Impact of post-hepatectomy liver failure on morbidity and short- and long-term survival after major hepatectomy

Abstract

Background: Post-hepatectomy liver failure (PHLF) is one of the most serious postoperative complications after hepatectomy. The aim of this study was to assess the impact of the International Study Group of Liver Surgery (ISGLS) definition of PHLF on morbidity and short- and long-term survival after major hepatectomy.

Methods: This was a retrospective review of all patients who underwent major hepatectomy (three or more liver segments) for various liver tumours between 2010 and 2018 at two Swedish tertiary centres for hepatopancreatobiliary surgery. Descriptive statistics, regression models, and survival analyses were used.

Results: A total of 799 patients underwent major hepatectomy, of which 218 patients (27 per cent) developed ISGLS-defined PHLF, including 115 patients (14 per cent) with ISGLS grade A, 76 patients (10 per cent) with grade B, and 27 patients (3 per cent) with grade C. The presence of cirrhosis, perihilar cholangiocarcinoma, and gallbladder cancer, right-sided hemihepatectomy and trisectionectomy all significantly increased the risk of clinically relevant PHLF (grades B and C). Clinically relevant PHLF increased the risk of 90-day mortality and was associated with impaired long-term survival. ISGLS grade A had more major postoperative complications compared with no PHLF but failed to be an independent predictor of both 90-day mortality and long-term survival. The impact of PHLF grade B/C on long-term survival was no longer present in patients surviving the first 90 days after surgery.

Conclusions: The presently used ISGLS definition for PHLF should be reconsidered regarding mortality as only PHLF grade B/C was associated with a negative impact on short-term survival; however, even ISGLS grade A had clinical implications.

Fig. 1

a Kaplan–Meier estimates of overall survival in patients with or without post-hepatectomy liver failure (PHLF) defined by the International Study Group of Liver Surgery (ISGLS). Grade A and grade B/C PHLF had a median survival and 5-year overall survival of 34 months (95 per cent c.i. 26 to 44 months) and 36 per cent for grade A and 18 months (95 per cent c.i. 14 to 26 month) and 24 per cent respectively, for grade B/C (log rank test, P = 0.006). No PHLF resulted in a median survival of 47 months (95 per cent c.i. 41 to 57 months) and 5-year overall survival of 45 per cent. b Kaplan–Meier estimates of overall survival in patients with or without PHLF according to the ‘50–50 criteria’ defined by Balzan et al. No PHLF had a median survival and 5-year overall survival of 42 months (95 per cent c.i. 35 to 47 months) and 41 per cent respectively, and PHLF according to the ‘50–50’ criteria had a median survival and 5-year overall survival of 10 months (95 per cent c.i. 4 to 38 months) and 26 per cent (log rank test, P < 0.001).

Fig. 2

a Kaplan–Meier estimates of overall survival in patients surviving 90 days after hepatectomy according to post-hepatectomy liver failure (PHLF) defined by the International Study Group of Liver Surgery (ISGLS). Grade A and grade B/C PHLF had a median survival and 5-year overall survival of 36 months (95 per cent c.i. 28 to 48 months) and 38 per cent, respectively, for grade A and 27 months (95 per cent c.i. 21 to 40 months) and 30 per cent respectively, for grade B/C (log rank test, P = 0.213). No PHLF resulted in a median survival of 49 months (95 per cent c.i. 42 to 59 months) and 5-year overall survival of 45 per cent. b Kaplan–Meier estimates of overall survival in patients surviving 90 days after hepatectomy with or without PHLF according to the ‘50–50 criteria’ defined by Balzan et al. No PHLF had a median survival and 5-year overall survival of 44 months (95 per cent c.i. 39 to 51 months) and 43 per cent respectively, with corresponding survival estimates in PHLF of 38 months (95 per cent c.i. 12 to not reached) and 37 per cent respectively (log rank test, P = 0.237).