring model for predicting mortality risk in critically ill cirrhosis patients.

BACKGROUND AND AIM: Critically ill cirrhosis patients have an increased risk of morbidity and mortality, even after admission to the ICU. Our objectives were to compare the predictive accuracy of model for end-stage liver disease (MELD), MELD-Na, UK model for end-stage liver disease, and chronic liver failure-sequential organ failure assessment (CLIF-SOFA) by the development and validation of an easy-to-use prognostic model [named quick CLIF-SOFA (qCLIF-SOFA)] for early risk prediction in critically ill patients with cirrhosis. PATIENTS AND METHODS: Overall, 1460 patients were extracted from the MIMIC-III database and enrolled in this study at 30-day and 90-day follow-up. qCLIF-SOFA was developed in the established cohort (n=730) and a performance analysis was completed in the validation cohort (n=730) using area under the receiver operating characteristic curve. Results were compared with CLIF-SOFA. RESULTS: The performance of CLIF-SOFA was significantly better than that of MELD, MELD-Na, and UK model for end-stage liver disease for predicting both 30-day and 90-day mortality (all P<0.05). qCLIF-SOFA consisted of five independent factors (bilirubin, creatinine, international normalized ratio, mean arterial pressure, and vasopressin) associated with mortality. In the established cohort, CLIF-SOFA and qCLIF-SOFA predicted mortality with area under the receiver operating characteristic curve values of 0.768 versus 0.743 at 30-day, 0.747 versus 0.744 at 90-day, and 0.699 versus 0.706 at 1 year, respectively (all P>0.05). A similar result was observed in the validation cohort (0.735 vs. 0.734 at 30 days, 0.723 vs. 0.737 at 90 days, and 0.682 vs. 0.700 at 1 year, respectively, all P>0.05). CONCLUSION: The utility of CLIF-SOFA was further shown to predict mortality for critically ill cirrhosis patients. The novel and simpler qCLIF-SOFA model showed comparable accuracy compared with existing CLIF-SOFA for prognostic prediction.

Liver failure after hepatectomy: A risk assessment using the pre-hepatectomy shear wave elastography technique.

OBJECTIVE: To determine the efficacy of liver stiffness (LS) measurements utilizing the Shear Wave Elastography (SWE) technique for predicting post-hepatectomy liver failure (PHLF) among patients with hepatocellular carcinoma (HCC). METHODS: Data from eighty consecutive patients who were undergoing hepatectomy for HCC were prospectively identified and evaluated with preoperative SWE. The SWE was measured with advanced ultrasound equipment (Philips EPIQ7; Philips Healthcare, Seattle, WA, USA). PHLF classification was defined according to the International Study Group of Liver Surgery Recommendations (ISGLS). RESULTS: SWE was successfully performed in 77 patients. According to the ISGLS criteria, PHLF occurred in 35.1% of patients (27 patients), including 2/25 patients with Grade A/B, respectively. Elevated SWE values (P=0.002) and histological cirrhosis (P=0.003) were independent predictors of PHLF according to the multivariate analysis. Patients with SWE values higher than or equal to 6.9kPa were identified at higher risk of PHLF (area under the curve: 0.843, sensitivity: 77.8% and specificity: 78.0%). Postoperative dynamic course of the median the Model For End-stage Liver Disease (MELD) score showed irregular changes among patients with an SWE >6.9kPa. Patients with an SWE <6.9kPa, postoperative dynamic course of the median MELD score gradually decreased. CONCLUSION: LS measured with SWE is a valid and reliable method for the prediction of PHLF grade A/B among patients with HCC. SWE could become a routine examination for the preoperative evaluation of PHLF.

Measurement of liver function using hepatobiliary scintigraphy improves risk assessment in patients undergoing major liver resection.

BACKGROUND: (99m)Tc-mebrofenin-hepatobiliary-scintigraphy (HBS) enables measurement of future remnant liver (FRL)-function and was implemented in our preoperative routine after calculation of the cut-off value for prediction of postoperative liver failure (LF). This study evaluates our results since the implementation of HBS. Additionally, CT-volumetric methods of FRL-assessment, standardized liver volumetry and FRL/body-weight ratio (FRL-BWR), were evaluated. METHODS: 163 patients who underwent major liver resection were included. Insufficient FRL-volume and/or FRL-function <2.7%/min/m(2) were indications for portal vein embolization (PVE). Non-PVE patients were compared with a historical cohort (n = 55). Primary endpoints were postoperative LF and LF related mortality. Secondary endpoint was preoperative identification of patients at risk for LF using the CT-volumetric methods. RESULTS: 29/163 patients underwent PVE; 8/29 patients because of insufficient FRL-function despite sufficient FRL-volume. According to FRL-BWR and standardized liver volumetry, 16/29 and 11/29 patients, respectively, would not have undergone PVE. LF and LF related mortality were significantly reduced compared to the historical cohort. HBS appeared superior in the identification of patients with increased surgical risk compared to the CT-volumetric methods. DISCUSSION: Implementation of HBS in the preoperative work-up led to a function oriented use of PVE and was associated with a significant decrease in postoperative LF and LF related mortality.

A reliable scoring system after major liver resection in mice.

BACKGROUND: Posthepatectomy liver failure and its transplant counterpart, small-for-size syndrome, remain significant limitations for liver resections and segmental liver transplantation. Partial hepatectomy in mice is one of the most commonly used models to study liver regeneration, but blood and tissue sampling necessary to collect data can affect outcomes or even require euthanasia. We therefore developed a quantitative observational system to predict death from hepatectomy during the first 24 postoperative hours. MATERIALS AND METHODS: A total of 100 female, 10 to 12-week-old C57BL/6 mice underwent two-thirds hepatectomy and were monitored for up to 7 d. Our scoring system was based on five categories, each assigned 0-2 points: activity level, body posture, fur condition, respiratory status, and eye appearance. Seventy-five mice were scored 6 h, 12 h, 24 h, 2 d, 3 d, 5 d, and 7 d after surgery. The remaining 25 mice were scored similarly, but underwent, in addition, blood sampling for serum alanine aminotransferase, total bilirubin, interleukin-6, tumor necrosis factor-alpha, or euthanasia with liver sampling for conventional hematoxylin-eosin and Ki-67 staining. RESULTS: Retrospective analysis indicated that body condition scores ≤5 on two consecutive time points within the first 24 postoperative hours accurately predicted eventual death. Animals in the low scoring group also had significantly higher serum alanine aminotransferase, total bilirubin, interleukin-6, tumor necrosis factor-alpha, more hepatocyte necrosis in hematoxylin-eosin, and fewer Ki-67 positive hepatocytes. CONCLUSIONS: Our scoring system accurately predicts survival, hepatocyte damage, liver regeneration, and systemic inflammation in a mouse hepatectomy model, within the first 24 hours of surgery. This could be useful in evaluating posthepatectomy interventions for their effect on survival and liver regeneration.

Risk Factors for 30-Day Readmissions of Individuals with Decompensated Cirrhosis.

OBJECTIVES: Patients with cirrhosis have a high rate of 30-day hospital readmission that affects their quality of life and contributes to increased healthcare-related costs. The aim of our study was to identify frequency, predictors, and preventable causes of hospital readmissions among patients with decompensated cirrhosis. METHODS: We retrospectively reviewed electronic medical records of all patients with a confirmed diagnosis of decompensated cirrhosis admitted to Dayton VA Medical Center between 2009 and 2013. Demographics, clinical factors, laboratory values, and outcomes were recorded. Univariate analysis was performed using independent samples t tests and Wilcoxon rank sums tests for continuous variables and χ(2) or Fisher exact tests for categorical variables. A multiple logistic regression analysis was performed for variables found to be significant by univariate analysis to predict the risk factors for 30-day readmission. A detailed chart review was conducted for all patients readmitted within 30 days by a single gastroenterologist to identify the reason for readmission and to decide whether any of these readmissions were preventable. RESULTS: The 30-day readmission rate for decompensated cirrhotic patients was 27.03%. The risk factors for 30-day readmission were higher body mass index (BMI), lower body temperature, higher blood urea nitrogen, higher creatinine, more cirrhosis-related complications, and more readmissions per year per univariate analysis. Multivariable analysis revealed only BMI as a significant predictor of 30-day readmission (P = 0.023). A total of 36.7% of 30-day readmissions were possibly preventable. CONCLUSIONS: The independent variable that predicted 30-day readmission in patients with decompensated cirrhosis was higher BMI. Approximately one-third of 30-day readmissions were possibly preventable. These findings support the need to develop specific interventions for disease management to improve patient care and save on extraneous healthcare costs.

Non-invasive assessment of liver fibrosis and prognosis.

Over the past decade, several advances have been made in the non-invasive assessment of liver fibrosis. Both serum markers and imaging-based tissue elastography predict the presence of advanced fibrosis compared with liver biopsy. Serum markers may be indirect or direct markers of liver structure and function. Imaging-based techniques measure liver stiffness as a surrogate for fibrosis and include ultrasound and MRI-based methods. Most non-invasive techniques work well at identifying subjects at the extremes of fibrosis but may not accurately discern intermediate stages. In addition to being a diagnostic tool, elastography may have an evolving role in prognosis. Increasing stiffness is associated with higher rates of liver decompensation, need for transplantation, hepatocellular carcinoma, and death. There are special populations of patients where elastography may serve as a non-invasive method to impart useful clinical information, such as patients after liver transplantation, those with congenital heart disease and those being treated for chronic viral hepatitis. The role of non-invasive markers in accurately predicting the presence of fibrosis in obese patients needs to be further refined.