Application of ultrasound elastography and splenic size in predicting post-hepatectomy liver failure: Unveiling new clinical perspectives

Abstract

In this article, we discuss the study by Cheng et al, published in the World Journal of Gastroenterology, focusing on predictive methods for post-hepatectomy liver failure (PHLF). PHLF is a common and serious complication, and accurate prediction is critical for clinical management. The study examines the potential of ultrasound elastography and splenic size in predicting PHLF. Ultrasound elastography reflects liver functional reserve, while splenic size provides additional predictive value. By integrating these factors with serological markers, we developed a comprehensive prediction model that effectively stratifies patient risk and supports personalized clinical decisions. This approach offers new insights into predicting PHLF. These methods not only assist clinicians in identifying high-risk patients earlier but also provide scientific support for personalized treatment strategies. Future research will aim to validate the model's accuracy with larger sample sizes, further enhancing the clinical application of these non-invasive indicators.

Key Words: Ultrasound elastography; Splenic size; Post-hepatectomy liver failure; Prediction model; Risk stratification

Core Tip: This article discusses a study on predictive methods for post-hepatectomy liver failure (PHLF), highlighting the potential of ultrasound elastography and splenic size in predicting PHLF, as these factors reflect liver function and portal hemodynamics. By combining these variables with serological markers, a comprehensive prediction model was developed to aid in risk stratification and inform personalized clinical decisions. This approach offers new insights into the early identification of high-risk patients and supports personalized treatment strategies. Future research will validate the model’s accuracy using with larger sample sizes for broader clinical application.

TO THE EDITOR

Liver resection is an effective treatment for hepatic tumors and other diseases, but it carries the risk of post-hepatectomy liver failure (PHLF)[1,2]. Predicting and identifying patients at risk for PHLF, along with determining how to intervene effectively, presents significant challenges[3-5]. Ultrasound elastography and splenic size have emerged as potential predictive indicators of PHLF[6-9].

Liver resection is a cornerstone treatment for various hepatic diseases, offering curative potential but also the risk of PHLF. PHLF is a complex syndrome characterized by impaired liver function postoperatively, leading to significant morbidity and mortality. The incidence of PHLF ranges from 0.7% to 39.6%[1,10], and its mortality rate is approximately 50%[2]. Despite advances in surgical techniques, managing PHLF remains challenging, with few medical tools to predict or treat this condition effectively[11,12]. Accurate prediction of PHLF is critical for improving clinical outcomes and guiding personalized treatment. The lack of reliable, non-invasive tools for early identification of high-risk patients emphasizes the need for new predictive models.

Recent advances in imaging technologies, particularly ultrasound elastography and splenic size assessment, show promise in predicting PHLF[13-15]. Ultrasound elastography measures liver stiffness (LS), an indicator of liver parenchymal health and functional reserve[16-18]. This non-invasive technique provides real-time assessment, offering clinicians valuable insights into the liver's ability to regenerate and recover post-surgery.

Additionally, evaluating splenic size through ultrasound provides indirect information about portal hypertension, a critical factor influencing liver hemodynamics and postoperative outcomes[19]. Spleen enlargement reflects increased portal venous pressure, which correlates with portal venous flow disturbances and hepatic congestion-factors contributing to PHLF development[20,21]. Guidelines for assessing liver fibrosis using LS measurements via shear wave elastography (SWE) have been established and provide a foundation for PHLF prediction[22-24]. An enlarged spleen, a marker of portal hypertension, is associated with a worse prognosis[25]. Ultrasound offers a practical and effective method for assessing spleen size.

Integrating these imaging modalities with traditional serological markers provides a comprehensive approach to risk assessment. Early identification of patients at risk for PHLF enables personalized perioperative management, including optimized surgical techniques, tailored care protocols, and targeted medical therapies. These interventions aim to mitigate risks, enhance postoperative recovery, and improve outcomes following liver resection.

Clinical application of ultrasound imaging and spleen size in predicting PHLF

Previous studies have confirmed that liver resection is a key treatment for liver malignancies and other serious liver diseases. Despite significant progress in alleviating patient pain and prolonging life, PHLF remains a major challenge in treatment. PHLF not only increases postoperative mortality, but also imposes a substantial burden on medical resource utilization. Therefore, effective prediction and timely intervention are crucial for improving surgical safety and postoperative quality of life.

In recent years, ultrasound imaging and spleen size assessment have shown significant potential in this field. Ultrasound elastography, a real-time, non-invasive technique reflecting liver tissue stiffness, can evaluate postoperative liver regeneration and help clinicians predict PHLF risk more accurately. By measuring liver elasticity, clinicians can assess liver parenchyma recovery post-surgery and develop personalized perioperative management strategies. This technique does not rely on traditional serological markers but provides key physiological information through real-time imaging, improving the accuracy and timeliness of postoperative monitoring.

Additionally, assessing spleen size, an indirect indicator of portal hypertension, provides important clues for predicting PHLF. Portal hypertension can disturb liver hemodynamics post-surgery and is a key contributor to PHLF. Ultrasound measurements of spleen size and morphological changes help clinicians evaluate portal blood flow, detect potential issues early, and intervene to reduce PHLF incidence.

The combination of these imaging techniques provide a comprehensive risk assessment framework. Prior to surgery, clinicians can evaluate liver and spleen status using ultrasound imaging, identify high-risk patients, and optimize preoperative preparation. During surgery, real-time monitoring aids in adjusting surgical strategies, while postoperative monitoring helps detect complications early and ensures timely intervention.

In the latest issue of the World Journal of Gastroenterology, Cheng et al[26] published an interesting paper: A multicenter study on a nomogram utilizing LS and spleen area (SPA) measured by ultrasound for predicting PHLF. This study introduces an important concept of reflecting liver reserve function using ultrasound elastography and LS measurement in splenomegaly. The study involved two cohorts (training and validation) with inclusion and exclusion criteria, primarily collecting basic and surgical data, such as hepatic portal block time, blood loss (BL), and liver resection range (RR). The study used the Aixplorer ultrasound system with SC6-1 convex array probes (Supersonic Image, Aix-en-Provence, France) to perform two-dimensional SWE. (SPA, cm²) was calculated as length (cm) × width (cm) at the intercostal position near the tenth rib. A model was established through logistic regression to predict PHLF using ultrasound elastography combined with spleen size and serological indicators. The PHLF model (PM) is as follows: PM = -8.343 + 0.176 × LS + 0.082 × SPA + 0.001 × BL - 1.086 × RR (major = 1; minor = 0) + 0.049TB + 0.148 × INR (multiplied by 10). The predicted probability is: PHLF = 1/[1 + exp (-PM + 8.298)]. This model suggests that LS and spleen size are useful for risk stratification in patients.

According to the literature, the incidence of PHLF ranges from 9.0% to 18.6%[27], which aligns with the research results. With the continued development of ultrasound technology and further exploration of clinical practice, we anticipate that ultrasound imaging and spleen size assessment will become essential components of standardized liver surgery management. This will improve clinical outcomes post-resection and support more efficient utilization of medical resources, enhancing overall medical quality and patient quality of life. Further research in this area is necessary.

Specifically, the inclusion criteria for this study were patients aged 18 to 85 years, scheduled for partial hepatectomy for hepatocellular carcinoma (HCC), with Child-Pugh liver function A, B, or C, an ECOG score of 0-2, and undergoing preoperative 2D-SWE LS measurement and ultrasound spleen examination within one week. Exclusion criteria included postoperative non-HCC pathology, prior anticancer treatments (such as transarterial chemoembolization), intraoperative ablation therapy, previous liver resection, failed LS measurement, and missing data. The training cohort included 500 HCC patients, with data on age, gender, laboratory indicators, tumor characteristics, and surgical data. The validation cohort consisted of sixty-two patients with similar baseline characteristics but a smaller sample size. All patients underwent liver resection under general anesthesia, with surgical data recorded and classified into large resection (≥ 3 Couinaud segments) and small resection (< 3 Couinaud segments). Postoperatively, PHLF was diagnosed according to ISGLS criteria, and severity was assessed by INR and bilirubin levels. The study's limitations include a focus on hepatitis B-related HCC, the 2D-SWE measurement reflecting only local LS, and a small sample size in the external validation cohort, requiring further validation.

Clinical implications

Ultrasound elastography provides a non-invasive method to assess LS, which correlates directly with liver functional reserve. By monitoring postoperative changes in LS, clinicians can more accurately gauge the risk of developing PHLF. Additionally, spleen size, easily measured via ultrasound, offers supplementary information. An enlarged spleen often indicates portal hypertension, a condition associated with liver dysfunction and postoperative complications. The clinical significance of ultrasound elastography and spleen size in predicting PHLF lies in their potential to improve patient outcomes through early risk assessment and personalized management strategies.

A column chart based on clinical variables was developed to predict the risk of PHLF after liver resection. The PHLF score and its predicted probability are determined using the following formulas: PM = -8.343 + 0.176 × LS + 0.082 × SPA + 0.001 × BL - 1.086 × RR (major = 1; minor = 0) + 0.049TB + 0.148 × INR (multiplied by 10). The predicted probability of PHLF is calculated as: 1/[1 + exp (-PM + 8.298)]. The column chart formula incorporates multiple clinical indicators, including LS, age, and gender, with the optimal cutoff value of 0.05 determined via receiver operating characteristic curve analysis. Patients with predicted scores exceeding this threshold are at significantly increased risk of postoperative liver failure. The model consistently demonstrates higher sensitivity compared to the serological model, though its specificity is not always superior, suggesting it has high predictive accuracy. All data was collected from October 2019 to March 2022.

CONCLUSION

Liver resection, while essential for treating hepatic conditions, carries the risk of PHLF, a serious complication associated with significant morbidity and mortality. Traditional predictive methods have limitations in identifying at-risk patients early enough to intervene effectively.

Integrating these imaging techniques with serological markers enhances predictive accuracy. Early identification of high-risk patients enables timely intervention strategies, such as optimized perioperative care, pharmacological treatments, or adjustments to surgical techniques. This approach not only improves patient safety but also supports more efficient allocation of healthcare resources by focusing intensive monitoring and interventions on those most likely to benefit.

In conclusion, the use of ultrasound elastography and spleen size in predicting PHLF represents a significant advancement in perioperative care. It enables clinicians to tailor treatment strategies to individual patient risk profiles, improving clinical outcomes and enhancing overall patient care in the context of liver resection.

ACKNOWLEDGEMENTS

We would like to express our sincere gratitude to all those who contributed to the completion of this manuscript.