Adding Liver Stiffness Measurement to the Routine Evaluation of Hepatocellular Carcinoma Resectability Can Optimize Clinical Outcome

Abstract

Purpose Liver stiffness (LS) has been shown to be of use in chronic liver disease patients but its utility in surgical judgment still needs to be proven. A decision-making approach was applied to evaluate whether LS measurement before surgery of hepatocellular carcinoma (HCC) can be useful in avoiding post-hepatectomy liver failure (PHLF).

Materials and Methods Decision curve analysis (DCA) was applied to 202 HCC patients (2008 – 14) with LS measurement prior to hepatectomy to verify whether the occurrence of PHLF grades B/C should be reduced through a decision-making approach with LS. 

Results Within 90 days of surgery, 4 patients died (2 %) and grades B/C PHLF occurred in 29.7 % of cases. Ascites and/or pleural effusion, treatable with medical therapy, were the most frequent complications. DCA showed that using the “expected utility theory” LS measurement can reduce up to 39 % of cases of PHLF without the exclusion of any patient from surgery that duly undergoes an uncomplicated postoperative course. LS measurement does not add any information to normal clinical judgment for patients with a low (< 10 %) risk of PHLF.

Conclusion LS measurement can determine a reduction of PHLF under “expected utility theory” fulfilment. However, the degree of PHLF can be minor and “risk seeking” individuals can accept such a risk on the basis of surgical benefits.

Zusammenfassung

Ziel Der Einsatz der Lebersteifigkeit (LS) hat sich bei Patienten mit chronischen Lebererkrankungen als hilfreich erwiesen, aber dessen Nutzen bei der chirurgischen Entscheidung muss noch überprüft werden. Ein Entscheidungsfindungsansatz wurde angewandt, um festzustellen, ob präoperative LS-Bestimmungen beim hepatozellulärem Karzinom (HCC) von Nutzen sind, um das postoperative Leberversagen (posthepatectomy liver failure, PHLF) zu verhindern.

Material und Methoden Bei 202 HCC-Patienten mit LS-Bestimmung vor Leberresektion (2008 – 14) wurde eine „Decision Curve Analysis“ (DCA) durchgeführt, um zu überprüfen, ob das Auftreten eines PHLF-Grad B/C durch die Entscheidungsfindung mittels LS verringert werden kann.

Ergebnisse Innerhalb von 90 Tagen nach Leberresektion starben 4 Patienten (2 %) und Grad B/C PHLF trat in 29,7 % der Fälle auf. Aszites und / oder Pleuraergüsse, die medikamentös behandelbar sind, waren die häufigsten Komplikationen. Die DCA zeigte, dass die Anwendung der LS-Bestimmung mittels „Expected Utility Theory“ die Fälle mit PHLF um bis zu 39 % reduzieren kann, ohne irgendeinen Patienten mit ordnungsgemäßem unkomplizierten postoperativen Verlauf von der Operation auszuschließen. Die LS-Bestimmung liefert keine zusätzliche Information für die normale klinische Entscheidung über Patienten mit niedrigem PHLF-Risiko (< 10 %).

Schlussfolgerung Die LS-Bestimmung kann zu einer Reduktion des PHLF bei Durchführung der „Expected Utility Theory“ führen. Allerdings kann der Grad des PHLF gering sein, und „risikobereite“ Personen können ein solches Risiko im Hinblick auf den chirurgischen Nutzen akzeptieren.

Key words

abdomen - liver stiffness - hepatocellular carcinoma - hepatic resection - decision analysis

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