Abstract: Objective:To investigate the risk factors resulting in the perioperative liver failure and death for the HBVassociated hepatocellular carcinoma (HCC) patients with or without cirrhosis.
Methods:The method of retrospective casecontrol study was performed. The clinicopathological data of 1 083 HCC patients with positive HBsAg who received curative liver resection at the Southwest Hospital from January 2008 to December 2012 were collected. According to the absence or presence of cirrhosis, the HCC patients with positive HBsAg were divided into the 2 groups, including the cirrhosis group (633 patients) and the noncirrhosis group (450 patients). The intraoperative conditions (operation time, volume of intraoperative blood loss, rate of blood transfusion, rate of pringle maneuver) and postoperative conditions (incidence of perioperative complications, duration of postoperative hospital stay, perioperative mortality) of HCC patients were observed. The gender, age, alanine transaminase (ALT), aspartate transaminase (AST), albumin (Alb), total bilirubin (TBil), platelet (PLT), ChildPugh classification, operation time, volume of intraoperative blood loss, blood transfusion, pringle maneuver, extent of liver resection, number of tumors, tumor diameter, tumor thrombus and liver cirrhosis were enrolled and prognostic factors resulting in perioperative liver failure and death for the HCC patients were explored. Measurement data with skewed distribution were presented as M (range) and comparison between the 2 groups was analyzed using MannWhitney U test. Count data were presented as counts (percentage) and comparison between the 2 groups was analyzed using chisquare test or Fisher exact probability. Univariate analysis was performed by chisquare test and multivariate analysis was performed by Logistic regression model (forward).
Results:(1) The intraoperative conditions: the volume of intraoperative blood loss were 500 mL (range, 30-7 000 mL) in the cirrhosis group and 400 mL (range, 50-8 000 mL) in the noncirrhosis group, with a statistically significant difference between the 2 groups (Z=-2.209, P<0.05). The operation time, rate of blood transfusion and rate of pringle maneuver were 250 minutes (range, 8²-715 minutes), 29.86%(189/633), 62.24%(394/633) in the cirrhosis group and 242 minutes (range, 85-738 minutes), 27.11%(122/450), 66.67%(300/450) in the noncirrhosis group, respectively, with no statistical differences between the 2 groups (Z=-1.212, χ²=0.969, 2.236, P>0.05). (2) The postoperative conditions: the incidence of perioperative complications was 30.49%(193/633) in the cirrhosis group and 21.11%(95/450) in the noncirrhosis group, with a statistically significant difference between the 2 groups (χ²=11.851, P<0.05). The incidence of lung infection, abdominal infection and liver failure were 6.48% (41/633), 2.69% (17/633), 5.53% (35/633) in the cirrhosis group and 3.56%(16/450), 0.89%(4/450), 1.33%(6/450) in the noncirrhosis group, respectively, with statistically significant differences between the 2 groups (χ²=4.502, 4.465, 12.713, P<0.05). The duration of postoperative hospital stay was 15 days (range, 0-70 days) in the cirrhosis group and 14 days (range, 0- 71 days) in the noncirrhosis group, with a statistically significant difference between the 2 groups (Z=-3.448, P<0.05). The perioperative mortality was 5.85%(37/633) in the cirrhosis group and 2.44%(11/450) in the noncirrhosis group, with a statistically significant difference between the 2 groups (χ²=7.181, P<0.05). (3) Results of risk factors affecting perioperative liver failure: ①results of univariate analysis showed that age, AST, Alb, ChildPugh classification, operation time, volume of intraoperative blood loss, blood transfusion, extent of liver resection, tumor diameter, liver cirrhosis with positive HBsAg were associated with perioperative liver failure in HCC patients (χ²=5.013, 7.979, 8.855, 16.968, 14.148, 9.764, 18.511, 11.749, 5.534, 12.713, P<0.05); age, AST, Alb, ChildPugh classification, operation time, blood transfusion, extent of liver resection and tumor diameter were associated with perioperative liver failure in the cirrhosis group (χ²=5.877, 5.380, 11.087, 13.672, 8.849, 13.170, 12.418, 5.805, P<0.05); volume of intraoperative blood loss was associated with perioperative liver failure in the noncirrhosis group (P<0.05). ②Results of multivariate analysis showed that age≥60 years, ChildPugh class B, operation time>360 minutes, blood transfusion, extent of liver resection≥ 3 segments and liver cirrhosis were independent risk factors affecting perioperative liver failure in HCC patients with positive HBsAg ［OR=2.285, 2.716, 2.315, 2.159, 2.459, 4.322; 95% confidence interval (CI): 1.081-4.831, 1.100-6.706, 1.064-5.038, 1.068-4.362, 1.264-9.786, 1.763-10.598, P<0.05］; Alb<38 g/L, ChildPugh class B, blood transfusion and extent of liver resection≥3 segments were independent risk factors affecting perioperative liver failure in the cirrhosis group (OR=2.231, 2.857, 2.186, 2.927, 95% CI: 1.038-4.795, 1.095-7.451, 1.045-4.576, 1.426-6.008, P<0.05); volume of intraoperative blood loss>1 200 mL was an independent risk factor affecting perioperative liver failure in the noncirrhosis group (OR=15.077, 95% CI: 2.695-84.353, P<0.05). (4) Risk factors affecting perioperative death: ①results of univariate analysis showed that gender, Alb, TBil, ChildPugh classification, blood transfusion, extent of liver resection, tumor diameter, tumor thrombus and liver cirrhosis were associated with perioperative death in HCC patients with positive HBsAg (χ²=4.462, 8.783, 4.212, 4.869, 7.189, 11.745, 6.837, 4.323, 7.181, P<0.05); Alb, extent of liver resection and tumor diameter were associated with perioperative death in the cirrhosis group (χ²=12.173, 12.793, 10.981, P<0.05); blood transfusion and tumor thrombus were associated with perioperative death in the noncirrhosis group (χ²=5.836, 6.417, P<0.05). ② Results of multivariate analysis showed that Alb< 38 g/L, extent of liver resection≥3 segments and liver cirrhosis were independent risk factors affecting perioperative death in HCC patients with positive HBsAg (OR=2.560, 2.657, 2.567, 95% CI: 1.38²-4.742, 1.471-4.800, 1.283-5.134, P<0.05); Alb<38 g/L, extent of liver resection≥ 3 segments and tumor diameter≥5 cm were independent risk factors affecting perioperative death in the cirrhosis group (OR=3.003, 2.533, 3.060, 95% CI: 1.495-6.034, 1.251-5.128, 1.135-8.251, P<0.05); blood transfusion and tumor thrombus were independent risk factors affecting perioperative death in the noncirrhosis group (OR=3.755, 4.036, 95% CI: 1.047-13.467, 1.126-14.469, P<0.05).
Conclusions:Liver cirrhosis is an independent risk factor for perioperative liver failure and death in HCC patients with positive HBsAg. The risk of perioperative liver failure and death in HCC patients with cirrhosis is significantly higher than that in HCC patients without cirrhosis, and there is a difference in the risk factors for perioperative liver failure and death.