Univ. Lille, CHU Lille, Service de Chirurgie Digestive et Transplantations, Lille, France.
Univ. Lille, CHU Lille, EA 2694 - Santé publique:épidémiologie et qualité des soins, Department of Biostatistics, F-59000 Lille, France.
J Hepatol. 2019 Nov;71(5):920-929. doi: 10.1016/j.jhep.2019.06.003. Epub 2019 Jun 14.
BACKGROUND & AIMS: Selection criteria for hepatectomy in patients with cirrhosis are controversial. In this study we aimed to build prognostic models of symptomatic post-hepatectomy liver failure (PHLF) in patients with cirrhosis.
This was a cohort study of patients with histologically proven cirrhosis undergoing hepatectomy in 6 French tertiary care hepato-biliary-pancreatic centres. The primary endpoint was symptomatic (grade B or C) PHLF, according to the International Study Group of Liver Surgery's definition. Twenty-six preoperative and 5 intraoperative variables were considered. An ordered ordinal logistic regression model with proportional odds ratio was used with 3 classes: O/A (No PHLF or grade A PHLF), B (grade B PHLF) and C (grade C PHLF).
Of the 343 patients included, the main indication was hepatocellular carcinoma (88%). Laparoscopic liver resection was performed in 112 patients. Three-month mortality was 5.25%. The observed grades of PHLF were: 0/A: 61%, B: 28%, C: 11%. Based on the results of univariate analyses, 3 preoperative variables (platelet count, liver remnant volume ratio and intent-to-treat laparoscopy) were retained in a preoperative model and 2 intraoperative variables (per protocol laparoscopy and intraoperative blood loss) were added to the latter in a postoperative model. The preoperative model estimated the probabilities of PHLF grades with acceptable discrimination (area under the receiver-operating characteristic curve [AUC] 0.73, B/C vs. 0/A; AUC 0.75, C vs. 0/A/B) and the performance of the postoperative model was even better (AUC 0.77, B/C vs. 0/A; AUC 0.81, C vs. 0/A/B; p <0.001).
By accurately predicting the risk of symptomatic PHLF in patients with cirrhosis, the preoperative model should be useful at the selection stage. Prediction can be adjusted at the end of surgery by also considering blood loss and conversion to laparotomy in a postoperative model, which might influence postoperative management.
In patients with liver cirrhosis, the risk of a hepatectomy is difficult to appreciate. We propose a statistical tool to estimate this risk, preoperatively and immediately after surgery, using readily available parameters and on online calculator. This model could help to improve the selection of patients with the best risk-benefit profiles for hepatectomy.
肝硬化患者行肝切除术的选择标准存在争议。本研究旨在建立肝硬化患者术后症状性肝衰竭（PHLF）的预后模型。
这是一项在法国 6 家三级肝胆胰中心行肝切除术的组织学证实为肝硬化患者的队列研究。主要终点为根据国际肝脏外科研究组定义的症状性（B 或 C 级）PHLF。考虑了 26 项术前和 5 项术中变量。采用具有比例优势比的有序有序逻辑回归模型，分为 3 类：O/A（无 PHLF 或 A 级 PHLF）、B（B 级 PHLF）和 C（C 级 PHLF）。
343 例患者中，主要适应证为肝细胞癌（88%）。112 例患者行腹腔镜肝切除术。3 个月死亡率为 5.25%。观察到的 PHLF 分级为：O/A：61%，B：28%，C：11%。基于单因素分析结果，保留了 3 项术前变量（血小板计数、肝残留体积比和治疗意向腹腔镜）和 2 项术中变量（方案腹腔镜和术中出血量）进入术后模型。术前模型对 PHLF 分级的预测概率具有可接受的区分能力（受试者工作特征曲线下面积[AUC]0.73，B/C 与 0/A；AUC 0.75，C 与 0/A/B），术后模型的性能甚至更好（AUC 0.77，B/C 与 0/A；AUC 0.81，C 与 0/A/B；p<0.001）。
通过准确预测肝硬化患者症状性 PHLF 的风险，术前模型应在选择阶段有用。通过在术后模型中还考虑出血量和剖腹术转换，可在手术结束时调整预测，这可能会影响术后管理。
在肝硬化患者中，肝切除术的风险难以评估。我们提出了一种统计工具，使用易于获得的参数和在线计算器，在术前和术后即刻估计这种风险。该模型可帮助改善对肝切除术风险-效益最佳的患者的选择。
