Objective: To estimate risk factors affecting the early outcome after hepatic resection in a high volume center specialized in hepatobiliary surgery and to analyze the changing of results during 3 different periods of treatment. Design: Retrospective review. Patients: A series of 1500 consecutive patients who underwent hepatic resection. Methods: Postoperative morbidity and mortality were analyzed in relation to indications for surgery, period of operation, patient characteristics, and intraoperative variables. Patients were classified into 4 groups, according to the indication for surgery: primary liver tumors with cirrhosis (group 1, G1); other liver malignancies (group 2, G2); biliary malignancies (group 3, G3); and benign diseases (group 4, G4). Patients were also divided into 3 groups, according to the year of operation (period 1: June 1985 to October 1993; period 2: November 1993 to September 1999; period 3: October 1999 to September 2007). Results: Overall mortality and morbidity were 3% and 22.5%, respectively. Multivariate analysis revealed that blood transfusions, G1, and additional procedures were associated with an increased risk of postoperative complications, whereas blood transfusions, G1, G3, and extended hepatectomy were associated with an increased risk of postoperative mortality. G1 decreased, whereas G3, extended hepatectomies and additional procedures significantly increased between periods 2 and 3 (P < 0.05). The complication rate was significantly lower in period 2 (18.8%) compared with period 1 (23.8%) and period 3 (24.8%). Similarly, there was a significantly lower mortality rate in period 2 (1.6%) compared with period 1 (3.4%) and period 3 (4%). Conclusions: Slightly worse short-term outcomes in liver surgery were observed in recent years, with a concomitant increase of the aggressiveness of operative strategies. Nevertheless, the present results still justify an aggressive approach in liver resections.

Objective: To evaluate the efficacy of preoperative liver stiffness (LS) measurement in predicting postoperative liver failure (PLF) after hepatectomy for hepatocellular carcinoma (HCC). Background: Hepatectomy for HCC in cirrhosis is affected by the risk of PLF, which is not completely predictable with common biochemical tests. Transient elastography with FibroScan is used to calculate the degree of LS, and it may be applicable to patients scheduled for hepatectomy to estimate perioperative complications. Methods: Ninety-two patients undergoing hepatectomy for HCC were prospectively evaluated with preoperative FibroScan. Accuracy of LS measurement in predicting PLF, the presence of cirrhosis, and the presence of clinical signs of portal hypertension (PH) were assessed using receiver operating characteristic (ROC) analysis. Results: In 2 patients, LS measurement could not be performed because of obesity; consequently, 90 patients were suitable for the study. Perioperative mortality was 2.2% (2 patients); PLF occurred in 28.9% of patients (26 patients). ROC analysis identified patients with LS value higher than or equal to 15.7 kPa as being at higher risk of PLF [area under the curve (AUC) = 0.865, 95% confidence interval: 0.776–0.928; sensitivity = 96.1%; specificity = 68.7%; positive predictive value = 55.6%; negative predictive value = 97.8%; positive likelihood ratio = 3.08; negative likelihood ratio = 0.056; P < 0.001]. Patients with LS value lower than 14.8 kPa had no PLF. LS value higher than 12.6 kPa and higher than 19.6 kPa was correlated with the presence of cirrhosis (AUC = 0.880; P < 0.001), and of PH (AUC = 0.786; P < 0.001), respectively. Multivariate analysis showed that low preoperative serum sodium levels (P = 0.012), histological cirrhosis (P = 0.024), and elevated LS (P = 0.005) were independent predictors of PLF. Conclusions: LS measured with FibroScan is a valid tool for prediction of PLF in patients undergoing hepatectomy for HCC.

The practice of treating candidates for liver transplantation (LT) for hepatocellular carcinoma (HCC), with locoregional therapies, is common in most transplant centers. However, for T1 tumors and expected waiting times to LT <6 months, there is no evidence that these treatments are beneficial. For T2 tumors and for longer waiting times, neo-adjuvant treatments are usually performed with transarterial chemoembolization (TACE), ablation techniques and liver resection in selected cases. The treatment choice should be based on the BCLC staging system. At present, there is no evidence of the superiority of ablation/resection vs. TACE, but some studies showed better results of the former in achieving a complete response. The response to neo-adjuvant treatments should be evaluated through mRECIST criteria, but few studies adopted these criteria and properly analyzed factors affecting response. The simultaneous evaluation of the impact of neo-adjuvant therapies on dropout rate, post-LT HCC recurrence and patient survival is rarely reported. Tumor stage and volume, alpha-fetoprotein levels, response to treatments and liver function affect pre-LT outcomes. These same factors, together with vascular invasion and poor tumor differentiation, are major determinants of poor post-LT outcomes. Due to the low number of prospective studies with well-defined entry criteria and the variability of results, the role of downstaging is still to be defined. Novel molecular markers seem promising for the estimation of prognosis and/or response to treatments. With a persistent scarcity of organ donors, neo-adjuvant treatments can help identify patients with different probabilities of cancer progression, and consequently balance the priority of HCC and non-HCC-candidates through revised additional scores for HCC.

Hypothermic Oxygenated Perfusion (HOPE) of the liver can reduce the incidence of early allograft dysfunction (EAD) and failure in extended criteria donors (ECD) grafts, although data from prospective studies are very limited. In this monocentric, open‐label study, from December 2018 to January 2021, 110 patients undergoing transplantation of an ECD liver graft were randomized to receive a liver after HOPE or after static cold storage (SCS) alone. The primary endpoint was the incidence of EAD. The secondary endpoints included graft and patient survival, the EASE risk score, and the rate of graft or other graft‐related complications. Patients in the HOPE group had a significantly lower rate of EAD (13% vs. 35%, p = .007) and were more frequently allocated to the intermediate or higher risk group according to the EASE score (2% vs. 11%, p = .05). The survival analysis confirmed that patients in the HOPE group were associated with higher graft survival one year after LT (p = .03, log‐rank test). In addition, patients in the SCS group had a higher re‐admission and overall complication rate at six months, in particular cardio‐vascular adverse events (p = .04 and p = .03, respectively). HOPE of ECD grafts compared to the traditional SCS preservation method is associated with lower dysfunction rates and better graft survival.

Background. Systemic inflammation markers, such as neutrophil-to-lymphocyte ratio (NLR), have recently emerged as the prognostic factors for recurrence of liver tumors. Methods. We assessed the ability of NLR and of other variables to predict the outcomes of orthotopic liver transplantation (OLT) for hepatocellular carcinoma (HCC). A retrospective analysis was performed in 219 patients with HCC who underwent OLT between 1997 and 2009, with a median follow-up of 40 months. Results. Overall 3- and 5-year patient survival rates were 76.6% and 70.7%, respectively. Overall 3- and 5-year recurrence-free survival (RFS) rates were 83.8% and 82.1%, respectively. On univariate analysis, the factors affecting overall survival were α-fetoprotein more than 30 ng/mL (P=0.006), NLR more than or equal to 5 (P<0.0001), hepatitis C infection (P=0.043), and presence of microvascular invasion (MVI; P=0.006). Preoperative treatments (P=0.006), α-fetoprotein more than 30 ng/mL (P=0.003), NLR more than or equal to 5 (P<0.0001), exceeding Milan criteria at final histology (P=0.001), poor tumor differentiation (P=0.02), and presence of MVI (P<0.0001) predicted a lower RFS. Cox's proportional hazard model showed that only increased NLR and presence of MVI independently predicted overall survival and RFS. Conclusions. NLR is an important predictor of outcome after OLT for HCC and should be used to identify OLT candidates at high risk of recurrence.