NAFLD-related hepatocellular carcinoma tied to greater hepatectomy complications
Patients with nonalcoholic fatty liver disease (NAFLD)-related hepatocellular carcinoma (HCC) suffer from higher surgical morbidity and posthepatectomy liver failure, according to a new Singapore study.
“NAFLD is a well-recognized chronic liver disease in Asia and an increasingly important cause of HCC,” said researchers. “[T]his study represents the largest series of surgically resected NAFLD HCC. The approach with comparison of well-matched variables between NAFLD and non-NAFLD aetiologies provides a strong evidence for the intrinsic differences in disease characteristics, survival outcomes and perioperative morbidity.”
In 996 patients who underwent liver resection for HCC, majority (n=844; median age, 63 years; 78.6 percent male) had non-NAFLD aetiologies; only 152 (median age, 69 years; 73.0 percent male) had NAFLD-related HCC. Those with NAFLD-related malignancies tended to be older and have more comorbidities, such as diabetes mellitus and hypertension. [J Am Coll Surg 2019;doi:10.1016/j.jamcollsurg.2019.07.012]
More than half (54.5 percent; n=84) of the NAFLD group experienced at least one postoperative complication. This was significantly higher than that in patients with non-NAFLD aetiologies (30.8 percent; n=260; p=0.0115).
Further analysis according to the type of complication showed that NAFLD-related HCC led to significantly higher rates of minor (41.2 percent vs 24.2 percent; p=0.0003) and major (16.2 percent vs 8.1 percent; p=0.0432) complications, as well as of pulmonary embolism (2.0 percent vs 0.4 percent; p=0.0219). The NAFLD group also spent a significantly longer time in the hospital (median, 8 vs 6 days; p<0.0001).
Grade A (29.5 percent vs 9.5 percent) and grade B/C (20.1 percent vs 7.2 percent; p=0.0008 for all) posthepatectomy liver failure likewise occurred with significantly higher frequencies in patients with NAFLD-related HCC.
Despite worse postoperative outcomes, patients with NAFLD-related HCC demonstrated superior survival rates. For instance, only 1.99 percent of the NAFLD group died within a 90-day period as opposed to 2.46 in the non-NAFLD patients. Median overall survival (OS) was also longer in those with NAFLD-related aetiologies (108 vs 91.3 months).
This relative advantage persisted until the long-term. OS rates at 1, 3, 5 and 10 years were 94.0 percent, 82.5 percent, 70.1 percent and 49.6 percent in the NAFLD group and 90.1 percent, 73.4 percent, 60.9 percent and 41.0 percent in their non-NAFLD counterparts (p=0.0411 for all OS outcomes).
Similar trends were observed for recurrence-free survival, though statistical significance was not achieved (p=0.0931).
Advancements in surgical techniques and postoperative care may have contributed greatly to the improved survival rates after hepatectomy, the researchers explained. “However, these advances have not been translated wholly into improved care for the specific group of patients with NAFLD-related HCC.”
“In our study, overall morbidity for NAFLD-related HCC posthepatectomy was over 50 percent,” they pointed out. “The most common postoperative complication was liver failure, followed by cardiorespiratory complications and pulmonary embolism.”
Preoperative identification of NAFLD may help with the management of and counselling about such risks, the researchers added.