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Marasco et al. Hepatoma Res 2020;6:32 I http://dx.doi.org/10.20517/2394-5079.2019.54 Page 7 of 17

Table 3. Studies evaluating LSM by elastography in predicting PHLF
Authors Country Population Etiology Outcome Nr. cases Technique LSM cut-off AUROC
Kim et al. [83] 2008 South Korea 72 83% HCV PHLF 7 TE 25.6 kPa 0.824
Cescon et al. [84] 2012 Italy 90 66% HCV PHLF 26 TE 15.7 kPa 0.865
Harada et al. [85] 2012 Japan 50 68% HCV Ascites 19 ARFI 1.68 m/s 0.900
Wong et al. [86] 2013 China 105 67% HBV Major complications 15 TE 12 kPa 0.790
Zhang et al. [87] 2015 China 75 HBV Ascites 13 TE 15.6 kPa 0.902
PHLF 4 14.3 kPa 0.915
Nishio et al. [88] 2016 Japan 177 Mixed PHLF B or C 21 ARFI 1.61 m/s 0.780
Cucchetti et al. [11] 2017 Italy 202 64% HCV PHLF 60 TE N/A N/A
Chong et al. [89] 2017 China 255 82% HBV PHLF B or C 46 TE 11.5 kPa 0.650
20 kPa 0.825
Han et al. [90] 2017 China 77 90% HBV PHLF 27 2D-SWE 6.9 kPa 0.843
Abe et al. [91] 2017 Japan 175 Mixed Major complications 28 MRE 5.3 kPa 0.810
Shen et al. [92] 2017 China 280 HBV PHLF 55 2D-SWE 11.8 kPa 0.720
Rajakannu et al. [93] 2017 France 106 Mixed Decompensation 9 TE 22 kPa 0.810
Donadon et al. [94] 2017 Italy 340 Mixed Complications 95 TE 9.7 kPa 0.728
Wu et al. [95] 2017 China 54 65% HBV PHLF 7 TE 16.2 kPa 0.760
Lei et al. [96] 2017 China 247 HBV PHLF 37 TE 14 kPa 0.860
Hu et al. [97] 2018 China 216 88% HBV PHLF 64 SWE N/A 0.850
Sato et al. [98] 2018 Japan 96 Mixed Major complications 15 MRE 4.3 kPa 0.813
Procopet et al. [99] 2018 Romania 51 65% Viral Decompensation 15 TE 13.6/21 kPa 0.780
PHLF 20 N/A NS
ARFI: Acoustic radiation force impulse; HBV: hepatitis B virus; HCV hepatitis C virus; LSM: liver stiffness measurement; MRE: magnetic
resonance elastography; N/A: not available; PHLF: post-hepatectomy liver failure; SWE: Shear wave elastography; TE: transient
elastography

ULTRASOUND-BASED AND OTHER IMAGING PREDICTORS
Liver stiffness measurement
In the last few years, the liver stiffness measurement (LSM) has been proposed as a practical and widely
validated surrogate of liver fibrosis and portal hypertension, able to accurately predict the risk of cirrhosis ,
[79]
[80]
[82]
[81]
CSPH and its complications, such as the development of varices and hepatic decompensation . Given
that these attributes are major determinants of the risk of PHLF development, LSM has been investigated as
a predictor of decompensation and other complications after hepatic resection with several methods that are
mainly ultrasound-based [11,83-99] [Table 3].
The study by Cescon et al. was one of the first papers to demonstrate that LSM, evaluated by transient
[84]
elastography (TE), was an independent predictor of PHLF, together with histological cirrhosis and lower
sodium levels. Since then, numerous studies have confirmed that LSM by TE is an important prognostic pre-
operative variable that is able to stratify the risk of decompensation, PHLF and overall complications after
liver resection [83,93,94,96,100] . Different cut-offs have been proposed for this purpose, ranging from 9.7 to 22
[80]
kPa [93,94] , which correspond to current cut-offs for advanced chronic liver disease and CSPH respectively .
Positive findings have also been described for LSM evaluated by other elastosonography techniques. For
[97]
instance, Hu et al. developed and validated a nomogram including LSM assessment by shear-wave
elastography, which is able to accurately predict the risk of any grade of PHLF (c-statistic 0.825). More
[98]
recently, Sato et al. reported in a series of 96 consecutive patients who underwent liver resection, that LSM
by magnetic resonance elastography (MRE), with a best-cut-off of 4.3 kPa, was an independent predictor of
major surgical complications. When compared to other indices of portal hypertension, the accuracy of LSM
[93]
was found to be non-inferior to that of the gold standard, hepatic venous pressure gradient (HVPG) , and
[83]
superior to that of ICG-r15 Some preliminary studies have reported a promising role of the spleen stiffness
measurement (SSM) [12,77] , which is known to be a more accurate surrogate of portal hypertension [101] but its
prognostic role and accuracy in this context have yet to be established.