Intraoperatively measured prehepatectomy portal vein pressure as a useful predictor of postoperative liver failure

doi:10.21203/rs.3.rs-4666668/v1

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Research Article

Intraoperatively measured prehepatectomy portal vein pressure as a useful predictor of postoperative liver failure

https://doi.org/10.21203/rs.3.rs-4666668/v1

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Background

Predicting posthepatectomy liver failure (PLF) may be a critical requirement for liver disease patients undergoing hepatectomy. This study retrospectively analyzed the impact of the intraoperatively measured portal vein pressure (PVP) prior to hepatectomy on the prediction of PLF in hepatectomized patients.

Methods

A total of 334 hepatectomized patients in whom the PVP was intraoperatively measured before resection at our institution were enrolled in the present study. Outcomes were assessed according to the International Study Group of Liver Surgery definition and the severity of PLF grading.

Results

Thirty-nine of the 334 patients (11.6%) developed grade B/C PLF. The following factors were significantly associated with grade B/C PLF in a univariate analysis: indocyanine green retention rate after 15 minutes, Child-Pugh score, prehepatectomy PVP, and transfusion (each P < 0.0001). A prehepatectomy PVP value of 19.5 cmH₂O was the optimal cutoff value for predicting grade B/C PLF. In a multivariate analysis, prehepatectomy PVP (≥ 19.5 cmH₂O) was selected as the most relevant risk factor for grade B/C PLF (P = 0.0003, hazard ratio: 5.96, 95% CI: 1.80–19.70).

Conclusions

Prehepatectomy PVP can serve as a useful predictor of the risk of PLF in patients who have undergone hepatectomy. The results emphasize the possibility of reducing the planned extent of hepatic resection when the prehepatectomy PVP value measured intraoperatively exceeds 19.5 cmH₂O, and the importance of predicting the PVP before the operation.

Portal vein pressure

Posthepatectomy liver failure

Hepatectomy

Preoperative liver function

Despite careful patient selection and improved surgical techniques and perioperative management, postoperative liver failure (PLF) remains one of the least favorable complications after hepatectomy and the main cause of perioperative mortality [1–3]. In 2011, the International Study Group of Liver Surgery (ISGLS) proposed the first internationally standardized definitions and grading for PLF to facilitate the early detection of PLF and allow appropriate therapeutic strategies to be adapted [4]. The practicality of the ISGLS definition of PLF has been validated in several studies [4–6].

Portal vein pressure (PVP) is associated with the hepatic functional reserve and elevation of it is a major risk for PLF or intestinal bleeding in hepatectomized patients [7–9]. In studies on the relationship between PVP and PLF, elevated post-resection PVP has been shown to predict PLF, death and other complications after a major hepatectomy in patients without cirrhosis [7]. The intraoperative measurement of PVP may therefore contribute to appropriate risk assessment and management for PLF [7–15]. Although, the significance of the measurement of PVP before hepatectomy remains unclear and has not been a focus of investigation, the intraoperative PVP kinetics are considered to serve as independent predictive biomarker of PLF after major hepatectomy [9, 11–15].

The prediction of PLF prior to hepatectomy, which has the potential to limit the planned extent of hepatic resection, would naturally be better for avoiding severe complications. We hypothesized that the prehepatectomy PVP itself may predict an increased risk of PLF.

In the present study, we investigated the surgical outcomes of hepatectomized patients who underwent intraoperative measurement of the PVP prior to resection and analyzed the impact of prehepatectomy PVP measurement on the prediction of PLF.

Patient recruitment This retrospective study was conducted at Meiwa General Hospital, Japan. Data from all hepatectomized patients from January 2013 to December 2023 were prospectively collected from a dedicated database and retrospectively analyzed.

The study protocol was approved by the Ethics Committee of the Meiwa General Hospital (approval no. 15000063). Information on the characteristics and clinical courses of the patients was obtained from their medical records at a single institution.

Study population During the study period, 1170 consecutive patients underwent hepatectomy for liver disease. Among these patients, 459 patients who underwent laparoscopic resection, 35 who underwent repeated hepatectomy after round ligament resection, and 43 patients with portal venous tumor thrombosis in the first or secondary branch were excluded from the main analysis. We included hepatectomized patients for whom PVP was intraoperatively measured prior to resection (n = 524). Among these patients, 26 patients with PVP measurement failure, mainly due to the inability to recanalize blood flow in the umbilical vein, were excluded. Sixty-six patients with additional biliary reconstruction, 21 with resected liver weight ≤ 20 g, and 77 who underwent additional underwent ablation therapy were also excluded. Thus, 334 eligible patients (28.5%) met our inclusion criteria (Fig. 1).

Data collection and patient management The collected data included the patient demographics and surgical outcomes. The study was reviewed and approved by the institutional review board of Meiwa General Hospital. All methods were performed in accordance with the relevant guidelines and regulations. Indications for surgery, regardless of liver disease, were always decided by the hepato-pancreato-biliary multidisciplinary team conference, consisting of surgeons, radiologists, and hepatologists. While oncological systemic therapy as needed was conducted before and after surgery according to national standards, the surgical treatment strategy followed currently available guidelines for each primary tumor [16–18]. The policy of technical resectability was premised on the foundations of performing complete resection accompanied with sufficient preservation of future liver remnants.

The type of hepatectomy was defined as major or minor resection according to the Brisbane 2000 system of terminology (≤ 2 segments: minor; > 2 segments: major) [19]. To determine whether a hepatectomy procedure was acceptably safe for a given patient, we adopted a predictive score (PS) introduced by Yamanaka et al [20, 21]. The PS was computed using a multiple regression equation that consists of the percentage anticipated resection fraction calculated from computed tomographic (CT) volumetry, the percentage indocyanine green retention rate after 15 minutes (ICG R15), and the patient's age in years. A PS of < 45 indicates that a given hepatectomy is acceptable. For patients with a PS of > 45, another surgical strategy (e.g., two-stage hepatectomy, preoperative portal vein embolization or resection, and reconstruction of major vessels during hepatectomy) was considered in order to maximally preserve functional liver parenchyma.

Volumetric assessment of the liver CT examinations were performed using a 256-slice CT scanner (Brilliance iCT; Philips Healthcare, Cleveland, OH, USA). The data obtained for the hepatic arterial, portal venous, and hepatic venous phases were transmitted to a workstation running the SYNAPSE VINCENT (Fuji Medical Systems, Tokyo, Japan) 3-dimensional image-analysis system. This system can display operative simulation by 3D-vascular images and calculate the total liver volume, tumor volume, and volume of the planned extent of the resected region.

Surgery and perioperative management All patients underwent reversed L-shaped or J-shaped laparotomy. Hepatectomy was performed using intraoperative ultrasound to confirm the tumor location and to contribute to a parenchyma-sparing approach. The liver parenchyma was transected using a Cavitron ultrasonic surgical aspirator (CUSA Excel; Integra Lifesciences Corp.) and occasionally using the clamp crushing technique. The Pringle maneuver, with up to 15 min occlusion and 5 min reperfusion, was applied selectively in cases with significant intraoperative bleeding. Combined vascular resection was performed when the portal vein or hepatic artery was macroscopically invaded and could not be detached from the tumor based on imaging or surgical exploration. Drains were commonly placed at the end of surgery. Patients were admitted to the intensive care unit for postoperative monitoring for at least overnight and transferred to the general ward the following day or later, once hemodynamic stability was confirmed.

Intraoperatively measurement of prehepatectomy PVP The PVP (cmH₂O) was measured using a round ligament. After laparotomy, the round ligament was resected with a margin of length, and the lumen of the ligament was opened using a sonde to recanalize the blood flow in the umbilical vein. A 5-French feeding tube, the lumen of which was filled with water, was inserted into the lumen of the ligament. The tube with air bubbles removed was positioned vertically and set at the level of the main portal vein as the reference point. PVP was measured in the water column pressure using a ruler. Visual measurements of the PVP were reviewed by 2 or more faculty hepato-pancreato-biliary surgeons.

Definition of postoperative complications The severity of PLF grading was defined according to the ISGLS criteria based on abnormal bilirubin levels and prothrombin time-international normalized ratio (PT-INR) (according to the normal limits of the local laboratory) on postoperative day 5 or later. PLF was further rated as grade A (impaired liver function), grade B (deviation from the expected postoperative course, no need for invasive support), or grade C (multiple organ failure requiring invasive support) [4, 5]. Postoperative complications were classified according to the Clavien-Dindo classification system [22]. Mortality was defined as death within 90 days after surgery.

Statistical analyses Categorical variables were compared using either the Wilcoxon rank-sum test, χ² test, or Fisher`s exact test, as appropriate. Continuous variables are expressed as the median (interquartile range) and compared using the Mann-Whitney U-test. Correlations between continuous variables were assessed using regression analysis. Multivariate analyses were performed using a logistic regression model. Factors that showed statistical significance in the univariate analyses (P < 0.05) were included in the multivariate model. Continuous variables with predictive power for grade B/C PLF were evaluated using a receiver operating characteristic (ROC) curve analysis, and the area under the ROC curve (AUROC). P values of < 0.05 were considered to indicate statistical significance. All statistical analyses were performed using the JMP® Pro 16.0.0 software program (SAS Institute Inc., Cary, NC, USA).

Clinical characteristics The patient demographics are summarized in Table Ⅰ. There were 228 male and 106 female patients, with a median age of 69 (33–89) years. The etiology was hepatitis virus in 184 patients (64.5%), while 99 patients (22.6%) had no epidemiological liver disease. Hepatectomy was indicated to treat a hepatocellular carcinoma in 238 patients (70.9%), followed by metastatic cancer in 68 patients (20.3%). The most common surgical procedure was monosectionectomy (n = 113; 33.8%). Sixty-four patients (19.1%) required non-anatomical partial resection.

Relationship between prehepatectomy PVP and other parameters Fig. 2 shows a scatter plot of the multivariate correlation between preoperative liver function parameters. There were significant correlations between prehepatectomy PVP and the other parameters (each P < 0.0001).

Patient characteristics of grade 0/A and B/C PLF defined by ISGLS The patient characteristics of grade 0/A and B/C PLF, as defined by the ISGLS are summarized in Table ⅠI. Thirty-nine of the 334 patients (11.6%) developed grade B/C PLF. There were 295 patients with grade 0/A PLF (88.3%). No significant differences were noted between the two groups in terms of age, sex, or indications for hepatectomy. Albumin levels were significantly lower, while total bilirubin and aspartate aminotransferase (AST) were significantly higher in patients with grade B/C PLF than in those with grade 0/A PLF. The PT-INR tended to be higher in patients with grade B/C PLF than in those with grade 0/A PLF, although the differences were not statistically significant. Factors notably associated with grade B/C PLF in the univariate analysis were ICG R15, Child-Pugh score, and prehepatectomy PVP (each P < 0.0001).

Surgical outcomes Table ⅡI shows the surgical outcomes. The median resected liver weight was 265 (range 25-2440) g in patients with grade 0/A PLF and 255 (range 22-2774) g in patients with grade B/C PLF. Both the median length of operation and the estimated blood loss were significantly higher in patients with grade B/C PLF (385 min and 1210 ml, respectively) than in patients with grade 0/A PLF (340 min and 530 ml, respectively). The incidence of transfusion was higher in patients with grade B/C PLF than in those with grade 0/A PLF (48.7 vs. 13.9%, P < 0.0001). Regarding the postoperative outcomes, both total bilirubin and the PT-INR on postoperative day 5, which are the constituent factors of the 50–50 criteria [23] were significantly higher in patients with grade B/C PLF than in those with grade 0/A PLF. Major morbidities (Clavien-Dindo grade ≥ IIIa) occurred in 58 patients (17.3%). No marked between-group differences were observed in the proportion of 90-day mortality.

The optimal cutoff value of prehepatectomy PVP for predicting grade B/C PLF The ROC curve showed that a prehepatectomy PVP of 19.5 cmH₂O was the optimal cutoff value for grade B/C PLF, with an AUROC of 0.838 (Fig. 3).

Predictive factors associated with grade B/C PLF In multivariate analyses, a prehepatectomy PVP ≥ 19.5 cmH₂O (P = 0.0003, hazard ratio [HR]: 5.96, 95% confidence interval [CI]: 1.80–19.70) was the most relevant risk factor for grade B/C PLF. It was comparable to estimated blood loss ≥ 580 ml (P = 0.0037, HR: 8.19, 95% CI: 1.13–58.99) which was also a significant factor (Table IV).

Predicting PLF before hepatectomy may be of great significance for avoiding severe postoperative complications. To the best of our knowledge, this is the largest study to analyze the predictive value of intraoperatively measured prehepatectomy PVP in hepatectomized patients with respect to the prediction of PLF. In a multivariate analysis, we found that the prehepatectomy PVP value itself can serve as a sensitive and strong predictor of the risk of PLF in hepatectomized patients with liver disease. Notably, this study demonstrated that limiting the planned extent of hepatectomy when the prehepatectomy PVP exceeds 19.5 cmH₂O, may reduce the risk of PLF.

Despite technical advances, including the widespread prevalence of laparoscopic and/or robotic hepatectomy in hepato-biliary surgery, PLF remains a crucial clinical challenge [24–26]. Previous studies have deliberated on the significance of PLF, according to the ISGLS definition and severity, on hepatectomized patients, and the practicality of the definition in selecting early postoperative treatment strategies has been well-established and validated [4–6, 27, 28]. In recent publications, ISGLS grades B and C have been summarized as ‘clinically relevant’ because they require a change of clinical management [29–31]. In our study, 11.6% of all patients were diagnosed with grade B/C PLF, which is roughly consistent with the frequency in some reports on major hepatectomy [3, 32]. Once PLF develops, despite various attempts to assist the regenerating remnant liver, liver transplantation is the only effective treatment [6]. Hence, to the overcome this problem, the best way to manage PLF is to simply avoid its occurrence.

Based on the findings of various studies, several approaches have been used to predict the preoperative risk of PLF. A systematic review to evaluate the current evidence in the context of the PLF prediction model led to the conclusion that statistical models integrating the future liver remnant volume into one or more factors associated with portal hypertension may allow high performance in predicting PLF [28]. PVP, along with liver stiffness measured with transient elastography, platelet count, Fibrosis-4 (FIB-4) index, and AST to platelet ratio (APRI) score, is one of the parameters that is most strongly associated with portal hypertension [28]. Various studies have discussed the significance of intraoperative measurement of PVP with respect to the prediction of PLF. A study on 277 patients who underwent major hepatectomy with a noncirrhotic liver and for whom a PVP measurement was performed at the end of the resection showed that an intraoperative posthepatectomy PVP of ≥ 21 mmHg was an independent predictor of PLF and 90-day postoperative mortality [7]. More recently, Bogner et al. investigated the intraoperative changes in hepatic macrohemodynamics and their association with ascites and PLF after major hepatectomy [9]. They measured the PVP, portal venous flow, and hepatic arterial flow intraoperatively before and after resection, and concluded that intraoperative PVP kinetics serve as independent predictive biomarkers of PLF after major hepatectomy. Their study also emphasized the importance of assessing pre- and postresection PVP values as dynamic biomarkers. A systematic review of these studies, which consisted of 712 patients, demonstrated that the median PVP value increased from 11.4 to 15.9 mmHg following liver resection, and the overall median incidence of PLF was 19%. While it was not possible to define a specific threshold PVP for predicting PLF, their searches found an association between an elevated PVP after hepatectomy and increased rates of PLF [8]. The intraoperative measurement of PVP might therefore contribute to appropriate risk assessment and management of PLF and provide a gateway for pharmacological or surgical PVP modulation (e.g., reversible PV diameter modification, artery ligation, shunting or splenectomy) [10, 33, 34]. However, these studies did not successfully extract analyses concerning the predictive value of PVP measurements before hepatectomy and did not clarify the potential strategies utilizing PVP to mitigate the incidence of PLF.

The prediction of PLF before hepatectomy would be desirable for avoiding PLF; however, no previous studies have investigated the predictive value of the prehepatectomy PVP for the severity of PLF in hepatectomized patients. Several studies have proposed approaches to predicting and preventing PLF before surgery, including the application of invasive measurement of the hepatic vein pressure gradient or the use of a mathematical model to predict the portocaval gradient at the end of hepatectomy [35, 36]. We insisted on the early prediction of PLF by focusing on the prehepatectomy PVP and assessing its correlation with the incidence of PLF. This concept is based on the significance of avoiding PLF rather than predicting PLF before it occurs, without restricting the adaptation of this concept to major hepatectomy. As a result, our study suggests that the prehepatectomy PVP itself may be a sensitive predictor of the risk of PLF in hepatectomized patients. Furthermore, the ROC analysis to determine the cutoff value of the prehepatectomy PVP for predicting grade B/C PLF demonstrated that limiting the planned extent of hepatectomy when the intraoperatively measured prehepatectomy PVP exceeds 19.5 cmH₂O may be appropriate. Our measurement method is technically primitive but is less invasive and safe, and readily enables the immediate prediction of PLF before hepatectomy. This large-scale study demonstrated that the significance of prehepatectomy PVP measurements for predicting PLF should not be underestimated.

The present study was associated with several limitations. First, due to the single-center retrospective study design, the generalizability of the results to other institutions is unclear. A multicenter analysis that includes more hepatectomized patients undergoing the intraoperative measurement of the PVP prior to resection may help clarify the impact of prehepatectomy PVP on the risk of PLF, and the validity of its prediction. Second, our study excluded patients who underwent laparoscopic hepatectomy because of the difficulty in measuring the PVP laparoscopically. This dilemma may be resolved by precisely predicting the prehepatectomy PVP before surgery, regardless of the liver resection approach. Our next study on predicting the prehepatectomy PVP by a multiple regression equation using preoperative ultrasonography may contribute to evaluating the extent of hepatectomy that is commensurate with the hepatic functional reserve before the operation. Finally, we could not rule out the influence of surgical techniques or procedures that may affect PLF, such as a parenchyma-sparing approach, Pringle maneuver, or combined major vessel resection. These procedures might have led to correction of the predictive value of prehepatectomy PVP. Additional studies to explain the potential effect of surgical management on the prehepatectomy PVP may overcome this limitation.

The prehepatectomy PVP is a sensitive predictor of the risk of PLF in patients who have undergone hepatectomy, regardless of liver disease. A prehepatectomy PVP of 19.5 cmH₂O was the optimal cutoff value for predicting the risk of PLF. When the prehepatectomy PVP exceeds 19.5 cmH₂O, limiting the extent of resection before undergoing the proposed procedure may reduce the risk of PLF. The prediction of PLF based on preoperative PVP measurements is useful and may be worth exploring.

Authors’ Contributions

The study concept and design were by Nakajima, S. Ikuta, Aihara and Yamanaka. Nakajima, S. Ikuta, Aihara, L. Ikuta, Matsuki, Fujikawa, Ichise, Okamoto, Nakamoto, Yanagi and Yamanaka were responsible for the interpretation of the study. Drafting of the manuscript was by Nakajima and S. Ikuta.

Acknowledgements

The authors would like to thank all the patients and medical staff at the institution who contributed to this study.

Funding/Support

The authors received no funding regarding the content of this article.

Conflict of interest/Disclosure

The authors have no conflicts of interest regarding the content of this article.

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Table Ⅰ. Patient characteristics of the study population

Characteristics

All patients (N = 334)

Age, years

69 (33-89)

Sex

Male

Female

228 (68.3%)

106 (31.7%)

Etiology

HBs antigen positive

HCV antibody positive

Both HBs antigen and HCV antibody positive

Alcoholic liver disease

Nonalcoholic fatty liver disease

Primary biliary cirrhosis

No epidemiological liver disease

43 (12.8%)

140 (41.9%)

1 (0.2%)

28 (8.3%)

22 (6.5%)

1 (0.2%)

99 (29.6%)

Indication for liver resection

Hepatocellular carcinoma

Intrahepatic cholangiocellular carcinoma

Combined hepatocellular-cholangiocarcinoma

Metastatic cancer

Others^†

237 (70.9%)

16 (4.7%)

5 (1.4%)

68 (20.3%)

8 (2.3%)

Surgical procedure

Trisectionectomy

Bisectionectomy

Monosectionectomy

Systemic subsegmentectomy

Partial resection

6 (1.7%)

94 (28.1%)

113 (33.8%)

57 (17.0%)

64 (19.1%)

Data were shown as number (%) or median (interquartile range).

^†Neuroendocrine carcinoma (n = 3), biliary adenofibroma (n = 1), cystadenocarcinoma (n = 1), Hepatic inflammatory pseudotumor (n = 1), Intraductal papillary neoplasms of the bile duct (n = 1) and primary hepatic diffuse large B-cell lymphoma (n = 1).

Table Ⅱ. Patient characteristics of grade 0/A and B/C PLF defined by ISGLS

Variable	All patients (N = 334)	PLF Grade 0/A (n = 295)	PLF Grade B/C (n = 39)	P-value
Age, years	69 (33-89)	70 (33-89)	67 (36-82)	0.27
Sex Male Female	228 (68.3%) 106 (31.7%)	200 (67.8%) 95 (32.2%)	28 (71.7%) 11 (28.2%)	0.61
Indications HCC Other than HCC	237 (70.9%) 97 (29.0%)	205 (69.4%) 90 (30.5%)	32 (82.0%) 7 (17.9%)	0.10
Albumin, g/dl	3.9 (2.4-5.1)	3.9 (2.4-4.9)	3.6 (2.7-5.1)	0.0007
Total bilirubin, g/dl	0.7 (0.2-6.0)	0.7 (0.2-6.0)	0.9 (0.3-3.0)	0.0012
AST, IU/l	34 (10-277)	33 (10-277)	49 (16-255)	0.0079
ALT, IU/l	30 (6-284)	28 (6-284)	35 (8-169)	0.21
Platelet, 10⁹/l	158 (35-720)	161 (45-630)	136 (35-720)	0.91
PT-INR	1.11 (0.85-3.39)	1.10 (0.85-3.39)	1.15 (0.97-1.72)	0.06
ICG R15, %	14.0 (2.0-67.4)	13.4 (2.0-57.2)	21.8 (4.5-67.4)	<0.0001
Child-Pugh score	5 (5-8)	5 (5-7)	6 (5-8)	<0.0001
Prehepatectomy PVP, cmH₂O	17 (8-38)	17 (8-34)	24 (16-38)	<0.0001

Data were shown as number (%) or median (interquartile range).

PLF, postoperative liver failure; ISGLS, International Study Group of Liver Surgery; HCC, hepatocellular carcinoma; AST, aspartate aminotransferase; ALT, alanine aminotransferase; PT-INR, prothrombin time-international normalized ratio; ICG R15, indocyanine green retention rate after 15 minutes; PVP, portal vein pressure.

^†Some data were missing, regarding PT-INR (6 patients) and ICG R15 (9 patients).

Table III. Postoperative outcomes of grade 0/A and B/C PLF defined by ISGLS

Variable	All patients (N = 334)	PLF Grade 0/A (n = 295)	PLF Grade B/C (n = 39)	P-value
Resected liver weight, g	257 (22-2774)	265 (25-2440)	255 (22-2774)	0.07
Length of operation, min	345 (157-840)	340 (157-800)	385 (201-840)	0.0299
Estimated blood loss, ml	560 (10-7330)	530 (10-7330)	1210 (350-4400)	0.0053
Transfusion	60 (17.9%)	41 (13.9%)	19 (48.7%)	<0.0001
Postoperative total bilirubin, g/dl (POD5)	1.0 (0.3-9.0)	1.0 (0.3-6.5)	1.4 (0.3-9.0)	<0.0001
Postoperative PT-INR (POD5)	1.26 (0.96-3.72)	1.24 (0.96-1.94)	1.41 (1.11-3.72)	<0.0001
Morbidity, Clavien-Dindo grade ≥ Ⅲa	58 (17.3%)	42 (14.2%)	16 (41.0%)	0.0002
Mortality	2 (0.6%)	1 (0.3%)	1 (2.5%)	0.09

Data were shown as number (%) or median (interquartile range).

PLF, postoperative liver failure; ISGLS, International Study Group of Liver Surgery; POD, postoperative day; PT-INR, prothrombin time-international normalized ratio.

^†Some data were missing, regarding resected liver weight (9 patients), length of operation (4 patients), estimated blood loss (4 patients) and postoperative PT-INR (POD5) (8 patients).

Table IV. Multivariate analyses of risk factors for PLF ≥ Grade B defined by ISGLS

Variable	HR (95%CI)	P-value
Albumin: ≥ vs < 3.5 g/dl	0.99 (0.18-5.43)	0.99
Total bilirubin: ≥ vs < 1.0 g/dl	1.39 (0.43-4.55)	0.57
AST: ≥ vs < 30 IU/l	3.18 (0.73-13.72)	0.12
ICG R15: ≥ vs < 21.8%	3.14 (0.91-10.75)	0.06
Child-Pugh score: ≥ vs < 6	1.81 (0.36-8.95)	0.46
Prehepatectomy PVP: ≥ vs < 19.5 cmH₂O	5.96 (1.80-19.70)	0.0003
Length of operation: ≥ vs < 539 min	2.34 (0.37-14.71)	0.36
Estimated blood loss: ≥ vs < 580 ml	8.19 (1.13-58.99)	0.0037
Transfusion: done vs none	1.21 (0.21-6.83)	0.82

PLF, postoperative liver failure; ISGLS, International Study Group of Liver Surgery; AST, aspartate aminotransferase; ICG R15, indocyanine green retention rate after 15 minutes; PVP, portal vein pressure.

No competing interests reported.

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Intraoperatively measured prehepatectomy portal vein pressure as a useful predictor of postoperative liver failure

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