| Hepatocellular carcinoma (HCC) is one of the most common malignancies worldwide, with a particularly high incidence in the Chinese population because of the prevalence of hepatitis B viral infection. Hepatic resection and liver transplantation are considered the only curative treatments for HCC. Liver transplantation for HCCs <5 cm in diameter has been shown to produce favorable survival results, but its application is limited by the lack of donors. Therefore, hepatic resection remains the first choice for patients who are not transplantation candidates because of large tumor, macroscopic vascular invasion, or advanced age. Although surgical therapy level and refined operative techniques have improved considerably in recent years, and experienced liver surgeons have developed selection criteria that allow them to avoid or to limit liver resection in patients whose ability to tolerate resection appears liver failure, postoperative liver failure is the leading cause of hospital mortality, particularly in patients with cirrhosis. So accurate liver functional reserve assessment is one of the difficult problems in liver surgery. Traditional liver function indexs and analytical liver function tests include albumin, bilirubin, prothrombin time, the glucose tolerance test, half milk tolerance test, aminopyrine breath test, and so on. The Child-Pugh classification, firstly designed toward assessing the portal hypertension devascularization, remains effective guiding hepatectomy. Recently, the effectiveness of the indocyanine green discharge experiment has been recognized around the world, particularly because the introduction of the economic and convenient non-invasive ICG makes it more practical. Although the liver biopsy pathology evaluation is the most accurate method for liver functional reserve assessment, it's operability is low. Due to the complexity of liver function, so far there is no single reliable index or experiment that can reflect the liver functional reserve accurately. There haven't been generally recognized criteria on how to evaluate the preoperative liver functional reserve and how to select the treatment plan based on the results of the evaluation. Consequently, one must integrate all clinical indices in order to evaluate the safety and prognosis of hepatectomy. In this study, we discuss preliminarily the comprehensive analysis of the preoperative risk factors, evaluation of the complications related to postoperative liver dysfunction, and the reliability of the indocyanine green discharge experiment, all based on 128 cases of hepatectomy.ObjectiveThis prospective study was performed to examine the predictive value of Child-Pugh classification, retention rate of indocyanine green 15-minutes (ICGR15), effective hepatic blood flow (EHBF) and other clinical indexs in preoperative liver function reserve assessment.MethodsBetween June 2007 and August 2008, 128 patients with hepatic tumors undergoing hepatic resection were enrolled: 82 for hepatocellular carcinoma (HCC), 8 for cholangiocellular carcinoma, 12 for metastases,and 26 for benign tumors.(1) ICGR15 and EHBF were measured non-invasively and instantaneously using pulse dye densitometry (PDD), the relations of ICGR15, EHBF, Child-Pugh classification and postoperative complications were studied.(2) The correlation of postoperative ALT, total bilirubin and ICGR15, EHBF were analyzed.(3) ICGR15, EHBF, Child-Pugh score, clinical and biochemical parameters were analyzed to predict postoperative complications and rates of death (60-day).(4) The relationship of positive predictive indexs and HAI score were studied.(5) The Sensitivity, specificity and predictive values of Child-Pugh, ICGR15 and EHBF were analyzed.Results(1) The mean of ICGR15 in Child A and Child B was respectively 8.2±5.1% and 15.6±5.6%, there was a significant difference between the two groups (P<0.001). The mean of EHBF in Child A and Child B was respectively 1.166±0.215 (L/min) and 0.943±0.175 (L/min), there was a significant difference between the two groups (P<0.001).(2) The ICGR15 of complications group and no-complications group was 18.4±5.6% and 8.4±4.0% (P < 0.001); The EHBF of complications group and no-complications group was 0.853±0.157(L/min) and 1.161±0.196 (L/min) (P<0.001). The complications incidence rate of ICGR15 < 14% group, 14%≤ICGR15<20% group and ICGR15≥20% group was respectively 6.2%, 16.7% and 58.3%, there was a significant difference between the three groups (P<0.001); The complications incidence rate of EHBF≥1.0 L/min group and EHBF<1.0 L/min group was respectively 11.3% and 27.3%, there was a statistically significant difference between the two groups (P<0.001).(3) ICGR15 and EHBF were correlated with indexs related to liver function recovery(P<0.05). The Child-Pugh score, total bilirubin and ICGR15 were higher in complications group than no-complications group(P<0.05); The EHBF was lower in complications group than no-complications group(P < 0.05). In a logistic regression model, age, ICGR15 and EHBF were significant predictors of postoperative complications related to liver dysfunction.(4) ICGR15 was positively correlated with HAI score(r=0.768,P<0.001); the amount of total bilirubin was positively correlated with HAI score (r=0.414,P<0.05); EHBF was negatively correlated with HAI score(r=-0.545,P<0.05); HAI score and age were not correlated (r=0.236,P>0.05). (5) The sensitivity of Child-Pugh, ICGR15 and EHBF was respectively 50%, 67% and 56%; The specificity of Child-Pugh, ICGR15 and EHBF was respectively 62%, 64% and 87%.Conclusions(1) ICGR15 and EHBF are useful for evaluating perioperative liver function reserve. EHBF and ICGR15 are significant predictors of postoperative complications related to liver dysfunction and early prognosis.(2) Child-Pugh classification is the fastest and rather accurate, while the ICGR15 and EHBF should be counted into routine examination in order to comprehensively evaluate the safety and prognosis of the operation.
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