The 3-60 criteria challenge established predictors of postoperative mortality and enable timely therapeutic intervention after liver resection
Open accessAbstract
BACKGROUND: To date, definitions of liver dysfunction (LD) after hepatic resection rely on late postoperative time points. Further, the used parameters are markedly influenced by perioperative management. Thus, we aimed to establish a very early postoperative score to predict postoperative mortality. METHODS: Liver related parameters were evaluated after liver resection in a retrospective evaluation cohort of 228 colorectal cancer patients with liver metastasis (mCRC) and subsequent validation in a prospective set of 482 consecutive patients from 4 independent institutions undergoing hepatic resection was performed. RESULTS: C-reactive protein (CRP, AUC =0.739, P<0.001) and antithrombinIII-activity (ATIII, AUC =0.844, P<0.001) on the first postoperative day (POD) were found to be elevated in patients with LD. Cut-off values for CRP at 3 mg/dL and for ATIII at 60% significantly identified high-risk patients for postoperative LD and mortality (P<0.001) and thus defined the 3-60 criteria on POD1. The 3-60 criteria showed superior sensitivity and specificity compared to established criteria for LD [3-60 criteria: total positive patients: 26 patients (70% mortality detected), odds ratio (OR): 48.8; International Study Group for Liver Surgery: total positive patients: 43 (70% mortality detected), OR: 23.3; Peak7: total positive patients: 9 (30% mortality detected), OR: 27.8; 50-50: total positive patients: 9 (30% mortality detected), OR: 27.8]. These results could be validated in a multi-center analysis and ultimately the 3-60 criteria remained an independent predictor of postoperative mortality upon multivariable analysis. CONCLUSIONS: The 3-60 criteria on POD1 predict postoperative LD and mortality early after liver resection with a comparable or better accuracy than established criteria, allowing for immediate identification of high-risk patients.
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Serum lactate, CRP, and antithrombin III were demonstrated to identify imminent PHLF as early as within 24 h of surgery.
“More recently, markers such as serum lactate, CRP, and antithrombin III were demonstrated to identify imminent PHLF as early as within 24 h of surgery [11,12,13].”
From The Role of Perioperative Interleukin-6 Serum Levels on Liver Dysfunction and Infectious Complications After Hepatectomy—A Systematic Review (2025) · cites this paper as [11]
The Discussion reports that CRP and antithrombin III measured on postoperative day 1 predicted liver dysfunction after resection. The paper does not report serum lactate as a predictor, so it supports only part of the three-marker claim. (LLM, conf=0.88)
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Research works printed but not linked: 21
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Primavesi, F., Maglione, M., Cipriani, F., Denecke, T., Oberkofler, C. E., Starlinger, P., Dasari, B. V. M., Heil, J., Sgarbura, O., Søreide, K., et al. (2023) · British Journal of Surgery · doi:10.1093/bjs/znad233 · Cited by 97 · see citing works
Self-citationKofler, A., Trattner, M., Mairinger, V., Urban, I., Søreide, K., Stättner, S., & Primavesi, F. (2025) · Cancers · doi:10.3390/cancers17193120 · Cited by 4 · see citing works
“While postoperative CRP has recently been assessed in a large multicenter project with appropriate methodology [11], no robust evidence so far has been published on how IL-6 serum measurements can differentiate between PHLF and infection early after liver resection.”
- Authors
- Gyoeri, G. P., Pereyra, D., Braunwarth, E., Ammann, M., Jonas, P., Offensperger, F., Klinglmueller, F., Baumgartner, R., Holzer, S., Gnant, M., Laengle, F., Staettner, S., Gruenberger, T., & Starlinger, P.
- Affiliations
- Vienna General Hospital (AT)
- Innsbruck Medical University (AT)
- Kaiser-Franz-Josef-Spital (AT)
- Medical University of Vienna (AT)
- Corresponding author
- Starlinger, Patrick
- ORCID
- Venue
- HepatoBiliary Surgery and Nutrition
- Publisher
- AME Publishing Company
- Published
- 2019-04
- Volume
- 8
- Issue
- 2
- Pages
- 111-124
- ISSN
- 2304-3881 (ISSN-L)
- 2304-389X
- PMC
- PMC6503244
- OpenAlex
- W2924428391
- Cited by
- 20
- References
- 0
- Citations by year
- 2026: 3 · 2025: 5 · 2024: 1 · 2023: 1 · 2022: 2 · 2021: 3 · 2020: 2 · 2019: 3
- FWCI
- 1.59
- Type
- journal article
- Language
- en
- Open access
- diamond
- doi.org
- Licence
- cc-by-nc-nd
- Locations
- HepatoBiliary Surgery and Nutrition (publishedVersion, cc-by-nc-nd)
- PubMed Central (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Health Sciences › Medicine › Hepatology › Hepatocellular Carcinoma Treatment and Prognosis
- Health Sciences › Medicine › Oncology › Inflammatory Biomarkers in Disease Prognosis
- Health Sciences › Medicine › Oncology › Colorectal Cancer Treatments and Studies
- Keywords
- postoperative liver dysfunction, postoperative mortality prediction, hepatectomy, colorectal liver metastases, C-reactive protein, antithrombin III, prognostic scoring
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