Relation between postoperative prognostic nutritional index and severe complications after hepatectomy in patients with hepatocellular carcinoma_CHINESE JOURNAL OF BASES AND CLINICS IN GENERAL SURGERY

Authors：

LU Shuaihang ^1,2 , ZHANG Lixia ¹ , GONG Chen ¹ , FENG Xielin ¹ ,  WANG Haiqing ¹ , TANG Xiaoli ¹

1. Department of Hepato-Biliary-Pancreatic Surgery, Sichuan Cancer Hospital, Sichuan Cancer Center & Institute, Cancer Hospital Affiliate to School of Medicine, University of Electronic Science and Technology of China, Chengdu 610041, P. R. China;
2. Chengdu University of Traditional Chinese Medicine, Chengdu 610075, P. R. China;

Corresponding author：

WANG Haiqing, Email: wanghaiqing241286@163.com

Keywords：

prognostic nutritional index; hepatocellular carcinoma; hepatectomy; complications

DOI：

10.7507/1007-9424.202202026

Video：

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Objective To discuss the relation between postoperative prognostic nutritional index (PNI) and serious complications (Clavien-Dindo complications classification Ⅲ to Ⅴ) after hepatectomy for patients with hepatocellular carcinoma (HCC). Methods According to the inclusion and exclusion criteria, the HCC patients who underwent hepatectomy in the Sichuan Cancer Hospital from January 2009 to January 2016 were retrospectively collected. The predictive ability of postoperative PNI for postoperative complications was evaluated by receiver operating characteristic (ROC) curve, and the optimal cutoff value was determined. At the same time, the related factors affecting the severe complications and overall survival after hepatectomy in the HCC patients were analyzed by non-conditional logistic regression and Cox proportional hazards regression analysis, respectively. Results A total of 779 patients were enrolled, and the postoperative complications occurred in 238 (30.6%) cases, including 68 (8.7%) cases of serious complications. The postoperative PNI of all patients was 35.8±4.9, the ROC curve analysis showed that the area under the ROC curve of postoperative PNI for predicting postoperative severe complications was 0.735, the optimal cutoff value was 35.7, and the sensitivity and specificity were 0.868 and 0.518, respectively. The patients were classified as a lower postoperative PNI (≤35.7, 397 patients) and higher postoperative PNI (>35.7, 382 patients) based on the optimal cutoff value. Compared with patients with higher postoperative PNI, the patients with lower postoperative PNI had later stage of tumor (P<0.001) , worse liver function (P<0.05), and larger volume of excised liver (P<0.001), more blood loss (P<0.001), and higher proportion of intraoperative blood transfusion (P<0.001), higher serious complication (P<0.001) and mortality (P=0.039). The multivariate logistic regression analysis found that the preoperative Child-Pugh score grade B, American Society of Anesthesiologists grade Ⅲ–Ⅳ, intraoperation blood transfusion, preoperative decreased platelet level, and lower postoperative PNI increased the probability of postoperative serious complications in the HCC patients (P<0.05). The overall survival of HCC patients with higher postoperative PNI was better than that of patients with lower postoperative PNI (P=0.007), but there was no statistical difference in tumor-free survival between the two (P=0.073), and it was not fount that the postoperative PNI was associated with the overall survival of HCC patients underwent hepatectomy by the Cox proportional hazards regression multivariate analysis (P=0.276). Conclusions The optimal cutoff value of postoperative PNI for predicting postoperative serous complications determined in this study is 35.7, which has a higher predictive value. Patients with higher postoperative PNI and lower postoperative PNI in incidence of postoperative serious complications are obviously different, patients with higher postoperative PNI has a better overall survival than those with lower postoperative PNI.

Citation： LU Shuaihang, ZHANG Lixia, GONG Chen, FENG Xielin, WANG Haiqing, TANG Xiaoli. Relation between postoperative prognostic nutritional index and severe complications after hepatectomy in patients with hepatocellular carcinoma. CHINESE JOURNAL OF BASES AND CLINICS IN GENERAL SURGERY, 2022, 29(10): 1344-1349. doi: 10.7507/1007-9424.202202026 Copy

1.	Villanueva A. Hepatocellular carcinoma. N Engl J Med, 2019, 380: 1450-1462.
2.	Wang H, Li L, Bo W, et al. Immediate postoperative fibrosis-4 predicts postoperative liver failure for patients with hepatocellular carcinoma undergoing curative surgery. Dig Liver Dis, 2018, 50(1): 61-67.
3.	Ke M, Xu T, Li N, et al. Prognostic nutritional index predicts short-term outcomes after liver resection for hepatocellular carcinoma within the Milan criteria. Oncotarget, 2016, 7(49): 81611-81620.
4.	Man Z, Pang Q, Zhou L, et al. Prognostic significance of preoperative prognostic nutritional index in hepatocellular carcinoma: a meta-analysis. HPB (Oxford), 2018, 20(10): 888-895.
5.	Goh BK, Kam JH, Lee SY, et al. Significance of neutrophil-to-lymphocyte ratio, platelet-to-lymphocyte ratio and prognostic nutrition index as preoperative predictors of early mortality after liver resection for huge (≥10 cm) hepatocellular carcinoma. J Surg Oncol, 2016, 113(6): 621-627.
6.	Bruix J, Sherman M; American Association for the Study of Liver Diseases. Management of hepatocellular carcinoma: an update. Hepatology, 2011, 53(3): 1020-1022.
7.	Onodera T, Goseki N, Kosaki G. Prognostic nutritional index in gastrointestinal surgery of malnourished cancer patients. Nihon Geka Gakkai Zasshi, 1984, 85: 1001-1005.
8.	Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6 336 patients and results of a survey. Ann Surg, 2004, 240(2): 205-213.
9.	Rahbari NN, Garden OJ, Padbury R, et al. Posthepatectomy liver failure: a definition and grading by the International Study Group of Liver Surgery (ISGLS). Surgery, 2011, 149(5): 713-724.
10.	Alkozai EM, Nijsten MW, de Jong KP, et al. Immediate postoperative low platelet count is associated with delayed liver function recovery after partial liver resection. Ann Surg, 2010, 251(2): 300-306.
11.	Yang Y, Gao P, Song Y, et al. The prognostic nutritional index is a predictive indicator of prognosis and postoperative complications in gastric cancer: a meta-analysis. Eur J Surg Oncol, 2016, 42(8): 1176-1182.
12.	Kang M, Chang CT, Sung HH, et al. Prognostic significance of pre- to postoperative dynamics of the prognostic nutritional index for patients with renal cell carcinoma who underwent radical nephrectomy. Ann Surg Oncol, 2017, 24(13): 4067-4075.
13.	Mohri Y, Inoue Y, Tanaka K, et al. Prognostic nutritional index predicts postoperative outcome in colorectal cancer. World J Surg, 2013, 37(11): 2688-2692.
14.	Wang Z, Wang J, Wang P. The prognostic value of prognostic nutritional index in hepatocellular carcinoma patients: a meta-analysis of observational studies. PLoS One, 2018, 13(10): e0202987. doi: 10.1371/journal.pone.0202987.
15.	Zhang X, Li C, Wen T, et al. Postoperative prognostic nutritional index predicts survival of patients with hepatocellular carcinoma within Milan criteria and hypersplenism. J Gastrointest Surg, 2017, 21(10): 1626-1634.
16.	Peng W, Li C, Wen TF, et al. Postoperative prognostic nutritional index change is an independent predictor of survival in patients with small hepatocellular carcinoma. Am J Surg, 2016, 212(1): 122-127.
17.	Schütte K, Tippelt B, Schulz C, et al. Malnutrition is a prognostic factor in patients with hepatocellular carcinoma (HCC). Clin Nutr, 2015, 34(6): 1122-1127.
18.	Schütte K, Schulz C, Malfertheiner P. Nutrition and hepatocellular cancer. Gastrointest Tumors, 2016, 2(4): 188-194.
19.	Helling TS, Blondeau B, Wittek BJ. Perioperative factors and outcome associated with massive blood loss during major liver resections. HPB (Oxford), 2004, 6(3): 181-185.
20.	Palavecino M, Kishi Y, Chun YS, et al. Two-surgeon technique of parenchymal transection contributes to reduced transfusion rate in patients undergoing major hepatectomy: analysis of 1 557 consecutive liver resections. Surgery, 2010, 147(1): 40-48.
21.	Chan AW, Chan SL, Wong GL, et al. Prognostic nutritional index (PNI) predicts tumor recurrence of very early/early stage hepatocellular carcinoma after surgical resection. Ann Surg Oncol, 2015, 22(13): 4138-4148.
22.	Liu C, Li L, Lu WS, et al. A novel combined systemic inflammation-based score can predict survival of intermediate-to-advanced hepatocellular carcinoma patients undergoing transarterial chemoembolization. BMC Cancer, 2018, 18(1): 216. doi: 10.1186/s12885-018-4121-3.
23.	Ji F, Liang Y, Fu S, et al. Prognostic value of combined preoperative prognostic nutritional index and body mass index in HCC after hepatectomy. HPB (Oxford), 2017, 19(8): 695-705.
24.	Wu SJ, Lin YX, Ye H, et al. Lymphocyte to monocyte ratio and prognostic nutritional index predict survival outcomes of hepatitis B virus-associated hepatocellular carcinoma patients after curative hepatectomy. J Surg Oncol, 2016, 114(2): 202-210.

1. Villanueva A. Hepatocellular carcinoma. N Engl J Med, 2019, 380: 1450-1462.
2. Wang H, Li L, Bo W, et al. Immediate postoperative fibrosis-4 predicts postoperative liver failure for patients with hepatocellular carcinoma undergoing curative surgery. Dig Liver Dis, 2018, 50(1): 61-67.
3. Ke M, Xu T, Li N, et al. Prognostic nutritional index predicts short-term outcomes after liver resection for hepatocellular carcinoma within the Milan criteria. Oncotarget, 2016, 7(49): 81611-81620.
4. Man Z, Pang Q, Zhou L, et al. Prognostic significance of preoperative prognostic nutritional index in hepatocellular carcinoma: a meta-analysis. HPB (Oxford), 2018, 20(10): 888-895.
5. Goh BK, Kam JH, Lee SY, et al. Significance of neutrophil-to-lymphocyte ratio, platelet-to-lymphocyte ratio and prognostic nutrition index as preoperative predictors of early mortality after liver resection for huge (≥10 cm) hepatocellular carcinoma. J Surg Oncol, 2016, 113(6): 621-627.
6. Bruix J, Sherman M; American Association for the Study of Liver Diseases. Management of hepatocellular carcinoma: an update. Hepatology, 2011, 53(3): 1020-1022.
7. Onodera T, Goseki N, Kosaki G. Prognostic nutritional index in gastrointestinal surgery of malnourished cancer patients. Nihon Geka Gakkai Zasshi, 1984, 85: 1001-1005.
8. Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6 336 patients and results of a survey. Ann Surg, 2004, 240(2): 205-213.
9. Rahbari NN, Garden OJ, Padbury R, et al. Posthepatectomy liver failure: a definition and grading by the International Study Group of Liver Surgery (ISGLS). Surgery, 2011, 149(5): 713-724.
10. Alkozai EM, Nijsten MW, de Jong KP, et al. Immediate postoperative low platelet count is associated with delayed liver function recovery after partial liver resection. Ann Surg, 2010, 251(2): 300-306.
11. Yang Y, Gao P, Song Y, et al. The prognostic nutritional index is a predictive indicator of prognosis and postoperative complications in gastric cancer: a meta-analysis. Eur J Surg Oncol, 2016, 42(8): 1176-1182.
12. Kang M, Chang CT, Sung HH, et al. Prognostic significance of pre- to postoperative dynamics of the prognostic nutritional index for patients with renal cell carcinoma who underwent radical nephrectomy. Ann Surg Oncol, 2017, 24(13): 4067-4075.
13. Mohri Y, Inoue Y, Tanaka K, et al. Prognostic nutritional index predicts postoperative outcome in colorectal cancer. World J Surg, 2013, 37(11): 2688-2692.
14. Wang Z, Wang J, Wang P. The prognostic value of prognostic nutritional index in hepatocellular carcinoma patients: a meta-analysis of observational studies. PLoS One, 2018, 13(10): e0202987. doi: 10.1371/journal.pone.0202987.
15. Zhang X, Li C, Wen T, et al. Postoperative prognostic nutritional index predicts survival of patients with hepatocellular carcinoma within Milan criteria and hypersplenism. J Gastrointest Surg, 2017, 21(10): 1626-1634.
16. Peng W, Li C, Wen TF, et al. Postoperative prognostic nutritional index change is an independent predictor of survival in patients with small hepatocellular carcinoma. Am J Surg, 2016, 212(1): 122-127.
17. Schütte K, Tippelt B, Schulz C, et al. Malnutrition is a prognostic factor in patients with hepatocellular carcinoma (HCC). Clin Nutr, 2015, 34(6): 1122-1127.
18. Schütte K, Schulz C, Malfertheiner P. Nutrition and hepatocellular cancer. Gastrointest Tumors, 2016, 2(4): 188-194.
19. Helling TS, Blondeau B, Wittek BJ. Perioperative factors and outcome associated with massive blood loss during major liver resections. HPB (Oxford), 2004, 6(3): 181-185.
20. Palavecino M, Kishi Y, Chun YS, et al. Two-surgeon technique of parenchymal transection contributes to reduced transfusion rate in patients undergoing major hepatectomy: analysis of 1 557 consecutive liver resections. Surgery, 2010, 147(1): 40-48.
21. Chan AW, Chan SL, Wong GL, et al. Prognostic nutritional index (PNI) predicts tumor recurrence of very early/early stage hepatocellular carcinoma after surgical resection. Ann Surg Oncol, 2015, 22(13): 4138-4148.
22. Liu C, Li L, Lu WS, et al. A novel combined systemic inflammation-based score can predict survival of intermediate-to-advanced hepatocellular carcinoma patients undergoing transarterial chemoembolization. BMC Cancer, 2018, 18(1): 216. doi: 10.1186/s12885-018-4121-3.
23. Ji F, Liang Y, Fu S, et al. Prognostic value of combined preoperative prognostic nutritional index and body mass index in HCC after hepatectomy. HPB (Oxford), 2017, 19(8): 695-705.
24. Wu SJ, Lin YX, Ye H, et al. Lymphocyte to monocyte ratio and prognostic nutritional index predict survival outcomes of hepatitis B virus-associated hepatocellular carcinoma patients after curative hepatectomy. J Surg Oncol, 2016, 114(2): 202-210.

CHINESE JOURNAL OF BASES AND CLINICS IN GENERAL SURGERY

Relation between postoperative prognostic nutritional index and severe complications after hepatectomy in patients with hepatocellular carcinoma

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