This document discusses predicting postoperative outcomes for patients undergoing surgery for hepatocellular carcinoma (HCC). It finds that acceptable postoperative mortality in cirrhotic patients is less than 5%. Pre-operative parameters like liver stiffness measurement, hepatic venous pressure gradient, and indocyanine green clearance can help predict outcomes. Laparoscopic surgery and modulating portal flow may help improve outcomes compared to open surgery for cirrhotic patients undergoing liver resection. Direct assessment of liver function and parenchyma quality are important to predict postoperative liver decompensation risk, especially for patients with a MELD score greater than 8 undergoing minor hepatectomy.

1. How to predict post-operative course
before and during surgery for HCC
Pr Eric Vibert, MD, PhD
Centre Hépato-Biliaire,
Hop. Paul Brousse

2. Plan
• Mortality and Morbidity of HCC surgery ?
• Which pre-operative parameters were
relevant in Child A/B patient before surgery ?
• How to predict and, perhaps, improve the
post-operative courses ?

3. Plan
• Mortality and Morbidity of HCC surgery ?
• Which pre-operative parameters were
relevant in Child A/B patient before surgery ?
• How to predict and, perhaps, improve the
post-operative courses ?

4. Mortality of Liver Resection for HCC
Authors Period N 90 days Mortality Underlying Parenchyma
Greco et al. 2001-2005 129 4.1% Abnormal Liver
Rosaye et al 2005-2011 2342 3.5% Abnormal Liver
Zhong et al 2000-2007 908 3.1% Abnormal Liver
Vigano et al 2000-2012 192 2.1% Abnormal Liver
Donadon et al 2004-2013 336 2% Abnormal Liver
Kim et al 2005-2010 454 0.7% Healthy Liver
Zhou et al 2006-2009 124 0.5% Healthy Liver
Faber et a; 2000-2010 148 0% Healthy Liver
« Acceptable » post-operative mortality in cirrhotic patient is inferior to 5%
3-months Mortality of Liver Transplantation : 9% (Adam et al. J Hep 2012)

5. ACHBT Web Prospective Registry

6. Nov 2014 – Aug 2016
N = 418 Liver Resection for HCC
Other Indications
Excluded
N = 312
Study Population
HCC
N = 106
Web Prospective Registry
MELD ≤12, platelet count ≥80,000
No preoperative HVPG assessment
TACE than PVE before Right Hep. in abnormal liver
Hepatectomy for HCC in last 2 years in
Paul Brousse Hospital - Villejuif

7. Laparoscopy, N=29 (28%) Laparotomy, N=77 (73%)
Minor Hepatectomy, N=69 (65%) Major Hepatectomy, N=37 (35%)

8. 90-day Post-operative Outcomes
Overall Cohort, N = 106 Advanced Liver Disease Cohort (F3/F4), N = 67
* Five patients died in 90-day postoperative period: 2 from liver failure, 1 with ascites and sepsis from
colonic perforation, 1 with biliary sepsis and 1 from suspected cardiac event after discharge
Minor N=81(76.4%)
Major N=25(23.6%)
Minor N=51(76.1%)
Major N=16(23.9%)
4.7%

9. Specific Complication Pathological Liver
CHILD A/B CHILD CNormal Liver
Metastable
3 types of Equilibrium
Stable Unstable
Liver Surgery
Clinical Ascitis and/or Jaundice and/or
Encephalopathy at 3 months po.
Liver Decompensation

10. Persistent Hepatic Decompensation
9/67 pts (13%) (F3/F4) had liver
decompensation after hepatectomy
Post-operative
Decompensation
N=29 (27.4%)
90-day Mortality
Post-op Liver Failure, N=2
Ascites and Sepsis, N = 1
Patients Alive with
Persitant Hepatic
Decompensation
Ascites, N=5
Jaundice, N=1
Persistent Ascites

11. When I plan a treatment to Mister
Durand, I think to Mister Dupond…
Who will be more beneficiated of
liver transplantation relatively to
resection ?
Risk and Interest of oncologic hepatectomy ?
VS

12. Plan
• Mortality and Morbidity of HCC surgery ?
• Which pre-operative parameters were
relevant in Child A/B patient before surgery ?
• How to predict and, perhaps, improve the
post-operative courses ?

13. Feasibility of Surgery ?
MELD < 10
MELD < 12
Independant predictive
factor of mortality
Cuccheti et al. Liver Transpl 2006Farges et al. Ann Surg 2012

14. BCLC B BCLC C

15. The location and the type of the
unique HCC inferior to 5 cm ?
LiverSP by SIGHT

16. 29 patients operated by laparotomy for
HCC on Child A cirrhosis
Only hepatic venous pressure gradient > 10 mmHg was significant
in multivariate analysis for decompensated cirrhosis after hepat.
Risk factor in univariate analysis
Bilirubin rate
Urea rate
Rate of platelet
ICG Clearence
Hepatic venous pressure gradiant,
1996

17. 2015

18. Same portal hypertension and nodule
But different location…
Segmentectomy
Segmentectomy 8 by Laparotomy Resection in Segment 3 by Lap’

19. Portal Hypertension is an indirect
method to assess of liver parenchyma

20. Pathological liver classified as cirrhotic
« Soft » cirrhosis post HBV « Hard » cirrhosis post HCV

21. How to improve pre-operative
assessment of po. Course ?
• Liver biopsy
• Elastometry (LS) and Controlled Attenuation Par. (CAP)
• Indocyanine Green (Global liver function)
• Scintigraphy (Global and localized liver function)
By Direct liver parenchyma and function evaluation

22. In absence of large right tumor
Assessment by US on left side

23. Liver Stiffness and Posthepatectomy complications
Cescon et al, Ann Surg 2012 Wong et al, Ann Surg 2013
>16 kPa 12 kPa

24. LSM was an independent Risk Factor of
mortality and po. Liver decompensation
Parameter AUROC 95% CI Cut-off Se (%) Sp(%)
LSM
(kPa)
0.80 0.64 - 0.97
12 86 67
15 43 82
22 43 93
HVPG
(mm Hg)
0.71 0.497 – 0. 91 10 29 96
LSM was systematically measured preop. in 167 pts operated for HCC
HVPG was measured intra-operatively when feasible (N=x)
Rajakunnu et al., Vibert. Surgery 2017

25. • Indocyanine Green Dye (ICG) – Intravenous injection
• Passive hepatocytes captation and active biliary secretion
• Decrease of the ICG secretion  Decrease of liver function

26. Makuuchi et al., 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%
Adapted liver resection to reserve

27. 2008
1994-2004 : 455 pts included 130 with PHT : No impact…
Child A / Sans HTP
56%
71%
Child A / Avec HTP
No early impact but lower longtime
survival after resection of PHT

28. ICG-15’ was superior to Platelet rate to
predict 3-month post-operative ascitis
Pre-operative ICG-R15’ > 15%
34% of po. Ascitis
2012-2014 : 147 pts operated for HCC
In 3 Frenchs Centers (PB, Marseille, Lyon)
Le Roy et al, Vibert. Submitted to World J Surg

29. Major Hepatectomy in cirrhotic patient
< 20% of standard liver volume or 0.5% body weight on non cirrhotic liver
Truant et al. JACS 2008Ribeiro, Vauthey et al. BJS 2007
MELD Score < 10

30. 2003
PVE is an « effort test » for
the pathological liver…

31. Global Liver Function (ICG) is relevant
Global Liver Function (ICG) is not relevant
Image de Scinti post PVE
Image de Scinti sans PVE
Ref about ICG post PVE

32. Plan
• Mortality and Morbidity of HCC surgery ?
• Which pre-operative parameters were
relevant in Child A/B patient before surgery ?
• How to predict and, perhaps, improved the
post-operative courses ?

33. Impact of laparoscopic liver resection in patients with cirrhosis
on post-operative liver failure : A Propensity Score Analysis
M. Prodeau, S. Truant, E. Vibert, O. Farges, J.Y. Mabrut,
J. Hardwigsen, J.M. Régimbeau, G. Millet, O. Soubrane,
R. Adam, D. Cherqui, F.R. Pruvot, E. Boleslawski
The ACHBT French
Hepatectomy
Study Group
Oct 2012 – June 2016
6 French HPB Centers
343 Hepatectomy in F3/F4 89 pts by Lap (26%)

34. RESULTS
LAPOPEN
Propensity score
PHLF (ISGLS Grade B and C)
16% in LAP
32% in OPEN
OR 0.31 [0.12-0.78]; p<0.001
Matched-LAP Matched-OPEN
Age (years) 65.3 65.3
BMI (kg/m²) 26.9 26.9
MELD 8.6 8.5
Platelets (x
1000/mm3)
167 167
ICG (15 min) 15.2 % 15.0 %
HVPG (mmHg) 7.9 8.1
LS (kPa) 21.8 21.9
RLV (%) 88.6 87.6

35. Intra Operative Portal Pressure ?
28 mm Hg…10 mm Hg

36. Corrélation linéaire…
YesNo
PosthepatectomyPVP(mmHg)
22.5 mmHg
15 mmHg
P < 0.001
Liver failure « 50-50 » criteria
1. Allard….. Vibert - Ann Surg. 2013 Nov;258(5):822-9
277 hépatectomies majeures sur foie non cirrhotique
2013

37. Intraoperative Portal Flow modulation
MODHEP-1 : Phase I/II in Human
(Hop. Paul Brousse – Villejuif), n=4 pts
New Device now tested to improve it
1. Splenic Artery Ligation
2. Portal Caval Shunt (8 mm Goretex)
Today… Tomorrow…

38. 75% Hepatectomy in Pig with or without Portal Flow Modulation from POD-0 to POD3
Lower Bilirubin at PO3 and POD5 and Higher ki67 index at POD3
2017

39. Arterial Lactate > 3.0 mmol/L after abdominal closure  USI
2017

40. Conclusion
• Pathological liver is metastable situation
• Acceptable po. Mortality is around 5%
• Direct parenchyma and liver function could
replaced indirect evaluation with elastography
and ICG in minor hepatectomy with MELD > 8
• Response to PVE before Right Hep in path liver
• Laparoscopic and portal pressure assessment