Relevance of the ISGLS Definition of Posthepatectomy Liver Failure in Early Prediction of Poor Outcome After Liver Resection

Abstract

Objective: To assess the relevance of the International Study Group of Liver Surgery (ISGLS) definition of posthepatectomy liver failure compared with 2 well-established criteria, 50-50 and Peak Bili >7, as early predictors of posthepatectomy outcome. Background: There is limited data on the postoperative use of ISGLS definition of posthepatectomy liver failure as early predictor of outcome. Methods: Between 2007 and 2012, a total of 680 hepatectomies were analyzed from a prospective database. The value of each definition for prediction of 3-month major complications (Clavien III-V) and mortality was assessed either within 10 days of surgery or on postoperative day 5. Results: Three-month major morbidity and mortality rates were 16.5% and 4.4%, respectively. Within 10 days, 79 patients fulfilled ISGLS definition compared with 24 for 50-50 and 44 for Peak Bili >7 criteria. Sensitivities of ISGLS definition and 50-50 and Peak Bili >7 criteria for prediction of major morbidity and mortality were 35.8, 17.4, 24.8% and 56.7, 36.7, 56.7%, respectively. Patients with no positive score had a risk of death or major complication below 5% and 15%, respectively. In patients with a positive score, the ISGLS definition was the least relevant to predict major complications and mortality (positive predictive values of 49.4% and 21.8% vs 79.2% and 47.8% for 50-50 and 61.4% and 40.5% for Peak Bili >7 criteria). The relative risk of death was 6.9 (95% confidence interval, 3.1-15.4) if the ISGLS definition was evaluated on postoperative day 5 versus 21.1 (95% confidence interval, 7.7-57.7) for 50-50 and 21.7 (95% confidence interval, 7.4-63.3) for Peak Bili >7 criteria. Conclusions: ISGLS definition was less discriminatory than 50-50 and Peak Bili >7 criteria in identifying patients at risk of posthepatectomy major complications or death.

Postoperative Liver Failure Criteria for Predicting Mortality after Major Hepatectomy with Extrahepatic Bile Duct Resection

“…The potential utility of the ISGLS criterion has remained unknown because 2 large-scale validation studies revealed that other criteria were more useful as early predictors of post-operative morbidity or mortality [5, 18]. The first validation study of the ISGLS criterion was reported in 2011 by Rahbari et al [2].…”

“…While they recommended using the model for end-stage liver disease score as a predictor of PHLF, they also concluded that use of the ISGLS criterion enables adequate risk stratification for perioperative mortality. Another study in 2014 by Skrzypczyk et al [18] validated the ISGLS criterion using 680 hepatectomies. They compared the ISGLS, original 50-50, and peak bilirubin (similar to our Max T-Bili) criterion.…”

Validation of the peak bilirubin criterion for outcome after partial hepatectomy

“…14 However, this is a rather short period of time since the majority of complications occur within 90 days after liver resection. 16 The peak bilirubin criterion is one of the main predictors used in daily practice, 17 but modern practice has changed in the last decade.…”

“…10,11 However, these parameters have revealed to be suboptimal to detect patients with developing PLF based on their definitions as shown by recent validation studies. [12][13][14] In 2007, Mullen et al proposed a definition for PLF based on analysis of 1059 patients without cirrhosis who underwent major hepatectomy between 1995 and 2005 at three hepatobiliary centres in the United States and Italy. 15 The authors stated that the occurrence of a systemic bilirubin level of >7.0 mg/dL (120 mmol/L, 'peak bilirubin criterion') within 90 days after major hepatectomy provides a sensitivity of 93.3% for liverrelated death and an odds ratio (OR) of 250 (95% confidence interval, 25.0 to >1000) for 90-day liver-related mortality.…”

Central hepatectomy: A valuable option to avoid posthepatectomy liver insufficiency in patients requiring extensive liver resection

“…It has been reported that liver insufficiency may occur in as high as 12% of posthepatectomy patients, especially in those who have a concomitant chronic liver disease, hepatosteatosis or history of receiving long-course (>6 cycles) chemotherapy (1). Central hepatectomy or mesohepatectomy, defined as en-bloc anatomical resection of liver segments 4-5 and 8, is a valuable option in patients with central large or multiple liver lesions to minimize PLF caused by the loss of a considerable portion of functional liver parenchyma following extensive resections (2).…”