Quels impact de l'hépatopathie sous jacente? - Journées de Chirurgie 2016

1. Quel impact de
l’hépatopathie sous-jacente
sur l’insuffisance
hépatique post-operatoire
Andrea Laurenzi - Daniel Cherqui

2. Hépatopathie
• Cirrhose
• Chimiothérapie
• Cholestase

3. Hépatopathie
• Cirrhose
• Chimiothérapie
• Cholestase

4. Operative risk and underlying liver
1023 liver resections (1990-2008)
22
7,9
3,7
1,5
27
8,8 8,5
3,7
0
5
10
15
20
25
30
Transfusions <2000 Transfusions >2000 Mortality <2000 Mortality >2000
%
Cirrhosis
No Liver Disease
Cherqui unpublished data

5. 0 Cx Gr 1 Gr 2 Gr 3A Gr 3B Gr 4 Gr 5
MAJOR Rx 6 1 8 4 2 2 0
MINOR Rx 22 3 8 1 3 0 0
Liver Resection for HCC
Paul Brousse Hospital 2013 - 2015
95 Patients
28 Laparoscopic
Cirrhosis 57
Fibrosis 15
NASH 14
Normal 9
Mortality 2
Morbidity 40%

6. • Preoperative: patient selection
– Liver functional reserve
– Planning by imaging
– Portal vein embolization
• Intraoperative
– Reduction of hemorrhage
– Parenchymal preservation
– Coelioscopie
• Postoperative
– Postop care
– Follow up
Progress in Surgery for HCC

7. Cirrhose
• Sélection
• Management

8. Cirrhose
• Sélection
• Traitement

9. Sélection
• CHILD score
• MELD score
• Vert d’Indocyanine
• HTP (gradient P-S, plaquettes….)
• Fibrose (biopsie, fibroscan)
• Volumetrie

10. CHILD-PUGH
• 2007-2013
• 1242 patients
• 166 (13,4%) PHLF
• Mortality 1%
Wang, BJS 2016

11. MELD
N Mortalité P
Cucchetti, J Am Coll Surg 2006
Cucchetti, Liver Transpl 2006
Teh, J Gastrointest Surg 2005

12. MELD
Cucchetti, Liver Transpl 2006
IHC postop

13. Makuuchi, Semin Surg Oncol 1993
Ascites
None or controlled Not controlled
ICGR15 Limited resection Enucleation Not indicated for hepatectomy
Trisectorectomy
bisectorectomy
Left-sided
hepatectomy
Right-sided
sectoriectomy
Segmentectomy Limited resection Enucleation
Normal 1.1 – 1.5 mg/dL 1.6 – 1.9 mg/dL > 2.0 mg/dL
Total bilirubin level
Normal 10% - 19% 30% - 39% > 40%20% - 29%
Vert d’Indocyanine

14. Major impact of pre-operative platelet rate < 150.000 / mL
22%
6%
Liver Failure: 11%
Mortality : 9%
2011
Maithel, JACS 2011

15. Only hepatic venous pressure gradient > 10 mmHg was significant in
multivariate analysis for decompensated cirrhosis after hepatectomy
Risk factor in univariate analysis
Bilirubin rate
Urea rate
Rate of platelet
ICG Clearence
Hepatic venous pressure gradiant,
Décompensation de la cirrhose : Persistance d’une ascite à 3 mois Bruix, Gastro 1996

16. Cucchetti, J Hep 2016

17. Cucchetti, J Hep 2016

18. Child A / Sans HTP
56%
71%
Child A / Avec HTP
No early impact but lower longtime
survival after resection of PHT

19. Capussotti, WJS 2011

20. Capussotti, WJS 2011
p=0,02
All patients
Child A patients
p=0,5

21. Cescon, Ann Surg 2012

22. > 16 kpA: Ascite and/or POLF
Cescon, Ann Surg 2012

23. Truant, JACS 2007
• RLV-BWR was more relevant than RLV-TLV in predicting postoperative course after
right trisectionectomy
• Patients with an anticipated RLV < 0,5% of the body weight were at risk of hepatic
dysfunction
• No deaths in the group of patients with RLV/BWR >0,5%

24. Paradis, Hepatology 2009

25. Paradis, Hepatology 2009

26. Agrawal, HPB 2011
Pre-operative liver biopsy to detect NASH in order to:
• Limit the extent of hepatic resection
• Use the PVE to optimize the post-operative outcome
• Aggressively treat the cardiovascular associated
disease

27. Wakai, JGIS 2011
• 225 patients
• 3 groups NAFLD – HCV – HBV
• Morbidity 59% vs 31/28% p= 0,043
• Mortality 12% vs 0,7%/3,3% p= 0,016

28. Cirrhose
• Sélection
• Management

29. Farges, Ann Surg 2003

30. Farges, Ann Surg 2003
Bilirubine Prothrombin Time

31. Post-operative Liver failure: Post-operative mortality:
- TACE + PVE 4% - TACE + PVE 0%
- PVE only 12% - PVE only 3%
Yoo, Ann Surg Oncol 2011

32. Optimal Technique
• Reduce blood loss
• Fluid restriction anesthesia
• Precise technique
• Intermittent Pringle Maneuver

33. T T
Limited resection “wedge“ Anatomical resection
Parenchymal preserving
Anatomical Resection
Planning of resection

34. Man, Ann Surg 1997

35. Man, Ann Surg 1997

36. Morise, JHBP Sc 2015

37. Cirrhose - Conclusions
• Major hepatectomy (≥ 3 segments)
– Child A – MELD <9
– No varices, platelets > 100 000, gradient <10 mmHg
– Response to portal vein embolization for Right Hepatectomy
– FLR ≥ 30-40%

38. Cirrhose - Conclusions
• Major hepatectomy (≥ 3 segments)
– Child A
– No varices, platelets > 100 000, gradient <10 mmHg
– Response to portal vein embolization
– FLR ≥ 30-40%
• Minor hepatectomy
– Child A (B for tumorectomy)
– grade 1-2 varices (laparoscopic)

39. Hépatopathie
• Cirrhose
• Chimiothérapie
• Cholestase

40. SOS (Blue Liver): Steatoheapatitis (Yellow liver):
Oxaliplatin Irinotecan
Liver Toxicity

41. Khan JHBP Surg 2009

42. Rubbia-Brandt, Ann Oncol 2004
• 51% of patients who received pre-operative
chemotherapy had sinusoidal dilatation
• 25% perisinusoidal and venocclusive fibrosis
• Developement correlated to the use of Oxaliplatine

43. Karoui, Ann Surg 2006

44. Karoui, Ann Surg 2006

45. Wicherts, Ann Surg Oncol 2011
15% of patients who received pre-operative chemotherapy
Increased
GGT and Bilirubine
are predictors
markers

46. Ribero, Cancer 2007
p = 0.006

47. Vauthey, JCO 2006

48. Kishi, Ann Surg Oncol 2010
Extended chemotherapy increases liver toxicity without
improving the pathological response

49. YesNo
PosthepatectomyPVP(mmHg)
22.5 mmHg
15 mmHg
Liver failure « 50-50 » criteria
Allard, Ann Surg 2013

50. De Graaf, J Nucl Med 2010
Cut-off 2,5%/min/m2 can predict the incidence of liver failure
3% vs 56%

51. Chimiothérapie - Conclusions
• Attention aux lésions induites par la chimiothérapie
(> 6 cycles)
• Augmentation de la morbidité post-opératoire
• Une augmentation des cycles n’augmente pas la
réponse pathologique
• Bevacizumab a un effet protecteur sur le
développent de SOS

52. Hépatopathie
• Cirrhose
• Chimiothérapie
• Cholestase

53. Cescon, Ann Surg 2009

54. Kawasaki, Ann Surg 2003
Morbidity related to biliary drainage 2,5%
No post-operative liver failure

55. Seyama, Ann Surg 2003
Cholangitis 30% (initial period)
1 Tumor seeding (percuteneous)
No post-operative liver failure

56. Grandadam, Ann Surg Oncol 2010
Mortality 10,5% in the group without optimization

57. Sugawara Surgery 2013
• 21% of cholangitis in patients with biliary
drainage
• 75% of positive bile cultures at the operation
• No difference in postoperative morbidity and
mortality in patients with and without biliary
drainage

58. Takahashi, BJS 2010
• PTBD recurrence 5,9%
• Survival in patients with PTBD poorer

59. Hirano, JHBP Sc 2014
P=0,004
• Tumor seeding on the of
percutaneous drainage
• Peritoneal recurrence in the
percutaneous group
• Better survival for endoscopic
drainage

60. Noie, Surgery 2001
Selective group:
• Increase of FLR >50%
• Better ATP synthesis
• Increased cytochrome P-450

61. • Hyperthrophy ratio and bilirubine clearance
higher in SBD vs TBD
Ishizawa, Am J Surg 2007

62. Iacono, Ann Surg 2013

63. Farges BJS 2013
• Biliary drainage does not affect mortality
• Decrease the mortality rate after right sided
hepatectomy
• Increase mortality after left sided
hepatectomy
• Preoperative bilirubine > 50 mmol increases
mortality

64. Farges BJS 2013

65. Cholestase - Conclusions
• Optimisation du patient avant chirurgie
• Drainage biliaire du foie restant par voie
endoscopique
• Traiter de façon systématique les patients avec
prothèses biliaires avec antibiotiques à large
spectre