A meta-analysis of cumulative incidence of hepatocellular carcinoma after the Fontan operation

Abstract

Background Hepatic complications are increasingly recognized after the Fontan operation. The development of hepatocellular carcinoma (HCC) is associated with high mortality when diagnosed, but its incidence and risk factors are poorly understood. We conducted a systematic review and meta-analysis of the cumulative incidence of HCC after Fontan and associated risk factors. Methods We searched PubMed, CINAHL, and MEDLINE databases for articles reporting the cumulative incidence of HCC after Fontan operation on March 21, 2023. A single-arm random effects meta-analysis was conducted to assess cumulative incidence at 10-, 20-, and 30-years after Fontan. Meta-analysis of the difference of the medians was used to assess the influence of risk factors on the development of HCC. Results Four studies including a total of 1,320 patients reported cumulative incidence. The cumulative incidence of HCC at 10-, 20-, and 30-years after Fontan was 0% (95% CI 0.00-0.01), 2% (0.01–0.06), and 7% (0.03–0.17) respectively. Seven studies including 6,250 patients reported overall incidence of HCC and associated risk factors. At a median 18.4 (IQR 11.9–24.9) years of follow-up, incidence of HCC was 2% (0.01–0.04). Only use of anticoagulation was associated with a lower risk of HCC (RR 0.3, 95% CI 0.1–0.88). Discussion By 30 years after Fontan, cumulative incidence of HCC is high (7%). Risk of HCC development prior to 10-years post-Fontan is low (0%) and HCC screening can be safely deferred in this population. Screening with ultrasound every 6 months starting 20-years post-Fontan is reasonable, however, further research regarding timing, cost-effectiveness, additional risk factors associated with HCC risk, and different screening modalities is required.