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[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.
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