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Original Investigation
January 4, 2017

Association of Remnant Liver Ischemia With Early Recurrence and Poor Survival After Liver Resection in Patients With Hepatocellular Carcinoma

Author Affiliations
  • 1Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
  • 2Department of Pathology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
JAMA Surg. Published online January 4, 2017. doi:10.1001/jamasurg.2016.5040
Key Points

Question  Will remnant liver ischemia after partial hepatectomy affect the oncologic outcomes of patients?

Findings  In this database study that included 328 patients who underwent hepatectomy for hepatocellular carcinoma, severe remnant liver ischemia was an independent risk factor for overall survival and disease-free survival.

Meaning  Preventive management and technical refinements in hepatectomy are important to decrease the risk of remnant liver ischemia and to improve survival of patients with hepatocellular carcinoma.

Abstract

Importance  The remnant liver after hepatectomy may have inadequate blood supply, especially following nonanatomical resection or vascular damage.

Objective  To evaluate whether remnant liver ischemia (RLI) may have an adverse effect on long-term survival and morbidity after liver resection in patients with hepatocellular carcinoma.

Design, Setting, and Participants  This study was a retrospective analysis at Seoul National University Bundang Hospital. Remnant liver ischemia was graded on postoperative computed tomographic scans in 328 patients who underwent hepatectomy for hepatocellular carcinoma between January 1, 2004, and December 31, 2013.

Main Outcomes and Measures  Remnant liver ischemia was defined as reduced or absent contrast enhancement during the venous phase. Remnant liver ischemia was classified as minimal (none or marginal) or severe (partial, segmental, or necrotic).

Results  Among 328 patients (252 male and 76 female; age range, 26-83 years [mean age, 58.2 years]), radiologic signs of severe RLI were found in 98 patients (29.9%), of whom 63, 16, and 19 had partial, segmental, or necrotic RLI, respectively. These patients experienced more complications and longer hospital stay than patients with minimal RLI. Preoperative history of transarterial embolization (odds ratio [OR], 1.77; 95% CI, 1.02-3.03; P = .04), use of the Pringle maneuver (OR, 1.96; 95% CI, 1.08-3.58; P = .03), and longer operative time (OR, 1.003; 95% CI, 1.002-1.005; P < .001) were independent risk factors for severe RLI. Early recurrence rates within 6 (60.2% vs 9.6%) or 12 (79.6% vs 18.7%) months after hepatectomy were higher in patients with severe RLI than in patients without RLI (P < .001). Severe remnant liver ischemia was an independent risk factor for overall survival (OR, 6.98; 95% CI, 4.27-11.43; P < .001) and disease-free survival (OR, 5.15; 95% CI, 3.62-7.35; P < .001).

Conclusions and Relevance  Preventive management and technical refinements in hepatectomy are important to decrease the risk of RLI and to improve survival of patients with hepatocellular carcinoma.

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