Non-invasive tests for the prediction of post-hepatectomy liver failure in the elderly

Abstract

Post-hepatectomy liver failure (PHLF) is associated with great morbidity and mortality after resection of hepatocellular carcinoma. Previous studies have underlined that advanced age could be a potential factor influencing post-operative complications and long-term survival. In the past, candidates for resection were based on the Child-Pugh classification, the predictive value of which was rather low. The selection of patients undergoing resection in Western countries is based on the assessment of portal hypertension (PH), which is clinically assessed by measurement of the hepatic venous pressure gradient, an invasive and costly process. Thus, there have been several attempts to identify the best non-invasive test (NIT) to accurately predict PHLF. Most biochemical NITs for the prediction of PHLF are focused on evaluation of underlying liver cirrhosis and PH. Amongst them, FIB-4, which also includes the patient's age, seems to have more robust supporting results. In Europe and the USA., the most tested and reliable NIT for predicting PHLF is the evaluation of liver stiffness measurement, which is also influenced by age. Imaging parameters are promising tools which are used only in specialized centers however, and when available. Liver volume parameters, as well as contrastenhanced data, demonstrate good accuracy in predicting PHLF. In this scenario, the evaluation of sarcopenia and bone mineral density through contextual imaging allows the delineation of PHLF in at-risk elderly patients. Further studies focused on parameters for the evaluation of PHLF in elderly patients are needed.

Sarcopenia Predicts Major Complications after Resection for Primary Hepatocellular Carcinoma in Compensated Cirrhosis

“…As mentioned above, patients with a single HCC nodule, a compensated cirrhosis as assessed by a Child-Pugh A class and normal bilirubin (<1 mg/dL), without portal hypertension, have the best prognosis and are ideal candidates for liver resection [3]. As a matter of fact, in Western countries the selection of candidates for resection is usually based on the assessment of portal hypertension, as clinically assessed (platelet count < 100,000/mL, associated with splenomegaly or esophageal varices) or by the measurement of the HVPG > 10 mmHg, which is an invasive and costly method [40].…”

“…Hepatocellular carcinoma (HCC) represents the fifth cancer worldwide, being diagnosed in compensated Advanced Chronic Liver Disease (cACLD) patients with an annual rate of 1-8% [1,2]. Patients with compensated liver disease including compensated Child-Pugh class A liver function with model for end-stage liver disease (MELD) score < 10, without portal hypertension (PH) and with an acceptable remaining parenchyma can be candidates for liver resection, which represents the best curative option for HCC [1,3,4]. Despite the latest improvements in clinical management and surgical techniques, the combination of the previous factors led to an expected post-hepatectomy liver failure (PHLF) incidence < 5% [1].…”

“…As matter of fact, PHLF is closely related both to the resection extent and the background liver disease [6]. A careful assessment of pre-operative liver function and portal hypertension is required to recognize the best candidates for liver resection [3,[7][8][9]. The Child-Pugh score, MELD score, and the evidence of clinical signs of PH or through the measurement of hepatic venous pressure gradient (HVPG) or the addition of an indocyanine green clearance [10] test are the most used pre-operative tools.…”

Prognostic Value of the Albumin-Bilirubin Grade for the Prediction of Post-Hepatectomy Liver Failure: A Systematic Review and Meta-Analysis

“…Thus, an accurate pre-operative assessment of patients undergoing LR is required to overcome the PHLF risk, through the evaluation of liver function and the assessment of portal hypertension [ 8 , 9 , 10 ]. Several markers have been previously proposed for this purpose, such as the Child–Pugh, liver stiffness measurement, and volumetric imaging for future liver remnant assessment, which are typically performed in the pre-operative work [ 9 , 11 ].…”