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Patient factors linked with liver remnant growth in staged hepatectomy

Liver International
Reuters Health - 16/06/2022 - In patients undergoing staged hepatectomy for liver tumors, a technique that combines portal vein ligation and parenchymal in situ split allows for rapid, enhanced hypertrophy of the future liver remnant, and now researchers say they have identified the variables that most consistently influence remnant growth. 

These include patients' height, weight, and gender, the researchers reported in Liver International. 

They studied 734 patients from 99 centers who underwent so-called associated liver partition and portal vein ligation for staged hepatectomy (ALPPS), using data from the International ALPPS Registry, coordinated at the University of Zurich, Switzerland. 

The median age was 60; 60.1% of patients were male. Mean height, weight, and body mass index (BMI) were 1.70 m, 73 kg, and 25, respectively. The most frequent indications for resection were metastatic colorectal cancer (65.1%), hepatocellular carcinoma (13.4%), and intrahepatic cholangiocarcinoma (7.2%). 

The median standardized future liver remnant (sFLR) was 0.23 at stage 1 and 0.39 at stage 2. The median sFLR increase was 0.15. FLR was considered insufficient when it was less than 25% in patients with a healthy liver and less than 35% in those who had received chemotherapy or who had steatosis. 

Factors associated with a lower increase from sFLR1 to sFLR2 were age ˃68 (p=0.02), height ˃1.76 m (p˂0.01), weight ˃83 kg (p˂0.01), BMI ˃28 (p˂0.01), male gender (p˂0.01), antihypertensive therapy (p˂0.01), operative time ˃370 minutes (p˂0.01), and hospital stay ˃14 days (p˂0.01). 

Median sFLR increases were 0.17 in patients younger than 53 vs 0.14 in patients older than 68, and 0.16 in patients weighing <63 kg vs 0.14 for weight >83 kg. The median increase in sFLR was 0.15 for males and 0.16 for females. 

Lower rate of volume increase was associated with age ˃68 (p˂0.01), weight ˃83 kg (p˂0.01), male gender (p=0.03), no chemotherapy (p˂0.01), antihypertensive therapy (p˂0.01), liver disease (p=0.01), operative time ˃370 minutes (p=0.01,) and hospital stay ˃14 days (p˂0.01). 

Sufficient volume for stage 2 was achieved within 7 days by 50% of females and 40.3% of males; 15.3% of females and 20.6% of males needed more than 14 days to achieve sufficient volume. Thirty patients did not reach stage 2 and had a higher rate of complications (64.4% vs 29.1%, p<0.001) and mortality (43.3% vs 0. 7%; p<0.001). 

Operative time (p˂0.01), hospital stay (p˂0.01), and gender (p=0.03) were associated with longer time until stage 2 was reached. 

The majority of patients (64%) had colorectal liver metastases. In this group, variables associated with a lower increase from sFLR1 to sFLR2 and slower rate of volume increase were age ˃68 years (p=0.09 and p=0.02, respectively), height ˃1.76 m (p˂0.01 and p=0.03), weight ˃83 kg (p˂0.01 and p˂0.01), BMI ˃28 (p=0.03 and p=0.04), male gender (p˂0.01 and p=0.03), antihypertensive therapy (p˂0.01 and p˂0.01), and hospital stay ˃14 days (p˂0.01 and p=0.01). Comparing patients with liver primary malignancies to patients with colorectal metastases, the colon cancer patients greater increase in %FLR (0.16 vs 0.14; p <0.001], with fewer patients needing blood transfusion (18.2% vs 34.1%; p <0.001), shorter hospital stay (9 vs 12 days; p <0.001) and fewer inter-stage complications (27.1% vs 38.2%; p=0.01). 

Study leader Dr. Victor Lopez-Lopez from the Virgen de la Arrixaca Clinic and University and his colleagues concluded, "Height, weight, size and gender are the variables that most constantly influence both daily growths, the interstage percentage increase and the standardized FLR before the second stage." 

"Other variables such as the negative effect of antihypertensive drugs on rapid regeneration represent a novelty that had not been described in humans," they continued. "This observation requires more studies to know the real extent of their impact on liver regeneration. Similarly, the concept that chemotherapy increased the risk of liver failure, according to the findings of this study, could be related to drug-induced liver damage, but not to a decreased capacity for regeneration. Even so, more studies in this direction are necessary to corroborate the findings." 

SOURCE: https://bit.ly/3xTzhw6  Liver International, online May 9, 2022. 

By Patricia A. Sheiner MD 

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