肝僵硬：肝細胞癌患者術後並發症的新預測因子

StephenW

[email protected]
       
October 01, 2020
Liver stiffness: A novel predictor of postoperative complications in patients with hepatocellular carcinoma
To the Editor:
We read with great interest the article published in Journal of Hepatology by Serenari et al.,

in which the authors carried out a retrospective study including 471 patients who underwent hepatic resection for hepatocellular carcinoma (HCC) to comprehensively investigate the predictive role of liver stiffness measurement (LSM) assessed by transient elastography on the occurrence of postoperative complications. A nomogram, combining LSM values, age and liver function tests, was developed to predict severe complications according to the new comprehensive complication index (CCI). Considering that all the variables included in the nomogram can be acquired easily and non-invasively, the significant implication for clinical practice and novelty of this result should be emphasized. Meanwhile, some crucial concerns should be discussed further.

The CCI ≥26.2 group showed a significantly higher number of patients with clinically significant portal hypertension (CSPH) compared to the CCI <26.2 group (80% vs. 20%, p <0.001). A positive correlation between LSM values and CSPH was revealed in the study (r = 0.213, p <0.001). And a meta-analysis demonstrated a negative prognostic impact of CSPH presence on postoperative complications.

Given the reasons above, the predictive role of CSPH on postoperative complications should be evaluated through logistic regression analyses. Furthermore, considering that significant differences existed in a few baseline features, the propensity score matching analysis was also suggested to enable better balance between groups across all putative risk factors.

Additionally, CSPH was defined as the presence of esophageal varices and/or platelet count <100 × 103 /ml in association with splenomegaly in the study. However, in the AASLD guidelines, CSPH was defined as a hepatic venous pressure gradient (HVPG) >10 mmHg.
The measurement of HVPG through hepatic vein catheterization remains the gold-standard to assess CSPH. Moreover, according to the published study, CSPH is present in approximately 50–60% of patients with compensated cirrhosis without gastroesophageal varices. Therefore, the impact of CSPH on the predictive role of LSM on the postoperative complication warrants further investigation.

Finally, it seems inappropriate that the variables of Child-Pugh grade, model for end-stage liver disease score, albumin and international normalized ratio were all incorporated into the univariate and multivariate analyses, because many overlaps exist among these variables.
In summary, we congratulate the authors for their interesting and important work.

StephenW

[email protected]

2020年10月1日
肝僵硬：肝細胞癌患者術後並發症的新預測因子
致編輯：
我們非常感興趣地閱讀了Serenari等在《肝病學雜誌》上發表的文章，

在該研究中，作者進行了一項回顧性研究，納入了471例因肝細胞癌（HCC）接受肝切除術的患者，以全面研究通過瞬時彈性成像評估肝硬度測量（LSM）對術後並發症發生的預測作用。根據新的綜合併發症指數（CCI），開發了結合LSM值，年齡和肝功能測試的列線圖以預測嚴重並發症。考慮到諾模圖中包含的所有變量都可以輕鬆，無創地獲取，因此應強調其對臨床實踐的重要意義和這一結果的新穎性。同時，應進一步討論一些關鍵問題。

與CCI <26.2組相比，CCI≥26.2組顯示具有臨床顯著門靜脈高壓症（CSPH）的患者數量顯著增加（80％對20％，p <0.001）。該研究顯示，LSM值與CSPH之間存在正相關（r = 0.213，p <0.001）。薈萃分析顯示CSPH存在對術後並發症的負面預後影響。

鑑於上述原因，應通過logistic回歸分析評估CSPH對術後並發症的預測作用。此外，考慮到一些基線特徵之間存在顯著差異，因此還建議進行傾向得分匹配分析，以便在所有假定的風險因素之間實現更好的平衡。

此外，CSPH被定義為與研究中的脾腫大有關的食管靜脈曲張和/或血小板計數<100×103 / ml。但是，在AASLD指南中，CSPH被定義為肝靜脈壓力梯度（HVPG）> 10 mmHg。
通過肝靜脈導管測量HVPG仍然是評估CSPH的金標準。此外，根據已發表的研究，CSPH存在於約50-60％的無胃食管靜脈曲張的代償性肝硬化患者中。因此，CSPH對LSM對術後並發症的預測作用的影響值得進一步研究。

最後，將Child-Pugh等級，終末期肝病評分模型，白蛋白和國際標準化比率等變量都納入單變量和多變量分析似乎是不合適的，因為這些變量之間存在許多重疊。
總而言之，我們祝賀作者的有趣和重要的工作。