Post on 01-Apr-2015
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Jacques BelghitiSilvio 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
Mortality after Liver Resection
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
0 10 20 30 40
1
3
5
7
9
11
13
15
17
19
21
23
25
Post Operative Days
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)
Elective Liver Resectionn = 775 (1998 – 2002)
Liver Parenchymal Status
0 10 20 30 40
1
3
5
7
9
11
13
15
17
19
21
23
Post Operative Days
Normal (n = 5)
Disead (n = 18) 78%
Severe Infection or Renal Failure
0 10 20 30 40
1
3
5
7
9
11
13
15
17
19
21
23
Post Operative Days
Incidence: 74%Median POD: 10 (range 2-18)
Occurrence before or at POD 5: 30 %
In Hospital Deaths (n = 26)
0 10 20 30 40
1
3
5
7
9
11
13
15
17
19
21
23
25
Post Operative Days
Early post operative deaths within 3 days•Myocardiac infarction (n = 1)•Peritonitis due to bowel necrosis (n = 2)
Median post operative deathsLink to liver FailurePOD 16 (range 5-39)
• 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 ?
What is Post operative Liver Failure ?
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
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.
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
Peri-operative risk assessment in cirrhosis:
Child-Pugh Score: Criteria of POLF
•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 ?
Liver Tests after Major Hepatectomy
50
55
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100
105
TPj-1 TPj1 TPj3 TPj5 TPj7 TPj9 TPj115
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15
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40
Bbj-1 Bbj1 Bbj3 Bbj5 Bbj7 Bbj9 Bbj11
40
60
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GG
TJ-
1
GG
TJ1
GG
TJ3
GG
TJ5
GG
TJ7
GG
TJ9
GG
TJ1
1
0
50
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350
ASTj-1 ASTj1 ASTj3 ASTj5 ASTj7 ASTj9 ASTj110
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ALTj-1 ALTj1 ALTj3 ALTj5 ALTj7 ALTj9 ALTj11100
110
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210
PAj-1 PAj1 PAj3 PAj5 PAj7 PAj9 PAj11
Prothrombin Time Bilirubinemia GGT
ASAT ALAT ALP
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%
Postoperative Liver Tests1998 – 2002: 775 elective liver resection
30
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110
-2 -1 0 1 2 3 4 5 6 7 8
Postoperative Day
Pro
thro
mb
in T
ime (
% o
f n
orm
al)
10
15
20
25
30
35
40
45
Seru
m T
ota
l B
ilir
ub
in (
µm
ol/
L)
In Hospital Deaths (n = 26)
0 10 20 30 40
1
3
5
7
9
11
13
15
17
19
21
23
25
Post Operative Days
Median post operative deathsLink to liver FailurePOD 16 (range 5-39)
Postoperative Morbidity vs No Complications
40
50
60
70
80
90
100
110
TPj-1 TPj1 TPj3 TPj5 TPj7 TPj9 TPj11
0
20
40
60
80
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120
Bbj-1 Bbj1 Bbj3 Bbj5 Bbj7 Bbj9 Bbj11
0
50
100
150
200
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400
ASTj-1 ASTj1 ASTj3 ASTj5 ASTj7 ASTj9 ASTj1180
100
120
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220
PAj-1 PAj1 PAj3 PAj5 PAj7 PAj9 PAj11
ALP
PT Bilirubinemia
ASAT
50
55
60
65
70
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100
105
TPj-1 TPj1 TPj3 TPj5 TPj7 TPj9 TPj11
Prothrombin Time (%)
PT < 50% 1 3 5 7
Incidence 21% 16% 6% 4%
Mortality if present 10% 16% 33% 40%
absent 1.5 % 1.3 % 1.3 % 1%
5
10
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40
Bbj-1 Bbj1 Bbj3 Bbj5 Bbj7 Bbj9 Bbj11
Bilirubinemia
> 50 µml/L 1 3 5 7
Incidence 17% 19% 16% 11%
Mortality if present 7% 11% 15% 17%
absent 2 % 2 % 1 % 1%
30
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110
-2 -1 0 1 2 3 4 5 6 7 8
Postoperative Day
Pro
thro
mb
in T
ime (
% o
f n
orm
al)
10
15
20
25
30
35
40
45
Seru
m T
ota
l B
ilir
ub
in (
µm
ol/
L)
Mortality day 5
PT < 50% 33%SB > 50 µml/L 15%
PT<50% and SB>50 µml/L 59%
Fifty – Fifty at day Five Criteria after Hepatectomy
59 %4 %Bil > 50 µmol/L
7 %1 %Bil < 50 µmol/L
PT <50%PT >50%DAY 5
Mortality according to PT< 50% and Bilirubinemia >50 µmol/L
25 Patients with 50-50 criteria
•14 deaths 11 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 candida4 severe sepsis
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
“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.
Case75 yrs male30/03/2004 Right hemicolectomy Dukes C, 2 metastases in right liver - 12/2004 Systemic chemotherapy (Oxaliplatin+5FU+LV)10/02/2005 Right hepatectomy Labo dataAST: 43 IU/LALT: 66 IU/LGGT: 248 IU/L T-Bil: 5 µmol/LPT: 76%
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-2 -1 0 1 2 3 4 5 6 7 8 9 10
Postoperative Day
Pro
thro
mb
in T
ime
(% o
f n
orm
al)
0
50
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Ser
um
To
tal
Bil
iru
bin
(µ
mo
l/L
)
Death
MARS
PT
Bil
FIFTY-FIFTY AT DAY FIVE CRITERIA
-Dead with 50-50 criteria at day 5 present
1 no context of liver failure12 infected ascites – portal thrombosis
pneumopathy
-Dead without 50-50 criteria at day 5
3 digestive bleeding – biliar peritonitessepticemia by candida
7 portal thrombosis – infected ascites (3)
-No dead despite 50-50 criteria present
3 transient criteria (only at day 5) – uncomplicated outcome9 100% of morbidity
USI 22 days (4 - 57)Hospitalization 43 days (17 - 69)
FIFTY-FIFTY AT DAY FIVE CRITERIA
-Deaths without 50-50 criteria at day 5
3 digestive bleeding biliar peritonitessepticemia with candida
7 portal thrombosis infected ascites (3)
Prothrombin Time (%)
50
55
60
65
70
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80
85
90
95
100
105
TPj-1 TPj1 TPj3 TPj5 TPj7 TPj9 TPj11
Bilirubinemia
5
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40
Bbj-1 Bbj1 Bbj3 Bbj5 Bbj7 Bbj9 Bbj11