how to predict po course before and during surgery for hcc
TRANSCRIPT
How to predict post-operative course before and during surgery for HCC
Pr Eric Vibert, MD, PhD
Centre Hépato-Biliaire,
Hop. Paul Brousse
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 ?
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 ?
Mortality of Liver Resection for HCC
Authors Period N 90 days Mortality Underlying Parenchyma
Greco et al. 2001-2005 129 4.1% Abnormal LiverRosaye et al 2005-2011 2342 3.5% Abnormal LiverZhong et al 2000-2007 908 3.1% Abnormal LiverVigano 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 LiverZhou et al 2006-2009 124 0.5% Healthy LiverFaber 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)
Nov 2014 – Aug 2016
N = 418 Liver Resection for HCC
Other Indications ExcludedN = 312
Study PopulationHCC
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
Laparoscopy, N=29 (28%) Laparotomy, N=77 (73%)
Minor Hepatectomy, N=69 (65%) Major Hepatectomy, N=37 (35%)
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%
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
Persistent Hepatic Decompensation
9/67 pts (13%) (F3/F4) had liver
decompensation after hepatectomy
Post-operativeDecompensation
N=29 (27.4%)
90-day MortalityPost-op Liver Failure, N=2 Ascites and Sepsis, N = 1
Patients Alive withPersitant HepaticDecompensation
Ascites, N=5Jaundice, N=1
Persistent Ascites
When I plan a treatment to MisterDurand, I think to Mister Dupond…Who will be more beneficiated ofliver transplantation relatively toresection ?
Risk and Interest of oncologic hepatectomy ?
VS
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 ?
Feasibility of Surgery ?
MELD < 10
MELD < 12
Independant predictivefactor of mortality
Cuccheti et al. Liver Transpl 2006Farges et al. Ann Surg 2012
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 rateUrea rateRate of plateletICG ClearenceHepatic venous pressure gradiant,
1996
Same portal hypertension and nodule But different location…
Segmentectomy
Segmentectomy 8 by Laparotomy Resection in Segment 3 by Lap’
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
Liver Stiffness and Posthepatectomy complications
Cescon et al, Ann Surg 2012 Wong et al, Ann Surg 2013
>16 kPa 12 kPa
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 HCCHVPG was measured intra-operatively when feasible (N=x)
Rajakunnu et al., Vibert. Surgery 2017
• Indocyanine Green Dye (ICG) – Intravenous injection
• Passive hepatocytes captation and active biliary secretion
• Decrease of the ICG secretion Decrease of liver function
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 hepatectomyRight-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
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
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 HCCIn 3 Frenchs Centers (PB, Marseille, Lyon)
Le Roy et al, Vibert. Submitted to World J Surg
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
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
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 ?
Impact of laparoscopic liver resection in patients with cirrhosison 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 20166 French HPB Centers
343 Hepatectomy in F3/F4 89 pts by Lap (26%)
RESULTS
LAPOPEN
Propensity score
PHLF (ISGLS Grade B and C)16% in LAP32% in OPENOR 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
Corrélation linéaire…
YesNo
Post
hep
atec
tom
y P
VP
(m
mH
g)
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
Intraoperative Portal Flow modulation
MODHEP-1 : Phase I/II in Human(Hop. Paul Brousse – Villejuif), n=4 ptsNew Device now tested to improve it
1. Splenic Artery Ligation
2. Portal Caval Shunt (8 mm Goretex)
Today… Tomorrow…
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
Conclusion
• Pathological liver is metastable situation
• Acceptable po. Mortality is around 5%
• Direct parenchyma and liver function could replaced indirect evaluation with elastographyand ICG in minor hepatectomy with MELD > 8
• Response to PVE before Right Hep in path liver
• Laparoscopic and portal pressure assessment