Jae Seong Jang

Association of Remnant Liver Ischemia With Early Recurrence and Poor Survival After Liver Resection in Patients With Hepatocellular Carcinoma

Importance The remnant liver after hepatectomy may have inadequate blood supply, especially following nonanatomical resection or vascular damage. Objective To evaluate whether remnant liver ischemia (RLI) may have an adverse effect on long-term survival and morbidity after liver resection in patients with hepatocellular carcinoma. Design, Setting, and Participants This study was a retrospective analysis at Seoul National University Bundang Hospital. Remnant liver ischemia was graded on postoperative computed tomographic scans in 328 patients who underwent hepatectomy for hepatocellular carcinoma between January 1, 2004, and December 31, 2013. Main Outcomes and Measures Remnant liver ischemia was defined as reduced or absent contrast enhancement during the venous phase. Remnant liver ischemia was classified as minimal (none or marginal) or severe (partial, segmental, or necrotic). Results Among 328 patients (252 male and 76 female; age range, 26-83 years [mean age, 58.2 years]), radiologic signs of severe RLI were found in 98 patients (29.9%), of whom 63, 16, and 19 had partial, segmental, or necrotic RLI, respectively. These patients experienced more complications and longer hospital stay than patients with minimal RLI. Preoperative history of transarterial embolization (odds ratio [OR], 1.77; 95% CI, 1.02-3.03; P = .04), use of the Pringle maneuver (OR, 1.96; 95% CI, 1.08-3.58; P = .03), and longer operative time (OR, 1.003; 95% CI, 1.002-1.005; P < .001) were independent risk factors for severe RLI. Early recurrence rates within 6 (60.2% vs 9.6%) or 12 (79.6% vs 18.7%) months after hepatectomy were higher in patients with severe RLI than in patients without RLI (P < .001). Severe remnant liver ischemia was an independent risk factor for overall survival (OR, 6.98; 95% CI, 4.27-11.43; P < .001) and disease-free survival (OR, 5.15; 95% CI, 3.62-7.35; P < .001). Conclusions and Relevance Preventive management and technical refinements in hepatectomy are important to decrease the risk of RLI and to improve survival of patients with hepatocellular carcinoma.

Remnant Liver Ischemia is Associated with Early Recurrence and Poorer Survival after Liver Resection in Patients with Hepatocellular Carcinoma

Background and Aims: Non-anatomical hepatectomy or compromised blood supply to the remnant liver may result in remnant liver ischemia (RLI) of various extension and severity. There are a few reports showing association between ischemia-reperfusion injury and tumor recurrence in animal liver transplantation model. However, there is no report to evaluate the impact of RLI after hepatectomy for hepatocellular carcinoma (HCC) on patient survival. Methods: Remnant liver ischemia was graded on postoperative CT scan in 328 patients who underwent hepatectomy for HCC between January 2004 and December 2013. We defined RLI as reduced or absent contrast enhancement during the venous phase and classified to minimal (none or marginal) or significant (partial, segmental, and necrosis). Results:We observed radiologic signs of significant RLI in 98 patients (29.9%): 63 partial, 16 segmental, and 19 necrosis, and these patients showed more complications (p < 0.001) and longer hospital stays (p = 0.002). Preoperative history of transarterial embolization (p = 0.040), use of Pringle maneuver (p = 0.028), and longer operation time (p < 0.001) were independent risk factors for developing RLI. Patients with significant RLI showed higher rates of early recurrence within 6 or 12months after hepatectomycompared thosewithout (p < 0.001). Moreover, RLI was independent risk factors for both overall patient (p < 0.001; RR = 6.984; 95% CI, 4.268–11.426) and disease-free survival (p < 0.001; RR = 5.153; 95% CI, 3.615–7.345). Conclusions: Partial hepatectomy without RLI and medical treatment for RLI are highly recommended in patients with HCC.