Rompianesi Gianluca, Han Ho-Seong, Fusai Giuseppe, Lopez-Ben Santiago, Maestri Marcello, Ercolani Giorgio, Di Martino Marcello, Diaz-Nieto Rafael, Ielpo Benedetto, Perez-Alonso Alejandro, Morare Nolitha, Casellas Margarida, Gallotti Anna, de la Hoz Rodriguez Angela, Burdio Fernando, Ravaioli Federico, Venetucci Pietro, Lo Bianco Emanuela, Ceriello Arianna, Montalti Roberto, Troisi Roberto Ivan
HPB, Minimally Invasive, Robotic and Transplant Surgery Unit, Department of Clinical Medicine and Surgery, Federico II University Hospital, Naples, Italy.
HPB Surgery Unit, Seoul National University Bundang Hospital, Seoul, South Korea.
Eur J Surg Oncol. 2025 Aug;51(8):108778. doi: 10.1016/j.ejso.2024.108778. Epub 2024 Oct 22.
Post-hepatectomy liver failure (PHLF) can significantly compromise outcomes, especially in cirrhotic patients. The identification of accurate and non-invasive pre-operative predictors is of paramount importance to appropriately stratify patients according to their estimated risk and select the best treatment strategy.
Consecutive patients undergoing liver resection for HCC on cirrhosis between 1-2015 and 12-2020 at 10 international Institutions were enrolled and their pre-operative CT scans were evaluated for the presence of spontaneous portosystemic shunts (SPSS) to identify predictors of PHLF and develop a nomogram.
The analysis of the CT scans identified SPSS in 74 patients (17.4 %). PHLF was developed in 27 out of 425 cases (6.4 %), with grades B/C observed in 17 patients (4 %). At the multivariable analysis, the presence of SPSS resulted an independent risk factor for all-grades PHLF (OR 6.83, 95%CI 2.39-19.51, p < 0.001) and clinically significant PHLF development (OR 7.92, 95%CI 2.03-30.85, p = 0.003) alongside a patient's age ≥74 years, a pre-operative platelets count <106x10/μL, a multiple-segments liver resection, and an intraoperative blood loss ≥1200 mL. The 30- and 90-days mortality in patients with and without SPSS resulted 2.7 % vs 0.3 % (p = 0.024) and 5.4 % vs 1.1 % (p = 0.014). The accuracy of SPSS in predicting PHLF development was 0.847 (95%n CI 0.809-0.880). The internally validated nomogram showed excellent performance in predicting grades B/C PHLF (c-statistic = 0.933 (95%CI 0.888-0.979)).
The pre-operative presence of SPSS assessed on the pre-operative imaging proved to be a valuable radiological biomarker able to predict PHLF development in patients undergoing liver resection for HCC.
肝切除术后肝衰竭（PHLF）会显著影响治疗结果，尤其是在肝硬化患者中。识别准确且无创的术前预测指标对于根据患者估计风险进行适当分层并选择最佳治疗策略至关重要。
纳入2015年1月至2020年12月期间在10家国际机构接受肝硬化相关肝癌肝切除术的连续患者，并对其术前CT扫描进行评估，以确定是否存在自发性门体分流（SPSS），从而识别PHLF的预测指标并制定列线图。
CT扫描分析发现74例患者（17.4%）存在SPSS。425例病例中有27例发生PHLF（6.4%），其中17例（4%）为B/C级。多变量分析显示，SPSS的存在是所有级别的PHLF（比值比6.83，95%置信区间2.39 - 19.51，p < 0.001）和临床显著PHLF发生（比值比7.92，95%置信区间2.03 - 30.85，p = 0.003）的独立危险因素，同时患者年龄≥74岁、术前血小板计数<106×10⁹/μL、多段肝切除以及术中失血≥1200 mL也是危险因素。有SPSS和无SPSS患者的30天和90天死亡率分别为2.7%对0.3%（p = 0.024）和5.4%对1.1%（p = 0.014）。SPSS预测PHLF发生的准确性为0.847（95%非参数置信区间0.809 - 0.880）。内部验证的列线图在预测B/C级PHLF方面表现出色（c统计量 = 0.933（95%置信区间0.888 - 0.979））。
术前影像学评估发现的SPSS被证明是一种有价值的放射学生物标志物，能够预测接受肝癌肝切除术患者的PHLF发生。
