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Comment on “Outcomes of curative liver resection for hepatocellular carcinoma in patients with cirrhosis” Xiao-Long Tang, Yan-Dong Miao, Deng-Hai Mi Xiao-Long Tang, The First Clinical Medical College of Lanzhou University, Lanzhou, Gansu, PR China The Second Department of Gastrointestinal Surgery, Affiliated Hospital of North Sichuan Medical College, Nanchong City, Sichuan Province, China Yan-Dong Miao, The First Clinical Medical College of Lanzhou University, Lanzhou, Gansu, PR China Deng-Hai Mi, The First Clinical Medical College of Lanzhou University, Lanzhou, Gansu, PR China Gansu Academy of Traditional Chinese Medicine, Lanzhou City, Gansu Province, China Author contributions: Xiao-Long Tang and Yan-Dong Miao designed research; Xiao-Long Tang and Yan-Dong Miao performed research; Xiao-Long Tang and Yan-Dong Miao analyzed data; Xiao-Long Tang wrote the comment; and Deng-Hai Mi revised the comment. Supported by: the Special Plan for Condition Construction of Gansu Provincial Scientific Research Institutes (Grants No. 20JR10RA432) Corresponding author: Deng-Hai Mi, MD, Gansu Academy of Traditional Chinese Medicine, Lanzhou City, Gansu Province, China. mi.dh@outlook.com Abstract The present comment to the editor is related to Omar Elshaarawy et al. Outcomes of curative liver resection for hepatocellular carcinoma in patients with cirrhosis. World J Gastroenterol 2021;13(5):424-439. Preoperative evaluation of liver reserve function in hepatocellular carcinoma (HCC) patients with cirrhosis is critical, and there is no global consensus on how to evaluate it. Through retrospective analysis, Omar Elshaarawy et al. evaluated the influence of various traditional clinical indicators on liver failure and prognosis after hepatectomy in HCC patients with cirrhosis. We suggest that we should make an effort to look for new evaluation indicators such as indocyanine green retention rate at 15 min (ICG-R15). Keywords: ICG-R15, hepatectomy, Cirrhosis, Hepatocellular carcinoma Core tip: Improper hepatectomy can lead to liver failure and even death for HCC patients with cirrhosis. The major highlight of this comment is to stress the urgency of searching and validating new predictors before hepatectomy in HCC patients with cirrhosis. TO THE EDITOR In “Outcomes of curative liver resection for hepatocellular carcinoma in patients with cirrhosis”, Omar Elshaarawy et al. assessed many traditional predictors for liver failure and prognosis in cirrhosis patients undergoing radical resection of HCC via univariate and multivariate analyses[1]. They found that the preoperative MELD score, tumor diameter, length of stay after radical resection of liver cancer, and hospital stay length are significant independent predictors of liver decompensation. Preoperative MELD score, different levels of PHLF, and postoperative HCC recurrence resection are significant independent predictors of prognosis. This research is valuable information and is helpful for doctors to improve the preoperative evaluation of HCC patients with cirrhosis. Although we appreciate this work very much, we consider that the article would have been far more interesting if the author had adopted the indocyanine green retention rate at 15 min (ICG-R15). For more details about this opinion, we are looking forward to evaluation and discussion with the authors. With the remarkable progress of surgical techniques, the methods of hepatectomy are becoming more and more radical. Improper surgery can lead to liver failure and even death. It is valuable for the surgeon to focus on verifying significant predictors of postoperative liver decompensation and prognosis. As we all know, The ICG-R15 is superior to many biochemical measures as a single assessment and has been widely used for the preoperative evaluation of hepatic functional reserve. However, the ICG-R15, a sensitive predictor of liver function reserve, was not mentioned in this study. ICG is selectively ingested by liver cells after injection, secreted by liver cells into bile, and rapidly excreted by the biliary tract[2]. ICG does not have any chemical reaction in the body and is only excreted from the liver, so that it can be a good assessment of liver function reserve. ICG-R15 can respond to the current liver function injury when there are no abnormalities in many conventional biochemical indicators. Thus it provides the necessary means for clinical prevention of surgical trauma, liver loss of blood, and other blows caused by acute liver failure. Recently, Kokudo, Takashi et al. noted that ICG R15 might enhance physicians' ability to stratify patients at risk for postoperative liver failure[3]. Furthermore, Wang, Yan-Yan et al. based on a comparative study of 185 patients, demonstrated that ICG-R15 is more reliable than the MELD score and Child-Pugh score in predicting hepatic functional reserve before hepatectomy[4]. Accurate evaluation of liver function reserve is very important for the correct treatment of HCC patients with cirrhosis. Correct preoperative evaluation is vital to patient recovery. Although no global consensus on the evaluation tool for the liver functional reserve is currently available, we feel that we should actively explore more novel and valuable predictors to adapt to the development of surgical techniques. ACKNOWLEDGEMENTS This work was supported by the Special Plan for Condition Construction of Gansu Provincial Scientific Research Institutes (Grants No. 20JR10RA432). REFERENCES 1 Elshaarawy O, Aman A, Zakaria HM, Zakareya T, Gomaa A, Elshimi E, Abdelsameea E. Outcomes of curative liver resection for hepatocellular carcinoma in patients with cirrhosis. WJGO 2021; 13: 424–439. [DOI: 10.4251/wjgo.v13.i5.424] 2 Inagaki Y, Kokudo T, Kamiya M, Uno S-N, Sato M, Kaneko J, Kokudo N, Urano Y, Hasegawa K. A novel liver-specific fluorescent anti-cancer drug delivery system using indocyanine green. Sci Rep 2019; 9: 3044. [PMID: 30816163 DOI: 10.1038/s41598-019-39269-0] 3 Kokudo T, Hasegawa K, Shirata C, Tanimoto M, Ishizawa T, Kaneko J, Akamatsu N, Arita J, Demartines N, Uldry E, Kokudo N, Halkic N. Assessment of Preoperative Liver Function for Surgical Decision Making in Patients with Hepatocellular Carcinoma. Liver Cancer 2019; 8: 447–456. [PMID: 31799202 DOI: 10.1159/000501368] 4 Wang Y-Y, Zhao X-H, Ma L, Ye J-Z, Wu F-X, Tang J, You X-M, Xiang B-D, Li L-Q. Comparison of the ability of Child-Pugh score, MELD score, and ICG-R15 to assess preoperative hepatic functional reserve in patients with hepatocellular carcinoma. J Surg Oncol 2018; 118: 440–445. [PMID: 30259515 DOI: 10.1002/jso.25184]

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05449863

May 14, 2021, 13:55

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It is difficult for doctors to accurately evaluate the prognostic factors of decompensation and productivity in clinical work due to the great differences in clinical characteristics of HCC patients.By univariate and multivariate COX analysis, the authors calculated the factors affecting postoperative liver decompensation and prognosis of patients, which provided a reference for clinicians to choose the appropriate treatment time.

Thank you very much for your comments.