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Abstract Background Hepatic vein embolization in double vein embolization (DVE) can be performed with transhepatic, transjugular or transfemoral access. This study evaluates the feasibility and technical success of using a transfemoral access for the hepatic vein embolization in patients undergoing preoperative to induce hypertrophy of the future liver remnant (FLR). Material and methods Retrospective analysis of single center cohort including 17 consecutive patients. The baseline standardized FLR was 18.2% (range 14.7–24.9). Portal vein embolization was performed with vascular plugs and glue through an ipsilateral transhepatic access. Hepatic vein embolization was performed using vascular plugs. Access for the hepatic vein was either transhepatic, transjugular or transfemoral. Technical success, number of hepatic veins embolized and complications were registered. In addition, volumetric data including degree of hypertrophy (DH) and kinetic growth rate (KGR), and resection data were registered. R: Seven of the 17 patients had transfemoral hepatic vein embolization, with 100% technical success. No severe complications were registered. In the whole cohort, the median number of hepatic veins embolized was 2 (1–6). DH was 8.6% (3.0–19.4) and KGR was 3.6%/week (1.4–7.4), without significant differences between the patients having transfemoral versus transhepatic /transjugular access (p = 0.48 and 0.54 respectively). Time from DVE to surgery was median 4.8 weeks (2.6–33.9) for the whole cohort, with one patient declining surgery, two having explorative laparotomy and one patient having change of surgical strategy due to insufficient growth. Conclusion Transfemoral access is a feasible option with a high degree of technical success for hepatic vein embolization in patients with small future liver remnants needing DVE.

Background: Hepatic vein embolization in double vein embolization (DVE) can be performed with transhepatic, transjugular or transfemoral access. This study evaluates the feasibility and technical success of using a transfemoral access for the hepatic vein embolization in patients undergoing preoperative to induce hypertrophy of the future liver remnant (FLR). Material and methods: Retrospective analysis of single center cohort including 17 consecutive patients. The baseline standardized FLR was 18.2% (range 14.7–24.9). Portal vein embolization was performed with vascular plugs and glue through an ipsilateral transhepatic access. Hepatic vein embolization was performed using vascular plugs. Access for the hepatic vein was either transhepatic, transjugular or transfemoral. Technical success, number of hepatic veins embolized and complications were registered. In addition, volumetric data including degree of hypertrophy (DH) and kinetic growth rate (KGR), and resection data were registered. R: Seven of the 17 patients had transfemoral hepatic vein embolization, with 100% technical success. No severe complications were registered. In the whole cohort, the median number of hepatic veins embolized was 2 (1–6). DH was 8.6% (3.0–19.4) and KGR was 3.6%/week (1.4–7.4), without significant differences between the patients having transfemoral versus transhepatic /transjugular access (p = 0.48 and 0.54 respectively). Time from DVE to surgery was median 4.8 weeks (2.6–33.9) for the whole cohort, with one patient declining surgery, two having explorative laparotomy and one patient having change of surgical strategy due to insufficient growth. Conclusion: Transfemoral access is a feasible option with a high degree of technical success for hepatic vein embolization in patients with small future liver remnants needing DVE. [ABSTRACT FROM AUTHOR]

OBJECTIVE: The aim in this study was to determine the efficacy of shear wave dispersion (SWD) technique for the prediction of post hepatectomy liver failure (PHLF) in patients with hepatocellular carcinoma after hepatectomy and develop an SWD based risk prediction model. METHODS & MATERIALS: We prospectively enrolled 205 consecutive patients who were scheduled to undergo hepatectomy for hepatocellular carcinoma (HCC), pre-operative SWD examination, laboratory data and some other clinicopathological tests were collected. The risk factors of PHLF were identified according to univariate and multivariate analysis, a predictive model was established based on logistic regression analyses. RESULTS: SWD examination was successfully performed in 205 patients. PHLF occurred in 51 patients (24.9%), including 37/11/3 patients with Grade A/B/C, respectively. There was a high correlation between SWD value of liver and liver fibrosis stage (r = 0.873, p < 0.05). Patients with PHLF has a higher median SWD value of liver than patients without PHLF [17.4 vs 14.7 (m/s)/kHz, p < 0.05]. The SWD value of liver, total bilirubin (TB), international normalized ratio of prothrombin time (INR) and splenomegaly were significantly related to PHLF based on the multivariate analysis. A new prediction model (PM) for PHLF was established (PM = –12.918 + 0.183× SWD + 6.668× INR +0.100×TB+1.240×splenomegaly). The optimal cutoff value of SWD for predicting PHLF was 16.7 (m/s)/kHz. The area under the curve (AUC) of the PM for PHLF was 0.833, which was higher than that of SWD, INR, Forns, FIB4, APRI (p < 0.005, respectively). CONCLUSION: SWD is a promising and reliable method for PHLF prediction in patients with HCC who were undergoing hepatectomy. Compared with SWD, Forns, APRI and FIB-4, PM demonstrate better efficacy for preoperative PHLF prediction. [ABSTRACT FROM AUTHOR]

Introduction: Post hepatectomy liver failure is the most common cause of death following major hepatic resections with a perioperative mortality rate between 40% to 60%. Various strategies have been devised to increase the volume and function of future liver remnant (FLR). This study aims to review the strategies used for volume and flow modulation to reduce the incidence of post hepatectomy liver failure. Method: An electronic search was performed of the MEDLINE, EMBASE and PubMed databases from 2000 to 2022 using the following search strategy "Post hepatectomy liver failure", "flow modulation", "small for size flow syndrome", "portal vein embolization", "dual vein embolization", "ALPPS" and "staged hepatectomy" to identify all articles published relating to this topic. Results: Volume and flow modulation strategies have evolved over time to maximize the volume and function of FLR to mitigate the risk of PHLF. Portal vein with or without hepatic vein embolization/ligation, ALPPS, and staged hepatectomy have resulted in significant hypertrophy and kinetic growth of FLR. Similarly, techniques including portal flow diversion, splenic artery ligation, splenectomy and pharmacological agents like somatostatin and terlipressin are employed to reduce the risk of small for size flow syndrome SFSF syndrome by decreasing portal venous flow and increasing hepatic artery flow at the same time. Conclusion: The current review outlines the various strategies of volume and flow modulation that can be used in isolation or combination in the management of patients at risk of PHLF. [ABSTRACT FROM AUTHOR]

Abstract Background Post hepatectomy liver failure (PHLF) remains a significant risk in patients undergoing curative liver resection for cancer, however currently available PHLF risk prediction investigations are not sufficiently accurate. The Hepatectomy risk assessment with functional magnetic resonance imaging trial (HEPARIM) aims to establish if quantitative MRI biomarkers of liver function & perfusion can be used to more accurately predict PHLF risk and FLR function, measured against indocyanine green (ICG) liver function test. Methods HEPARIM is an observational cohort study recruiting patients undergoing liver resection of 2 segments or more, prior to surgery patients will have both Dynamic Gadoxetate-enhanced (DGE) liver MRI and ICG testing. Day one post op ICG testing is repeated and R15 compared to the Gadoxetate Clearance (GC) of the future liver remnant (FLR-GC) as measure by preoperative DGE- MRI which is the primary outcome, and preoperative ICG R15 compared to GC of whole liver (WL-GC) as a secondary outcome. Data will be collected from medical records, biochemistry, pathology and radiology reports and used in a multi-variate analysis to the value of functional MRI and derive multivariant prediction models for future validation. Discussion If successful, this test will potentially provide an efficient means to quantitatively assess FLR function and PHLF risk enabling surgeons to push boundaries of liver surgery further while maintaining safe practice and thereby offering chance of cure to patients who would previously been deemed inoperable. MRI has the added benefit of already being part of the routine diagnostic pathway and as such would have limited additional burden on patients time or cost to health care systems. (Hepatectomy Risk Assessment With Functional Magnetic Resonance Imaging - Full Text View - ClinicalTrials.gov , n.d.) Trial registration ClinicalTrials.gov, ClinicalTrials.gov NCT04705194 - Registered 12th January 2021 – Retrospectively registered

IntroductionPost hepatectomy liver failure is the most common cause of death following major hepatic resections with a perioperative mortality rate between 40% to 60%. Various strategies have been devised to increase the volume and function of future liver remnant (FLR). This study aims to review the strategies used for volume and flow modulation to reduce the incidence of post hepatectomy liver failure.MethodAn electronic search was performed of the MEDLINE, EMBASE and PubMed databases from 2000 to 2022 using the following search strategy “Post hepatectomy liver failure”, “flow modulation”, “small for size flow syndrome”, “portal vein embolization”, “dual vein embolization”, “ALPPS” and “staged hepatectomy” to identify all articles published relating to this topic.ResultsVolume and flow modulation strategies have evolved over time to maximize the volume and function of FLR to mitigate the risk of PHLF. Portal vein with or without hepatic vein embolization/ligation, ALPPS, and staged hepatectomy have resulted in significant hypertrophy and kinetic growth of FLR. Similarly, techniques including portal flow diversion, splenic artery ligation, splenectomy and pharmacological agents like somatostatin and terlipressin are employed to reduce the risk of small for size flow syndrome SFSF syndrome by decreasing portal venous flow and increasing hepatic artery flow at the same time.ConclusionThe current review outlines the various strategies of volume and flow modulation that can be used in isolation or combination in the management of patients at risk of PHLF.

Purpose:The indocyanine green retention rate at 15 min (ICG-R15) is of great importance in the accurate assessment of hepatic functional reserve for safe hepatic resection. To assist clinicians to evaluate hepatic functional reserve in medical institutions that lack expensive equipment, we aimed to explore a novel approach to predict ICG-R15 based on CT images and clinical data in patients with hepatocellular carcinoma (HCC).MethodsIn this retrospective study, 350 eligible patients were enrolled and randomly assigned to the training cohort (245 patients) and test cohort (105 patients). Radiomics features and clinical factors were analyzed to pick out the key variables, and based on which, we developed the random forest regression, extreme gradient boosting regression (XGBR), and artificial neural network models for predicting ICG-R15, respectively. Pearson's correlation coefficient (R) was adopted to evaluate the performance of the models.ResultsWe extracted 660 CT image features in total from each patient. Fourteen variables significantly associated with ICG-R15 were picked out for model development. Compared to the other two models, the XGBR achieved the best performance in predicting ICG-R15, with a mean difference of 1.59% (median, 1.53%) and an R-value of 0.90. Delong test result showed no significant difference in the area under the receiver operating characteristic (AUROCs) for predicting post hepatectomy liver failure between actual and estimated ICG-R15.ConclusionThe proposed approach that incorporates the optimal radiomics features and clinical factors can allow for individualized prediction of ICG-R15 value of patients with HCC, regardless of the specific equipment and detection reagent (NO. ChiCTR2100053042; URL, http://www.chictr.org.cn).

Background: Post hepatectomy liver failure (PHLF) remains a significant risk in patients undergoing curative liver resection for cancer, however currently available PHLF risk prediction investigations are not sufficiently accurate. The Hepatectomy risk assessment with functional magnetic resonance imaging trial (HEPARIM) aims to establish if quantitative MRI biomarkers of liver function & perfusion can be used to more accurately predict PHLF risk and FLR function, measured against indocyanine green (ICG) liver function test.Methods: HEPARIM is an observational cohort study recruiting patients undergoing liver resection of 2 segments or more, prior to surgery patients will have both Dynamic Gadoxetate-enhanced (DGE) liver MRI and ICG testing. Day one post op ICG testing is repeated and R15 compared to the Gadoxetate Clearance (GC) of the future liver remnant (FLR-GC) as measure by preoperative DGE- MRI which is the primary outcome, and preoperative ICG R15 compared to GC of whole liver (WL-GC) as a secondary outcome. Data will be collected from medical records, biochemistry, pathology and radiology reports and used in a multi-variate analysis to the value of functional MRI and derive multivariant prediction models for future validation.Discussion: If successful, this test will potentially provide an efficient means to quantitatively assess FLR function and PHLF risk enabling surgeons to push boundaries of liver surgery further while maintaining safe practice and thereby offering chance of cure to patients who would previously been deemed inoperable. MRI has the added benefit of already being part of the routine diagnostic pathway and as such would have limited additional burden on patients time or cost to health care systems. (Hepatectomy Risk Assessment With Functional Magnetic Resonance Imaging - Full Text View - ClinicalTrials.gov , n.d.) TRIAL REGISTRATION: ClinicalTrials.gov, ClinicalTrials.gov NCT04705194 - Registered 12th January 2021 - Retrospectively registered. [ABSTRACT FROM AUTHOR]

Background: Malignant biliary neoplasm is relatively common in Southeast Asia. Portal vein embolization (PVE) is a preoperative procedure to induce hypertrophy of future liver remnants. PVE can decrease the rate of post hepatectomy liver failure (PHLF). Objective: To evaluate the efficacy of preoperative PVE of biliary neoplasm patient prior to major hepatic resection. Materials and Methods: The study included 53 patients with biliary neoplasm planned for major hepatic resection and that underwent PVE between July 2013 and August 2019. Liver volumetry before and after PVE was analyzed. Operative procedure and post hepatectomy outcome were evaluated. Results: Peri-hilar type cholangiocarcinoma, Bismuth-Corlette classification IIIA was the most frequent tumor. The technical success rate of PVE is 100%. Future liver remnant (FLR) volume after PVE was significantly increased from 379.1 to 460 mL (p<0.001). Post PVE FLR over total functional liver volume (TFLV) ratio was significantly increased from 27.8% to 34.6%(p<0.001). The mean kinetic growth rate (KGR) per week was 7.1%. Twenty-four patients underwent subsequent hepatectomy, and two patients presented with PHLF. Twenty-nine patients (54.7%) did not undergo subsequent hepatectomy as planned due to advanced disease with 21 (72.4%) because of locally advanced cancer, peritoneal carcinomatosis, and N2 lymph nodes metastasis), four (13.8%) that refused surgical treatment, and three (10.3%) that were loss to follow-up. Conclusion: Preoperative PVE before major hepatic resection in biliary neoplasm patients is an effective procedure to increase FLR, FLR/TFLV ratio, and provide good KGR. However, more than half of post preoperative PVE could not be obtained hepatectomy because of the progression to advanced stage of disease. [ABSTRACT FROM AUTHOR]

Intraoperative blood loss (IBL) during liver resection is a predictor of morbidity, mortality, and tumor recurrence after hepatectomy; however, there have been few reports on patient factors associated with increased IBL. We enrolled consecutive patients who underwent liver resection for primary liver malignancies, and evaluated the predictors of IBL using a data set in which factors that might influence IBL, such as surgical devices, methods and anesthetic technique, were all standardized. We studied 244 patients. A multivariate analysis revealed that higher IBL was an independent risk factor for post-hepatectomy liver failure grade ≥B and overall survival. Multiple linear regression analyses showed serum creatinine, clinically significant portal hypertension (CSPH), tumor size, and major hepatectomy were all significant predictors of IBL. In conclusion, higher IBL was significantly associated with increased morbidity and mortality in patients with primary HCC who underwent liver resection. The risk of IBL was related to several factors including tumor size, serum creatinine, CSPH, and major hepatectomy. [ABSTRACT FROM AUTHOR]

Liver resection (LR) is the primary treatment for hepatic tumors, yet posthepatectomy liver failure (PHLF) remains a significant concern. While the precise etiology of PHLF remains elusive, dysregulated inflammatory processes are pivotal. Therefore, we explored the theragnostic potential of extracellular high-mobility-group-box protein 1 (HMGB1), a key damage-associated molecular pattern (DAMP) released by hepatocytes, in liver recovery post LR in patients and animal models. Plasma from 96 LR patients and liver tissues from a subset of 24 LR patients were analyzed for HMGB1 levels, and associations with PHLF and liver injury markers were assessed. In a murine LR model, the HMGB1 inhibitor glycyrrhizin, was administered to assess its impact on liver regeneration. Furthermore, plasma levels of keratin-18 (K18) and cleaved cytokeratin-18 (ccK18) were quantified to assess suitability as predictive biomarkers for PHLF. Patients experiencing PHLF exhibited elevated levels of intrahepatic and circulating HMGB1, correlating with markers of liver injury. In a murine LR model, inhibition of HMGB1 improved liver function, reduced steatosis, enhanced regeneration and decreased hepatic cell death. Elevated levels of hepatic cell death markers K18 and ccK18 were detected in patients with PHLF and correlations with levels of circulating HMGB1 was observed. Our study underscores the therapeutic and predictive potential of HMGB1 in PHLF mitigation. Elevated HMGB1, K18, and ccK18 levels correlate with patient outcomes, highlighting their predictive significance. Targeting HMGB1 enhances liver regeneration in murine LR models, emphasizing its role in potential intervention and prediction strategies for liver surgery.

Posthepatectomy liver failure (PHLF) still represents a severe complication after major liver resection associated with a high mortality. In addition to an insufficient residual liver volume various factors play an important role in the pathophysiology of PHLF. These include the quality of the parenchyma, liver function, perfusion, i.e. maintenance of adequate inflow and outflow, as well as the condition of the patient and comorbidities. While the liver volume is relatively easy to evaluate using modern imaging techniques, the evaluation of liver function and liver quality require a differentiated approach. Both factors can be influenced by the constitutional status of the patient, medical history and previous treatment and must be given sufficient consideration in the risk evaluation. An adequate perfusion, e.g. portal and arterial circulation and adequate outflow by at least one hepatic vein as well an adequate biliary drainage should be always guaranteed in order to allow regeneration of the residual liver tissue. Only the understanding of all these aspects will support the surgeon in a correct and safe evaluation of the resectability. Additionally, the liver surgeon should be aware of all available perioperative and postoperative options to treat and to prevent PHLF. In this review article the most important questions regarding the risk factors related to PHLF are presented and the potential therapeutic and prophylactic management is described. The main goal is to ensure functional operability of the patient if oncological resectability is possible. In other words: in the case of correct oncological indication, the liver surgeon should be able to resect what is resectable or, alternatively, make resectable what primarily was not resectable. [ABSTRACT FROM AUTHOR]

Small-for-size liver syndrome and posthepatectomy liver failure remain a major challenge for surgeons. Recently, updates in literature points to describe this two syndrome as two face of the same coin. These syndromes are characterized by hyperbilirubinemia, coagulopathy, hyper-GGT, high portal pressure and flow in liver remnant, occurring within the first postoperative week. It can lead to post-operative sepsis and bleeding, increasing mortality and morbidity. Despite the large experience in the field of transplantation, few studies are focused on small-for-size syndrome after major hepatectomy. For years, scientists were focused on the size of liver remnant, supposing a small liver remnant, in relation with the primary liver size, was the cause of the syndrome. The strategies used to prevent it after transplantation, have however shown a predominant role of high portal pressure and flow, leading to an alteration in functional regeneration of liver parenchyma, as the prevalent mechanism. According to these evidences, we suggest adopting another nomenclature for the two syndromes: small-for-flow-liver failure. In this article, we analyze and summarize different experiences, proposing our inward algorithm, including the role of portal flow and pressure measurements. This review seeks to be an operative instrument for surgeons and hepatologists in an effort to find a common point of view regarding small for flow liver failure and its management strategies.

• Post hepatectomy liver failure (PHFL) represents a major issue in liver surgery. • The role of Indocyanine Green (ICG) in predicting PHLF is still a matter of debate. • A systematic review and meta-analysis was performed to evaluate the diagnostic performance of ICG in predicting PHLF. • ICG clearance test pooled AUC was 0.673 (95% CI: 0.632-0.713). • Preoperative ICG clearance test alone may not represent a reliable method to predict PHLF. Post hepatectomy liver failure (PHFL) still represents a potentially fatal complication after major liver resection. Indocyanine green (ICG) clearance test represents one of the most widely adopted examinations in the preoperative workup. Despite a copious body of evidence which has been published on this topic, the role of ICG in predicting PHLF is still a matter of debate. A systematic review of the literature was conducted according to PRISMA-DTA guidelines. The primary outcome was the assessment of diagnostic performance of ICG in predicting PHLF. The secondary outcome was the mean ICG R15 and ICG PDR in patients experiencing PHLF. Seventeen studies, for a total of 4852 patients, were deemed eligible. Sensitivity ranged from 25% to 83%; Specificity ranged from 66.1% to 93.8%. ICG clearance test pooled AUC was 0.673 (95% CI: 0.632-0.713). The weighted mean ICG R15 was 11 (95%CI: 8.3-13.7). The weighted mean ICG PDR was 16.5 (95%CI: 13.3-19.8). High risk of bias was detected in all examined domains. Preoperative ICG clearance test alone may not represent a reliable method to predict post hepatectomy liver failure. Its diagnostic significance should be framed within multiparametric models involving clinical and imaging features. [ABSTRACT FROM AUTHOR]

Background: Cholangiocarcinoma (CCA) is a cancer of biliary tract with a different incidence across the globe. The northeast part of Thailand has the highest incidence of CCA. Post-hepatectomy liver failure (PHLF) is the most severe and life-threatening complication in CCA patients.  The aim of this study was to identify factors related to PHLF incidence in patients with CCA., Methods:  An analytical cross-sectional study was performed in a university hospital in northeast Thailand between January 1, 2014 and December 31, 2020. PHLF grading criteria was used according to the international study group of liver surgery definition for PHLF. Multiple Logistic Regression with a stepwise forward method was employed to identify the predictive factors related to PHLF., Result: The study findings revealed that 185 patients developed PHLF, of whom 56.22% experience grade A, 36.76% grade B, and 7.06% grade C PHLF. Based on our findings, seventeen factors were significantly correlated with PHLF incidence, namely age, cholangiocarcinoma type, hepatectomy type, preoperative biliary drainage, cholangitis, Child-Turcotte-Pugh grade, operation time, total blood loss, total blood transfusion, level of serum albumin, total bilirubin, direct bilirubin, alanine transaminase, aspartate transaminase, alkaline phosphatase, prothrombin time, and level of international normalized ratio. Total bilirubin (adjusted OR=14.07, 95% CI 7.54-26.27), Child-Turcotte-Pugh grade (adjusted OR=3.34, 95% CI 1.43-7.81), total blood transfusion (adjusted OR=2.32, 95% CI 1.19-4.54), and operation time (adjusted OR=1.77, 95% CI 1.05-2.97) could significantly predict PHLF incidence with a positive predictive value of 86.03% and a negative predictive value of 80.23%, while the accuracy of prediction was 81.88%., Conclusion: The findings of this study identified total bilirubin, Child-Turcotte-Pugh grade, total blood transfusion, and operation time as clinical predictive factors of PHLF. Therefore, modification of these factors is recommended to reduce the probability of liver failure in CCA patients.

Background Extended hepatectomy (≥ 5 liver segments resection) may be required to have a complete surgical resection and provide the best chance of cure of hepatobiliary tumors. It is associated with high morbidity and mortality but with good perioperative care, its outcomes can be improved. This study was conducted to evaluate the early outcomes of extended hepatectomy at a university hospital in Nepal. Methods For this study, prospectively collected data from all patients who underwent extended hepatectomy from October 2012 to April 2022 were reviewed and analyzed retrospectively. Demographic data, liver volume augmentation methods used, intraoperative variables, and postoperative complications were analyzed. Results Seventeen patients underwent extended hepatectomy from October 2012 to April 2022. Among them 11 (64.7%) were female and the mean age was 53.9 ±16.3 years (18-72 years). Right extended hepatectomy was the most commonly performed procedure (n = 15, 88.2%), and left extended hepatectomy was performed in the remaining (n = 2, 11.8%). Six patients underwent liver volume augmentation procedures (35.3%) with portal vein embolization (PVE) in three, portal vein ligation (PVL) in one, and partial associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) in two patients. Overall complications were 70% with major complications (Clavien Dindo ≥ IIIa) constituting 35.3%. The most common hepatectomy-specific complication was post-hepatectomy liver failure (PHLF) in six cases. The 30-day mortality was 17.6% (three patients). Conclusion Extended hepatectomy can be performed with acceptable major complications and mortality rates in selected patients., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2023, Sharma et al.)

Purpose: The indocyanine green retention rate at 15 min (ICG-R15) is of great importance in the accurate assessment of hepatic functional reserve for safe hepatic resection. To assist clinicians to evaluate hepatic functional reserve in medical institutions that lack expensive equipment, we aimed to explore a novel approach to predict ICG-R15 based on CT images and clinical data in patients with hepatocellular carcinoma (HCC)., Methods: In this retrospective study, 350 eligible patients were enrolled and randomly assigned to the training cohort (245 patients) and test cohort (105 patients). Radiomics features and clinical factors were analyzed to pick out the key variables, and based on which, we developed the random forest regression, extreme gradient boosting regression (XGBR), and artificial neural network models for predicting ICG-R15, respectively. Pearson's correlation coefficient (R) was adopted to evaluate the performance of the models., Results: We extracted 660 CT image features in total from each patient. Fourteen variables significantly associated with ICG-R15 were picked out for model development. Compared to the other two models, the XGBR achieved the best performance in predicting ICG-R15, with a mean difference of 1.59% (median, 1.53%) and an R -value of 0.90. Delong test result showed no significant difference in the area under the receiver operating characteristic (AUROCs) for predicting post hepatectomy liver failure between actual and estimated ICG-R15., Conclusion: The proposed approach that incorporates the optimal radiomics features and clinical factors can allow for individualized prediction of ICG-R15 value of patients with HCC, regardless of the specific equipment and detection reagent (NO. ChiCTR2100053042; URL, http://www.chictr.org.cn)., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Wu, Xie, Ji, Zhang, Luo, Xia, Lu, He, Sha, Zheng, Yong, Li, Zhao, Yang, Xia and Xue.)

Backgrounds/aims: Post-hepatectomy liver failure (PHLF) is a serious complication following liver resection, with limited treatment options, and is associated with high mortality. There is a need to evaluate the role of systems that support the function of the liver after PHLF., Aims: The aim of this study was to review the literature and summarize the role of liver support systems (LSS) in the management of PHLF. Publications of interest were identified using systematically designed searches. Following screening, data from the relevant publications was extracted, and pooled where possible., Findings: Systematic review identified nine studies, which used either Plasma Exchange (PE) or Molecular Adsorbent Recirculating System (MARS) as LSS after PHLF. Across all studies, the pooled 90-day mortality rate was 38% (95% CI: 9-70%). However, there was substantial heterogeneity, likely since studies used a variety of definitions for PHLF, and had different selection criteria for patient eligibility for LSS treatment., Conclusions: The current evidence is insufficient to recommend LSS for the routine management of severe PHLF, with the current literature consisting of only a limited number of studies. There is a definite need for larger, multicenter, prospective studies, evaluating the conventional and newer modalities of support systems, with a view to improve the outcomes in this group of patients.

Intraoperative blood loss (IBL) during liver resection is a predictor of morbidity, mortality, and tumor recurrence after hepatectomy; however, there have been few reports on patient factors associated with increased IBL. We enrolled consecutive patients who underwent liver resection for primary liver malignancies, and evaluated the predictors of IBL using a data set in which factors that might influence IBL, such as surgical devices, methods and anesthetic technique, were all standardized. We studied 244 patients. A multivariate analysis revealed that higher IBL was an independent risk factor for post-hepatectomy liver failure grade ≥B and overall survival. Multiple linear regression analyses showed serum creatinine, clinically significant portal hypertension (CSPH), tumor size, and major hepatectomy were all significant predictors of IBL. In conclusion, higher IBL was significantly associated with increased morbidity and mortality in patients with primary HCC who underwent liver resection. The risk of IBL was related to several factors including tumor size, serum creatinine, CSPH, and major hepatectomy.

As the number of liver resections in the United States has increased, operations are more commonly performed on older patients with multiple comorbidities. The advent of effective chemotherapy and techniques such as portal vein embolization, have compounded the number of increasingly complex resections taking up to 75% of healthy livers. Four potentially devastating complications of liver resection include postoperative hemorrhage, venous thromboembolism, bile leak, and post-hepatectomy liver failure. The risk factors and management of these complications are herein explored, stressing the importance of identifying preoperative factors that can decrease the risk for these potentially fatal complications., (Copyright © 2015 Elsevier Inc. All rights reserved.)