Cirrhosis aggravates the ninety-day mortality after liver resection for hepatocellular carcinoma
Keywords:Cirrhosis, Hepatocellular carcinoma, Liver resection, 90-day postoperative mortality
Background: Ninety-day postoperative mortality (90-D POM) measures accurately the liver resection-related mortality. In cirrhotic patients, reporting post-hepatectomy-related death only as in-hospital or thirty-day postoperative mortality (30-D POM) may underestimate cirrhosis-related death after liver resection.
Methods: Medical records of adult cirrhotic (cirrhosis group) and matched non-cirrhotic (control group) patients, who underwent elective liver resection at Sohag University Hospital (April 2014- March 2018), were analyzed. The 90-D POM versus in-hospital mortality and 30-D POM were compared in both groups.
Results: Forty-six patients (23 per group) were eligible for the study. Liver resection was carried out in all cirrhosis group patients for hepatocellular carcinoma (HCC). In the control group, liver resection was indicated for colorectal metastasis (13), benign masses (7) and intrahepatic cholangiocarcinoma (3). Compared with the control group, cirrhotic patients exhibited significantly higher complication rates (p<0.05), prolonged hospital stays (p<0.05), increased postoperative levels of serum bilirubin and reduced prothrombin concentration (p<0.05). In the control group, in-hospital mortality and 30-D POM were zero while 90-D POM was 4%. In the cirrhosis group, the in-hospital mortality and 30-D POM were identical (8.7%), however the 90-D POM was significantly higher and almost doubled (17%).
Conclusion: Liver cirrhosis triggers significant mortality that may extend for ninety days postoperatively. In cirrhotic patients, post-hepatectomy death should be reported as 90-D POM rather than the obviously misleading in-hospital mortality or 30-D POM.
Damhuis RM, Wijnhoven BPL, Plaisier PW, Kirkels WJ, Kranse R, van Lanschot JJ. Comparison of 30-day, 90-day and in-hospital postoperative mortality for eight different cancer types. Br J Surg. 2012;99(8):1149-54.
Schiergens TS, Dörsch M, Mittermeier L, Brand K, Küchenhoff H, Lee SM, et al. Thirty-day mortality leads to underestimation of postoperative death after liver resection: a novel method to define the acute postoperative period. Surgery. 2015;158(6):1530-7.
Franken LC, Schreuder AM, Roos E, van Dieren S, Busch OR, Besselink MG, et al. Morbidity and mortality after major liver resection in patients with perihilar cholangiocarcinoma: A systematic review and meta-analysis. Surgery. 2019;165(5):918-28.
Subramanian KKK, Tandon M, Pandey CK, Jain P. Patients with Cirrhosis of Liver Operated for Non-transplant Surgery: A Retrospective Analysis. J Clin Transl Hepatol. 2019;7(1):9-14.
Goussous N, Hosseini M, Sill AM, Cunningham SC. Minimally invasive and open gallbladder cancer resections: 30- vs 90-day mortality. Hepatobiliary Pancreat Dis Int HBPD INT. 2017;16(4):405-11.
Booth CM, Nanji S, Wei X, Mackillop WJ. Management and Outcome of Colorectal Cancer Liver Metastases in Elderly Patients: A Population-Based Study. JAMA Oncol. 2015;1(8):1111-9.
Swanson RS, Pezzi CM, Mallin K, Loomis AM, Winchester DP. The 90-day mortality after pancreatectomy for cancer is double the 30-day mortality: more than 20,000 resections from the national cancer data base. Ann Surg Oncol. 2014;21(13):4059-67.
Li SS, Costantino CL, Mullen JT. Morbidity and Mortality of Total Gastrectomy: a Comprehensive Analysis of 90-Day Outcomes. J Gastrointest Surg Off J Soc Surg Aliment Tract. 2019;23(7):1340-8.
Mizushima T, Yamamoto H, Marubashi S, Kamiya K, Wakabayashi G, Miyata H, et al. Validity and significance of 30‐day mortality rate as a quality indicator for gastrointestinal cancer surgeries. Ann Gastroenterological Surg. 2018;2(3):231-40.
In H, Palis BE, Merkow RP, Posner MC, Ferguson MK, Winchester DP, et al. Doubling of 30-Day Mortality by 90 Days After Esophagectomy. Annals of surgery. 2016;1;263(2):286-91.
Pezzi CM, Mallin K, Mendez AS, Greer Gay E, Putnam JB. Ninety-day mortality after resection for lung cancer is nearly double 30-day mortality. J Thorac Cardiovasc Surg. 2014;148(5):2269-77.
Spencer RJ, Hacker KE, Griggs JJ, Rice LW, Reynolds RK, Uppal S. Ninety-Day Mortality as a Reporting Parameter for High-Grade Serous Ovarian Cancer Cytoreduction Surgery. Obstet Gynecol. 2017;130(2):305-14.
Abu Rmilah A, Zhou W, Nelson E, Lin L, Amiot B, Nyberg SL. Understanding the marvels behind liver regeneration. Wiley Interdiscip Rev Dev Biol. 2019;8(3):340.
Clavien P-A, Oberkofler CE, Raptis DA, Lehmann K, Rickenbacher A, El-Badry AM. What is critical for liver surgery and partial liver transplantation: size or quality? Hepatol Baltim Md. 2010;52(2):715-29.
Abu-Dief E, Mohammed D, Abd El-Haliem N, Mohammed S, El-Badry A. Impact of omega-3 fatty acids on evolution of carbon tetrachloride- (CCl4) induced liver cirrhosis in mice: A histological and immunohistochemical study. Egypt J Histol. 2018;41(1):61-72.
El-Badry AM, Graf R, Clavien P-A. Omega 3 - Omega 6: What is right for the liver? J Hepatol. 2007;47(5):718-25.
El-Badry AM, Jang JH, Elsherbiny A, Contaldo C, Tian Y, Raptis DA, et al. Chemical composition of hepatic lipids mediates reperfusion injury of the macrosteatotic mouse liver through thromboxane A2. J Hepatol. 2011;1;55(6):1291-9.
El-Badry AM, Moritz W, Contaldo C, Tian Y, Graf R, Clavien P-A. Prevention of reperfusion injury and microcirculatory failure in macrosteatotic mouse liver by omega-3 fatty acids. Hepatol Baltim Md. 2007;45(4):855-63.
Kulik L, El-Serag HB. Epidemiology and Management of Hepatocellular Carcinoma. Gastroenterology. 2019;156(2):477-91.
Alboraie M, Youssef N, Sherief AF, Afify S, Wifi MN, Omran D, et al. Egyptian liver library: An indexed database for liver disease evidence in Egypt. Arab J Gastroenterol. 2019;4.
Abdelaziz AO, Nabil MM, Abdelmaksoud AH, Shousha HI, Hashem MB, Hassan EM et al. Tumor behavior of hepatocellular carcinoma after hepatitis C treatment by direct-acting antivirals: comparative analysis with non-direct-acting antivirals-treated patients. Eur J Gastroenterol Hepatol. 2019;1;31(1):75-9.
Adamson DT, Bozeman MC, Benns MV, Burton A, Davis EG, Jones CM. Operative Considerations for the General Surgeon in Patients with Chronic Liver Disease. Am Surg. 2019;85(2):234-44.
Clavien PA, Barkun J, De Oliveira ML, Vauthey JN, Dindo D, Schulick RD, et al. The Clavien-Dindo classification of surgical complications: five-year experience. Ann Surg. 2009;1;250(2):187-96.
El-Badry AM, Abdelraheem O. Clinical outcome after liver resection for colorectal versus non-colorectal metastasis: a comparative study. Int Surg J. 2018;5(2):390-7.
El-Badry AM, Ahmed AE. Evaluation of the “50-50 criteria” of post-hepatectomy liver failure as mortality predictor after resection of liver tumors. Int Surg J. 2019;6(3):648-52.
Gonwa TA, Morris CA, Goldstein RM, Husberg BS, Klintmalm GB. Long-term survival and renal function following liver transplantation in patients with and without hepatorenal syndrome--experience in 300 patients. Transplantation. 1991;51(2):428-30.
Mayo SC, Shore AD, Nathan H, Edil BH, Hirose K, Anders RA, et al. Refining the definition of perioperative mortality following hepatectomy using death within 90 days as the standard criterion. HPB. 2011;13(7):473-82.
Dasari BV, Hodson J, Sutcliffe RP, Marudanayagam R, Roberts KJ, Abradelo M, et al. Developing and validating a preoperative risk score to predict 90‐day mortality after liver resection. J Surgical Oncol. 2019;119(4):472-8.
Pedersen T, Watt SK, Tolstrup M-B, Gögenur I. 30-Day, 90-day and 1-year mortality after emergency colonic surgery. Eur J Trauma Emerg Surg Off Publ Eur Trauma Soc. 2017;43(3):299-305.
Mullen JT, Ribero D, Reddy SK, Donadon M, Zorzi D, Gautam S, et al. Hepatic insufficiency and mortality in 1,059 noncirrhotic patients undergoing major hepatectomy. J Am Coll Surgeons. 2007;1;204(5):854-62.
Levesque E, Winter A, Noorah Z, Daurès JP, Landais P, Feray C, Azoulay D. Impact of acute‐on‐chronic liver failure on 90‐day mortality following a first liver transplantation. Liver International. 2017;37(5):684-93.
Hackl C, Schlitt HJ, Renner P, Lang SA. Liver surgery in cirrhosis and portal hypertension. World J Gastroenterol. 2016;22(9):2725-35.
Cordero-Espinoza L, Huch M. The balancing act of the liver: tissue regeneration versus fibrosis. J Clin Invest. 2018;128(1):85-96.
Balzan S, Belghiti J, Farges O, Ogata S, Sauvanet A, Delefosse D, et al. The “50-50 criteria” on postoperative day 5: an accurate predictor of liver failure and death after hepatectomy. Ann Surg. 2005;242(6):824.
Alkozai EM, Nijsten MW, de Jong KP, de Boer MT, Peeters PM, Slooff MJ, et al. Immediate postoperative low platelet count is associated with delayed liver function recovery after partial liver resection. Ann Surg. 2010;1;251(2):300-6.
Tian Y, Graf R, El-Badry AM, Lesurtel M, Furrer K, Moritz W, et al. Activation of serotonin receptor-2B rescues small-for-size liver graft failure in mice. Hepatol Baltim Md. 2011;53(1):253-62.
Lesurtel M, Clavien P-A. Platelet-derived serotonin: translational implications for liver regeneration. Hepatol Baltim Md. 2014;60(1):30-3.
Pearce N. Analysis of matched case-control studies. BMJ. 2016;352:969.