title: Hierarchic Interaction of Factors Associated With Liver Decompensation After Resection for Hepatocellular Carcinoma.
abstract: Liver resection is the treatment of choice for hepatocellular carcinoma (HCC) in well-compensated liver cirrhosis. Postoperative liver decompensation (LD) is the most representative and least predictable cause of morbidity and mortality.
  
  
  
  To determine the hierarchy and interaction of factors associated with the risk for LD and to define applicable risk classes among surgical candidates.
  
  
  
  This retrospective review collected data from 543 patients with chronic liver disease who underwent hepatic resection for HCC from January 1, 2000, through December 31, 2013, in a tertiary comprehensive cancer center. Final follow-up was completed on January 31, 2015, and data were assessed from February 1 to 28, 2015.
  
  
  
  Preoperative prognostic factors and risk stratification for postoperative LD. Multivariate logistic regression was performed, and the independent risk factors for LD were included in a recursive partitioning analysis model. Results were validated by means of 10-fold cross-validation.
  
  
  
  The analysis included 543 patients, of whom 411 (75.7%) were male, 132 (24.3%) were female, and the median age was 68 (interquartile range, 62-73) years. An independent association with LD was found for major hepatectomy (odds ratio [OR], 2.41; 95% CI, 1.17-4.30; P = .01), portal hypertension (OR, 2.20; 95% CI, 1.13-4.30; P = .01), and Model for End-Stage Liver Disease (MELD) score greater than 9 (OR, 2.26; 95% CI, 1.10-4.58; P = .02). Recursive partitioning analysis confirmed portal hypertension as the most important factor (OR, 2.99; 95% CI, 1.93-4.62; P < .001), followed by extension of hepatectomy with (OR, 2.76; 95% CI, 1.85-4.77; P = .03) and without (OR, 2.98; 95% CI, 1.97-4.52; P < .001) portal hypertension, and MELD score (OR, 1.79; 95% CI, 1.23-2.13; P < .001). Low-risk patients (LD rate, 4.9% [11 of 226]) without portal hypertension underwent minor resection with a MELD score of 9 or less; intermediate-risk patients (LD rate, 28.6% [85 of 297]) had no portal hypertension and underwent major resections or, in case of minor resections, had portal hypertension or a MELD score greater than 9; and high-risk patients (LD rate, 60.0% [12 of 20]) underwent major resection with portal hypertension. Risk-class progression paralleled median length of stay (7, 8, and 11 days, respectively; P < .001) and liver-related mortality (4.4% [10 of 226], 9.0% [27 of 297], and 25.0% [5 of 20], respectively; P = .001). A 10-fold cross-validation of the model resulted in a C index of 0.78 (95% CI, 0.74-0.82) and an overall error rate of 0.06.
  
  
  
  The risk for postoperative LD after resection for HCC in chronic liver disease is associated with preoperative hierarchic interaction of portal hypertension, planned extension of hepatectomy, and the MELD score.
authors.affiliation: Hepatology and Liver Transplantation Unit, Department of Surgery, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico, Istituto Nazionale Tumori, Milan, Italy.
authors.forename: Davide
authors.initials: D
authors.lastname: Citterio
authors.affiliation: Division of Gastroenterology, Department of Medical Sciences, University of Foggia, Azienda Ospedaliera Universitaria Ospedali Riuniti, Foggia, Italy.
authors.forename: Antonio
authors.initials: A
authors.lastname: Facciorusso
authors.affiliation: Hepatology and Liver Transplantation Unit, Department of Surgery, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico, Istituto Nazionale Tumori, Milan, Italy.
authors.forename: Carlo
authors.initials: C
authors.lastname: Sposito
authors.affiliation: Hepatology and Liver Transplantation Unit, Department of Surgery, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico, Istituto Nazionale Tumori, Milan, Italy.
authors.forename: Roberta
authors.initials: R
authors.lastname: Rota
authors.affiliation: Hepatology and Liver Transplantation Unit, Department of Surgery, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico, Istituto Nazionale Tumori, Milan, Italy.
authors.forename: Sherrie
authors.initials: S
authors.lastname: Bhoori
authors.affiliation: Hepatology and Liver Transplantation Unit, Department of Surgery, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico, Istituto Nazionale Tumori, Milan, Italy.
authors.forename: Vincenzo
authors.initials: V
authors.lastname: Mazzaferro
mesh_terms: D000368:Aged; D006528:Carcinoma, Hepatocellular / Q000503:physiopathology / Q000601:surgery*; D058625:End Stage Liver Disease / Q000453:epidemiology; D005260:Female; D006498:Hepatectomy / Q000009:adverse effects*; D006801:Humans; D006975:Hypertension, Portal / Q000453:epidemiology*; D007902:Length of Stay / Q000706:statistics & numerical data; D008099:Liver / Q000503:physiopathology* / Q000601:surgery; D008113:Liver Neoplasms / Q000503:physiopathology / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D012720:Severity of Illness Index