Hierarchic Interaction of Factors Associated With Liver Decompensation After Resection for Hepatocellular Carcinoma
Authors: Davide Citterio, Antonio Facciorusso, Carlo Sposito, Roberta Rota, Sherrie Bhoori, Vincenzo Mazzaferro
Journal: JAMA Surgery (2016)

<h3>Importance</h3> Liver resection is the treatment of choice for hepatocellular carcinoma (HCC) in well-compensated liver cirrhosis. Postoperative liver decompensation (LD) is the most representative and least predictable cause of morbidity and mortality. <h3>Objectives</h3> To determine the hierarchy and interaction of factors associated with the risk for LD and to define applicable risk classes among surgical candidates. <h3>Design, Setting, and Participants</h3> This retrospective review collected data from 543 patients with chronic liver disease who underwent hepatic resection for HCC from January 1, 2000, through December 31, 2013, in a tertiary comprehensive cancer center. Final follow-up was completed on January 31, 2015, and data were assessed from February 1 to 28, 2015. <h3>Major Outcomes and Measures</h3> Preoperative prognostic factors and risk stratification for postoperative LD. Multivariate logistic regression was performed, and the independent risk factors for LD were included in a recursive partitioning analysis model. Results were validated by means of 10-fold cross-validation. <h3>Results</h3> The analysis included 543 patients, of whom 411 (75.7%) were male, 132 (24.3%) were female, and the median age was 68 (interquartile range, 62-73) years. An independent association with LD was found for major hepatectomy (odds ratio [OR], 2.41; 95% CI, 1.17-4.30;<i>P</i> = .01), portal hypertension (OR, 2.20; 95% CI, 1.13-4.30;<i>P</i> = .01), and Model for End-Stage Liver Disease (MELD) score greater than 9 (OR, 2.26; 95% CI, 1.10-4.58;<i>P</i> = .02). Recursive partitioning analysis confirmed portal hypertension as the most important factor (OR, 2.99; 95% CI, 1.93-4.62;<i>P</i> &lt; .001), followed by extension of hepatectomy with (OR, 2.76; 95% CI, 1.85-4.77;<i>P</i> = .03) and without (OR, 2.98; 95% CI, 1.97-4.52;<i>P</i> &lt; .001) portal hypertension, and MELD score (OR, 1.79; 95% CI, 1.23-2.13;<i>P</i> &lt; .001). Low-risk patients (LD rate, 4.9% [11 of 226]) without portal hypertension underwent minor resection with a MELD score of 9 or less; intermediate-risk patients (LD rate, 28.6% [85 of 297]) had no portal hypertension and underwent major resections or, in case of minor resections, had portal hypertension or a MELD score greater than 9; and high-risk patients (LD rate, 60.0% [12 of 20]) underwent major resection with portal hypertension. Risk-class progression paralleled median length of stay (7, 8, and 11 days, respectively;<i>P</i> &lt; .001) and liver-related mortality (4.4% [10 of 226], 9.0% [27 of 297], and 25.0% [5 of 20], respectively;<i>P</i> = .001). A 10-fold cross-validation of the model resulted in a C index of 0.78 (95% CI, 0.74-0.82) and an overall error rate of 0.06. <h3>Conclusions and Relevance</h3> The risk for postoperative LD after resection for HCC in chronic liver disease is associated with preoperative hierarchic interaction of portal hypertension, planned extension of hepatectomy, and the MELD score.