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Mortality after Liver Resection

Mortality after Liver Resection. Jacques Belghiti Silvio Balzan, Fabien Stenard, Satoshi Ogata. Department of Hepato-Pancreatico-Biliary and United Federation of Hepato-Gastroenterology and Digestive Surgery of Beaujon Hospital, Clichy, University Paris 7. France.

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Mortality after Liver Resection

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  1. Mortality after Liver Resection Jacques Belghiti Silvio Balzan, Fabien Stenard, Satoshi Ogata Department of Hepato-Pancreatico-Biliary and United Federation of Hepato-Gastroenterology and Digestive Surgery of Beaujon Hospital, Clichy, University Paris 7. France

  2. 427 Resection of HCC: 1990 - 2003 Normal Chronic Liver Liver Disease Mortality 1.2% 7.7% • Bleeding 2% 8% • Ascites 15% 45% • Jaundice 4% 12% • Infection 15% 25% • Renal failure 0% 8% • Liver Failure 0.5% 6% Absence or insufficient liver regeneration

  3. Elective Liver Resectionn = 775 (1998 – 2002) • Early post operative deaths within 3 days • Myocardiac infarction (n = 1) • Peritonitis due to bowel necrosis (n = 2) In-Hospital Mortality (n = 26) 3.3% Median post operative deaths POD 16 (range 5-39) Post Operative Days

  4. Liver Parenchymal Status Normal (n = 5) Disead (n = 18) 78% Post Operative Days

  5. Severe Infection or Renal Failure Incidence: 74% Median POD: 10 (range 2-18) Occurrence before or at POD 5: 30％ Post Operative Days

  6. In Hospital Deaths (n = 26) • Early post operative deaths within 3 days • Myocardiac infarction (n = 1) • Peritonitis due to bowel necrosis (n = 2) Median post operative deaths Link to liver Failure POD 16 (range 5-39) Post Operative Days

  7. Postoperative Liver Failure remains the most dangerous complication after Liver Resection • Risk of Death • Insufficient absolute or functional liver parenchyma. • Impaired tolerance to infectious complications. • Definition ? • Prevalence ? • Impact on postoperative mortality ?

  8. Clinical Biological - Encephalopathy - Bilirubinemia > 150 µmol/L - Jaundice - PT < 50% - - Ascites - Factor V < 50% - ICG 15 min > 20 or 15% Encephalopathy, ascites or coagulopathy requering specific treatment. Hemming AW et al. Ann Surg 2003,5:686-93. Prolonged hyperbilirubinemia, ascites,coagulopathy requering fresh-frozen plasma, and/or encephalopathy. Jarnagin WR et al. Ann Surg 2003,4:397-407. Bilirubinemia > 5 mg/dL (85 µmol/L), PT < 50% for 3 or more consecutive days. Imamura H. Arch Surg 2003,138:1198-1206. Two of Bilirubinemia >60 µmol/L, asterixis, and prothrombin time<30%. Azoulay D. Ann Surg 2000,232:665-72 What is Post operative Liver Failure ?

  9. Objective Criteria of Post operative Liver Failure predicting high mortality rate. Simple: quick, cheap and non invasive. Efficient: allowing early diagnosis and early management. Standardized: compare results.

  10. Peri-operative risk assessment in cirrhosis: FIFTY-FIFTY AT DAY FIVE CRITERIA Child-Pugh Score Encephalopathy absent controlled medically poorly controlled Ascites absent controlled medically poorly controlled Albumin (g/l) > 35 28 – 35 < 28 Serum Bilirubin (µmol/l) < 35 35 – 50 > 50 Prothrombin Time (%) > 50 40 – 50 < 40

  11. Encephalopathy poorly controlled Ascites poorly controlled Albumin (g/l) < 28 Serum Bilirubin (µmol/l) > 50 Prothrombin Time (%) < 50 Post operative period ⇨ Not applicable (anesthesia) ⇨ Frequent after liver resection ⇨ Useless (post. hemodiluition) ⇨ When ? ⇨ When ? Child-Pugh Score: Criteria of POLF

  12. Liver Tests after Major Hepatectomy GGT Prothrombin Time Bilirubinemia 200 40 105 180 35 100 160 95 30 90 140 85 25 120 80 20 75 100 70 15 80 65 60 60 10 55 40 5 50 GGTJ1 GGTJ3 GGTJ5 GGTJ7 GGTJ9 GGTJ-1 GGTJ11 Bbj-1 Bbj1 Bbj3 Bbj5 Bbj7 Bbj9 Bbj11 TPj-1 TPj1 TPj3 TPj5 TPj7 TPj9 TPj11 ASAT ALAT ALP 350 350 210 200 300 300 190 250 180 250 170 200 200 160 150 150 150 140 100 100 130 120 50 50 110 0 0 100 ASTj-1 ASTj1 ASTj3 ASTj5 ASTj7 ASTj9 ASTj11 ALTj-1 ALTj1 ALTj3 ALTj5 ALTj7 ALTj9 ALTj11 PAj-1 PAj1 PAj3 PAj5 PAj7 PAj9 PAj11

  13. Prospective Database from 1998 – 2002 775 elective liver resection* • Aged: 54 ± 10 years • Malignant tumors: 531 (69%) • Major resection: 464 (60%) • Diseased Liver present: 307 (40%) • Fibrosis 237 (31%) • Cirrhosis 94 (12%) • Steatosis >30%: 107 (14%) • In hospital mortality:(n=26) 3.3%

  14. Postoperative Liver Tests1998 – 2002: 775 elective liver resection

  15. In Hospital Deaths (n = 26) Median post operative deaths Link to liver Failure POD 16 (range 5-39) Post Operative Days

  16. Postoperative Morbidity vs No Complications Bilirubinemia PT ALP ASAT

  17. 105 100 95 90 85 80 75 70 65 60 55 50 TPj-1 TPj1 TPj3 TPj5 TPj7 TPj9 TPj11 Prothrombin Time (%) PT < 50% 1 3 57 Incidence 21% 16% 6% 4% Mortality if present 10% 16% 33% 40% absent 1.5 % 1.3 % 1.3 % 1%

  18. 40 35 30 25 20 15 10 5 Bbj-1 Bbj1 Bbj3 Bbj5 Bbj7 Bbj9 Bbj11 > 50 µml/L 1 3 57 Incidence 17% 19% 16% 11% Mortality if present 7% 11% 15% 17% absent 2 % 2 % 1 % 1% Bilirubinemia

  19. Mortality day 5 PT < 50% 33% SB > 50 µml/L15% PT<50% and SB>50 µml/L59%

  20. DAY 5 PT >50% PT <50% Bil < 50 µmol/L 1 % 7 % Bil > 50 µmol/L 4 % 59 % Fifty – Fifty at day Five Criteria after Hepatectomy Mortality according to PT< 50% and Bilirubinemia >50 µmol/L

  21. 25 Patients with 50-50 criteria • 14 deaths11 Severe Morbidity • ICU : 22 days (4 – 57) • Hospital stay: 43 days (17 – 69) • Dead without 50-50 criteria at day 5 (n=7) • 3 digestive bleeding with portal thrombosis • 2 biliar peritonites and septicemia by candida • 4 severe sepsis

  22. Conclusions The presence at day 5 of the criteria 50 – 50 (PT< 50% and Bilirubinemia > 50 µmol/L) is an early and strong predictor (60%) of mortality

  23. “50-50 criteria” • At day 5 the criteria 50 – 50 (PT< 50% and Bilirubinemia > 50 µmol/L) which is an early and strong predictor (60%) of mortality can be used as a criteria of Postoperative Liver Failure. • Most importantly, this criteria which precede any clinical evidence of complication and death by a median of 5 and 10 days can be used for: • early assessment of infection or portal thrombosis and • to implement specific therapeutic interventions such as prophylactic antimicrobial therapy, artificial liver support or even liver transplantation.

  24. Case 75 yrs male 30/03/2004 Right hemicolectomy Dukes C, 2 metastases in right liver - 12/2004 Systemic chemotherapy (Oxaliplatin+5FU+LV) 10/02/2005 Right hepatectomy Labo data AST: 43 IU/L ALT: 66 IU/L GGT: 248 IU/L T-Bil: 5 µmol/L PT: 76%

  25. Death MARS Bil PT

  26. FIFTY-FIFTY AT DAY FIVE CRITERIA • Dead with 50-50 criteria at day 5 present • 1 no context of liver failure • 12 infected ascites – portal thrombosis • pneumopathy • Dead without 50-50 criteria at day 5 • 3 digestive bleeding – biliar peritonites • septicemia by candida • 7 portal thrombosis – infected ascites (3) • No dead despite 50-50 criteria present • 3 transient criteria (only at day 5) – uncomplicated outcome • 9 100% of morbidity • USI 22 days(4 - 57) • Hospitalization 43 days (17 - 69)

  27. FIFTY-FIFTY AT DAY FIVE CRITERIA • Deaths without 50-50 criteria at day 5 • 3 digestive bleeding • biliar peritonites • septicemia with candida • 7 portal thrombosis • infected ascites (3)

  28. Prothrombin Time (%) 105 100 95 90 85 80 75 70 65 60 55 50 TPj-1 TPj1 TPj3 TPj5 TPj7 TPj9 TPj11

  29. Bilirubinemia 40 35 30 25 20 15 10 5 Bbj-1 Bbj1 Bbj3 Bbj5 Bbj7 Bbj9 Bbj11

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