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Background: Postoperative liver failure (PLF) is a severe complication after major liver resection (MLR). To increase the safety of patients, clinical bedside tests are of great importance. However, limitations of their applicability and validity impair their value. Methods: Preoperative measurements of the liver maximum capacity (LiMAx) were performed in n = 40 patients, who underwent MLR (≥3 segments). Matched postoperative LiMAx was measured in n = 21 patients. Liver function was compared between pretreated patients (n = 11 with portal vein embolisation (PVE) and n = 19 patients with preoperative chemotherapy) and therapy naïve patients. The LiMAx values were compared with liver-specific blood parameters and volumetric analysis. Results: In total, n = 40 patients were enrolled in this study. The majority of patients (n = 33; 82.5%) had high preoperative LiMAx values (>315 µg/kg/h), while only seven patients (17.5%) had medium values (140–315 µg/kg/h), and none of the patients had low values (<140 µg/kg/h). A comparison of pretreated patients (with PVE and/or chemotherapy) and therapy naïve patients showed no significant difference in the preoperative LiMAx values (p > 0.05). The preoperative LiMAx values were significantly higher than the matched postoperative values on postoperative day 1 (p < 0.0001). A comparison between the expected and measured postoperative LiMAx showed a difference (≥10%) in 7 out of 13 patients (53.8%). After an initial postoperative decrease in the LiMAx, the patients without complications (n = 12) showed a continuous increase until 14 days after surgery. In the patients with postoperative complications, a decrease in the LiMAx was associated with a prolonged recovery. Conclusions: For patients undergoing MLR within the 0.5% rule, which is the clinical gold standard, the LiMAx values do not offer any additional information. Additionally, the LiMAx may have reflected liver function, but it did not deliver additional information regarding postoperative liver recovery. The clinical use of LiMAx might be relevant in selected patients beyond the 0.5% rule. [ABSTRACT FROM AUTHOR]

(1) Background: Advancements in the field of liver surgery have led to a critical need for precise estimations of preoperative liver function to prevent post-hepatectomy liver failure (PHLF), a significant cause of morbidity and mortality. This study introduces a novel application of artificial intelligence (AI) in determining safe resection volumes according to a patient's liver function in major hepatectomies. (2) Methods: We incorporated a deep learning approach, incorporating a unique liver-specific loss function, to analyze patient characteristics, laboratory data, and liver volumetry from computed tomography scans of 52 patients. Our approach was evaluated against existing machine and deep learning techniques. (3) Results: Our approach achieved 68.8% accuracy in predicting safe resection volumes, demonstrating superior performance over traditional models. Furthermore, it significantly reduced the mean absolute error in under-predicted volumes to 23.72, indicating a more precise estimation of safe resection limits. These findings highlight the potential of integrating AI into surgical planning for liver resections. (4) Conclusion: By providing more accurate predictions of safe resection volumes, our method aims to minimize the risk of PHLF, thereby improving clinical outcomes for patients undergoing hepatectomy. [ABSTRACT FROM AUTHOR]

The preoperative risk assessment of liver resections (LR) is still an open issue. Liver parenchyma characteristics influence the outcome but cannot be adequately evaluated in the preoperative setting. The present study aims to elucidate the contribution of the radiomic analysis of non-tumoral parenchyma to the prediction of complications after elective LR. All consecutive patients undergoing LR between 2017 and 2021 having a preoperative computed tomography (CT) were included. Patients with associated biliary/colorectal resection were excluded. Radiomic features were extracted from a virtual biopsy of non-tumoral liver parenchyma (a 2 mL cylinder) outlined in the portal phase of preoperative CT. Data were internally validated. Overall, 378 patients were analyzed (245 males/133 females—median age 67 years—39 cirrhotics). Radiomics increased the performances of the preoperative clinical models for both liver dysfunction (at internal validaton, AUC = 0.727 vs. 0.678) and bile leak (AUC = 0.744 vs. 0.614). The final predictive model combined clinical and radiomic variables: for bile leak, segment 1 resection, exposure of Glissonean pedicles, HU-related indices, NGLDM_Contrast, GLRLM indices, and GLZLM_ZLNU; for liver dysfunction, cirrhosis, liver function tests, major hepatectomy, segment 1 resection, and NGLDM_Contrast. The combined clinical-radiomic model for bile leak based on preoperative data performed even better than the model including the intraoperative data (AUC = 0.629). The textural features extracted from a virtual biopsy of non-tumoral liver parenchyma improved the prediction of postoperative liver dysfunction and bile leak, implementing information given by standard clinical data. Radiomics should become part of the preoperative assessment of candidates to LR. [ABSTRACT FROM AUTHOR]

Background: Postoperative liver failure (PLF) is a severe complication after major liver resection (MLR). To increase the safety of patients, clinical bedside tests are of great importance. However, limitations of their applicability and validity impair their value. Methods: Preoperative measurements of the liver maximum capacity (LiMAx) were performed in n = 40 patients, who underwent MLR (≥3 segments). Matched postoperative LiMAx was measured in n = 21 patients. Liver function was compared between pretreated patients (n = 11 with portal vein embolisation (PVE) and n = 19 patients with preoperative chemotherapy) and therapy naïve patients. The LiMAx values were compared with liver-specific blood parameters and volumetric analysis. Results: In total, n = 40 patients were enrolled in this study. The majority of patients (n = 33; 82.5%) had high preoperative LiMAx values (>315 µg/kg/h), while only seven patients (17.5%) had medium values (140–315 µg/kg/h), and none of the patients had low values (p > 0.05). The preoperative LiMAx values were significantly higher than the matched postoperative values on postoperative day 1 (p < 0.0001). A comparison between the expected and measured postoperative LiMAx showed a difference (≥10%) in 7 out of 13 patients (53.8%). After an initial postoperative decrease in the LiMAx, the patients without complications (n = 12) showed a continuous increase until 14 days after surgery. In the patients with postoperative complications, a decrease in the LiMAx was associated with a prolonged recovery. Conclusions: For patients undergoing MLR within the 0.5% rule, which is the clinical gold standard, the LiMAx values do not offer any additional information. Additionally, the LiMAx may have reflected liver function, but it did not deliver additional information regarding postoperative liver recovery. The clinical use of LiMAx might be relevant in selected patients beyond the 0.5% rule.

Background: Surgical resection, where appropriate, remains one of the best treatment options for hepatocellular carcinoma (HCC), however outcomes can be compromised by the development of liver failure. We reviewed our experience of liver resection for HCC patients to identify factors that may predict the development of post-hepatectomy liver failure (PHLF) and survival.Methods: A single centre retrospective cohort study. Data was collected between 1999 and 2017 from all patients undergoing HCC resection in a tertiary university hospital from electronic medical records. PHLF was defined as per the International Study Group for Liver Surgery criteria. Variables with p < 0.15 on univariate analysis were included in a multivariate binary logistic regression model. Kaplan-Meier analyses were used to determine correlations with overall survival (OS) and disease-free survival (DFS), and variables with p < 0.15 on univariate analysis selected for a step-down Cox proportional hazard regression model.Results: Overall, 120 patients underwent liver resection within the study period, of which 22 (18%) developed PHLF. Patients with normal INR ≤1.20 at day 2 did not develop PHLF whereas patients with INR >1.60 were at significant risk. Resection of multiple tumours (odds ratio 21.63, p = 0.002) and deranged postoperative day 2 INR>1.6 (odds ratio 21.05, p < 0.0001) were identified as independent prognostic markers of PHLF.Conclusion: The use of INR measurement at day 2 predicts PHLF and may enable us to objectively identify and stratify patients who may be eligible for enhanced recovery programs from those who will merit close monitoring in high dependency areas. [ABSTRACT FROM AUTHOR]

Post-hepatectomy liver failure (PHLF) is the main cause of perioperative death after hepatocellular carcinoma (HCC) resection. PHLF occurrence is related to both the hepatectomy volume and the degree of cirrhosis. Accurate preoperative assessment of the degree of cirrhosis may aid in reducing the incidence of PHLF. Several studies have shown that the liver stiffness measurement (LSM) is well correlated with cirrhosis. This study explored the relationship between LSM and PHLF occurrence after radical HCC resection and the effect on long-term prognosis. We retrospectively analyzed the clinical data of 164 patients who underwent radical HCC resection at our center from January 2017 to January 2020. The related postoperative PHLF factors were analyzed. The LSM threshold in postoperative PHLF was calculated through receiver operating characteristic (ROC) curve analysis. Patients were grouped according to different LSM thresholds and survival analysis was performed. Forty-six patients experienced PHLF, of whom 19, 21, and 6 were classified as grades A, B, and C, respectively. Multivariate analysis indicated that LSM was an independent risk factor for PHLF after HCC surgery (OR = 1.174, P < 0.000). LSM (OR = 1.219, P < 0.000) and intraoperative bleeding (OR = 1.001, P = 0.047) were risk factors for grade B-C PHLF. The LSM threshold that predicted PHLF occurrence was 17.9 kPa (AUC = 0.831, P < 0.000) and 24.5 kPa (AUC = 0.867, P < 0.000) for grade B-C PHLF. LSM was correlated with PHLF severity (r = 0.439, P < 0.001). The median survival times were 32 vs 26 months (P = 0.016) for patients with LSM ≤ 17.9 kPa vs those with LSM > 17.9 kPa and 28 vs 24 months (P = 0.004) for patients with LSM ≤ 24.5 kPa vs those with LSM > 24.5 kPa. LSM is related to PHLF occurrence in patients undergoing HCC resection; a higher LSM is associated with the occurrence of more severe PHLF after surgery. In addition, LSM may aid in predicting long-term survival after liver resection in patients with HCC. [ABSTRACT FROM AUTHOR]

Introduction and Objectives: The fibrosis score 4 (FIB-4) has been identified as a biochemical surrogate for histological fibrogenesis and fibrosis in cirrhosis. This study investigates the impact of preoperative FIB-4 on postoperative liver failure of patients with hepatocellular carcinoma (HCC). Materials and methods: Data from 205 patients who underwent curative resection for HCC were retrospectively analyzed. The receiver operating characteristic (ROC) curve analysis was performed to determine the cutoff value of the FIB-4. Univariate analysis and multivariate analysis were performed to identify risk factors for postoperative liver failure. The clinical outcomes were compared between patients with high FIB-4 and low FIB-4. Results: The optimal cutoff value of the FIB-4 was set at 5.92 for postoperative liver failure according to ROC curve. By univariate and multivariate analysis, the number of resected segments, FIB-4, and model for end-stage liver disease score were identified as independent risk factors for postoperative liver failure. Patients with preoperative FIB-4 > 5.92 had poorer liver function and higher occurrence of postoperative liver failure. Conclusions: Preoperative FIB-4 was associated with postoperative liver failure. Patients with preoperative FIB-4 > 5.92 carry a high risk of postoperative liver failure.

Background: The role of ligation of the portal venous branches to the caudate lobe (cPVL) as preparation for planned major hepatectomy is unclear. The aim of this study was to evaluate the efficacy of laparoscopic cPVL (Lap-cPVL) concomitant with transileocolic portal vein embolization of the right portal venous system (rTIPE), namely, Lap-cPVL/rTIPE, for planned right hemihepatectomy (rHx) in advanced hepatobiliary cancer patients. Methods: Thirty-one patients who underwent rHx after rTIPE with/without Lap-cPVL between March 2013 and March 2020 were enrolled in this study. The Lap-cPVL was performed for the portal branches of the right caudate lobe. Results: Eight of the 31 patients underwent Lap-cPVL/rTIPE. The degree of hypertrophy was significantly increased in Lap-cPVL/rTIPE (19.3%, range 6.5–25.6%) as compared to rTIPE (7.2%, range - 1.1 to 21.2%) (p=0.027). The functional kinetic growth rate was also significantly increased in Lap-cPVL/rTIPE (5.40%, range 2.17–5.97) than that in rTIPE (1.85%, range - 0.22 to 6.45%) (p=0.046). Postoperative liver failure ≧ grade B occurred in 21.7% of patients in rTIPE, while there was no postoperative liver failure ≧ grade B in Lap-cPVL/rTIPE. Mortality rates were zero after rHx in this study. Conclusions: Lap-cPVL/rTIPE is safe and provides an additional effect on liver hypertrophy in advanced hepatobiliary cancers. [ABSTRACT FROM AUTHOR]

Background: Previous studies demonstrated that liver function in a veno-occlusive region is approximately 40% of that in a non-veno-occlusive region after hepatectomy with excision of major hepatic vein. We validated the preoperative assessment of future remnant liver (FRL) function based on 40% decreased function of the veno-occlusive region. Methods: Sixty patients who underwent hepatectomy with excision of major hepatic vein were analyzed. The FRL functions of the veno-occlusive and non-veno-occlusive regions were calculated with 99mTc–galactosyl human serum albumin scintigraphy single-proton emission computed tomography fusion system and SYNAPSE VINCENT® preoperatively. Risk assessment for hepatectomy was evaluated based on indocyanine green retention at 15 min, and patients with insufficient FRL function were described as marginal. Results: The median volume and function of the veno-occlusive region per whole liver were 111 ml and 11.0%, respectively. When the function of the veno-occlusive region was presumed as 0%, 40%, and 100%, the FRL function was 62.5%, 68.4%, and 75.0% and 21, 15, and 7 patients were classified as marginal, respectively. When the function of the veno-occlusive region was presumed as 40%, the posthepatectomy liver failure (PHLF) rate of marginal patients was significantly higher than that of safe patients (46.7% vs 8.9%, P = 0.002). Multivariable analysis indicated that marginal FRL function based on 40% decreased function of the veno-occlusive region was the only independent risk factor for PHLF (odds ratio 8.97, P = 0.002) after extended hepatectomy. Conclusion: Assessment of preoperative FRL function based on 40% decreased function of the veno-occlusive region may have high validity. [ABSTRACT FROM AUTHOR]

Background and Aims: The Child-Pugh (CP) score is a widely used method to assess liver function and predict postoperative outcomes in patients with hepatocellular carcinoma (HCC). Recently, the fibrosis index (FIB-4) has been demonstrated to be closely associated with liver fibrosis and cirrhosis. This study aimed to compare the capability of FIB-4 index with CP score in predicting the outcomes for HCC patients after hepatectomy.Methods: A total of 495 HCC patients who underwent hepatectomy were enrolled. The performance of the FIB-4 index in predicting postoperative liver failure (PHLF) and overall survival was compared with that of the CP score.Results: Of them, 9.3% (46/495) patients developed PHLF. The area under the receiver operating characteristic (ROC) curve of the FIB-4 index for predicting PHLF was greater than that of the CP score (0.744 versus 0.621; P = 0.044). The optimal cutoff value of the FIB-4 index for predicting PHLF was 4.16. Multivariable analyses revealed that the FIB-4 index was an independent predictor of PHLF regardless of the hepatectomy subgroups, but the CP grade was only a significant predictor of PHLF in the minor hepatectomy subgroup. The FIB-4 index (4.16) stratified patients into two distinct overall survival cohorts (P = 0.006). The FIB-4 index also classified patients with the Barcelona Clinical Liver Cancer (BCLC) stages 0 and A into two distinct overall survival cohorts (P = 0.001 and P = 0.034, respectively).Conclusion: The FIB-4 index may be a better predictor of PHLF and overall survival in HCC patients with hepatectomy than CP score. [ABSTRACT FROM AUTHOR]

Abstract Background Aggressive hepatectomy with venous resection has a higher risk of postoperative liver failure (POLF) than hepatectomy without venous reconstruction; however, venous reconstruction is technically demanding. We performed a novel two-stage hepatectomy (TSH) without venous reconstruction in a patient with bilobar multiple colorectal liver metastases located near the caval confluence, waiting for the development of intrahepatic venous collaterals between procedures. Case presentation A 60-year-old man was referred to our hospital with sigmoid colon cancer accompanied by intraabdominal abscess and two synchronous liver metastases. One of the liver tumors (tumor 1) was located in segment 8 near the caval confluence and was attached to both the right hepatic vein (RHV) and middle hepatic vein (MHV). The other tumor (tumor 2) in the left lobe invaded the umbilical portion of the portal vein. Both liver metastases decreased in size after four cycles of panitumumab/5-fluorouracil, leucovorin, and oxaliplatin (FOLFOX) therapy. Radical liver resection was planned because tumor 1 had not invaded the MHV. However, three-dimensional volumetric software showed that the non-congested volume of the future liver remnant was estimated at 354 ml, which corresponded to 26.3% of the total liver volume. TSH was scheduled to avoid POLF. We first performed limited resection of segment 8 with resection of the RHV root. After the first hepatectomy, the development of intrahepatic venous collaterals between the RHV and MHV was seen on computed tomography and magnetic resonance imaging. The estimated non-congested future liver remnant was 1242 ml, 78.5% of the total liver volume. Therefore, the patient underwent left hemihepatectomy 58 days after the first hepatectomy. We saw no adhesions around the porta hepatis, and the left hepatic artery and left branch of the portal vein were safely exposed and divided. Intraoperative Doppler ultrasonography revealed intrahepatic venous collaterals arising from RHV to MHV. The patient’s postoperative course was uneventful, and he underwent eight cycles of panitumumab/FOLFOX therapy for 5 months after the second hepatectomy. Conclusions Our TSH strategy helped avoid POLF by waiting for the development of intrahepatic venous collaterals.

Aim: To elucidate the clinical factors having an impact on liver regeneration rate following preoperative portal vein embolization (PVE) and subsequent extended hepatectomy. The correlation between liver volume and functional recovery after extended hepatectomy was also investigated. Methods: Records of patients who underwent extended hepatectomy with extrahepatic bile duct resection following PVE for perihilar cholangiocarcinoma were reviewed retrospectively with attention to liver regeneration. All patients underwent computed tomography before PVE, after PVE (immediately before surgery), and on postoperative day (POD) 7. The kinetic growth rate (KGR) was calculated as the percent increase in liver volume relative to the future liver remnant volume per day after PVE (KGRPVE) and after POD 7 (KGRPOD7) using the computed tomography images before PVE, after PVE, and on POD 7. Results: In the 289 study patients, the median of KGRPVE was 1.35%/day whereas that of KGRPOD7 was 5.56%/day. The extent of liver resection had the greatest impact on both KGRPVE and KGRPOD7 and the impacts of other factors were less. There was a significant negative correlation between KGRPVE and KGRPOD7 (P = 0.002). No correlations were observed between KGRPVE or KGRPOD7 and serum total bilirubin and prothrombin time – international normalized ratio on POD 7, nor in the incidence of liver failure after surgery. Conclusions: Early phase liver regeneration after extended hepatectomy was largely influenced by the extent of liver resection and showed no correlation with the indices of liver failure. There was a discrepancy between volume and functional recovery in early phase liver regeneration. [ABSTRACT FROM AUTHOR]

Background: Post-hepatectomy liver failure (PHLF) is a serious complication after major hepatectomy with extrahepatic bile duct resection (Hx with EBDR) that may cause severe morbidity and even death. The purpose of this study was to compare several criteria systems as predictors of PHLF-related mortality following Hx with EBDR for perihilar cholangiocarcinoma (PHCC). Methods: The study cohort consisted of 222 patients who underwent Hx with EBDR for PHCC. We compared several criteria systems, including previously established criteria (the International Study Group of Liver Surgery (ISGLS) criterion; and the "50-50" criterion), and our institution's novel systems "Max T-Bili" defined as total bilirubin (T-Bili) >7.3 mg/dL during post-operative days (POD) 1–7, and the "3-4-50" criterion, defined as total bilirubin >4 mg/dL and prothrombin time <50% on POD #3. Results: Thirteen patients (5.8%) died from PHLF-related causes. The 3-4-50 criterion showed high positive predictive values (39.1%), the 3-4-50, Max T-Bili, and 50-50 criterion showed high accuracies (91.7, 86.9, and 90.5%, respectively) and varying sensitivities (69.2, 69.2, and 38.5% respectively). Conclusions: The 3-4-50, Max T-Bili, and 50-50 criterion were all useful for predicting PHLF-related mortality after Hx with EBDR for PHCC. [ABSTRACT FROM AUTHOR]

ALPPS (associating liver partition and portal vein ligation for staged hepatectomy) is a new surgical technique for patients in whom conventional treatment is not feasible due to insufficient future remnant liver (FRL). During the first stage of ALPPS, accelerated hypertrophy of the FRL is induced by ligation of the portal vein and in situ split of the liver. In the second stage, the deportalized liver is removed when the FRL volume has reached ≥25% of total liver volume. However, FRL volume does not necessarily reflect FRL function. 99mTc-mebrofenin hepatobiliary scintigraphy (HBS) with SPECT-CT is a quantitative test enabling regional assessment of parenchymal uptake function using a validated cut-off value for the prediction of postoperative liver failure (2.7%/min/m2). This paper describes the changes in FRL function and FRL volume in a 79-year-old patient diagnosed with metachronous colonic liver metastases who underwent ALPPS. We have observed a substantial difference between the increase in FRL volume and FRL function suggesting that HBS with SPECT-CT enables monitoring of the FRL function and could be a useful tool in the timing of resection in the second stage of the ALPPS procedure.

Background: In biliary tract cancer treatment, a precise preoperative evaluation of the patient's liver function is essential to avoid post-hepatectomy liver failure (PHLF) and mortality. The present study aimed to evaluate the role of the Albumin-Indocyanine Green Evaluation (ALICE) grading system in predicting PHLF in biliary tract cancer patients. Methods: Data from 166 patients who underwent hepatectomy for biliary tract cancer between 2000 and 2016 were retrospectively analyzed. Univariate and multivariate analyses were performed to identify the risk factors for PHLF. Results: Among the 166 patients, major hepatectomy was performed in 101 (61%) and bile duct resection was performed in 99 (60%) patients. Thirteen (8%) patients developed PHLF. Furthermore, PHLF, major complications, and mortality were significantly higher in patients with high ALICE grades (≥2b) than in those with low ALICE grades (<2b) (PHLF, 42 vs. 18%, p = 0.002; major complications, 35 vs. 19%, p = 0.036; mortality, 9.3 vs. 0%, p = 0.001). In multivariate analysis, high ALICE grade (p = 0.016) and blood loss ≥1,500 mL (p = 0.009) were identified as independent risk factors for PHLF. Conclusions: The ALICE grading system effectively stratified the risks for PHLF for biliary tract cancer. [ABSTRACT FROM AUTHOR]

Introduction: Postoperative liver failure (POLF) is a relevant cause of morbimortality after liver surgery. An insufficient future liver remnant (FLR) is one of the main causes of POLF. The association of hepatic bipartition with portal ligation for 2-stage hepatectomy (ALPPS) is a relatively new technique that induces rapid parenchymal hypertrophy reducing the waiting time to achieve adequate FLR. Our aim is to communicate the experience and the initial results of the hepatectomy in 2-stages using the ALLPS technique. Material and Method: All patients in whom a 2-stage hepatectomy using ALPPS technique between June 1, 2014 and July 31, 2016 in the Digestive Surgery Unit of the Hospital Regional of Talca were included. Results: There were 47 hepatectomies performed at the Hospital Regional of Talca. In 3 cases (6.3%), a 2-stage hepatectomy was performed using the ALPPS technique, in all of which a hypertrophy of the future hepatic remnant (RHF) was achieved, which allowed completing the second stage without POLF clinically significant. Conclusion: In our initial experience, the ALPPS technique successfully allowed increase FLR in patients who initially had insufficient FLR to be submitted a major liver resection. [ABSTRACT FROM AUTHOR]

Surgery-related morbidity has been identified as prognostic risk factor for tumor recurrence for several tumor types, but data regarding hepatocellular carcinoma (HCC) are limited and controversial. The aim of this study was to analyze the impact of surgical complications on the risk of HCC recurrence after hepatic resection (HR). A Retrospective study was conducted on a cohort of patients submitted to HR in a tertiary teaching hospital, between January 2006 and December 2015. 112 patients were submitted to HR during the study period. Cirrhosis was present in 84% of cases, with portal hypertension in 19.6%. The median MELD score was 8 (range 6-15). The median number of lesions per patient was 1 (range 1-5) with a mean diameter of 5.4 ± 3.8 cm. Major HR were performed in 18.2% of cases. Overall post-op morbidity was 48.2% with Clavien-Dindo (CD) severity score ≥3 in 15.2% of cases. The most frequent complications were infected biloma (19.6%) and liver failure (14%). HCC recurred in 48% of patients. At univariate analysis overall post-op complications (HR 2.313, p = 0.003), CD score >2 (HR 2.075, p = 0.047), post-op liver failure (HR 2.990, p = 0.007), post-op iperbilirubinemia (HR 1.151, p = 0.049), post-op bleeding (HR 2.633, p < 0.001) and infected biloma (HR 2.696, p = 0.001) were risk factors for HCC recurrence. At multivariate analysis post-op liver failure (HR 4.081, p < 0.0001) and infected biloma (HR 2.971, p < 0.0001) maintained statistical significance for HCC recurrence. Thus Major surgical complications after HR, especially post-op liver failure and infected biloma are risk factors for HCC recurrence. [ABSTRACT FROM AUTHOR]

Background: Cirrhosis increases a patient's risk of developing postoperative liver failure (PLF). Liver stiffness (LS), assessed by two-dimensional shear wave elastography (SWE), indicates liver fibrosis with high accuracy. Whether LS is superior to portal hypertension (PHT) in predicting PLF remains to be studied.Methods: The study enrolled 280 patients who underwent hepatectomy for hepatocellular carcinoma from July 2015 to July 2016. All patients received preoperative assessments for LS, PHT, and serum markers of liver fibrosis in addition to other clinicopathological tests. Risk factors for grade A and grade B (or greater) PLF were subjected to univariate and multivariate analysis and receiver operating characteristic curve analysis.Results: Fifty-five patients (19.6%) experienced PLF. The cutoff value of LS for predicting cirrhosis was 10.1 kPa. Multivariate analysis identified LS, hyaluronic acid, IV collagen, and the presence of splenomegaly as independent predictors of PLF. The cutoff value of LS for predicting PLF and grade B (or greater) PLF was 11.75 and 11.9 kPa, respectively. LS was superior to PHT in predicting PLF or greater than grade B PLF (0.72 vs. 0.60, 0.76 vs. 0.59, P < 0.05).Conclusion: LS measured by SWE can predict risk of PLF with greater accuracy than PHT. [ABSTRACT FROM AUTHOR]

Purpose: Post-hepatectomy liver failure (PHLF) is the major risk factor for mortality after hepatectomy. Preoperative planning of the future liver remnant volume reduces PHLF rates; however, future liver remnant function (FLR-F) might have an even stronger predictive value. In this preliminary study, we used a new method to calculate FLR-F by the LiMAx test and computer tomography-assisted volumetric-analysis to visualize liver function changes after portal vein embolization (PVE) before extended hepatectomy. Methods: The subjects included patients undergoing extended right hepatectomy either directly (NO-PVE group) or after PVE (PVE group). Computed tomography (CT) scan and liver function tests (LiMAx) were done before PVE and preoperatively. FLR-F was calculated and correlated with the postoperative liver function. Results: There were 12 patients in the NO-PVE group and 19 patients in the PVE group. FLR-F and postoperative liver function correlated significantly in both groups ( p = 0.036, p = 0.011), although postoperative liver function was slightly overestimated, at 32 and 45 µg/kg/min, in the NO-PVE and PVE groups, respectively. LiMAx value did not change after PVE. Conclusions: Volume-function analysis using LiMAx and CT scan enables us to reliably predict early postoperative liver function. Global enzymatic liver function measured by the LiMAx test did not change after PVE, confirming that liver function distribution in the liver stays constant after PVE. An overestimation of FLR-F is needed to compensate for the intraoperative liver injury that occurs in patients undergoing extended hepatectomy. [ABSTRACT FROM AUTHOR]

Summary background data: Hepatic sinusoidal dilatation (SD) is a histopathological entity that occurs in up to 75% of patients undergoing oxaliplatin-based chemotherapy for colorectal liver metastases (CRLM). Objective: To study the influence of SD on outcome after partial hepatectomy in patients with CRLM. Methods: Medline, Embase, CENTRAL, LILACS and C1NAHL were searched for studies published between 01.01.2004 and 09.06.2015 with keywords: "sinusoidal obstruction syndrome", "hepatic veno-occlusive disease", and "Stuart-Bras syndrome". Studies comprising adults who underwent partial hepatectomy for CRLM with grading of SD and registration of postoperative morbidity and/or mortality were included. Risk of bias and quality of studies were evaluated with the Quality In Prognosis Studies Instrument (QUIPS) and modified GRADE framework. Results: Search strategies produced 2007 hits from which 23 and 13 articles were extracted for qualitative and quantitative analyses, respectively. Meta-analysis on the influence of SD grade 2 -3 vs. SD grade 0-1 on postoperative overall morbidity showed an odds ratio (OR) of 1.26 [95% Cl 0.74, 2.15](p = 0.40), an OR of 1.03 [0.15, 6.89l(p = 0.98) for liver failure, an OR of 1.21 [0.23,6.35](p = 0.82) for overall mortality, and an OR of 3.52 [0.31, 39.91 ](p = 0.31) for liver-related morbidity. QUIPS showed a low to high risk of bias for studies, and GRADE showed very low quality of evidence per outcome. Conclusions: No significant effect of SD grade 2 -3 on short-term outcome after partial hepatectomy was found. However, the data on which this conclusion was based were not very robust and therefore no solid conclusions could be drawn. [ABSTRACT FROM AUTHOR]

Background We intended to determine the usefulness of gadoxetic acid-enhanced magnetic resonance (MR) imaging on preoperative prediction of the risk of postoperative liver failure (PLF) using measurement of relative liver enhancement (RLE) in patients who underwent surgical resection of hepatocellular carcinoma (HCC). Methods A total of 121 HCC patients who had underwent gadoxetic acid-enhanced MRI before surgery between January 2012 and April 2015 at our hospital was retrospectively analyzed. RLE was calculated as the ratio of signal intensity measurements of the liver parenchyma in each liver segment before and 20 min after intravenous administration of gadoxetic acid. PLF was defined based on the '50-50 criteria' (prothrombin time <50% and serum bilirubin >5 mg/dL on 5 days after surgery). Results Of the 121 patients, 74 (61.2%) patients had liver cirrhosis, clinically. Median tumor size 2.8 cm (range, 1-14 cm), 106 (87.6%) patients had a single HCC, and 101 (83.5%) patients had HCC within Milan criteria. Based on the '50-50 criteria', PLF was observed in 7 (5.8%) patients. Mean RLE was significantly lower in patients with PLF than those without it (55.9% vs 85.5%, P < 0.01). In a multivariate analysis, decreased RLE was a significant independent risk factor for PLF in HCC patients (odds ratio 0.97, P = 0.03). Optimal cut-off RLE value was 82.36. Conclusions RLE was significantly lower in patients with PLF than those without it. Measurement of RLE using gadoxetic acid-enhanced MR imaging before surgery can be useful for prediction of PLF in HCC patients who receive surgical treatment. [ABSTRACT FROM AUTHOR]

ALPPS (associating liver partition and portal vein ligation for staged hepatectomy) is a new surgical technique for patients in whom conventional treatment is not feasible due to insufficient future remnant liver (FRL). During the first stage of ALPPS, accelerated hypertrophy of the FRL is induced by ligation of the portal vein and in situ split of the liver. In the second stage, the deportalized liver is removed when the FRL volume has reached ≥25% of total liver volume. However, FRL volume does not necessarily reflect FRL function. 99mTc-mebrofenin hepatobiliary scintigraphy (HBS) with SPECT-CT is a quantitative test enabling regional assessment of parenchymal uptake function using a validated cut-off value for the prediction of postoperative liver failure (2.7%/min/m2). This paper describes the changes in FRL function and FRL volume in a 79-year-old patient diagnosed with metachronous colonic liver metastases who underwent ALPPS. We have observed a substantial difference between the increase in FRL volume and FRL function suggesting that HBS with SPECT-CT enables monitoring of the FRL function and could be a useful tool in the timing of resection in the second stage of the ALPPS procedure. [ABSTRACT FROM AUTHOR]

Aim An accurate and noninvasive tool to predict Chemotherapy Associated Liver Injury (CALI) still lacks. Study aimed to evaluate chronic liver disease scores (Aspartate aminotransferase to Platelet Ratio Index, APRI and Fibrosis-4, FIB-4) as Postoperative Liver Failure (PLF) predictors in patients treated with Oxaliplatin for Colorectal Liver Metastases (CLM). Methods 8 patients who developed PLF after major hepatectomy (Group B) were compared to 24 patients who did not develop PLF (Group A) in a case-matched analysis for patients and disease characteristics. ROC curves analysis was performed to assess score accuracy. Results In Group A number of CT cycles was lower, (6 vs 9, p NS), interval between treatment and surgery was longer (11 vs 7 weeks, p < 0.05) and bevacizumab was more frequently administered (66.7% vs 37.5%, p < 0.05). In Group B median APRI score was 0.53 (range: 0.86–4.26) whereas in Group A was 0.30 (range: 0.06–2.21, p < 0.05). Median FIB-4 score was 2.46 (range: 0.86–13.65) in Group B and 1.58 (range: 0.27–7.68) in Group A ( p < 0.001). Multivariate analysis showed a significant correlation between APRI and the onset of PLF. A good accuracy of APRI score was evident in ROC curves with an area under the curve of 0.72 ( p 0.003). Conclusions APRI score is calculated considering both liver damage and platelet count, it is cost effective and easily available. This study demonstrates that there is a good accuracy in PLF prediction and consequently in CT induced liver damage evaluation. [ABSTRACT FROM AUTHOR]

Background: Preoperative portal vein embolization (PVE) is performed to enhance the future remnant liver function (FRLF) and volume (FRLV). However, the volume of the nonembolized liver does not increase enough in some patients, which results in an insufficient FRLF. The aim of this study was to evaluate the predictors of insufficient FRLF after PVE for extended hepatectomy. Methods: This retrospective study included 172 patients (107 patients with cholangiocarcinoma, 40 patients with metastatic liver cancer and 25 patients with hepatocellular carcinoma) who underwent PVE before extended hepatectomy. The total liver function was evaluated by measuring the indocyanine green plasma clearance rate (KICG). Computed tomography volumetry was conducted to evaluate the total liver volume and FRLV. The KICG of the future remnant liver (remK) was calculated using the following formula: KICG × FRLV/total liver volume. The safety margin for hepatectomy was set at remK after PVE (post-PVE remK) ≥0.05. Results: One hundred and twenty-three patients with a post-PVE remK level of >0.05 underwent hepatectomy without postoperative liver failure [sufficient liver regeneration (SLR) group], and 9 patients with a post-PVE remK level of <0.05 did not due to insufficient FRLF [insufficient liver regeneration (ILR) group]. In the SLR group, the KICG values did not change after PVE (median, 0.144-0.146, p = 0.523); however, the %FRLV and remK increased significantly (35.0-44.3%, p < 0.001 and 0.0488-0.0610, p < 0001, respectively). In contrast, in the ILR group, the KICG values decreased significantly (0.128-0.108, p = 0.021) and the %FRLV increased marginally (27.4-32.6%, p = 0.051). As a result, the remK did not increase significantly (0.0351-0.0365, p = 0.213). A receiver operating characteristic curve demonstrated an remK value of 0.04 obtained before PVE (pre-PVE remK) to be the optimal cutoff point for defective liver regeneration. The univariate and multivariate analyses revealed that a pre-PVE remK value of <0.04 was a factor for ILR. It was also correlated with postoperative liver failure in the analysis of the patients who underwent hepatectomy. Conclusions: The patients in the ILR group did not achieve SLR after PVE due to a significant decrease in the KICG and an insufficient increase in %FRLV. A pre-PVE remK value of <0.04 is a useful predictor of insufficient regeneration of the nonembolized liver, even after PVE. © 2013 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Surgical resection is the best option for prolonged survival in patients with primary or secondary liver tumors. A sufficient future liver remnant (FLR) volume is needed to prevent post-hepatectomy liver failure (PHLF). With the aim of increasing FLR, a new two-step technique has been recently developed. Our aim is to report our initial experience with associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) technique. Analysis was conducted of ten patients previously considered locally unresectable because of small FLR. During first surgical step liver parenchymal partition and portal vein ligation was performed. Seven days after the first procedure, once volumetric and functional studies have demonstrated an appropriate FLR volume, the resection of the deportalized hemiliver was achieved. This technique was successfully performed in all ten patients (feasibility 100 %). Six were male with mean age of 55.2 years (range 39-77). Mean preoperative FLR volume and FLR/total liver volume were 408.4 ml and 27.8 %. Mean postoperative FLR volume was 733 ml representing a mean volume increase of 325 ml or 82 % (range 31-140) ( p < 0.0001). All resections were R0 (4 right hepatectomies, 5 right trisectionectomies and 1 left trisectionectomy). There were two grade A post-hepatectomy liver failures. Morbidity was 40 % and mortality 0 %. With a mean follow-up of 187 days, disease-free survival and overall survival were 80 and 100 %, respectively. ALPPS induces a great and fast FLR hypertrophy allowing R0 resections in patients otherwise considered unresectable because of small FLR volume, without severe PHLF and low mortality in experience centers. Further experience is needed to determine long-term outcomes. [ABSTRACT FROM AUTHOR]

Introduction Enlarged hepatectomies consist of removal of five hepatic segments. Postoperative failure of the remnant liver represents the major complication related to this type of interventions. Material and method This paper presents a retrospective study upon 13 patients admitted in 1st Surgical Clinic, Tîrgu-Mureş, during January, 1st 2003-December, 31st 2010 who underwent enlarged hepatectomies for hepatic tumors. Changes in the levels of specific biological parameters were assessed. Results Patients included in our study had a favorable outcome, with a low morbidity rate and no mortality. Discussions Objective analysis of remnant hepatic volume and function, including biochemical and imagistic tests, needs to be done in order to reduce postoperative hepatic failure risk. In a certain amount of cases ligation of portal branch, followed by ipsilateral atrophy and compensatory hipertrophy is required. Conclusions Strict selection of the cases, surgical technique and team work are key points for the success of enlarged hepatectomies. [ABSTRACT FROM AUTHOR]

Postoperative liver failure (PLF) is a relatively frequent and life-threatening complication after extended liver resection. This study describes the economic burden of PLF from the hospitals' perspective and explores the role of liver function capacity. Economic data of total costs and cost distribution were analyzed for 48 patients who had participated in a prospective study with the LiMAx test, a novel test for liver function capacity. For this population, detailed individual data were available. The economic data were analyzed and adjusted for relevant covariates. In addition, economic data of 916 patients who had undergone liver resection during 2005–2007 were retrieved from the hospitals' medical controlling office for comparison. A significant difference between the costs of patients with regular recovery (25,980 Euro [95% confidence interval (95%CI) = 9,559 to 42,401]) versus patients developing PLF (82,199 Euro [95%CI = 42,812 to 121,586]; p = 0.013) was observed. The mean additional costs of PLF were 56,219 Euro. An equivalent cost difference of mortality was obtained from the analysis of 916 patients. Patients developing PLF had a decreased LiMAx of 61 µg/kg/h compared to the regular group 122 µg/kg/h ( p < 0.001) after surgery. Initial postoperative LiMAx and total costs revealed a linear correlation coefficient of r = −0.340 ( p = 0.018). PLF is a very relevant medical and economic problem. Liver function capacity does not only predict PLF but also correlates with total costs in general. [ABSTRACT FROM AUTHOR]

The preoperative assessment of liver function is extremely important for preventing postoperative liver failure and mortality after hepatic resection. Liver function tests may be divided into three types; conventional liver function tests, general scores, and quantitative liver function tests. General scores are based on selected clinical symptoms and conventional test results. Child–Turcotte–Pugh score has been the gold standard for four decades, but the Child–Turcotte–Pugh score has difficulty discriminating a good risk from a poor risk in patients with mild to moderate liver dysfunction. The model for end-stage liver disease score has also been applied to predict short-term outcome after hepatectomy, but it is only useful in patients with advanced cirrhosis. Quantitative liver function tests overcome the drawbacks of general scores. The indocyanine green retention rate at 15 minutes (ICG R15) has been reported to be a significant predictor of postoperative liver failure and mortality. The safety limit of the hepatic parenchymal resection rate can be estimated using the ICG R15, and a decision tree (known as the Makuuchi criteria) for selecting patients and hepatectomy procedures has been proposed. Hepatic resection can be performed with a mortality rate of nearly zero using this decision tree. If the future remnant liver volume does not fulfill the Makuuchi criteria, preoperative portal vein embolization should be performed to prevent postoperative liver failure. Galactosyl human serum albumin-diethylenetriamine-pentaacetic acid scintigraphy also provides data that complement the ICG test. Other quantitative liver function tests, however, require further validation and simplification. [ABSTRACT FROM AUTHOR]

Nine patients with postoperative liver failure were treated with plasma exchange (PE) or PE and continuous hemodiafiltration (CHDF), and various biochemical parameters were determined before and after treatment. Although citrate levels increased significantly after treatment compared with pretreatment levels in both the PE group and the PE + CHDF group (P < 0.0001 andP < 0.0001, respectively), the percentage of the increase in citrate levels was significantly higher in the PE group than in the PE + CHDF group (P = 0.0051). Total bilirubin (T-Bil) levels were significantly lower after treatment in both the PE and PE + CHDF groups (P < 0.0001 andP = 0.0001, respectively). There were no significant differences in T-Bil levels between the two groups (P = 0.5181). There were no significant differences in interleukin (IL)-6 levels before and after treatment in both the PE and PE + CHDF groups (P = 0.1281 and P = 0.2273, respectively). IL-18 levels were significantly lower after treatment in both the PE and PE + CHDF groups (P < 0.0001 andP = 0.0002, respectively), but there were no significant differences in the removal rate of IL-18 in both the PE and PE + CHDF groups (P = 0.8749). These results indicate that combining PE and CHDF in a series–parallel circuit is an effective modality for suppressing the elevation of blood citrate levels. This finding may have important implications for the development of an effective treatment for patients with postoperative liver failure. [ABSTRACT FROM AUTHOR]

Preoperative assessment of liver function and prediction of postoperative remaining functional liver parenchymal mass and reserve is of paramount importance to minimize surgical risk, especially in patients with hepatocellular carcinoma (HCC), the majority of whom have liver cirrhosis as a complication. We have established a decision tree for deciding the safe limit of hepatectomy based on three variables: whether ascites is present, the serum total bilirubin level, and the indocyanine green retention rate at 15 minutes (ICGR-15), an indicator of sinusoidal capillarization. In patients who show a sign of decompensated cirrhosis as reflected by an elevated bilirubin value or uncontrollable ascites, hepatectomy is not indicated. In patients without ascites and with normal bilirubin level, the ICGR-15 value becomes the main determinant for the resectability and hepatectomy procedure. Incorporation of ICGR-15 into the decision tree enables patients conventionally classified into Child–Turcotte–Pugh class A or score 5–6 to be subdivided into several groups in which various hepatectomy procedures are feasible: enucleation, limited resection, segmentectomy, mono- to bisectoriectomy, and trisectriectomy. During strict application of this decision tree to 1429 consecutive hepatectomies, of which 685 were performed on HCC patients, during the last 10 years, we encountered only a single mortality. [ABSTRACT FROM AUTHOR]

Impaired hepatic blood flow is one of the causative factors in postoperative liver failure. To restore the hepatic blood flow in case of hepatic artery interruption (HAI), the effect of continuous arterial infusion of prostaglandin E1 (PGE1 ), which has a strong vasodilatory effect on vascular smooth muscles, was assessed experimentally and clinically. Twelve pigs underwent ligation and division of the hepatic artery and were divided into 2 groups. In the control group, saline was infused in the superior mesenteric artery (SMA), and in the PGE1 group, 0.02 μg/kg/min of PGE1 was infused continuously in the SMA. Hepatic oxygen delivery (HDo2 ) in the control group was 87.8 ± 8.9 ml/min before HAI and decreased to 43.1 ± 2.6 ml/min at 60 min after HAI, showing 50.9% decrease by HAI. On the contrary, HDo2 in the PGE1 group was 86.7 ± 9.1 ml/min before HAI and was 76.6 ± 12.2 ml/min at 60 min after HAI, showing only 11.6% decrease by HAI. Clinically, a 65-year-old female suffering from cholangiocellular carcinoma underwent extended left hepatic lobectomy. At operation, the branch of the hepatic artery to the anterior segment of the liver was ligated, and the right branch of the portal vein became stenotic unavoidably. Postoperatively, severe liver dysfunction developed so that continuous PGE1 infusion in the SMA was initiated at a rate of 0.01 μg/kg/min on the eighth postoperative day and continued for 9 days. Plasma exchange was performed twice concomitantly. Portal venous flow increased from 612 ml/min to 1,192 ml/min, and bile flow from external biliary drainage tube doubled by the PGE1 infusion. The liver function was ameliorated after PGE1 infusion. [ABSTRACT FROM AUTHOR]

Background/aim: Right hepatectomy and extended right hepatectomy (Rt-Hr) are identified as risk factors for the development of post-hepatectomy liver failure (PHLF). Although portal vein embolization (PVE) has made it possible to safely perform extended hepatectomy, to ensure safety, in our department, PVE is performed prior to Rt-Hr for hepatocellular carcinoma (HCC) regardless of the resection rate. This study aimed to retrospectively investigate the clinical course of PVE prior to Rt-Hr for HCC cases resected in our department and the appropriateness of our policy by clarifying complications and deaths., Patients and Methods: The target period was from 2005 to 2020. Among the HCC cases resected at our hospital, those in which PVE was performed prior to Rt-Hr were included in this study. For PHLF, the definition of the International Study Group of Liver Surgery was used. The Clavien-Dindo classification was used for postoperative complications. Perioperative mortality was defined as the overall mortality within 30 days following surgery and surgery-related deaths within 90 days following surgery., Results: A total of 79 cases were included. Rt-Hr was possible in all cases after PVE and there were no cases in which serious complications occurred after PVE. PHLF was found in 14 cases (17.7%)/5 cases (6.4%)/0 cases (0%) of Grade A/B/C, respectively. Regarding postoperative complications, there were no Grade IV, and Grade IIIa/IIIb were found in 13 cases (16.5%). There were no perioperative deaths., Conclusion: Our department's policy of performing PVE prior to all Rt-Hr was considered to be a safe and reasonable treatment strategy., (Copyright © 2022 International Institute of Anticancer Research (Dr. George J. Delinasios), All rights reserved.)

For liver tumors (primary or metastases), surgery combined with neoadjuvant, or adjuvant chemotherapy is the treatment of choice, offering long term survival time and disease-free time period (Alvarez et al., 2012) Associating liver partition and portal vein ligation, or ALPPS, it's a surgical technique that increases the future liver remnant in a short period of time, trying to avoid postoperative liver failure (PLF), and achieving R0 resections in liver malignant tumors (Alvarez et al., 2012). A 43 years old woman with colorectal liver metastases in both lobes. Colorectal surgical procedure was performed 1 year previous the liver intervention, followed by adjuvant chemotherapy. Decision of a tri-segmental hepatectomy was made to resolve the metastases. Into the surgical procedure, we evaluated the liver parenchyma, and the future liver remnant tissue was insufficient, for that reason we decided to perform ALPPS procedure. Colorectal liver metastases (CLRM) are considered the most common indication for ALPPS procedure according to the international registry. Compared with the portal vein ligation, resection rate varies from 50 to 80%, and the non-resectability disease was explained by tumor progression. Postoperative mortality rate was 5.1% in young patients (<60 years old), and 8% in general for CRLM. Oncologic outcomes represent an increased disease-free survival period and overall survival time compared with non-surgical approach. The ALPPS procedure it's an interesting approach to patients with not enough liver remnant tissue, with good oncologic results in terms of disease-free survival time, and overall survival. Appropriate selection of the patient, careful postoperative management, and a multidisciplinary approach are related with good postoperative outcomes. • ALPPS should be in the surgical armamentarium in liver metastases from colorectal neoplasms, as well hepatocarcinoma and cholangiocarcinoma. • Multidisciplinary approach in liver metastases impact in postoperative outcomes • Adequate selection of patient reflects in postoperative outcomes and prolonged disease-free survival and overall survival period. • This case report, it's the first one published in Colombia. [ABSTRACT FROM AUTHOR]

Background: Liver resection is the most effective available therapy for patients with hepatocellular carcinoma (HCC). The accurate selection of patients for surgery requires determination of technical resectability and the risk of recurrence, as well as assessment of liver function and functional reserve to avoid postoperative liver failure. Previous studies have underlined the effectiveness and reliability of the LiMAx® test to evaluate liver function preoperatively. Nevertheless, data concerning HCC evaluation are lacking., Methods: From 2014 to 2019, 92 patients with HCC underwent additional assessment of liver function using the LiMAx test prior to decision for or against liver resection. Preoperative LiMAx results were compared between cirrhotic and noncirrhotic liver. The clinical decision for surgery was evaluated applying the various liver function parameters available., Results: Forty-six patients underwent liver resection. The LiMAx results were higher in resected patients (388 vs. 322 µg/kg/h; p = 0.004). LiMAx values were an independent risk factor for the presence of liver cirrhosis in multivariate analysis. In 17 patients, surgical treatment was cancelled due to major impairment of liver function. Only 4 out of 46 resected patients presented with post-hepatectomy liver failure (PHLF) grade ≥B. Histologic assessment revealed liver cirrhosis in 10 resected patients without PHLF., Conclusion: Preoperative determination of liver function by the LiMAx test enables effective and safe patient selection for HCC resection in both cirrhotic and noncirrhotic liver., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2020 by S. Karger AG, Basel.)