MELD-Based Indices as Predictors of Mortality in Chronic Liver Disease Patients Who Undergo Emergency Surgery with General Anesthesia

Background  

Underlying chronic liver disease is associated with high morbidity and mortality after emergency surgery, which complicates clinical decisions over performing such surgery. In addition, the Child–Turcotte–Pugh (CTP) score is limited in its ability to predict postoperative residual liver function. This study was designed to determine whether the scores of the Model for End-stage Liver Disease (MELD)-based indices are effective predictors of mortality following emergency surgery in patients with chronic liver disease.     

Assessment of hepatic reserve for indication of hepatic resection: decision tree incorporating indocyanine green test

Preoperative assessment of liver function and prediction of postoperative remaining functional liver parenchymal mass and reserve is of paramount importance to minimize surgical risk, especially in patients with hepatocellular carcinoma (HCC), the majority of whom have liver cirrhosis as a complication. We have established a decision tree for deciding the safe limit of hepatectomy based on three variables: whether ascites is present, the serum total bilirubin level, and the indocyanine green retention rate at 15 minutes (ICGR-15), an indicator of sinusoidal capillarization. In patients who show a sign of decompensated cirrhosis as reflected by an elevated bilirubin value or uncontrollable ascites, hepatectomy is not indicated. In patients without ascites and with normal bilirubin level, the ICGR-15 value becomes the main determinant for the resectability and hepatectomy procedure. Incorporation of ICGR-15 into the decision tree enables patients conventionally classified into Child–Turcotte–Pugh class A or score 5–6 to be subdivided into several groups in which various hepatectomy procedures are feasible: enucleation, limited resection, segmentectomy, mono- to bisectoriectomy, and trisectriectomy. During strict application of this decision tree to 1429 consecutive hepatectomies, of which 685 were performed on HCC patients, during the last 10 years, we encountered only a single mortality.     

不同评分系统评估肝癌患者行肝切除术围手术期风险的临床价值

目的比较Child-Pugh分级、终末期肝病模型（MELD）评分、慢性肝功能障碍评分（CLD）在肝癌患者行肝切除术围手术期风险评估中的应用价值。 方法回顾性分析141例肝切除术肝癌患者的临床资料,术前分别计算Child-Pugh分级、MELD评分及CLD评分,并分析3种评分与术后肝功能不全发生率的关系,对比不同肝功能恢复组的Child-Pugh、MELD、CLD评分。 结果①Child-Pugh A级与B级者的肝功能不全发生率差异无统计学意义,而MELD≤14分者与>14分者、CLD≤1.0分者与>1.0分者的发生率差异均有统计学意义(χ²=10.187、12.322,P<0.05);②肝功能恢复良好组、肝功轻度不全组的Child-Pugh评分差异无统计学意义,而肝功能恢复良好组、肝功轻度不全组、肝功能重度不全组的MELD评分及CLD评分均依次递增（P<0.05）;③CLD评分、MELD评分、Child-Pugh分级的ROC-AUC依次递增（P<0.05）;④在特异度95%时,CLD评分的敏感度最高,MELD评分次之,Child-Pugh分级最低（P<0.05）。 结论较之于目前普遍使用的Child-Pugh分级,MELD评分、CLD评分均可较准确地预测肝切除术后肝功能不全的发生情况,但CLD评分的准确性、敏感度更高,更符合我国肝病特点。     

Evaluation of liver function for hepatic resection for hepatocellular carcinoma in the liver with damaged parenchyma

Background

Liver functional parameters, including the Child—Pugh score and indocyanine green clearance (ICG), and volumetric parameters influencing postoperative liver function were evaluated with the aim of obtaining standardardized criteria for selecting patients for, and deciding the extent of, hepatectomy for hepatocellular carcinoma (HCC).

Materials and methods

The study population consisted of 120 patients with HCC undergoing hepatic resection excluding those with more than 3000 ml of intraoperative bleeding. Patients were classified as grades A, B, or C on the basis of, respectively, a Child—Pugh score of 5 or 6, 7-9, or ≥10 and were assigned to group D (postoperative liver dysfunction) or group N (no complication). Postoperative complications included massive ascites, pleural effusion, or hyperbilirubinemia. For each grade, the standardized estimated liver remnant ratio (STELR) was determined as the ratio of the liver remnant volume (estimated by computerized tomography) to the standardized total liver volume (STLV), estimated from the body surface area using the equation: liver volume [cm³] = 706 × body surface area [m²] + 2.4. The ICG retention rate at 15 min after injection (ICGR15) was then plotted against the STELR for each grade and a demarcation line separating patients in groups N and D was determined statistically by discriminant analysis.

Results

For grade A patients, the equation of the demarcation line was ICGR15 = 27.5 × STELR + 1.9 (Wilks’ Lambda: 0.667, P < 0.001), indicating that, for safe hepatic resection in patients with an ICGR15 of 10%, the STELR should be greater than 0.29. In contrast, for grade B patients, the equation was ICGR15 = 72 × STELR − 22.1 (0.589, P < 0.001), indicating that, in patients with a 10% ICGR15, the STELR should be greater than 0.44, a larger value than in grade A patients. The number of grade C patients was too small for analysis.

Conclusions

By combining the Child—Pugh score, ICG clearance, and liver volumetric parameters, criteria for the selection of patients for hepatic resection for HCC were established.     

肝切除术后肝衰竭风险预测指标及应对策略的研究现状

肝衰竭是肝切除术后严重并发症之一,术前患者自身因素,实验室指标,肝脏合并疾病,手术因素,门静脉高压症,药物因素都是肝衰竭的相关影响因素。笔者通过总结影响肝切除术后肝衰竭发生的危险因素,分析现有肝功能评分模型的评价效果,并根据评分指标探讨行肝切除术患者的围术期管理策略,以减少肝切除术后肝衰竭发生率,改善患者预后,提高长期生存率。     

Efficacy of preoperative portal vein embolization prior to major hepatectomy for patients with impaired liver function: A retrospective study

Hepatocellular carcinoma (HCC) is often associated with chronic liver disease, such as hepatitis or cirrhosis, and this association may limit the use of surgery as a therapy, and if surgery is pursued, may give rise to postoperative hepatic failure. We evaluated the outcome in patients with HCC given preoperative portal vein embolization (PVE) before they underwent major hepatectomy. After PVE, portal pressure increased significantly. Two weeks after PVE, both the volume of the non-embolized lobe and the 15-min indocyamine green retention rate (ICG R15) were significantly increased. The prognostic score, calculated on the basis of age, ICG R15, and the resection rate, was significantly decreased. The operative mortality rate was significantly lower in patients who underwent PVE before surgery than in patients who did not receive PVE. The cumulative survival rate of the PVE patients, even those with cirrhosis of the liver, was significantly higher. Prior PVE appears to allow more extensive major hepatectomy and to lessen the risk of this invasive surgery. However, patients in whom the portal pressure immediately after PVE was more than 30cm H₂O and/or whose prognostic score exceeded 50 points developed postoperative hepatic failure. These features should be kept in mind when it is decided whether surgery is indicated. Nevertheless, preoperative PVE appears to be a beneficial procedure for patients undergoing major hepatectomy, particularly those with chronic liver disease.     

中晚期肝癌的手术治疗

Hepatic cancer is currently the fifth most common malignant neoplasm in the world.Surgical resection is considered as radical treatment.Patients with hepatic cancer in middle or advanced stage accordin...     

Arguments for a selective approach of preoperative portal vein embolization before major hepatic resection

Preoperative PVE can induce hypertrophy of the future liver remnant volume resulting in a decrease of surgical risk after major hepatic resection. However, the number of patients with normal liver at risk is small and there is no arguments for inducing hypertrophy before standard right hepatectomy. Therefore, in patients with normal liver PVE is indicated in patients in whom very extended liver resection or associated major gastro-intestinal surgery is planned. In patients with chronic liver disease and in those with injuried liver (chemotherapy, major steatosis, cholestasis), PVE is indicated before major liver resection.     

Cardiac surgery for patients with liver cirrhosis

Liver cirrhosis has been shown a major preoperative risk factor in patients undergoing cardiac surgery. Although recent evidence comes from limited studies with relatively small number of patients, morbidity and mortality progressively increase with the severity of liver dysfunction. Patients with Child-Pugh classification B or C have significantly higher risks after open heart surgery using cardiopulmonary bypass. Recently, model for end-stage liver disease (MELD) score more reliably identifies patients who are at higher risk of mortality after open heart surgery. Off pump operation seems beneficial to prevent postoperative mortality and morbidity in patients with moderate to severe liver dysfunction in anecdotally reported cases, but further studies are warranted to prove its effectiveness. Incidence of major morbidity including hemodynamic instability caused by hyperdynamic circulation, systemic fluid retention, infection, and bleeding is high. Preoperative optimization of medical condition by correcting coagulopathy, poor nutrition, fluid retention and renal function is important in patients with high predictive risks. Non-cardiovascular morbidities including malignancies or hepatic decompression are the major limiting factors for long term survival. Careful consideration of expected risks and benefits is required to determine the surgical indication in those patients.     

Usefulness of an Estimation of Physiologic Ability and Surgical Stress (E-PASS) Scoring System to Predict the Incidence of Postoperative Complications in Gastrointestinal Surgery

Surgical intervention induces various host responses to maintain homeostasis. When postoperative inflammation is intense and persists for a long time, postoperative complications may occur, sometimes developing into multiple organ failure. Therefore, it is very important to assess surgical stress and predict the risk of morbidity and mortality. Using a new scoring system, an estimation of physiologic ability and surgical stress (E-PASS) scoring system, surgical stress following gastrointestinal surgery was evaluated to assess the feasibility of this scoring system. This system comprises a preoperative risk score (PRS), a surgical stress score (SSS), and a comprehensive risk score (CRS) that is calculated from both the PRS and the SSS. The relationship of the E-PASS score to the incidence of morbidity and mortality was examined. The relationship between the E-PASS score and a sequential organ failure (SOFA) score was also evaluated. The CRS had a significant positive correlation between not only the incidence but also the grade of postoperative complications. Total maximum SOFA score in patients with a CRS of more than 1 was significantly higher than that in patients with a CRS of less than 1. In conclusion, the E-PASS scoring system will be useful for predicting and recognizing the risk of postoperative complications. This scoring system is brief, simple, and reproducible and can be useful in all types of hospitals.     

A new scoring system to classify patients with colorectal liver metastases: proposal of criteria to select candidates for hepatic resection

Background Although many studies have reported the beneficial effects of hepatic resection for colorectal liver metastases on survival rates, it is still difficult to preoperatively select good candidates for hepatectomy.Methods Fifteen clinicopathological features, which were recognized only before or during surgery, were selected retrospectively in 81 consecutive patients in one hospital (Group I). These features were entered into a multivariate analysis to determine independent and significant variables affecting long-term prognosis after hepatectomy. Using selected variables, we created a scoring formula to classify patients with colorectal liver metastases to select good candidates for hepatic resection. The usefulness of the new scoring system was examined in a series of 70 patients from another hospital (Group II).Results Multivariate analysis, i.e., Cox regression analysis, showed that serosa invasion of primary cancers (P = 0.0720, risk ratio = 2.238); local lymph node metastases of primary cancers, i.e., Dukes C (P = 0.0976, risk ratio = 2.311); multiple nodules of hepatic metastases (P = 0.0461, risk ratio = 2.365); nodules of hepatic metastases greater than 5cm in diameter (P =0.0030, risk ratio = 4.277); and resectable extrahepatic distant metastases (P = 0.0080, risk ratio = 4.038) were significant and independent prognostic factors for poor survival after hepatectomy. Using thsee five variables, we created a new scoring formula to classify patients with colorectal liver metastases. Finally, our new scoring system classified patients in Group II and Group I well, according to long-term outcomes after hepatic resection.Conclusions Our new scoring system to classify patients with colorectal liver metastases is simple and useful in the preoperative selection of good candidates for hepatic resection.     

Partial hepatectomy in the mouse: technique and perioperative management.

Hepatic surgery in mice is challenging because of the delicate nature of the liver, lack of intravenous access, and risk of hemorrhage. In order to study the ability of the liver to regenerate after surgical resection, we developed a novel, rapid, and safe technique for partial hepatectomy in mice. We determined the relative contributions of the seven lobes of the mouse liver and resected the three most anterior lobes for a 68% hepatectomy. We used general anesthesia, a small upper midline incision, silk suture to tie off the lobes to be resected, warming pads and lights, as well as subcutaneous saline injection to ensure minimal morbidity. We have performed a safe two-thirds hepatic resection in 288 of 300 C57BL6 mice (96%). Perioperative mortality was due to technical error. Minimal long-term morbidity was appreciated. This technique may be applied to any type of hepatic resection in mice. In addition, the general operative technique and perioperative management of these mice may be applied to all types of murine intra-abdominal procedures used for surgical research.     

MELD评分系统评估慢性肝损伤患者肝脏储备功能的临床研究

目的：探索MELD 评分评估慢性肝损伤患者肝脏储备功能的价值。
方法：回顾性分析38例慢性肝损伤性肝脏移植患者术前测定的MELD 评分,同时采用计算机辅助数字图像分析法检测患者肝组织标本的纤维化程度,分析MELD 评分系统与肝组织纤维化图像定量分析的相互关系。
结果：慢性肝损伤患者的MELD 评分与肝纤维化面积百分比呈直线正相关;Child A,B,C 3组间MELD评分差异也有统计学意义。
结论：MELD 评分能准确评估慢性肝损伤患者的肝脏储备功能。     

肝癌合并中重度门静脉高压症外科治疗决策的风险因素分析

目的:探讨肝细胞肝癌(HCC)合并中重度门静脉高压症(PHT)手术治疗的安全性和有效性。方法:将2005年1月—2011年12月收治的247例符合相关标准的HCC-PHT患者分为单纯肝癌切除组(不伴门静脉高压或伴中、轻度门静脉高压)和肝切除联合门奇静脉断流组,进行实验室指标和术后肝性脑病、腹水、胃溃疡、再出血等风险因素对比分析。结果:联合手术组患者术后肝功能恢复、肝性脑病、腹水、胃溃疡、再出血等并发症的发生率与单纯手术组无统计学差异(P>0.05),但术后白细胞及血小板明显升高,远期出血率明显降低(均P<0.05)。结论:同期联合手术是治疗原发性肝癌伴有重度门脉高压症患者的安全有效的治疗方法,可改善患者生活质量,且并不增加手术的病死率及术后并发症的发生率。     

ICG-R15、iMELD及CLD评分在预测肝细胞癌术后肝功能不全程度中的作用及相关性研究

目的 以术后肝功能不全程度为标准来研究术前吲哚氰绿15 min内滞留率（indocyanine green retention rate at 15 minute,ICG-R15）、综合的终末期肝病模型评分（the integrated model for end-stage liver disease scores,iMELD）和慢性肝功能不全评分（chronic liver dysfunction scores, CLD）三者之间的相关性.方法 回顾性分析61例行手术切除的原发性肝细胞肝癌患者的临床资料,根据肝功能不全程度分为轻、中、重三组,利用脉冲式色素浓度分析法（pulse dyedensitonmetry,PDD）行吲哚氰绿（indocyanine green,ICG）排泄试验,同时计算患者的iMELD及CLD评分.结果 随着术后肝功能不全程度的递增,ICG-R15及CLD评分逐渐升高,差异具有统计学意义（P＜0.05）;ICG-R15与CLD评分相关性明显强于ICG-R15与iMELD评分的相关性（r=0.65,r=0.49）.结论 ICG-R15与CLD评分正向相关性明显强于iMELD评分.     

Predictors of extrahepatic recurrence after resection of colorectal liver metastases

BACKGROUND: It is important to identify patients at high risk of extrahepatic recurrence after surgery for liver metastases, in order to maximize the survival benefit obtained by prophylactic regional chemotherapy. METHODS: Data from 68 patients who underwent resection of colorectal liver metastases but who did not receive hepatic arterial chemotherapy or intravenous systemic chemotherapy were collected. Twenty-two variables were examined by univariate and multivariate analyses to determine which factors were relevant to extrahepatic recurrence. A scoring system was developed that included the most relevant factors. RESULTS: The extrahepatic recurrence rate at 3 years after hepatectomy was 57.8 per cent. Three variables were independently associated with extrahepatic recurrence including raised serum level of carcinoembryonic antigen after hepatectomy (relative risk (RR) 5.4, P < 0.001), venous invasion of the primary tumour (RR 4.0, P = 0.001) and high-grade budding of the primary tumour (RR 3.1, P = 0.006). Patients with none of these risk factors had a 3-year extrahepatic recurrence rate of 7.1 per cent, compared with 61.6 per cent for those with one risk factor and 100 per cent for those with two or three risk factors. CONCLUSION: It was possible to identify patients at high risk of disease relapse at extrahepatic sites. This system might be used on an individual basis to select patients with colorectal liver metastases for regional chemotherapy or systemic chemotherapy after surgical intervention.     

HA/GSA-Rmax Ratio as a Predictor of Postoperative Liver Failure

Background  Postoperative mortality after hepatectomy remains high compared with other types of surgery in patients who have cirrhosis or chronic hepatitis. Although there are several useful perioperative markers of liver dysfunction, there are no standard markers for predicting postoperative liver failure. This study investigated risk factors for postoperative liver failure after resection of hepatocellular carcinoma to detect markers that could identify candidates for hepatectomy. Methods  Perioperative risk factors for liver failure after hepatectomy were analyzed in 191 patients with hepatocellular carcinoma. Multivariate logistic regression analysis was done to investigate factors with a significant independent influence among 35 variables. The ratio of serum hyaluronic acid to the maximum removal rate of technetium-99 m diethylenetriaminepentaacetic acid galactosyl human serum albumin (hyaluronate/GSA-Rmax ratio) was calculated. Results  Liver failure occurred postoperatively in 16 patients, 3 of whom died. The hyaluronate/GSA-Rmax ratio was a risk factor for postoperative liver failure by univariate analysis and was the only risk factor according to multivariate analysis. All three patients who died had a hyaluronic acid/GSA-Rmax ratio ≥ 500 mg min/dl. This ratio had a sensitivity of 88% and a specificity of 92% for predicting liver failure. Conclusions  To reduce postoperative liver failure, preoperative planning should employ various measures of the hepatic functional reserve, including tests of both parenchymal and nonparenchymal liver function. The hyaluronate/GSA-Rmax ratio can predict liver failure after hepatectomy, and a ratio ≥ 500 mg min/dl is a relative contraindication to liver resection.     

结直肠癌肝转移预后评分系统的现状及临床应用

结直肠癌是中国第二常见的恶性肿瘤,其中约50％的患者最终会发生肝转移.有效的全身治疗和积极包括手术在内的局部治疗,是提升结直肠癌肝转移患者疗效的关键.肝切除术后复发是导致结直肠癌肝转移患者死亡的主要原因,不同复发风险的患者治疗选择也有所不同,因此建立有效的结直肠癌肝转移预后评分系统,以指导其个体化治疗至关重要.临床危险...     

Neutrophil Depletion and Chemokine Response after Liver Ischemia and Reperfusion

Hepatic surgery in mice is challenging because of the delicate nature of the liver, lack of intravenous access, and risk of hemorrhage. In order to study the ability of the liver to regenerate after surgical resection, we developed a novel, rapid, and safe technique for partial hepatectomy in mice. We determined the relative contributions of the seven lobes of the mouse liver and resected the three most anterior lobes for a 68% hepatectomy. We used general anesthesia, a small upper midline incision, silk suture to tie off the lobes to be resected, warming pads and lights, as well as subcutaneous saline injection to ensure minimal morbidity. We have performed a safe two-thirds hepatic resection in 288 of 300 C57BL6 mice (96%). Perioperative mortality was due to technical error. Minimal long-term morbidity was appreciated. This technique may be applied to any type of hepatic resection in mice. In addition, the general operative technique and perioperative management of these mice may be applied to all types of murine intra-abdominal procedures used for surgical research.     

腹腔镜右肝肿瘤切除术的初步探讨(附15例报告)

目的:探讨腹腔镜右肝肿瘤切除术的可行性、安全性。方法:回顾分析2012年9月至2014年2月为15例右肝肿瘤患者行腹腔镜肝切除术的临床资料。其中肝血管瘤9例,原发性肝癌6例。结果:12例成功完成完全腹腔镜下手术,3例行手辅助腹腔镜手术,无一例中转开腹。其中10例行肝右后叶切除术,5例行右前叶肿瘤切除术。术中13例需阻断肝门,阻断时间平均(17.3±3.5)min。手术时间平均(150±55)min,术中出血量平均(168±39)ml,术后平均住院(11.2±2.7)d。结论:腹腔镜右肝肿瘤切除术受技术问题、手术风险性、肿瘤治疗原则的限制,对术者腹腔镜技术要求较高,操作过程复杂,但在严格把握手术适应证、熟练掌握腹腔镜技术的前提下,肝右叶的肿瘤行腹腔镜肝肿瘤切除术是安全、可行的。