Postoperative complication III-V is closely related with hepatectomy-related mortality for hepatocellular carcinoma (HCC) patients. The aim of the study was to investigate the relationship between CONUTS and postoperative complication III-V. 1334 HCC patients who underwent hepatectomy were divided into two groups: high CONUTS group (early postoperative CONUTS ≥ 8, n = 659) and low CONUTS group (early postoperative CONUTS < 8, n = 675). The characteristics and clinical outcomes were compared and analyzed. Risk factors for postoperative complication III-V were evaluated by univariate and multivariate analysis. early postoperative CONUTS showed a good prediction ability for postoperative complication III-V (AUROC = 0.653, P < 0.001), with the cut-off value of 8. The high CONUTS group had higher incidence of postoperative pulmonary complications (12.0% vs 7.9%, P = 0.011), bile leakage (2.6% vs 0.9%, P = 0.018), intra-abdominal hemorrhage (4.9% vs 1.6%, P = 0.001), postoperative liver failure Grade C (3.6% vs 1.0%, P = 0.002), complication III-V (15.6% vs 6.2%, P < 0.001), length of ICU stay > 48 hours (9.4% vs 4.1%, P < 0.001) and mortality in 90 days (2.6% vs 0.4%, P = 0.001), longer period of postoperative hospitalization (10 (8–13) vs 9 (7–11) days, P < 0.001). Multivariable analysis revealed that early postoperative CONUTS ≥ 8 (OR = 2.054, 95%CI = 1.371–3.078, P < 0.001) was independently associated with postoperative complication III-V. Early postoperative CONUTS ≥ 8 was identified as a novel risk factor for postoperative complication III-V, and should be further evaluated as a predictive marker for who are to undergo liver resection.

• Recurrent hepatocellular carcinoma (RHCC)
• consensus
• multidisciplinary management

Geriatric nutritional risk index (GNRI) is a novel and useful screening tool for evaluating nutritional status in elderly in-patients. We aimed to investigate whether the preoperative GNRI could be a predictive factor for outcomes in patients over 65 years of age with a diagnosis of hepatocellular carcinoma (HCC). We retrospectively enrolled 261 consecutive HCC patients after hepatectomy and classified them into four risk groups based on the GNRI values: high risk (GNRI, <82), moderate risk (GNRI, 82–92), low risk (GNRI, 92–98), and normal (GNRI, >98). We found that the lower GNRI value was significantly associated with severe postoperative complications (P < 0.001) and liver failure (P < 0.001). By multivariate logistic regression analysis, high risk- and moderate risk GNRI groups were identified as independent risk factors for postoperative serve complications and liver failure. Multivariate Cox regression analysis revealed preoperative GNRI (P < 0.001) adversely affected overall survival. In conclusion, preoperative GNRI could predict severe postoperative complications included liver failure, and the lower GNRI value was associated with worse overall survival after hepatectomy in elderly HCC patients.

• Carcinoma
• Fibrosis-4
• Hepatectomy
• Hepatocellular
• Non-invasive index

• ALT
• Meta-analysis
• Vascular occlusion

Though accumulated evidence proved the advantages of laparoscopic hepatectomy, bleeding still remains the most important challenge in clinical practice. Our study aimed to compare the outcomes of Pringle maneuver (PM) and selective hemihepatic vascular occlusion (SHVO) surgeries for patients with liver cavernous hemangioma (LCH).

The SHVO (n = 26; mean age, 42) and PM (n = 78; mean age, 43) surgeries were performed in 104 LCH patients from January 2006 to January 2015. The intraoperative (bleeding, arterial pressure, oxyhemoglobin saturation, etc.) and postoperative parameters (anal exhaust time, complications, blood cell numbers, etc.) were measured and compared between the two groups. Liver function of all these patients was detected by blood test at 1-day preoperation, and at 1, 3, and 5 days postoperation.

Both of the two surgeries were successfully performed without any mortality. The intraoperative systolic arterial pressure and pulse in PM group were much higher than that in SHVO group (P < 0.01). The postoperative liver function parameters such as alanine transaminase (ALT), aspartate transaminase (AST), and total bilirubin (TBIL) increased much more in the PM group than that in the SHVO group compared with preoperation results (P < 0.05). However, there were no statistical differences in intraoperative bleeding, blood transfusion, hepatic inflow occlusion time, oxygen saturation occlusion, anal exhaust time and incidence of complications between the two groups (P > 0.05).

SHVO is safer with less ischemia reperfusion injury than PM surgery for hemangioma resection on patients with LCH.

Significant hemorrhage together with blood transfusion has negative impact on postoperative morbidity, mortality, and long-term survival of liver resection. Various techniques of vascular occlusion have been developed to reduce intraoperative blood loss. The objective of this study was to compare the outcomes of Pringle maneuver, hemi-hepatic vascular occlusion, and treatment without vascular occlusion used during liver resection.

Data of 574 patients with Hepatitis B virus (HBV)-related hepatocellular carcinoma (HCC), who underwent major hepatectomy between January 2009 to March 2013 by Pringle maneuver (N = 158), hemi-hepatic vascular inflow occlusion (N = 216), or without any vascular occlusion (N = 200), were included in this retrospective study. Perioperative blood transfusion, intraoperative blood loss, and postoperative liver function, and surgical complications were analyzed and compared between the three groups.

There were no significant difference observed in postoperative bilirubin, liver enzyme, and albumin levels between three groups (P>0.05). 5 patients (2.5%) in no occlusion group, 2 (1.3%) in Pringle group, and 8 (3.7%) in hemi-hepatic group had liver failure; but, there were no differences (P>0.05). The overall postoperative complications rate between three groups did not reach significant differences (33.5% vs 34.2% vs 42.6%, respectively; P>0.05). However, significant differences in intraoperative blood loss between no occlusion group (638.2±426.8 ml) and Pringle group (518.0±451.0 ml) or hemi-hepatic group (513.0±366.7 ml) (P<0.01).

Although there were no differences found between three groups regarding postoperative complications rate, no vascular occlusion group had more blood loss than the other two groups during liver resection.

The aim of the present study was to develop and validate a prediction score for postoperative complications by severity and guide perioperative management and patient selection in hepatitis B-related hepatocellular carcinoma patients undergoing liver resection.

A total of 1543 consecutive liver resections cases were included in the study. Randomly selected sample set of 70% of the study cohort was used to develop a score to predict complications III–V and the remaining 30% was used to validate the score. Based on the preoperative and predictable intraoperative parameters, logistic regression analysis was used to identify risk factors and create an integer score for the predicting of complication.

American Society of Anesthesiologists category, portal hypertension, major liver resection (more than 3 segments) and extrahepatic procedures were identified as independent predictors for complications III–V by logistic regression analysis. A score system integrating these 4 factors was stratified into three groups and significantly predicted the risk of complications III–V, with a rate of 1.6%, 11.9% and 65.6% for low, moderate and high risk, respectively. Using the score, the complications risk could be predicted accurately in the validation set, without significant differences between predicted (10.4%) and observed (8.4%) risks for complications III–V (P = 0.466).

Based on four preoperative risk factors, we have developed and validated an integer-based risk score to predict postoperative severe complications after liver resection for hepatitis B-related hepatocellular carcinoma patients in high-volume surgical center. This score may contribute to preoperative risk stratification and clinical decision-making.

• Aged
• Carcinoma, Hepatocellular/surgery
• Carcinoma, Hepatocellular/virology
• Female
• Hepatectomy
• Hepatitis B/surgery
• Humans
• Liver Neoplasms/surgery
• Liver Neoplasms/virology
• Male
• Middle Aged
• Postoperative Complications/diagnosis
• Postoperative Complications/prevention & control
• Prognosis
• ROC Curve
• Risk Assessment
• Treatment Outcome

Although many studies on evaluating the safety of liver resection in obese patients have been conducted, the results remain contradictory. The aim of our study was to investigate the safety of overweight and obese patients undergoing liver resection for hepatitis B-related hepatocellular carcinoma in a large sample.

In a retrospective cohort with 1543 hepatitis B-related hepatocellular carcinoma patients, the subjects were stratified into four groups according to their body mass index(BMI): obesity(BMI≥28), overweight(BMI:24.0–27.9), normal weight(BMI:18.5–23.9) and underweight(BMI<18.5). The Dindo–Clavien classification system was used for grading complications. Clinical characteristics and operative outcomes were compared among the four groups. Risk factors for postoperative complications were evaluated by multivariate analysis.

According to the category criteria of the Working Group on Obesity in China (WGOC) criteria, 73(4.7%) obese, 412(26.7%) overweight, 982(63.6%) normal weight and 76(4.9%) underweight patients were included in our cohort. Overweight and obese patients had more preoperative comorbidities such as hypertension(P<0.001). Mortality, total complications and complications classified by Clavien system were similar among the four groups except that the underweight patients had fewer total complications. However, postoperative wound complication was more common in overweight and obese patients(6.3% vs 2.5%,P<0.001,11.0% vs 2.5%,P = 0.001). Multivariate analysis revealed that BMI was not an independently significant factor for postoperative complications.

Liver resection for obese and overweight patients is safe and BMI itself is not a risk factor for mortality and morbidity.

• Adult
• Carcinoma, Hepatocellular/complications
• Carcinoma, Hepatocellular/surgery
• Carcinoma, Hepatocellular/virology
• Female
• Hepatectomy/adverse effects
• Hepatitis B/complications
• Humans
• Liver Neoplasms/complications
• Liver Neoplasms/surgery
• Liver Neoplasms/virology
• Logistic Models
• Male
• Middle Aged
• Obesity/complications
• Perioperative Care
• Postoperative Complications/etiology
• Prognosis
• Treatment Outcome

AIM: To compare the morbidity and mortality in young and elderly hepatocellular carcinoma (HCC) patients undergoing liver resection.

METHODS: We retrospectively enrolled 1543 consecutive hepatitis B (HBV)-related HCC patients undergoing elective hepatic resection in our cohort, including 207 elderly patients (≥ 65 years) and 1336 younger patients (＜ 65 years). Patient characteristics and clinical outcomes after liver resection were compared between the two groups.

RESULTS: Elderly patients had more preoperative comorbidities and lower alanine aminotransferase and aspartate aminotransferase levels. Positive rates for hepatitis B surface antigen (P ＜ 0.001), hepatitis B e antigen (P ＜ 0.001) and HBV DNA (P = 0.017) were more common in younger patients. Overall complications and their severity classified using the Clavien system were similar in the two groups (33.3% vs 29.6%, P = 0.271). Elderly patients had a higher rate of postoperative cardiovascular complications (3.9% vs 0.6%, P = 0.001), neurological complications (2.9% vs 0.4%, P ＜ 0.001) and mortality (3.4% vs 1.2%, P = 0.035), and had more hospital stay requirement (13 d vs 12 d , P < 0.001) and more intensive care unit stay (36.7% vs 27.8%, P = 0.008) compared with younger patients. However, postoperative hepatic insufficiency was more common in the younger group (7.7% vs 3.4%, P = 0.024).

CONCLUSION: Hepatectomy can be safely performed in elderly patients. Age should not be regarded as a contraindication to liver resection with expected higher complication and mortality rates.

• Elderly
• Hepatocellular carcinoma
• Hepatectomy
• Complication
• Hepatitis B

• Adult
• Age Factors
• Aged
• Carcinoma, Hepatocellular/complications
• Carcinoma, Hepatocellular/surgery
• Comorbidity
• Female
• Hepatectomy/adverse effects
• Hepatectomy/methods
• Hepatitis B/complications
• Hepatitis B/surgery
• Hepatitis B Surface Antigens/blood
• Hepatitis B e Antigens/blood
• Humans
• Liver Neoplasms/complications
• Liver Neoplasms/surgery
• Male
• Middle Aged
• Postoperative Complications
• Retrospective Studies
• Treatment Outcome

AIM: To investigate the application of selective semi-hepatic vascular occlusion combined with low central venous pressure (LCVP) in hepatectomy, and to analyze its effect on liver and kidney function and systemic haemodynamics.

METHODS: The clinical data for 44 patients with liver diseases who underwent hepatectomy from January 2008 to January 2011 at our hospital were retrospectively analyzed. The patients were randomly divided into an experimental group (group A, n = 22) and a control group (Group B, n = 22). When patients in Group A underwent hepatectomy, the central venous pressure (CVP) was controlled between 2-4 mm Hg (1 mmHg = 0.133 kPa) and blood pressure ≥ 90 mmHg, and selective semi-hepatic vascular occlusion was performed. Conventional surgical treatment was given to patients in group B. Intraoperative blood loss, blood pressure, heart rate, changes in liver and kidney function, postoperative hospital stay, and postoperative complications were compared between the two groups.

RESULTS: Intraoperative blood loss was significantly lower in group A than in group B (350.2 mL ± 175.4 mL vs 450.3 mL ± 135.1 mL, P < 0.05). Serum alanine aminotransferase (ALT) was significantly better in group A than in group B on postoperative days 1 and 3 (day 1: 514.3 U/L ± 215.6 U/L vs 720.2 U/L ± 350.7 U/L, P < 0.05; day 3: 360.1 U/L ± 146.4 U/L vs 489.1 U/L ± 231.5 U/L, P < 0.05). Serum albumin (ALB) on postoperative day 1 was significantly higher in group A than in group B (37.5 g/L ± 2.2 g/L vs 35.4 g/L ± 3.9 g/L, P < 0.05). There were no statistical differences in intraoperative blood pressure (131.1 mmHg ± 18.8 mmHg vs 129.2 mmHg ± 14.7 mmHg, P > 0.05), heart rate (83.1 times/min ± 11.2 times/min vs 75.4 times/min ± 12.3 times/min, P > 0.05), postoperative renal function (P > 0.05), hospital stay (11.3 d ± 2.4 d vs 12.1 d ± 2.2 d, P > 0.05) or rate of complications (18.2% vs 22.7%, P > 0.05) between the two groups.

CONCLUSION: During hepatectomy, selective semi-hepatic vascular occlusion combined with low central venous pressure is effective in reducing intraoperative blood loss, protecting liver function, reducing ischemia-reperfusion injury, and has no significant influence on renal function, postoperative hospital stay and systemic hemodynamics.

• Liver
• Hepatectomy
• Central venous pressure