Hepatectomy for Hepatocellular Carcinoma in Patients with Elevated Pre-Operative Bilirubin: an ACS-NSQIP HPB Collaborative Analysis

Presenter: Jon Gerry MD | Providence Portland Medical Center Background: Recent changes to MELD exception rules decrease availability of organs to HCC patients with low biological MELD. We seek to understand if resection of hepatocellular carcinoma (HCC) outside of guidelines, including those with elevated serum bilirubin and those with multifocal HCC, results in unacceptably high morbidity and mortality. Methods: The ACS-NSQIP targeted hepatectomy database was used to identify patients with HCC who underwent resection from 2014 to 2017. Univariate and multivariate analyses were performed to determine pre-operative and intra-operative factors associated with post-hepatectomy liver failure (PHLF) and in-hospital mortality. Results: Among 2433 patients who underwent liver resection for HCC, 314 patients (13%) had a bilirubin greater than 1.0 mg/dL, and 975 (40%) had cirrhotic liver texture. PHLF occurred in 176 patients (7.2%), and 46 (1.9%) died in the hospital within 30 days. In multivariate regression, elevated bilirubin was not predictive of PHLF or mortality. Predictors of PHLF included cirrhotic liver texture (OR 1.65, p=0.006) and extent of liver resection with reference to partial hepatectomy (right hepatectomy OR 4.54, p<0.001; trisegementectomy OR 4.22, p<0.001). These were not predictors of in-hospital mortality. In a subgroup analysis of patients with cirrhotic liver texture undergoing partial hepatectomy, an elevated bilirubin was associated with increased PHLF (11% vs. 5.5%, p=0.017) and increased in-hospital mortality (4.5% vs. 1.7%, p=0.023), which compare to a rates of PHLF (16% and 14%) and mortality (2.9% and 4.7%) seen in non-cirrhotic patients undergoing right hepatectomy or trisegementectomy. Conclusion: In the setting of cirrhosis, PHLF and in-hospital mortality after partial hepatectomy are worse in patients with an elevated bilirubin greater than 1 mg/dL, but the rates are similar to non-cirrhotic patients undergoing major hepatectomy. A mildly elevated bilirubin should not prevent limited resection of HCC in patients with cirrhosis.