Combining ALT/AST Values with Surgical APGAR Score Improves Prediction of Major Complications after Hepatectomy

Abstract

Hepatectomy is a complex procedure with high morbidity and mortality. Early prediction/prevention of major complications is highly valuable for patient care. Surgical APGAR score (SAS) has been validated to predict post-surgical complications (PCs). We aimed to define a simple complications classification following hepatectomy based on a therapy-oriented severity Clavien-Dindo classification (CDC). 119 patients undergoing liver resection were included. PCs were determined at follow-up based on CDC. Clinicopathological factors were used to calculate SAS. A receiver-operator characteristic (ROC) curve analysis estimated the predictive value of SAS for PCs. Circulating markers levels of liver injury were analyzed as critical elements on PCs. SAS (P=0.008), estimated blood-loss (P=0.018) and operation time (P=0.0008) were associated with PCs. SAS was reduced in patients with (+) compared to those without (-) complications (6.64±1.84 vs 5.70±1.79, P=0.0079). The area-under-the-curve was 0.646 by ROC, indicating an acceptable discrimination with 65% possibility to distinguish (-) and (+) groups (P=0.004). Best cutoff value for SAS was ≤6/≥7, at which sensitivity and specificity were maximal. ALT/ASL levels were significantly different within the group with 9-10 SAS points (P=0.01 and 0.02). In conclusion, SAS provides accurate risk stratification for major PCs after hepatectomy, and might help improving the overall patient outcome.

Keywords: Circulating markers; Hepatectomy; Liver disease; Postoperative Complications; Surgical APGAR Score.

Figure 1:

Relationship between SAS and postoperative complications. A) Distribution of patients with and without complications across different range of SAS points (0-2, 3-4, 5-6, 7-8, 9-10). Height of the bar indicates percentage of patients. The percentage above bars indicates the ratio of patients with complications after hepatectomy. B) Box and whisker plot representing SAS points of the patients without (−) or with (+) complications after hepatectomy, in which the lines within the box represent median value; the upper and lower lines of the boxes represent the 25^th and 75^th percentiles respectively; and the upper and lower bars outside box represents the 95^th and 5^th percentiles respectively. C) Receiver operator characteristic (ROC) curve of SAS points for predicting development of complications after hepatectomy. The calculated area under the curve (AUC) is shown on the graph and the dotted line indicates the best cutoff values (≤6/≥7) with maximum sensitivity and specificity. D) Bar plot representing percentage of patients without (−) or with (+) complications across SAS points cutoff values (≤6/≥7) after hepatectomy.

Figure 2:

Increased serum ALT/AST levels as a potential biomarker for postoperative complications. A) Box and whisker plot representing serum albumin, serum AST and serum ALT levels across patients without (−) and with (+) complications after hepatectomy. B) Box and whisker plot representing serum albumin, serum AST and serum ALT levels across different range of SAS points (0-2, 3-4, 5-6, 7-8, 9-10) after hepatectomy. In both plots, the lines within the box represent median value; the upper and lower lines of the boxes represent the 25^th and 75^th percentiles respectively; and the upper and lower bars outside box represent the 95^th and 5^th percentiles respectively.