Oral (pre-recorded)
Liver 		  
OL03 Liver: Surgical Outcomes 
Selection of Presentations from Abstract Submissions
OL03-01 Noninvasive Markers (ALBI and APRI) Predict Post-Hepatectomy Liver Failure in Patients with Hepatocellular Carcinoma
Tian Yang, China

J.-Y. Shi1, B. Quan2, H. Xing2, T.M. Pawlik3, Y.-H. Zhou4, Y. Lau Wan5, F. Shen2, T. Yang2
1Cancer Center, First Hospital of Jilin University, China, 2Department of Hepatobiliary Surgery, Eastern Hepatobiliary Surgery Hospital, China, 3Ohio State University, Department of Surgery, United States, 4Department of Hepatobiliary Surgery, Pu’er People’s Hospital, China, 5Faculty of Medicine, Chinese University of Hong Kong, China

Backgrounds and aims: Post-hepatectomy liver failure (PHLF) remains the primary cause of in-hospital mortality after hepatectomy. Identifying the predictors of PHLF is important to improve surgical safety. We aimed to identify predictive accuracy of two noninvasive markers, albumin-bilirubin (ALBI) and aspartate aminotransferase to platelet count ratio index (APRI), for predicting PHLF in patients with hepatocellular carcinoma (HCC).
Methods: Patients treated with HCC resection from 2013 to 2016 at 7 Chinese hospitals were retrospectively analyzed. The independent predictors of PHLF were identified by univariable and multivariable analyses and further were used for the construction of preoperative and postoperative nomogram models. Receiver operating characteristic (ROC) curves of these two predictive models, and ALBI, APRI, Child-Pugh, model for end-stage liver disease (MELD) scores were constructed to compare their predictive accuracy for PHLF.
Results: Of the 767 patients included, 102 (13.3%) experienced PHLF. Multivariable logistic regression analysis identified that high ALBI grade (>-2.6) and high APRI grade (>1.5) were independent risks of PHLF in both preoperative and postoperative models. Two nomogram predictive models and corresponding web-based calculators were subsequently constructed. The areas under the ROC curves of the postoperative and preoperative models, APRI, ALBI, MELD and Child-Pugh scores in predicting PHLF were 0.844, 0.789, 0.626, 0.609, 0.569, and 0.560, respectively.
Conclusion: ALBI and APRI showed more accurate ability for predicting PHLF than Child-Pugh and MELD. We established two online calculators combining ALBI and APRI, which could be useful for individually predicting the occurrence of PHLF in HCC patients.
[Figure. AUC for Major Morbidity PHLF.]
OL03-02 Association of Postoperative Morbidity with Survival and Recurrence Following Hepatectomy for Hepatocellular Carcinoma: A Large-Scale Multicenter Study
Tian Yang, China

L. Liang1, C. Li1, H. Xing1, Y.-M. Zhang2, W.-G. Zhang3, H. Wang4, Y.-H. Zhou5, T.-H. Chen6, T. Yang1
1Department of Hepatobiliary Surgery, Eastern Hepatobiliary Surgery Hospital, China, 2Second Department of Hepatobiliary Surgery, Meizhou People's Hospital, China, 3Department of Hepatic Surgery, Tongji Hospital, Huazhong University of Science and Technology, China, 4Department of General Surgery, Liuyang People’s Hospital, China, 5Department of Hepatobiliary Surgery, Pu’er People’s Hospital, China, 6Department of General Surgery, Ziyang First People’s Hospital, China

Background and aims: Postoperative morbidity following hepatectomy for hepatocellular carcinoma (HCC) is common and its impact on oncological outcome remains unclear. To investigate if postoperative morbidity impacts long-term survival and recurrence after HCC resection.
Methods: A multicenter database of curative-intent hepatectomy for HCC collected data from 10 Chinese hospitals. After excluding patients with postoperative early deaths (≤ 90 days), early (≤ 2 years) and late (> 2 years) recurrence rates, overall survival (OS), and time-to-recurrence (TTR) were compared between patients with and without postoperative morbidity.
Results: Among 2,161 patients eligible for the study, 758 (35.1%), 29 (1.3%) and 67 (3.1%) had postoperative 30-day morbidity, 30-day mortality and 90-day mortality, respectively. Multivariable analysis showed that diabetes mellitus, obesity, Child-Pugh grade B, cirrhosis, and intraoperative blood transfusion were independent risks of postoperative morbidity. The rates of early and late recurrence among patients with postoperative morbidity were greater than those without (50.7% vs. 38.8%, P< 0.001; and 41.7% vs. 34.1%, P=0.017). Postoperative morbidity was associated with a significant reduction in median OS
(48.1 vs 91.6 months; P< 0.001) and median TTR (19.8 vs 46.1 months; P< 0.001). After adjustment of confounding factors, multivariable Cox-regression analyses showed that postoperative morbidity was associated with a 27.8% and 18.7% greater likelihood of mortality (HR1.278; 95% confidence interval: 1.126-1.451) and recurrence (1.187; 1.058-1.331).
Conclusions: This large multicenter study provides strong evidence that postoperative morbidity adversely impacts long-term oncologic outcomes after hepatectomy for HCC. The prevention and management of postoperative adverse events may be oncologically important.
[Figure.]
OL03-03 Repeat Hepatectomy for Early and Late Recurrence of Hepatocellular Carcinoma: A Multicenter Study with Propensity Score Matching Analysis
Tian Yang, China

L. Liang1, C. Li1, Y.-H. Zhou2, H. Wang3, J.-H. Zhong4, W.-M. Gu5, T.-H. Chen6, T.M. Pawlik7, T. Yang1
1Department of Hepatobiliary Surgery, Eastern Hepatobiliary Surgery Hospital, China, 2Department of Hepatobiliary Surgery, Pu’er People’s Hospital, China, 3Department of General Surgery, Liuyang People’s Hospital, China, 4Department of Hepatobiliary Surgery, Affiliated Tumor Hospital of Guangxi Medical University, Nanning, China, 5First Department of General Surgery, Fourth Hospital of Harbin, China, 6Department of General Surgery, Ziyang First People’s Hospital, China, 7Department of General Surgery, Ohio State University, Wexner Medical Center, United States

Background: Repeat hepatectomy is a feasible treatment for intrahepatic recurrence after hepatectomy of hepatocellular carcinoma (HCC), yet the survival benefit remains ill-defined. The current study was to define long-term oncologic outcomes after repeat hepatectomy among patients with early recurrence (≤1 year after initial hepatectomy) and late recurrence (>1 year).
Methods: Patients undergoing curative-intent repeat hepatectomy for recurrent HCC were identified using a multi-intuitional database. Patient clinical characteristics, overall survival (OS) and disease-free survival (DFS) were compared among patients with early and late recurrence before and after propensity score matching (PSM).
Results: Among all the patients, 81 and 129 had early and late recurrence from which 74 matched pairs were included in the PSM analytic cohort. Before PSM, 5-year OS and DFS following resection of an early recurrence were 41.7% and 17.9%, respectively, which were worse compared with patients who had resection of a late recurrence (57.0% and 39.4%, both P< 0.01). After PSM, 5-year OS and DFS among patients with early recurrence were worse compared with patients with late recurrence (41.0% and 19.2% vs. 64.3% and 43.2%, both P< 0.01). After adjustment for other confounding factors on multivariable Cox-regression analysis, early recurrence remained independently associated with decreased OS and DFS (HR 2.22, 95% CI 1.35-3.34, and HR 1.86, 95% CI 1.26-2.74).
Conclusion: Repeat hepatectomy for early recurrence was associated with worse OS and DFS compared with late recurrence. These data may help inform patient and selection of patients being considered for repeat hepatectomy of recurrent HCC.
[Figure.]
OL03-05 Ligating the Corresponding Inflow and Outflow Vessels during Hepatectomy: A Prospective Randomized Controlled Trial and Animal Study
Binhao Zhang, China

B. Zhang1, B. Zhang2, X. Chen1
1Surgery, Tongji Hospital of Huazhong University of Science and Technology, China, 2Surgery, Huazhong University of Science and Technology, China

Background: We have devised a simple bleeding control technique ligating the corresponding inflow and outflow vessels without hilus dissection before the parenchyma transection during hepatectomy. The main objective of this study is to investigate the role of this simple technique on postoperative metastasis and survival.
Methods: During the past 10 years, 330 patients with primary HCC were performed hepatectomy with the new hemorrhage control technique, and prospective randomized controlled trial was applied. Circulating tumor cells (CTC) were detected in 24 hours postoperatively. We further applied a mice model ligating the pedicle of the lesion-located hepatic lobe before hepatectomy to imitate the clinic practice, and evaluated the role of the new technique on postoperative metastasis and survival.
Results: The new technique prolonged postoperative overall and disease-free survival for patients with primary HCC, and reduced the number of circulatin CTC postoperatively, when compared with the conventional hepatectomy. In the animal model, hepatectomy with the new technique showed lower metastasis, and longer survival when compared with conventional surgery. Human specific-AFP expressed at a high level in the serum of the metastasis bearing mice, but not expressed in metastasis-free mice.
Conclusion: Ligating the inflow and outflow vessels of the lesion-located hepatic lobe before hepatectomy reduces postoperative metastasis and prolongs survival of primary HCC. These results also indicate a potential mechanism that the new technique prevents hematogenous metastasis owing to its coincidence to principles of oncological surgery to avoid the intraoperative spread of tumour cells during hepatectomy.
OL03-06 Recommended Minimal Number of Harvested Lymph Nodes for Intrahepatic Cholangiocarcinoma
Sung Hyun Kim, Korea, Republic of

S.H. Kim, D.H. Han, G.H. Choi, J.S. Choi, K.S. Kim
Hepatobiliary and Pancreatic Surgery, Yonsei University College of Medicine, Korea, Republic of

Background: Lymph node (LN) metastasis is one factor indicating a poor prognosis after radical surgery for intrahepatic cholangiocarcinoma (ICC). Although several guidelines have recommended that LN dissection be strongly considered at the time of ICC surgery, no clear evidence regarding the appropriate number of harvested LNs has been established. Thus, we aimed to identify the minimum number of harvested LNs required for ICC by using a Bayesian Weibull model.
Methods: Data from 142 patients who underwent radical hepatectomy (R0) for ICC from January 2000 to December 2018 were retrospectively reviewed. A Bayesian Weibull model was developed to analyze the effect of number of harvested LNs on survival of patients without (N0; n=71) and with (N1; n=71) metastatic nodes. We also compared the percentage of N1 patients (i.e., the N1 rate) in each of five subgroups categorized according to the number of harvested LNs
(1-4, 5-8, 9-12, 13-16, and ≥17).
Results: In patients with 5 or more harvested LNs, the hazard ratio (HR) for LN metastasis was above the reference line (the HR with 5 harvested LNs: 1.95 [1.09-3.45]). The N1 rate of the 1-4 harvested LNs subgroup was lower than that of the other subgroups
(e.g., 1-4 vs. 5-8: 16.1% vs. 39.4%, p=0.014).
Conclusion: Our results suggest that at least 5 LNs should be harvested in patients who undergo radical surgery for ICC to promote accurate staging and potentially improve survival.
[Hazard ratio of lymph node metastasis according to the number of harvested lymph nodes]

Node numberNode status5-year survival (%)95% CIHazard ratio95% CI
Actual survivalN050.538.0 - 67.02.071.33 - 3.21
 N130.720.5 - 46.1  
4 harvested LNN056.739.9 - 71.71.900.96 - 3.73
 N134.018.7 - 51.7  
5 harvested LNN056.042.0 - 69.11.951.09 - 3.45
 N132.519.4 - 47.8  
6 harvested LNN055.543.1 - 67.51.981.18 - 3.31
 N131.319.8 - 45.0  
[Results from the Bayesian Weibull Proportional Hazard Model]
OL03-07 Portal Vein Embolization for Hepatocellular Carcinoma: A Propensity Score Matching Analysis
Wong Hoi She, Hong Kong

W.H. She, A.C.Y. Chan, K.W. Ma, S.H.Y. Tsang, W.C. Dai, T.T. Cheung, C.M. Lo
Surgery, University of Hong Kong, Hong Kong

Introduction: Portal vein embolization (PVE) increased the size of future liver remnant (FLR) which allowed patients became operable due to inadequate volume. The aim of the study is to review the outcome of patients who had undergone PVE and hepatectomy for hepatocellular carcinoma (HCC).
Methods: Patients received hepatectomy for HCC from January 2002 to December 2018 in single centre were reviewed. PVE Patients who had FLR < 30% of estimated standard liver volume (ESLV) would be included. Patients with PVE were compared with patients without. PSM matching was performed in 1:10 for comparison.
Results: There were total 1433 patients. 1371 patients had undergone hepatectomy alone (nPVE) and 62 patients had PVE. PVE patients had FLR < 30%. The FLR had increased significantly after PVE (p< 0.001). PVE patients had more major liver resections (p< 0.001). They had more blood loss (p=0.025) and longer operative time (p< 0.001). They also had more (p=0.013) and bigger tumors (p=0.001). There was no difference in the disease-free and overall survival. A PSM analysis was performed and 682 patients in nPVE were identified. There was no difference in comorbidities, and liver function. More patients received major resection in PVE group (p< 0.001), but there was no difference in intra- and post-operative outcome, so as the pathology. The disease-free survival was better in PVE group (PVE 24.6 vs 15.3 months, 5-year 45.4% vs 34.0%, p=0.032).
Conclusions: PVE not only had increased the resectability of HCC in patients with small FLR, patients also had better disease-free survival.
OL03-08 Clinical Scoring Model Determines Surgical Modality for Solitary and Small Hepatocellular Carcinoma with Child-Pugh A Liver Function
Erlei Zhang, China

E. Zhang1,2
1Tongji Hospital, Huazhong University of Science and Technology, Wuhan, China, 2Tongji Hospital of Huazhong University of Science and Technology, Wuhan, China

Introduction: Previous study indicated that clinical scoring model (CSM) could accurately predict the severity of cirrhosis. This study aimed to compare the therapeutic efficacy of liver resection (LR) and percutaneous microwave coagulation therapy (PMCT) for solitary and small hepatocellular carcinoma (HCC) using CSM.
Methods: In this study, 228 patients with single HCC ≤3 cm and Child-Pugh A liver function were retrospectively reviewed. Among these patients, 131 patients underwent LR, and 97 patients received PMCT. The short and long-term outcomes were compared between the two procedures.
Results: There was no 90-days mortality in either group. Major complications were significantly more frequent in the LR group compared to the PMCT group (18.8% vs 4.6%, p=0.003). The 1-, 3-, and 5-year overall survival (OS) rates for the LR group and PMCT group were 97.2%, 91.6%, 65.2% and 90.1%, 72.4%, 42%, respectively (p=0.006). The 1-, 3-, and 5-year disease-free survival (DFS) rates for the LR group and PMCT group were 95.4%, 74.5%, 51.7% and 83.4%, 51.2%, 31.5%,respectively (p=0.004). Nevertheless, subgroup analyses suggested that HCC patients with CSM score ≥4, PMCT may provide long-term outcomes that are similar to LR and lower complications.
Conclusions: LR may provide better OS and DFS rates than PMCT for solitary HCC≤ 3 cm and Child-Pugh A liver function. PMCT should be optimal choice for HCC patients with CSM score ≥4.
OL03-09 Impact of Perioperative Steroid Administration in Patients Undergoing Major Hepatectomy (RCT)
Shunsuke Onoe, Japan

S. Onoe, Y. Yokoyama, T. Ebata, T. Igami, T. Mizuno, J. Yamaguchi, N. Watanabe, M. Nagino
Department of Surgery, Nagoya University Graduate School of Medicine, Japan

Objective: To evaluate the clinical benefit of perioperative steroid administration for major hepatectomy with extrahepatic bile duct resection.
Background: To date, 5 randomized controlled trials have assessed the clinical benefit of perioperative steroid administration in hepatectomy. However, all of these studies involved a substantial number of ''minor'' hepatectomies. The benefit of steroid administration for patients undergoing “complicated” hepatectomy such as major hepatectomy with extrahepatic bile duct resection is still unclear.
Methods: Patients with suspected hilar malignancy scheduled to undergo major hepatectomy with extrahepatic bile duct resection were randomized into the control or steroid group. The steroid group received 500mg hydrocortisone immediately before hepatic-pedicle clamping, followed by 300mg hydrocortisone on postoperative day (POD) 1, 200mg on POD 2, and 100mg on POD 3. The control group received only physiologic saline. The primary endpoint was the incidence of postoperative liver failure.
Results: A total of 94 patients were randomized to the control (n=46) or steroid (n=48) group. There were no between-group differences in the baseline characteristics. There were no significant differences between the groups in the incidence of grade B/C postoperative liver failure (control group, n=8, 17%; steroid group, n=4, 8%; P=0.188) and other complications. Serum bilirubin levels on PODs 2 and 3 were significantly lower in the steroid group than those in the control group; however, these median values were within normal limits in both groups.
Conclusion: Perioperative steroid administration did not reduce the risk of postoperative complications, including liver failure following major hepatectomy with extrahepatic bile duct resection.
OL03-10 Age-adjusted Charlson-comorbidity Index Predicts Short-term and Long-term Outcomes after Hepatic Resection of Hepatocellular Carcinoma
Hiroji Shinkawa, Japan

H. Shinkawa, S. Tanaka, S. Takemura, R. Amano, K. Kimura, S. Yamazoe, G. Ohira, T. Nishioka, S. Kubo
Hepato-Biliary-Pancreatic Surgery, Osaka City University, Japan

Objective: This study aimed to evaluate the predictive value of Age-adjusted Charlson Comorbidity Index (ACCI) on outcomes after hepatic resection for hepatocellular carcinoma (HCC).
Methods: The subjects were 763 patients who underwent hepatic resection for HCC. The ACCI scores were grouped into 2 categories : ACCI ≤4(n=725) and ACCI ≥5 (n=38). The Outcome variables included postoperative complication (Clavien-Dindo classification ≥3) and overall survival.We used multivariable logistic regression analysis and multivariate Cox proportional hazards model to compare the incidence rate of postoperative complication and overall survival between patients with ACCI ≤4 and ACCI ≥5.
Results: Patients with ACCI ≥5 had a significant higher proportion of postoperative complications than those with ACCI ≤4 (28.9% vs. 12.7%, p = 0.0043), respectively. The 3-, 5-, 7- year overall survival rates were 78%, 65%, and 51% in ACCI ≤4 group, and 69%, 49%, and 29% in ACCI ≥5 group (p = 0.012). Multivariate analyses revealed that the odds ratio for postoperative complications and the hazard ratio for overall survival of ACCI ≥5 group with reference to ACCI ≤4 group were 3.37 (p = 0.0020) and 1.82 (p = 0.0028), respectively.The distribution of deaths due to HCC-related, liver-related, and other causes were 65.4%, 12.1%, and 22.5% in ACCI ≤4 group, 27.3%, 9.1%, and 63.6% in ACCI ≥5 group (p < 0.001).
Conclusions: ACCI predicted the short-term and long-term outcomes after hepatic resection of HCC.
OL03-11 Preoperative Risk Assessment for Loss of Independence after Hepatic Resection in Elderly Patients: A Prospective Multicenter Study
Shogo Tanaka, Japan

S. Tanaka1, H. Iida2, M. Ueno3, F. Hirokawa4, T. Nomi5, T. Nakai6, M. Kaibori7, H. Ikoma8, S. Kubo1
1Department of Hepato-Biliary-Pancreatic Surgery, Osaka City University Graduate School of Medicine, Japan, 2Division of Gastrointestinal, Breast, and General Surgery, Department of Surgery, Shiga University of Medical Science, Japan, 3Second Department of Surgery, Wakayama Medical University, Japan, 4Department of General and Gastroenterological Surgery, Osaka Medical College, Japan, 5Department of Surgery, Nara Medical University, Japan, 6Department of Surgery, Kindai University, Japan, 7Department of Surgery, Kansai Medical University, Japan, 8Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine, Japan

Backgrounds: Hepatic resection often results in loss of independence in preoperatively self-sufficient elderly people. Elderly patients should therefore be carefully selected for surgery. However, a preoperative risk assessment method for loss of independence after hepatic resection has not been established.
Methods: In this prospective, multicenter study, 347 independently-living patients aged ≥65 years, scheduled for hepatic resection, were divided into study (n=232) and validation (n=115) cohorts. We investigated the risk factors for postoperative loss of independence in the study cohort and verified our findings with the validation cohort. Loss of independence was defined as transfer to a rehabilitation facility, discharge to residence with home-based healthcare, 30-day readmission for poor functionality, and 90-day mortality (except for cancer-related deaths).
Results: In the study cohort, univariate and multivariate analyses indicated that frailty, age ≥ 76 years, and open surgery were independent risk factors for postoperative loss of independence. Proportions of patients with postoperative loss of independence in the study and validation cohorts were respectively 3.0% and 0% among those with no applicable risk factors, 8.1% and 12.5% among those with one applicable risk factor, 25.5% and 25.0% among those with two applicable risk factors, and 56.3% and 50.0% among those with all three factors applicable (P< 0.001 for both cohorts). Areas under the receiver operating characteristic curves for the study and validation groups were 0.777 and 0.783, respectively.
Conclusions: Preoperative risk-assessments using these three factors may be effective in predicting and planning for postoperative loss of independence after hepatic resection in elderly patients.
OL03-12 Early versus Late Recurrence of Hepatocellular Carcinoma after Surgical Resection Based on Post-recurrence Survival: An International Multi-institutional Analysis
Tao Wei, China

T. Wei1,2, X. Zhang2,3, T. Pawlik3
1The First Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China, 2The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China, 3The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, United States

Introduction: To define early versus late recurrence based on post-recurrence survival (PRS) among patients undergoing curative resection for hepatocellular carcinoma (HCC).
Method: Patients who underwent curative-intent resection for HCC between 2000 and 2017 were identified from an international multi-institutional database. The optimal cut-off time point to discriminate early versus late recurrence was determined relative to PRS.
Results: Among 1,004 patients, 443 (44.1%) patients experienced recurrence with a median recurrence-free survival time of 12 months. A cut-off time point of 8 months was defined as the optimal threshold based on sensitivity analyses relative to PRS for early (n=165, 37.2%) versus late relapse (n=278, 62.8%)(p=0.008). Early recurrence was associated with worse PRS (median PRS, 27.0 vs. 43.0 months, p=0.019), as well as Overall survival (OS) (median OS, 32.0 versus 74.0 months, p< 0.001) versus late recurrence. In addition, patients who recurred early were more likely to recur at extra- ± intrahepatic (35.5% vs. 19.8%, p=0.003) sites. Patients undergoing curative re-treatment of late recurrence had a comparable OS with patients who had no recurrence (median OS, 139.0 vs. 140.0 months); patients with early recurrence had inferior OS after curative re-treatment versus patients with no recurrence (median OS, 69.0 vs. 140.0 months, p=0.036), yet still better than patients who received palliative treatment for early recurrence (median OS, 69.0 vs. 21.0 months, p< 0.001).
Conclusions: Eight months was identified as the cut-off value to differentiate early versus late recurrence. Curative-intent treatment for recurrent intrahepatic tumors was associated with reasonable long-term outcomes.
OL03-14 Survival Outcome of Two or More Resections of Recurrence with or without Extrahepatic Disease After First Curative Resection for Colorectal Liver Metastases
Elena Panettieri, United States

E. Panettieri1, Y. Kawaguchi1, F. Ardito2, B.J. Kim1, T.E. Newhook1, J.D. Velasco1, C. Mele2, F. Guilante2, J.N. Vauthey1
1Surgical Oncology, The University of Texas MD Anderson Cancer Center, United States, 2Hepatobiliary Surgery, Fondazione Policlinico Universitario Agostino Gemelli IRCCS (Catholic University of the Sacred Heart), Italy

Introduction: Recurrence is common after hepatectomy for colorectal liver metastases (CLM). We sought to determine the oncologic impact of resection for recurrent disease after curative hepatectomy for CLM.
Methods: Clinicopathologic characteristics of 3160 patients undergoing initial hepatectomy for CLM during 1998-2016 at two academic institutions were collected. Patients with incomplete resection or synchronous extrahepatic disease were excluded. Overall survival (OS) was analyzed using Kaplan-Meier method and a Cox proportional hazards model.
Results: A total of 2160 patients met the inclusion criteria. Of these, 1456 patients (67.4%) recurred and 478 patients (32.8%) underwent resection of recurrent disease. Resection of recurrent disease resulted in significantly increased 5-year OS compared to no resection (70.2% vs. 24.0%; p< 0.001). 5-year OS did not differ by number of resections (one 67.7% vs. two 76.3%; p=0.319) (one vs. ≥3 73.2%; p=0.361) (Figure 1). Pattern of recurrence after initial hepatectomy significantly impacted 5-year OS for patients who underwent resection of single recurrent disease, with 5-year OS of 81.6% for lung resection vs. 64.3% for liver resection (p=0.028) vs. 54.1% for resection of other sites (p< 0.001).
Conclusions: Resection of recurrent disease significantly improves survival for patients who underwent curative hepatctomy CLM, regardless of number of resections. Surgical management of recurrent disease should be strongly considered for patients who have undergone initial hepatectomy for CLM.
[Overall survival by number of resections for recurrent disease]
OL03-16 Survival outcomes of patients with resected colorectal liver metastases based on the tumour burden score
Geoffrey Yuet Mun Wong, Australia

G.Y.M. Wong1, P. Cynthia2, J. Chen2, T. Price3, R. Padbury2
1Royal Adelaide Hospital, Australia, 2Flinders Medical Centre, Australia, 3The Queen Elizabeth Hospital, Australia

Background: The tumour burden score (TBS) is a novel prognostic model for patients undergoing hepatic resection of colorectal liver metastases based on the Metro-ticket paradigm. The aim of this study is to apply the TBS model to evaluate the survival outcomes in an Australian population.
Method: All patients who had undergone curative-intent liver surgery for colorectal liver metastases from 2006 were identified from the South Australian Clinical Registry for Metastatic Colorectal Cancer. Preoperative imaging and postoperative pathology were calculated using the Pythagorean theorem whereby [TBS2 = (maximum tumour diameter)2 X number of liver lesions)2]. Patients were stratified into 3 groups; zone 1: TBS < 3, zone 2: TBS ⩾ 3 to 9, and zone 3: TBS >9.
Results: A total of 510 patients met inclusion criteria. The overall 5-year survival was 52.3%. An incremental worsening of 5-year survival was noted as TBS increased. 5-year survival for preoperative CT TBS zones 1 [n = 210 (41.2%)], 2 [n = 282 (55.3%)] and 3 [ n = 18 (3.5%)] were 60.9%, 48.0% and 18.2% respectively; P < 0.001. 5-year survival for postoperative pathology TBS zones 1 [n = 143 (28.0%)], 2 [n = 339 (66.5%)] and 3 [n = 28 (5.5%)] were 64.8%, 47.6% and 44% respectively; P = 0.002. 5-year survival for imaging-based TBS and pathology-based TBS were comparable.
Conclusion: The TBS model has good discriminatory ability for survival in patients undergoing hepatic resection of colorectal liver metastases. This model may facilitate patients selection for surgery and further systemic treatment.
[FIGURE 1. Distribution according to TBS model and overall survival stratified by TBS.]
OL03-19 Major Laparoscopic versus Open Resection for Hepatocellular Carcinoma: A Propensity Score-matched Analysis Based on Surgeon Learning Curve
Seoung Yoon Rho, Korea, Republic of

G.H. Choi1, I. Kang1, S.Y. Rho2, D.H. Han1, J.S. Choi1
1Surgery, Yonsei University College of Medicine, Korea, Republic of, 2Surgery, Yonsei University College of Medicine, Korea, Republic of

Introduction: We aim to compare perioperative and long-term outcomes of laparoscopic and open surgery based on surgeon learning curve for laparoscopic liver resection (LLR) after propensity score-matched analysis (PMS).
Methods: A retrospective study of all patients with histologic diagnosis of hepatocellular carcinoma who underwent major hepatectomy between January 2013 and December 2018. A PMS analysis was used to compare the LLR and open major liver resection (OLR) before and after the learning curve was maximized.
Results: Among 405 patients, 106 underwent LLR and 299 underwent OLR; 79 were women and 326 were men. The mean age was 57.7 years. The learning curve was maximized after 42 cases. Compared to OLR, LLR had more liver-related injury and grade ≥ 3 complications during the learning phase. The LLR group had less blood loss, fewer transfusion requirements, and fewer liver-related injuries during the experienced phase. Hospital stay was significantly shorter during and after maximization of the learning curve in LLR compared to OLR. Operative time was comparable in the two phases. Overall, LLR was associated with less blood loss, fewer complications, and shorter hospital stay compared to open surgery. There was no significant difference in long-term survival outcomes between the two groups.
Conclusions: LLR was associated with higher incidence of liver-related complications during the surgeon's learning phase compared to the open approach. This association was significantly diminished with surgeon experience. Overall perioperative outcomes such as estimated blood loss, surgical complications, and hospital stay remained better for LLR compared to OLR.
VariableOLR (n = 83)LLR (n = 83)P value
Operative time, minutes, mean (SD)299.9 ± 0.95303.8 ± 107.50.823
Blood transfusion, n (%)10 (12%)5 (6%)0.179
Overall morbidity, n (%)56 (68.3)36 (43.4)0.001
Clavien-Dindo classification, n (%)  0.005
Grade I/III50 (60.2%)31 (37.3%) 
Grade III/IV/V6 (7.3%)7 (8.4%) 
Liver failure, n (%)7 (8.4%)6 (7.2%)0.773
Bile leak, n (%)1 (1.2%)3 (3.6%)0.311
LOH, days, mean (SD11.3 ± 6.49.5 ±5.90.046
[Overall perioperative outcomes of laparoscopic and open liver resection groups after propensity score matching.]
OL03-20 Time of Pulmonary Complication and Related Failure to Rescue After Liver Surgery
Fabio Bagante, Italy

F. Bagante1, K. Donadello2, D. Tsilimigras1, M. Tripepi1, A. Dalbeni2, D. Moris1, A. Ruzzenente2, A. Guglielmi2, T. Pawlik3
1The Ohio State University Wexner Medical Center, United States, 2University of Verona, Italy, 3Department of Surgery, The Ohio State University Wexner Medical Center, United States

Introduction: Liver surgery is associated with adverse changes in respiratory function (i.e. vital capacity reduction, hypoxemia, respiratory muscle damage and atelectasis). These factors interact with pre-existing comorbidities and postoperative pain to create a risk of pneumonia and respiratory failure, which may result in death.
Methods: Patients who underwent liver resections from the ACS-NSQIP Project between 2005 and 2017 were included in the analysis. Morbidity and in-hospital mortality were determined according with early (≤5 post-operative days [PODs]) and late (>5 PODs) occurrence.
Results: Among the 36,643 patients included in the registry, the incidence of complications increased from 16% (n=3,509) among partial hepatectomy patients to 33% (n=972) among trisegmentectomy patients. Among the 1,007 patients who had pneumonia (15% of complications), 792 (79%) patients had an early-pneumonia compared with 215 (21%) patients who had a late-pneumonia. While early-pneumonia was associated with factors related to surgery (operative time >360 minute, odds ratio [OR], 1.83, 95%CI:1.54-2.17; trisectionectomy, OR=1.51, 95%CI:1.18-1.92) and patient characteristics (history of congestive heart failure, OR=3.03, 95%CI:1.29-6.18; severe COPD, OR=2.70, 95%CI:2.05-3.52; and sepsis prior to surgery, OR=2.17; 95%CI:1.40-3.22), occurrence of early infective complications increased the risk of late-pneumonia (urinary tract infections, OR=2.60, 95%CI:1.27-4.95; sepsis, OR=3.98, 95%CI:2.32-6.52; septic shock, OR=2.3, 95%CI:1.14-4.43; all p< 0.02) independently of surgical characteristics. Incidence of failure-to-recue increased from 10% for early-pneumonia patients to 16% for late-pneumonia patients (p=0.022; Figure 1).
Conclusion: While early-pneumonia was associated with patient and surgical characteristics, late-pneumonia was associated with early infective complications and a higher incidence of failure-to-rescue.

[Figure]
OL03-22 Combined Liver and Multivisceral Resections: A Comparative Analysis of Short and Long-Term Outcomes
Jaime Arthur Pirola Kruger, Brazil

S. Silveira Jr, F.F. Coelho, F. Tustumi, A.J.F. Cassenote, V.B. Jeismann, G.M. Fonseca, J.A.P. Kruger, P. Herman
Liver Surgery Unit, University of Sao Paulo - Hospital das Clinicas, Brazil

Introduction: En-bloc liver and adjacent organs resections are technically demanding procedures aiming to obtain clear surgical margins. Few studies reported the outcomes of multivisceral liver resections (MLRs); therefore the indications are poorly defined. Our aim was tocompare short and long-term outcomes of patients submitted MLRs with those of contemporary patients submitted to isolated hepatectomies.
Methods: Consecutive adult patients submitted to liver resections between 2000 and 2018 were studied from a prospective database (1263 hepatectomies). A case-matched 1:2 study was performed comparing MLRs and isolated hepatectomy. The paired variables were sex, age, and type of liver resection. Additionally, a risk analysis was performed to evaluate the association between MLRs and perioperative morbidity and mortality.
Results: During the study period, 53 MLRs were compared with 106 well-matched controls. The groups were homogeneous regarding baseline characteristics. Patients undergoing MLRs had higher estimated blood loss (991±1492 vs. 507±591 ml; P=0.011), longer hospital stay (13±12 vs. 8±6 days; P=0.003) and higher postoperative mortality (9.4% vs. 1.9%, P=0.042). No difference in surgical complications was observed. Number of resected organs was not an independent prognostic factor for perioperative complications (Odds ratio [OR] 1 organ= 1.8 [0.54-6.05]; OR ≥ 2 organs= 4.0 [0.35-13.84]) or perioperative mortality (OR 1 organ= 5.2 [0,91-29.51]; OR ≥ 2 organs= 6.5 [0.52-79.60]). No difference in overall (P=0.771) and disease-free survival (P=0.28) was observed.
Conclusion: MLRs are feasible but incurs in higher perioperative morbidity and mortality even in a high-volume center. MLRs did not negatively affect long-term outcomes.
OL03-23 Preoperative APRI+ALBI Score Allows Risk Stratification Prior to Liver Resection
Patrick Starlinger, United States

P. Starlinger1, D. Ubl2, R. Smoot1, S. Cleary1, E.B. Habermann2
1Surgery, Mayo Clinic, United States, 2Department of Health Services Research, Mayo Clinic, United States

Background: Preoperative risk assessment for postoperative liver dysfunction (LD) still poses a major challenge in patients undergoing liver resection. Aspartate Aminotransferase/Platelet Ratio Index (APRI) and Albumin-Bilirubin Grade (ALBI) are validated markers in patients suffering from hepatic pathologies. Within this analysis, we aimed to validate our recent exploratory findings in a larger cohort focusing on clinically relevant outcome parameters and subsequently develop a web based application system to facilitate easy clinical translation.
Methods: Assessing the National Surgical Quality Improvement Program (NSQIP) database, we identified 13401 patients undergoing liver resection from 2014 to 2017 for preoperative blood values and detailed 30-day postoperative outcomes. Preoperative APRI+ALBI score was calculated from these routine laboratory tests.
Results: The scores (APRI and ALBI) significantly predicted postoperative grade C liver dysfunction, 30-days mortality and LD associated 30-days mortality upon receiver operating characteristic analyses (all P < 0.001). The combination of both scores was superior to MELD as well as each individual score. Upon multivariable analysis APRI+ALBI remained an independent predictor of postoperative LD associated 30-day mortality. We further developed a web based application to calculate the APRI+ALBI score to define the specific risk of postoperative grade C LD and more importantly 30-day mortality for the APRI+ALBI score.
Conclusion: APRI+ALBI is vital to predict clinically meaningful postoperative outcome after liver resection. Further we developed a web based application to allow clinical translation of these findings and facilitate quick and easy risk assessment prior to liver resection using routine laboratory parameters.
OL03-24 Zero Hospital Mortality and Improved Long Tern Survival in Laparoscopic Hepatectomy for Patients with HCC - A Propensity Score Analysis of 836 Patients
Tan To Cheung, Hong Kong

T.T. Cheung, K.W. Ma, W.H. She, S.H. Tsang, W.C. Dai, K.T. Ng, K.N. Man, C.M. Lo
Surgery, The University of Hong Kong, Hong Kong

Objective: To investigate the long-term outcomes of pure laparoscopic hepatectomy versus open hepatectomy for hepatocellular carcinoma (HCC).
Methods: Propensity score matching of patients receiving laparoscopic and open approach in a ratio of 1:3 was conducted. Blood for cytokine and chemokines expression was collect prospectively for comparison before and after surgery.
Results: There were 209 patients and 627 patients in the laparoscopic group and the open group, respectively. The laparoscopic group had less blood loss (200 vs 500 mL; P < 0.001), shorter operation time (201 vs 277 minutes; P < 0.001), and shorter hospital stay (4 vs 7 days; P < 0.001). There was zero hospital mortality in laparoscopic group. The 1, 3, and 5-year overall survival rates were 98.3%, 90.5%, and 82.4%, respectively, in the laparoscopic group, and 93.5%, 78.7%, and 67.9%, respectively, in the open group (P=0.006). The median disease-free survival was 73.1 months in the laparoscopic group and 42.7 months in the open group. The 1, 3, and 5-year disease-free survival rates were 84.1%, 66.0%, and 54.6%, respectively, in the laparoscopic group, and 73.1%, 52.1%, 44.2%, respectively, in the open group (P=0.003).
The median IL6 and IL8 were comparable before surgery. The median IL6 and IL8 were significantly lower in patients receiving laparoscopic hepatectomy.
Conclusions: An improved survival benefit is observed for laparoscopic hepatectomy for HCC with lower perioperative IL6 and IL8 expression.
OL03-27 Maximum Perioperative and Early Postoperative Arterial Lactate Concentrations Predict Post-hepatectomy Liver Failure and Associated Morbidity after Liver Resection
Bobby VM Dasari, United Kingdom

T. Niederwieser1, E. Braunwarth1, K. Pufal2, P. Szatmary3, H. Malik3, D. Öfner1, B. Dasari2, S. Stättner1, F. Primavesi1,3
1Department of Visceral, Transplantation and Thoracic Surgery, Medical University Innsbruck, Austria, 2Department of Hepatobiliary and Pancreatic Surgery, Queen Elizabeth Hospital Birmingham, United Kingdom, 3Hepatobiliary Surgery, Aintree University Hospital, Liverpool University Hospitals NHS Foundation Trust, United Kingdom

Introduction: Post-hepatectomy liver failure (PHLF) remains a critical complication after liver surgery. In contrast to liver transplantation evidence for lactate as a marker of liver dysfunction after resections is limited. We evaluated perioperative lactate dynamics to predict PHLF and associated morbidity.
Methods: Single-centre study with validation in two international high-volume units. We performed ROC-analysis to assess the predictive value of lactate for PHLF and analysed patient risk-groups according to calculated cut-off-levels.
Results: In the exploration cohort (n=509) the 90-day mortality, overall-morbidity and severe-morbidity was 3.3%, 40.9% and 29.3%, PHLF occurred in 12.2% of patients (4.5% ISGLS-grade A, 4.1% ISGLS-B and 3.5% ISGLS-C). ROC-analysis revealed an AUC of 0.829 for maximum lactate within 24h (Lactate_Max) to predict clinically-relevant grade B/C-PHLF (CR-PHLF). This was confirmed in the validation group (n=482; AUC 0.812). Optimal cut-off in the exploration cohort was 28mg/dl (3.1 mmol/l), which together with the lactate upper normal range value (20 mg/dl) was incorporated in an analysis for association with complications leading to three distinguished risk- groups assessed in the whole cohort (n=991). Lactate_Max level ≥28mg/dl patients significantly more often developed CR-PHLF (16.8%) than cases with levels between 20-27.9 mg/dl (6.3%) or < 20mg/dl (0.5%; p< 0.001). This also applied for 90-d mortality (7.2%/2.6%/0.9%), severe-morbidity (36%/20.6%/10.2%) and associated complications like renal failure (5.7%/3.2%/1.4%) and haemorrhage (5.6%/1.6%/1.4%; all p< 0.005; Figure 1). Similar findings were confirmed for Lactate_POD1 levels.
Conclusion: Perioperative lactate-values are powerful and readily available predictors for CR-PHLF and associated complications after hepatectomy with potential for postoperative care decision-making.
[Figure 1]
OL03-28 Intake of Selective Serotonin Re-uptake Inhibitors Modulates Postoperative Outcome after Liver Resection for Malignant Tumors
David Pereyra, Austria

D. Pereyra1, J. Santol1, G. Ortmayr1, C. Köditz1, P. Jonas2, T. Grünberger2, P. Starlinger1,3
1Department of Surgery, Medical University of Vienna, General Hospital Vienna, Austria, 2Department of Surgery, Kaiser Franz Josef Hospital, Austria, 3HPB Surgery, Mayo Clinic, United States

Introduction: Intra-platelet serotonin has been implicated in the process of liver regeneration and in the development of disease recurrence after liver resection for malignant diseases. While the effect of serotonin on liver regeneration and tumor promotion were only observed in independent experiments, we recently demonstrated a bivalent association in patients undergoing liver resection. This raised the question whether pharmacologic modification of intra-platelet serotonin might be beneficial for this patient cohort.
Methods: 497 patients were included out of our prospectively maintained institutional data base. Perioperative intake of selective serotonin reuptake inhibitors (SSRI) was recorded. Patients were followed up for postoperative liver dysfunction (LD), severe morbidity and disease recurrence.
Results: 52 patients (10.5%) were treated with SSRI during the perioperative course. Patients with SSRI intake showed a significantly higher incidence of severe morbidity (16.6%vs29.5%, p=0.031) and LD (10.4%vs25.0%,p=0.004). On the contrary, patients with SSRI intake showed a significantly decreased incidence of disease recurrence after 6 months (23.3%vs4.7%, p=0.005) and after 12 months (44.2%vs24.4%, p=0.015), which could also be confirmed in the subgroup analysis of patients with colorectal cancer liver metastases (p=0.024, p=0.048, respectively).
Conclusion: Within this study, we present solid evidence for a central impact of serotonin modification on the surgical and oncological outcome of patients undergoing liver resection. Intriguingly, treatment with SSRI seems to exert a dual effect on patients' outcome via disruption of both liver regeneration and tumor growth. Further, our data elucidates a potential pro-tumorigenic role of SSRIs, which clearly has to be confirmed in prospective trials.
OL03-29 Role of Integrated Functional Assessment Pathway Using 99m Tc -Mebrofinate SPECT-CT Scan, ICG, Elastography and HVPG in Patients at Risk of Post Hepatectomy Liver Failure
Bobby VM Dasari, United Kingdom

B.V. Dasari, P. Kadam, K.J. Roberts, R.P. Sutcliffe, N. Chatzizacharias, R. Marudanayagam, P. Muiesan, D.F. Mirza, J. Isaac
HPB and Liver Transplantation Unit, Queen Elizabeth Hospital, United Kingdom

Introduction: The study hypothesized that pre-operative integrated functional assessment pathway including liver function tests, ICG test, elastography and HVPG measurements, 99m Technetium -Mebrofinate scan, allow identification of patients at risk of PHLF and to improve post-operative outcomes.
Methods: 99m Tc-Mebrofenin SPECT-CT scan data were processed to assess the anatomical volumes, global liver function and lobar liver function (scintigraphy) as well as dynamic uptake. Amsterdam criteria of FRLF were taken as the cut-off for patients at risk of PHLF (2.69%/min/m2). LiMON-ICG module was used to assess the ICG PDR and R15. Elastography were performed using Fibroscan 502(EchoSens). HVPG was measured in patients with HCC planned for resection. ISGLS definition of PHLF was used. Post-operative outcomes before (2011-2016) and after (2018-2019) the introduction of the functional assessment pathway were compared.
Results: There was a significant reduction in the PHLF rates before and after the introduction of pathway [154/1180 (13%) vs. 20/353 (5.7%);p=0.0001]. In the subgroup of HCC resections, PHLF reduced from 10%(17/179) to 1.8%(1/53)(p=0,052). Of the at-risk patients who had 99m Tc-Mebrofenin SPECT-CT scan (CRLM: 24; HCC:23; Hilar CC:10; IHCC:4) and progressed to resectional surgery (CRLM:17;HCC:13;Hilar:4;IHCC:2), none developed PHLF. Based on the scan findings, three patients were excluded from surgical pathway and 11 patients were considered for alternate surgical strategy. One patient died of acute pulmonary oedema. Three patients had Clavien-Dindo Grade I-II infective complications.
Conclusion: Early results of the novel integrated functional assessment pathway demonstrate its feasibility and is associated with reduced incidence of PHLF.
OL03-30 Is Serum D-lactate a New Biomarker of Postoperative Complications after Liver Resection?
Mario De Bellis, Italy

A. Ruzzenente, M. De Bellis, A. Bianco, E. Danese, K. Donadello, G. Salvagno, E. Polati, G. Lippi, A. Guglielmi
University of Verona, Italy

Introduction: L-lactate is considered a prognostic factor for postoperative complications. However, the role of D-lactate produced by intestinal bacteria is not known in patients undergoing liver resection. The aims of the study were to assess factors related to the increase of serum lactates values and investigate the association between lactate isoforms and postoperative complications.
Methods: From February 2018 through October 2018, perioperative data of 68 consecutive patients underwent hepatic resection at the Division of Hepatobiliary Surgery, Verona University Hospital were prospectively collected. Serum levels of both L- and D-lactate were evaluated by arterial sampling before (T0) and after (T1) general anesthesia induction, before (T2) and after (T3) Pringle maneuver, during laparotomy suture (T4), 2-(T5) and 4-(T6) hours after surgery, in postoperative day 1(T7), 2(T8), 3(T9) and at discharge (T10).
Results: Complication Clavien-Dindo grade ≥ 3 and mortality were 20.6 and 1.5%, respectively. Factors related to the increase of perioperative serum lactates were major liver resection (T7, L-lactate p=0.001 and D-lactate p=0.018), hilar clamping (D-lactate, T3 p=0.004; T4, p=0.013), operative time > 300 minutes (L-lactate, T7 p=0.005; T9 p=0.034), and mean arterial pressure < 80 mmHg (L-lactate, T3 p=0.031; T4 p=0.021). Higher L-lactate values were associated to overall postoperative complications (T4, p=0.049; T9, p=0.002). Instead, higher D-lactate values resulted specifically associated only to postoperative infections (T7, p=0.007).
Conclusion: In this preliminary study we observed that surgery-related factors increase both isoforms of serum lactate. L-lactate raise if postoperative complications whereas higher D-lactate values may be used as biomarker of postoperative infections.
OL03-31 Is There a Role for Surgery in T2 and T3 Hepatocellular Carcinoma? A Propensity-matched Analysis of the National Cancer Database
Anai N. Kothari, United States

A.N. Kothari, C.W. Tzeng, T.A. Aloia, Y.S. Chun, J.N. Vauthey, H.S. Tran Cao
University of Texas MD Anderson Cancer Center, United States

Introduction: The role of hepatectomy for hepatocellular carcinoma (HCC) with multifocality or vascular involvement remains ill-defined. Our objective was to evaluate the potential benefit of surgical resection for patients with these high-risk tumors.
Methods: The National Cancer Database was used to identify patients with HCC with vascular involvement and/or multifocal disease (T2 and T3, AJCC Seventh Edition) between 2010 and 2016. Propensity score matching (k nearest neighbors, no replacement, 1:1) was used to create two balanced groups: patients treated with surgical resection and those treated with non-surgical modalities (ablation, radiation including radioembolization, chemotherapy including TACE, or any combination thereof). Groups were matched using patient, clinical, and liver-specific characteristics. Patients undergoing orthotopic liver transplant were excluded. Median overall survival (OS) was calculated using Kaplan-Meier method and adjusted analyses were performed using Cox proportional hazards models.
Results: A total of 24,488 patients met inclusion criteria, including 2,231 (9.1%) treated with surgical resection. Median OS for the cohort was 17.7 months. Following propensity matching, surgical resection was associated with a survival advantage (36.7 months) compared to non-surgical treatment (19.9 months, log-rank P< .001, Figure). Adjusted analysis demonstrated an OS advantage of surgery versus non-surgical treatments in both unmatched (adjusted hazard ratio, 0.58, 95% confidence interval, 0.54 - 0.62) and matched groups (adjusted hazard ratio, 0.55, 95% confidence interval, 0.51 - 0.60).
Conclusion: Surgical resection is associated with a survival advantage in HCC with multifocal disease and/or vascular involvement. The presence of these features should not contraindicate consideration of hepatectomy in suitable candidates.
[Figure. Survival in matched cohorts.]
OL03-32 Differences in Outcome of Laparoscopic Liver Surgery between Nationwide Daily Practice and High-volume Centers
Burak Gorgec, Netherlands

B. Gorgec1,2,3, R. Fichtinger4, D. Agayhan5, F. Ratti6, B. Edwin5, L.A. Aldrighetti6, R. Van Dam4, M. Abu Hilal2,3, M.G. Besselink1
1Department of Surgery, Amsterdam UMC, University of Amsterdam, Netherlands, 2Department of Surgery, Fondazione Poliambulanza - Istituto Ospedaliero, Italy, 3Department of Surgery, University Hospital Southampton NHS, United Kingdom, 4Department of Surgery, Maastricht University Medical Center+, Netherlands, 5Department of Surgery, Oslo University Hospital, Norway, 6Department of Surgery, San Raffaele Hospital, Italy

Introduction: Laparoscopic liver surgery has gradually been adopted in daily clinical practice(DCP). Although widely accepted that outcomes are better in high-volume expert(HVE) centers, it is unclear how outcomes compare in the various difficulty score strata.
Methods: This was an international, retrospective multicenter study including data from 20 DCP liver surgery centers in the Netherlands and three HVE centers (January 2011-December 2016). Consecutive patients undergoing elective LLS for all indications were included. Patients were stratified into low-, moderate- and high-risk Southampton difficulty score groups.
Results: A total of 2425 patients were included: 885 patients from DCP and 1540 patients from the HVE centers. In each risk group, the conversion rate was higher(6.7%; 5.7% and 11.4% absolute increase; all p< 0.001) and hospital stay was longer (2.0;3.3 and 2.2 days longer, all p< 0.001) in DCP centers compared to HVE centers. In the low-risk group, the rate of intraoperative incidents did not differ significantly, whereas it was significantly higher (24.5% vs 12.5%; p= 0.043) in the high-risk group in DCP compared to HVE centers. In none of the risk groups did severe postoperative complications and 90-day/in-hospital mortality differ between DCP and HVE centers.
Conclusion: Outcomes of LLS for low-risk patients in DCP are similar to HVE centers, whereas high-risk procedures in DCP are more challenging and may have slightly inferior outcomes. Collaborating networks of liver centers could be established with each center focusing on a specific risk group and aiming for high volume LLS in the respective risk group.
OL03-33 Short-term Outcomes after Minimally-invasive Liver Resection for Single Small Hepatocellular Carcinoma: An Analysis from the IGoMILS (Italian Group of Minimally Invasive Liver Surgery) Registry
Elena Panettieri, United States

F. Giuliante1, F. Ratti2, E. Panettieri1, A. Ferrero3, A. Guglielmi4, G.M. Ettorre5, F. Ardito1, L. Aldrighetti2, IGoMILS (Italian Group of Minimally Invasive Liver Surgery)
1Fondazione Policlinico Universitario A. Gemelli IRCCS, Italy, 2San Raffaele Hospital, Italy, 3Mauriziano Hospital, Italy, 4Verona University Hospital, Italy, 5San Camillo, Italy

Introduction: Safety of liver resection for hepatocellular carcinoma (HCC) improved over time, also in relation to the diffusion of minimally-invasive liver surgery (MILS). Aim of this study is to analyze short-term outcomes of MILS for solitary HCC < 3 cm at a nationwide level.
Methods: Patients who underwent MILS for single HCC < 3 cm between November 2014 and December 2019 were identified from the IGoMILS Registry.
Results: 748 patients underwent MILS: 73.5% were male (mean age 68.1 ± 9.6 years). 93% of patients were Child A, 6.9% Child B and 0.1% Child C; portal hypertension was present in 35.5% of cases. Mean HCC size was 2.1±6.3 cm, with 54.1% of tumors localized in the antero-medial segments and 45.9% in postero-superior segments. 85% of procedures were pure laparoscopic, 13.1% robotic and 1.9% performed by hybrid technique, with an overall conversion rate of 5.5%. 66.3% were wedge resections, 31.5% anatomic resections and 2.1% major hepatectomies. Intraoperative transfusions rate was 2.5%, with a mean blood loss of 182.4±283.3 ml. Mortality was nil. Overall morbidity rate was 23.3% (not significantly different between that following MILS in
the antero-lateral segments than that in the postero-superior segments: 21.7% vs. 25.1%; p=0.281, respectively) with 3.9% of major complications. Biliary fistula occurred in 2.4% of patients and ascites in 6.9%. Mean postoperative stay was 5.5 ± 4.5 days.
Conclusions: MILS for HCC < 3 cm should be carefully evaluated in the therapeutic decision making process, being associated with low operative risk, even following difficult posterior segments resection.
OL03-34 Optimal Hepatic Surgery: Are We Making Progress in North America?
Joal Beane, United States

J. Beane1, R. Mehta1, E. Gleeson2, V. Thompson3, T. Pawlik1, H. Pitt4
1Department of Surgery, The Ohio State University, United States, 2Division of Surgical Oncology, Icahn School of Medicine at Mount Sinai, United States, 3American College of Surgeons, United States, 4Lewis Katz School of Medicine at Temple University, United States

Introduction: Hepatic surgery is high-risk, but regionalization has occurred, and more minimally invasive hepatectomies (MIH) are being performed. Best practices have been defined with the goal of improving outcomes. The aim of this analysis was to determine whether optimal outcomes have increased in recent years.
Methods: The ACS-NSQIP procedure-targeted hepatectomy database was queried. Analyses were performed for major (≥ 3 segments), partial (≤2 segments) and all hepatectomies. Optimal hepatic surgery was defined as the absence of mortality, serious morbidity, the need for a postoperative biliary procedure or reoperation, prolonged length of stay (LOS < 75th percentile) or readmission. Tests of trend, Chi-square and multivariable analyses (MVA) were performed.
Results: From 2014-17, 12,880 hepatectomies including 4,028 major and 8,852 partial resections were performed. MIH increased over time (p< 0.01) and was performed more frequently in partial hepatectomies (p< 0.01, Table). Operative time decreased over time (p< 0.01) and was lower in partial hepatectomies (p< 0.01). Mortality and LOS were lower, and LOS decreased for partial hepatectomies (all p< 0.01,). On MVA, bile leaks decreased (p< 0.02) and optimal hepatic surgery increased over time (p< 0.01).
Conclusions: Over a four-year period in North America, minimally invasive hepatectomies have increased while operative time, perioperative transfusions, bile leaks and prolonged length of stay have decreased. Optimal hepatic surgery has increased for partial and all hepatectomies and is achieved more often in partial than in major resections.
 MIS Approach (%)Operative Time (min)Grade B/C Bile Leak (%)30-Day Mortality (%)Prolonged LOS (%)Optimal Surgery (%)
Major15.7*257†4.21.735.255.0
Partial37.2*‡183†‡2.0†0.7‡19.1†‡73.6*‡
All30.8*203†2.7†1.224.0†67.9*
[*p<0.01 increased over time, †p<0.01 decreased over time ‡p<0.01 vs Major Hepatectomy]
OL03-35 Osteopontin Affects Oncological Outcome after Liver Resection for Colorectal Metastasis
Daphni Ammonn, Austria

D. Ammonn1, D. Pereyra1,2, J. Santol1, S. Najarnia1, C. Brostjan1, A. Assinger2, T. Grünberger3, P. Starlinger1,4
1Department of Surgery, Medical University of Vienna, General Hospital Vienna, Austria, 2Institute of Physiology, Medical University of Vienna, Austria, 3Department of Surgery, Kaiser Franz Josef Hospital, Austria, 4HPB Surgery, Mayo Clinic, United States

Introduction: Osteopontin (OPN) - a chemoattractant and matrix protein - was previously described to be expressed by a variety of malignant tumors. As such, colorectal carcinoma was found to produce OPN. Further, a close relation of OPN to oncological outcome could be identified. Yet, OPN was not investigated in patients with colorectal cancer liver metastasis (CRCLM).
Method: Within this analysis 48 patients undergoing liver resection for CRCLM were included. Circulating OPN was evaluated prior to the operation. Further, OPN was stained on tumor tissue gathered during liver resection. Patients were followed up for disease recurrence.
Results: OPN expression in tumor tissue was tightly associated to circulating levels. Further, OPN was found to be significantly increased in patients that develop disease recurrence within two years after curative liver resection (median OPN no recurrence = 49.97 ng/mL vs median OPN recurrence = 72.38 ng/mL, p = 0.013). This difference was found to obtain a strikingly high predictive potential evaluated via receiver operating characteristics (AUC = 0.833, p = 0.015). Based on this analysis an optimal cut-off was identified at 60 ng/mL of OPN. Indeed, patients above this cut-off showed a significantly reduced disease-free survival when compared in a Kaplan-Meier analysis (difference in median disease-free survival = 1.3 years, p = 0.042).
Conclusions: OPN is a marker for early disease recurrence in patients suffering from CRCLM. Thus, assessment of OPN might be a useful tool for preoperative patient evaluation and should hence be included in the work-up of this patient cohort.
OL03-36 Predictors of Conversion and Outcomes for Patients Undergoing Minimally Invasive Hepatectomy: A Contemporary ASC NSQIP Analysis
Charles Vining, United States

C. Vining1, K. Kuchta2, D. Schuitevoerder1, P. Paterakos2, Y. Berger1, K. Roggin1, M. Talamonti2, M. Hogg2
1Surgery, University of Chicago, United States, 2Surgery, NorthShore University HealthSystem, United States

Introduction: Minimally-invasive techniques are growing for liver resections. Laparoscopic and robotic liver resections may differ in unplanned conversions. We sought to identify risk factors for conversion and if conversion was associated with increased morbidity and mortality.
Methods: This is an ACS-NSQIP multi-institutional retrospective study from 2014-2017. Patients were grouped into open, robotic and laparoscopic hepatectomy. Univariate and multivariate analysis (MVA) of factors associated with conversion and outcomes were investigated.
Results: Of 14,055 patients who underwent hepatectomy, 10,279(73.1%) were open, 3,452(24.6%) were laparoscopic and 324(2.3%) were robotic. The rate of unplanned conversions was significantly lower in robotic vs laparoscopic (5.6% vs 15.4%; p< 0.001). Robotic hepatectomy was associated with decreased conversion for minor (5.5% vs 13.7%; p< 0.001), major (5.9% vs 23.8%; p=0.003) and right (3.2% vs 24.4%; p=0.007) hepatectomy compared to laparoscopic. Operative factors associated with conversion on MVA included concurrent intraoperative ablation (OR=1.49 [95% CI 1.13-1.96]; p=0.005), Pringle (OR=2.15 [95% CI 1.70-2.73]; p< 0.001), and laparoscopy (OR=3.00 [95% CI 1.85-4.86]; p< 0.001). Patients who underwent minimally-invasive hepatectomy with conversion were associated with increased bile leak (13% vs 4.5%; p< 0.001), 30-day readmission (11.7% vs 5.9%; p< 0.001), 30-day mortality (1.6% vs 0.5%; p=0.008), length of stay (5 days vs 3 days; p< 0.001), and increased surgical (29.7% vs 9.7%; p< 0.001), wound (9.1% vs 3.6%; p< 0.001) and medical (17% vs 6.6%; p< 0.001) complications (Table 1).
Conclusion: Minimally-invasive hepatectomies with conversion are associated with increased complications. More conversions are associated with the laparoscopic approach compared to robotic.
[Table 1. Outcomes Associated with Conversion; Robotic and Laparoscopic Combined]
OL03-37 Impact of 2016 Enhanced Recovery after Surgery (ERAS) Recommendations on Outcomes after Hepatectomy
Thibault Lunel, France

T. Lunel1, K. Mohkam1, P. Merle2, A. Bonnet3, M. Gazon3, P.-N. Dumont1, C. Ducerf1, J.-Y. Mabrut1, M. Lesurtel1
1Digestive Surgery and Liver Transplantation, Croix Rousse University Hospital, Hospices Civils de Lyon, Lyon, France, 2Hepatology Unit, Croix Rousse University Hospital, Hospices Civils de Lyon, Lyon, France, 3Department of Anaesthesiology, Croix Rousse University Hospital, Hospices Civils de Lyon, Lyon, France

Introduction: The Enhanced Recovery After Surgery (ERAS) society published new recommendations for hepatectomy in 2016. Yet, no studies have formerly assessed its impact. The aim of the present study was to assess the impact of 2016 ERAS new guidelines on hepatectomy outcomes at a tertiary center.
Method: Postoperative outcomes of patients undergoing hepatectomy 18 months before and after ERAS implementation according to the 2016 guidelines were compared after propensity-score matching (PSM). Primary endpoint was 90-day morbidity and mortality.
Results: From 2016 to 2019 288 patients underwent hepatectomy including 141 procedures performed before and 147 after ERAS implementation. Before PSM, ERAS patients had an older age (66 vs. 62 years, p=0.01), higher ASA score (p=0.01), more cirrhosis (26% vs. 16%, p=0.03), and less laparoscopic procedures (31% vs. 47%). After PSM, both groups became well-balanced for all baseline variables. Median CCI score (0 vs. 21, p=0.02) and overall morbidity (41% vs. 64%, p< 0.001) were lower in the ERAS group, which was due to a higher rate of medical (Clavien grade 2) complications in the control group (35% vs. 15%, p=0.001). Blood loss (350 vs. 400 ml, p=0.67), operative time (235 vs. 240 min, p=0.61), 90-day mortality (4.5% vs. 3.6%, p=1.00), severe postoperative morbidity (18% vs. 22%, p=0.49), hospital stay (8 vs. 9 days, p=0.34) and readmission rate (10% vs. 7.3%, p=0.64) were similar between the 2 groups.
Conclusion: Perioperative ERAS program for hepatectomy results in improved outcomes due to a decreased rate of medical postoperative morbidity.
OL03-38 Short and Long-term Outcomes of Patients Undergoing Robotic Major Hepatectomy for Malignant Tumors
Iswanto Sucandy, United States

I. Sucandy, T. Lippert, K. Jacob, K. Luberice, T. Bourdeau, S. Ross, A. Rosemurgy
AdventHealth Tampa, United States

Introduction: This study was undertaken to examine our institutional experience with major robotic liver resections for malignant lesions and to identify factors affecting patient outcomes.
Methods: Patients undergoing robotic major hepatectomy from 2013 to 2019 were prospectively followed. Patients were stratified by pathology and analyzed utilizing Cox Proportional-Hazards analysis and multivariate linear regression to evaluate associations between patient survival and predictor variables.
Results: 80 patients underwent robotic major hepatectomy, of which, 34% were for colorectal liver metastasis, 33% for hepatocellular carcinoma, 16% for intrahepatic cholangiocarcinoma, 5% for gallbladder cancer, and 12% for 'other' malignant lesions. Median age was 65 years (63±12.5), 46% were women, BMI was 28 (28±6.0) kg/m2 and ASA Class was 3 (3± 0.6). Five patients experienced postoperative complications. 11 patients were readmitted within 30 days.
Disease free survival, overall survival, operative duration, estimated blood loss (EBL), conversions to open, perioperative complications, tumor size, length of stay, in-hospital mortality, readmission within 30days are stratified by pathology and depicted in Table1 and Figure1. Patients with intrahepatic cholangiocarcinoma had a significantly larger tumor size and consequently longer operative time (p=0.001, p=0.01, respectively). Patients undergoing resection for hepatocellular carcinoma had the longest disease-free survival, with a median disease-free survival of 55 months (b=-2.095, s.e.=0.946, p=0.027).
Conclusion: Our experience supports that robotic major hepatectomy is safe and feasible for patients with malignant liver disease. Our complications were limited. A reduction in disease recurrence was noted in patients undergoing robotic major hepatectomy for hepatocellular carcinoma.
[Pathology vs. Variables]
OL03-39 Improved Mortality, Morbidity and Long-Term Outcome after Anatomical Hepatectomy with the Glissonean Pedicle Approach in Patients with Hepatocellular Carcinoma: 30 Years Experience at TWMU
Shunichi Ariizumi, Japan

S. Ariizumi, Y. Kotera, S. Yamashita, T. Kato, A. Omori, S. Katagiri, H. Egawa, K. Takasaki, M. Yamamoto
Dept. of Gastroenterological Surgery, Tokyo Women’s Medical University, Japan

Background: We evaluated the morbidity and mortality after anatomical hepatectomy with the glissonean pedicle approach, and attempted to clarify whether there might be differences in long-term outcomes in relation to the morbidity in patients with hepatocellular carcinoma (HCC).
Methods: Anatomical hepatectomy with the glissonean pedicle approach was developed in 1984. 1953 patients with HCC underwent various anatomical hepatectomies between 1985 and 2014. The morbidity (Clavien-Dindo class IIIa or more) and mortality (30-day and 90-day) were evaluated among six 5-year eras (1985-1989, 1990-1994, 1995-1999, 2000-2004, 2005-2009, 2010-2014).
Results: 460 patients (24%) showed morbidity after hepatectomy. The overall 30-day and 90-day mortality rates were 1.7% and 3.6%, respectively. Blood loss >2L (45%, 34%, 33%, 17%, 14%, 8%: p< 0.0001) and bile leakage (29%, 15%, 19%, 11%, 13%, 7%: p< 0.0001), and morbidity (41%, 23%, 28%, 17%, 20%, 14%: p< 0.0001) were decreased gradually over the eras. 30-day (3.9%, 3.0%, 1.8%, 1.3%, 0.3%, 0.5%: p=0.0074) and 90-day mortality (7.8%, 4.3%, 3.8%, 2.8%, 2.2%, 1.4%: p=0.0036) were significantly improved over the eras. Blood loss >2L (p= 0.0244) was an independent risk factor for 30-day mortality, and blood loss >2L (p=0.0271) and bile leakage (p=0.0078) were independent risk factors for 90-day mortality on multivariate analysis. Bile leakage (p=0.004) and morbidity (p< 0.0001) were significant independent prognostic factors for overall survival in patients with HCC.
Conclusions: Anatomical hepatectomy with the glissonean pedicle approach was achieved safely in patients with HCC. For more safety and longer survival, blood loss, bile leakage, and morbidity should be reduced.
OL03-40 Hepatic Uptake Index in the Hepatobiliary Phase of Gd-EOB-DTPA-Enhanced Magnetic Resonance Imaging Estimates Functional Liver Reserve and Predicts Post-Hepatectomy Liver Failure
Matteo Donadon, Italy

M. Donadon1, E. Lanza2, B. Branciforte1, R. Muglia2, L. Balzarini2, G. Torzilli1
1Department of Hepatobiliary and General Surgery, Humanitas Research Hospital, Rozzano, Milan, Italy, 2Department of Radiology, Humanitas Research Hospital, Rozzano, Milan, Italy

Background: Recent evidence suggests that gadolinium-ethoxybenzyl-diethylenetriamine penta-acetic-acid-enhanced magnetic resonance imaging (Gd-EOB-DTPA MRI) may be used to evaluate liver function. The aim of this study was to assess whether the signal intensity of Gd-EOB-DTPA MRI may be used to predict functional liver reserve and post-hepatectomy liver failure (PHLF) in patients undergoing hepatectomy for liver tumors.
Methods: This is an observational retrospective study on 137 preoperative Gd-EOB-DTPA MRIs of patients undergoing hepatectomy. Mean signal intensity of liver (L20) and spleen (S20) were measured on T1-weighted single-breath-hold 3D fat-saturated gradient-echo sequences acquired 20 minutes after Gd-EOB-DTPA administration. The hepatocellular uptake index (HUI) of liver volume (VL) was calculated with the following formula VL[(L20/S20)-1] and was tested with several clinical score systems for liver diseases and to the occurrence of PHLF.
Results: Patients with unhealthy liver had significantly lower values of HUI in comparison with those with normal function. This was found for MELD score ≤9 vs. >9 (p=0.0488), BILCHE score ≤2 vs. >2 (p=0.0208), ALBI grades (p=0.0357) and Humanitas score ≤6 vs. >6 (p=0.0311). Twenty-two (16%) patients developed PHLF, and two (1.4%) died within 90-day. HUI was significantly lower in those patients with PHLF (p=0.001). Receiver operating characteristics curve analysis revealed valuable HUI ability in predicting PHLF (AUC=0.84; 95%CI=0.71-0.92; p< 0.001), with a cutoff value of 574.33 (98% sensitivity; 83% specificity).
Conclusions: HUI measured on preoperative Gd-EOB-DTPA MRI identifies patients with unhealthy liver and predicts PHLF. This index could be used to discriminate those patients at higher risk of complications after hepatectomy.
OL03-42 Preoperative Nomogram to Predict Post-Hepatectomy Liver Failure in Patients Undergoing Liver Resection
Muthukumarassamy Rajakannu, India

M. Rajakannu1, D. Cherqui2, A. Sa Cunha1, D. Castaing2, R. Adam2, E. Vibert2
1Centre Hepato Biliaire, Hopital Paul Brousse, France, 2Centre Hépato-Biliaire, AH-HP Hôpital Paul Brousse, France

Background: Post-hepatectomy liver failure (PHLF) is a rare but serious complication after liver resection (LR) and a leading cause of mortality. The aim of the present study was to define preoperative predictors of PHLF and propose a predictive nomogram to be utilized in preoperative planning.
Methods: Consecutive patients planned for LR from October 2014 to August 2016 were prospectively recruited. Clinical and laboratory data including liver stiffness and indocyanine green retention at 15 min (ICG-R15) were collected at inclusion and until three months after LR. PHLF was defined by 50-50 criteria and/or postoperative peak total bilirubin >7mg/dL.
Results: Four hundred and eighteen LRs were performed in 244 men and 174 women whose median age was 62 years. PHLF was observed in 19 patients (4.6%) after major LR in 17 and minor LR in two. Mortality rate in patients developing PHLF was 21.1% while mortality rate in the entire cohort of 418 patients was 2.2%. Independent predictors of PHLF were diabetes mellitus (odds ratio (OR): 6.6; 95% confidence interval (CI):1.1-39.3), pre-operative chemotherapy cycles ≥8 (OR: 4.1; CI:0.8-20.9), tumor size ≥51mm (OR: 4.8; CI:0.9-26.1), platelet count < 150,000/mL (OR: 8.7; CI:1.3-56.8), ICG-R15 (OR: 10.4; CI:1.9-58.1) and number of resected liver segments ≥3 (OR: 12.9; CI:1.3-125.4). Nomogram built with these six factors had area under receiver operating characteristic curve of 0.92 and goodness-of-fit of p=0.44.
Conclusion: Predictive nomogram incorporating ICG-R15 would improve the safety of LR by enabling surgeons to identify high-risk patients and adapt the surgical strategy in them.
OL03-43 Role of Indocyanine Green Test in a Western Cohort: Nomogram to Predict 90-Day Major Complications after Major Hepatectomy
Muthukumarassamy Rajakannu, India

M. Rajakannu1, D. Cherqui2, G. Pittau2, O. Ciacio2, A. Sa Cunha2, D. Castaing2, R. Adam2, E. Vibert2
1Centre Hepato Biliaire, Hopital Paul Brousse, France, 2Centre Hépato-Biliaire, AH-HP Hôpital Paul Brousse, France

Background: Incidence of severe morbidity after major hepatectomy (MH) has remained significantly high despite considerable improvement in mortality rates over last two decades. No risk model is currently available to identify those patients at higher risk of major complications after MH.
Methods: Patients undergoing MH for various hepatobiliary diseases were prospectively recruited. Pre-operative clinical and laboratory data including liver stiffness and indocyanine green retention at 15 min (ICG-R15) were analyzed to identify independent risk factors for major complications, defined as >Grade II complications according to Clavien-Dindo grade of surgical complications during the 90-day post-operative period. A nomogram was built with only pre-operative predictors and validated by Heat map plot.
Results: Complications observed after 164 MHs (56.7% men, median age-62 years) were Grade I (12.8%), Grade II (39%), Grade IIIa (9.8%), Grade IIIb (17.1%), Grade IVa (0.6%), Grade IVb (0%) and Grade V (2.4%). Three pre-operative parameters namely, patient's age, ICG-R15, and extent of liver resection (3-6 segments), were identified and internally validated as independent predictors in 49 patients (29.9%) who developed severe morbidity. A nomogram built with these three factors had a good discriminatory performance with area under receiver operating curve of 0.76 and an excellent Goodness-of-fit in Heat map plot.
Conclusions: This novel and simple nomogram accurately predicts major post-operative complications in a patient undergoing MH and enables personalized pre-operative planning in patients at risk.
[Nomogram to predict major complications after major hepatectomy]
OL03-45 A Simple Preoperative Score to Predict Postoperative Mortality after Major Hepatectomy
Konstantinos Zorbas, United States

K. Zorbas1, A. Karachristos2
1Department of Surgery, Bronx Care Health System, United States, 2Division of Surgical Oncology, Department of Surgery, University of South Florida, United States

Background: Patients undergoing liver surgery have associated chronic liver disease or other comorbidities that might place them at increased risk for postoperative complications and mortality. A preoperative predictive score able to predict postoperative mortality in patients undergoing a major hepatectomy may improve both preoperative patient's optimization and clinical decision making.
Methods: The 2014-16 NSQIP hepatectomy Participant Use Files were queried for patients undergoing major hepatectomy (N=4469). Patients who had missing data on preoperative factors were excluded. Multivariable regression models were used to develop a score to predict who has higher odds for mortality after major hepatectomy.
Results: Of 4469 patients who underwent a major hepatectomy 2161 (48.4%) were of female gender and 2308 (51.6%) of male gender. Factors associated with postoperative mortality were preoperative Albumin-Bilirubin score (ALBI) grade 2 or 3 (p< 0.001), history of congestive heart failure(CHF) (p< 0.001), diabetes mellitus (p< 0.001), patient functional status (p=0.001), hypertension (p=0.003), age ≥ 65 (p< 0.001), male gender (p< 0.001), weight loss >10% (p=0.003) and preoperative chronic use of steroids (p< 0.001). In developing a Preoperative Prognostic Score for 30 days postoperative mortality, each factor was weighted 1. Higher scores were associated with a stepwise greater risk of 30-days mortality. Finally, our predictive score demonstrates very good discrimination for 30-days mortality (AUROC=0.734, 95% CI: 0.69-0.779).
Conclusions: Preoperative simple clinical information and laboratory tests can identify which patient undergoing a major hepatectomy is at higher risk for postoperative mortality and help guide surgeons with the final treatment plan.
[Table]