Early postoperative arterial lactate concentrations to stratify risk of post-hepatectomy liver failure

Abstract

Background Post-hepatectomy liver failure (PHLF) represents the major determinant for death after liver resection. Early recognition is essential. Perioperative lactate dynamics for risk assessment of PHLF and associated morbidity were evaluated. Methods This was a multicentre observational study of patients undergoing hepatectomy with validation in international high-volume units. Receiver operating characteristics analysis and cut-off calculation for the predictive value of lactate for clinically relevant International Study Group of Liver Surgery grade B/C PHLF (clinically relevant PHLF (CR-PHLF)) were performed. Lactate and other perioperative factors were assessed in a multivariable CR-PHLF regression model. Results The exploratory cohort comprised 509 patients. CR-PHLF, death, overall morbidity and severe morbidity occurred in 7.7, 3.3, 40.9 and 29.3 per cent of patients respectively. The areas under the curve (AUCs) regarding CR-PHLF were 0.829 (95 per cent c.i. 0.770 to 0.888) for maximum lactate within 24 h (Lactate_Max) and 0.870 (95 per cent c.i. 0.818 to 0.922) for postoperative day 1 levels (Lactate_POD1). The respective AUCs in the validation cohort (482 patients) were 0.812 and 0.751 and optimal Lactate_Max cut-offs were identical in both cohorts. Exploration cohort patients with Lactate_Max 50 mg/dl or greater more often developed CR-PHLF (50.0 per cent) than those with Lactate_Max between 20 and 49.9 mg/dl (7.4 per cent) or less than 20 mg/dl (0.5 per cent; P < 0.001). This also applied to death (18.4, 2.7 and 1.4 per cent), severe morbidity (71.1, 35.7 and 14.1 per cent) and associated complications such as acute kidney injury (26.3, 3.1 and 2.3 per cent) and haemorrhage (15.8, 3.1 and 1.4 per cent). These results were confirmed in the validation group. Combining Lactate_Max with Lactate_POD1 further increased AUC (ΔAUC = 0.053) utilizing lactate dynamics for risk assessment. Lactate_Max, major resections, age, cirrhosis and chronic kidney disease were independent risk factors for CR-PHLF. A freely available calculator facilitates clinical risk stratification (www.liver-calculator.com). Conclusion Early postoperative lactate values are powerful, readily available markers for CR-PHLF and associated complications after hepatectomy with potential for guiding postoperative care. Presented in part as an oral video abstract at the 2020 online Congress of the European Society for Surgical Research and the 2021 Congress of the Austrian Surgical Society.

Current evidence on posthepatectomy liver failure: comprehensive review

“…On or after postoperative day five, there are limited possibilities left to substantially influence and potentially treat postoperative liver dysfunction, given the immediate onset of liver regeneration after hepatectomy 13 . Recently, perioperative lactate dynamics were found to be suitable for early recognition of PHLF and prediction of both rate and fatalities 14 ; however, these attempts have not resulted in new and widely used definitions. Thus, to allow comparability of reported results, many suggest using the ISGLS criteria until a new definition, based on a broad international agreement, is available.…”

“…The incidence of PHLF is highly dependent on which definition is used and the reported cohort of patients (for example demographic data, diagnosis, and extent of resection) 15 . Using the ISGLS criteria, the incidence of PHLF in recent publications ranges between 9 per cent 16 and about 20 per cent in western cohorts at tertiary centres 14 ; however, in population-based studies, a significant difference in 90-day fatalities following hepatectomy has been reported when comparing low- and high-volume centres 1 , 17 . As PHLF has been found to be the single most important cause for 90-day fatalities 2 and research regarding PHLF mostly originates from high-volume centres, a different incidence of PHLF in other settings could be possible.…”

Prediction of the Postoperative Outcome in Liver Resection Using Perioperative Serum Lactate Levels

“…Lactate levels measured directly after surgery correlate with morbidity and mortality after LR [ 17 , 19 , 20 , 22 , 23 , 24 , 26 ]. Our results are in line with previous studies, which revealed lactate levels at the end of surgery as being an independent risk factor for postoperative complications and death [ 17 , 19 , 26 ].…”

“…To date, only a few studies have investigated the role of perioperative lactate levels as predictors for the postoperative outcome after LR [ 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 ], and differences in study design and a lack of data regarding early postoperative lactate release make further studies necessary.…”

The Impact of Liver Resection Volume on Pancreatic Function: Novel Insights into Acute Liver-Pancreas Crosstalk After Hepatectomy

“…The incidence of PHLF uctuates based on the diagnostic criteria employed and is presently estimated to be 3-28%. [34][35][36][37] PHLF continues to be the leading cause of postoperative mortality and poses a substantial clinical challenge for the hepatobiliary surgeon. Once PHLF develops, options are often limited to best supportive care.…”