Blood loss, liver failure predict survival after surgery in hepatocellular cancer

A Singapore study suggests that doctors who want to predict postoperative mortality in hepatocellular carcinoma (HCC) patients after hepatic resection should look at the following: intraoperative blood loss, Child-Pugh score, posthepatectomy liver failure (PLHF), and peak serum bilirubin.

“Our results serve to guide patient selection for surgical and nonsurgical approaches to the management of HCC,” the researchers said. “Less invasive approaches such as transarterial chemoembolization (TACE) and radiofrequency ablation (RFA) or combination therapies should be explored for patients with liver dysfunction or predicted technically difficult resection with potential for blood loss.”

The retrospective assessment looked at 244 HCC patients (median age 67 years, 84.4 percent men) after hepatic resection and included their clinical, biochemical, and radiological information. The outcomes of interest were 30-day and 90-day mortality, as well as longer-term survival.

Eight patients died within 30 days of the procedure, increasing to 13 by 90 days. The resulting mortality rates were 3.28 percent and 5.33 percent, respectively. Patients stayed in the hospital for a mean of 7 days after surgery; 47 required intensive care, 11 were placed on vasopressor support, and two underwent renal replacement therapy. [Visc Med 2021;37:102-109]

Multivariate Cox regression analysis was performed to identify predictors of 90-day mortality. Of all factors analysed, the 50-50 criterion for PLHF (bilirubin >50 µmol/L, international normalized ratio >1.7) had the strongest effect, increasing the likelihood of 90-day mortality by more than eight times (adjusted hazard ratio [HR], 8.628, 95 percent confidence interval [CI], 3.330–25.353; p<0.001).

Child-Pugh class B/C (adjusted HR, 3.44, 95 percent CI, 0.152–0.557; p<0.001) and peak serum bilirubin >119 µmol/L (adjusted HR, 2.963, 95 percent CI, 1.355–6.480; p=0.007) were likewise strong risk factors for 90-day mortality, both increasing its likelihood by around three times.

Intraoperative blood loss had a weaker effect but was nevertheless a significant predictor of 90-day mortality (adjusted HR, 1.486, 95 percent CI, 1.088–2.031; p=0.013).

Median patient survival was 39 months, suggesting that longer-term survival grew progressively worse. At 1 year, survival was 75.4 percent, dropping to 46.3 percent by year 3 and to 23 percent by 5 years.

“Liver function tests performed by serum biochemistry are sine qua non prior to hepatic resection,” the researchers said. “In patients with compromised liver function, treatment has to be tailored to ensure sufficient residual liver function, and in some instances, liver transplantation would be warranted.”

Important limitations need to be considered, they added. Because data were sourced from a single centre, findings are not readily generalizable to all demographic profiles. The retrospective nature of the study also precludes cause-effect analyses. Moreover, information on other key factors were lacking, including causes of death, early tumour recurrence, inflammation indices, and platelet count.