Published online Jun 27, 2025. doi: 10.4240/wjgs.v17.i6.106276
Revised: April 27, 2025
Accepted: May 15, 2025
Published online: June 27, 2025
Processing time: 65 Days and 3.1 Hours
Post-operative infection is a common and serious complication following drug-eluting trans arterial chemo embolization (D-TACE) in patients with hepatocellular carcinoma (HCC), potentially compromising treatment efficacy and increasing morbidity.
To investigate the risk factors associated with post-operative infection in HCC patients undergoing D-TACE, and to provide evidence for clinical prevention and targeted intervention strategies.
Clinical data of 77 primary HCC patients who underwent D-TACE in our hospital from January 2022 to December 2023 were retrospectively analyzed. Patient de
Post-operative infection occurred in 20 cases (25.97%) among the 77 patients. Univariate analysis showed that age ≥ 65 years, Child-Pugh grade B, tumor diameter ≥ 5 cm, operation time ≥ 120 minutes, preoperative albumin < 35 g/L, and comorbid diabetes were significantly associated with post-operative infection (P < 0.05). Multivariate logistic regression analysis identified Child-Pugh grade B (OR = 2.851, 95%CI: 1.426-5.698), operation time ≥ 120 minutes (OR = 2.367, 95%CI: 1.238-4.523), and preoperative albumin < 35 g/L (OR = 2.156, 95%CI: 1.147-4.052) as independent risk factors for post-operative infection.
Liver function status, operation time, and preoperative albumin level are significant factors affecting post-operative infection in HCC patients undergoing D-TACE. For high-risk patients, enhanced perioperative management, appropriate timing of surgery, and active improvement of nutritional status should be implemented to reduce the risk of post-operative infection.
Core Tip: Liver function status (Child-Pugh grade B) and preoperative hypoalbuminemia (< 35 g/L) are critical risk factors for postoperative infection following drug-eluting trans arterial chemo embolization in hepatocellular carcinoma patients, with prolonged operation time (≥ 120 minutes) further increasing infection risk. High-risk patients may benefit from enhanced preoperative nutritional support, optimized timing of surgery, and strict perioperative monitoring. Larger tumor size and Bilobar involvement are associated with higher infection rates, though these effects are likely mediated through liver function and procedural complexity. Proactive management of comorbidities, particularly diabetes mellitus, is essential to reducing infection risk. Personalized preventive measures based on individual risk profiles can improve outcomes and reduce postoperative complications.
- Citation: Wang G, Qi R. Analysis of risk factors for post-operative infection following drug-eluting trans arterial chemo embolization in hepatocellular carcinoma: A retrospective study. World J Gastrointest Surg 2025; 17(6): 106276
- URL: https://www.wjgnet.com/1948-9366/full/v17/i6/106276.htm
- DOI: https://dx.doi.org/10.4240/wjgs.v17.i6.106276
Hepatocellular carcinoma (HCC) is one of the most common primary liver malignancies worldwide, representing a significant global health burden with increasing incidence in recent years. Drug-eluting trans arterial chemo embolization (D-TACE), as an evolution of conventional trans arterial chemo embolization (TACE), has emerged as an important interventional therapy for unresectable HCC, showing promising results in local tumor control and survival benefits[1-4].
While D-TACE offers advantages in terms of sustained drug release and standardized embolization, post-operative infection remains a significant complication that can adversely affect patient outcomes. Infection following D-TACE not only prolongs the length of hospital stay and increase medical expenditure, but may also compromise the therapeutic efficacy, and cause serious complications in some instances. The rate of infection following TACE ranges from 10% to 30% based on various studies, but available data on the rate of infection post-D-TACE is limited[5-8].
Post-operative infection in HCC patients undergoing the D-TACE procedure is a complex process with multifactorial contributions potentially including patient-related factors, tumor characteristics, and procedural variables. In particular, since many patients with HCC also present with underlying liver cirrhosis and compromised liver function, their ability to fight off infection may also be impaired. Identifying the risk factors for post-operative infection is important to develop effective preventive measures and improve patients' outcomes[8-10].
D-TACE and conventional TACE have fundamental technical differences that may lead to distinct infection risk mechanisms. Conventional TACE uses iodized oil as an unstable carrier, while D-TACE employs drug-eluting beads providing standardized embolization and controlled drug release. D-TACE's infection risk profile stems from three main aspects: Sustained drug release causing prolonged local immunosuppression, uniform microspheres creating more predictable but potentially more extensive ischemic areas, and complex microcatheter manipulation required for superselective delivery extending operation time. While conventional TACE infection rates range from 10%-30%, research on D-TACE-specific infection rates is limited, with recent data showing approximately 22.3%. As D-TACE becomes widely used in HCC treatment, systematic evaluation of its specific infection risk factors has significant clinical importance for improving treatment outcomes and patient prognosis. Emerging molecular studies also indicate that tumor microenvironment changes after D-TACE might facilitate these bacteria translocation and colonization. The economic burden attributed to post-operative infections could raise hospitalization costs by 25%-40%[11-13]. Further stressing the necessity to create predictive models for infection risk stratification. Therefore, personalized preventive strategies should be implemented based on the individual risk profiles of each patient in order to further decrease infection rates and improve the overall benefit-risk ratio of D-TACE in patients with unresectable HCC.
While this complication has important clinical implications, there is a paucity of evaluation of risk factors for post-operative infection after D-TACE in the literature. Thus, this study intends to identify risk factors for post-operative infection in patients with HCC undergoing D-TACE and to provide evidence-based suggestions for clinical prevention and intervention as well.
This retrospective analysis was performed on patients diagnosed with primary HCC treated with D-TACE at our center from January 2022 to December 2023. HCC was diagnosed by imaging and/or histopathological examination based on the American Association for the Study of Liver Diseases guidelines. Inclusion criteria were: (1) Aged 18-75 years; (2) Diagnosed with primary HCC; (3) Child-Pugh class A or B; (4) Eastern Cooperative Oncology Group (ECOG) per
This study clearly defined post-operative infection as the presence of at least one of the following manifestations within 30 days after D-TACE: Body temperature > 38.5 °C lasting more than 24 hours, positive blood culture, clinical signs of infection with elevated white blood cell count and C-reactive protein, or imaging evidence of infection. For comprehensive analysis, we classified post-operative infections into four categories: Hepatic abscess [localized collection of purulent material within liver parenchyma, shown as hypodense lesions with peripheral enhancement and/or gas formation on contrast-enhanced computed tomography (CT) or magnetic resonance imaging (MRI)]; biliary infection (clinical evidence of cholangitis or imaging findings of biliary dilation, periductal edema, or biliary sludge formation); systemic infection (positive blood cultures or clinical sepsis without localized hepatobiliary source); and other infection types (including access site infections, pneumonia, or urinary tract infections). All suspected infections were confirmed by two independent physicians (an interventional radiologist and an infectious disease specialist) to ensure diagnostic accuracy. We systematically documented the type, onset time, severity (using CTCAE v5.0), treatment approach, and resolution of each infection.
All procedures were performed under strictly maintained sterile conditions in dedicated interventional radiology suites by a team of qualified interventional radiologists, each possessing a minimum of 5 years of specialized experience in hepatic vascular interventions. Prior to the procedure, patients underwent comprehensive pre-procedural assessment including laboratory evaluation, cross-sectional imaging review, and anesthesia consultation. After administration of local anesthesia (typically 2% lidocaine) at the planned puncture site, femoral arterial access was established using the modified Seldinger technique. This involved initial needle puncture of the common femoral artery, followed by insertion of a 0.035-inch guidewire, over which a 5-French vascular sheath was placed to maintain stable arterial access throughout the procedure. Diagnostic angiography was then performed using a 5-French catheter (typically Cobra or Simmons configuration) to evaluate the hepatic arterial anatomy. All patients received standardized prophylactic antibiotic treatment according to institutional D-TACE protocols, with intravenous administration of a single dose of second or third-generation cephalosporin (cefuroxime 1.5 g or ceftriaxone 2 g) 30-60 minutes before surgery to ensure adequate tissue drug concentrations during the intervention. For high-risk patients (defined as Child-Pugh grade B liver function or comorbid diabetes), antibiotic coverage was extended to 24 hours post-procedure with two additional doses given every 8 hours. Antibiotic selection was based on broad-spectrum coverage against common hepatobiliary infection microorganisms and pharmacokinetic properties in patients with liver dysfunction. The embolic agent used in all procedures was drug-eluting beads (DC Bead®, Boston Scientific) with 100-300 μm diameter, loaded with doxorubicin at a dose of 25-75 mg/m² according to patient body surface area. The drug loading process was performed under sterile conditions in the hospital pharmacy according to manufacturer specifications, ensuring complete absorption of the chemotherapeutic agent into the beads. The procedure was considered technically complete and terminated when angiographic evidence demonstrated stasis of blood flow in the tumor-feeding vessels, typically characterized by near-complete contrast column stasis for approximately 5 heartbeats. Post-embolization angiography was performed to document the final result and to assess for potential non-target embolization. The microcatheter and guiding catheter were then carefully withdrawn, and hemostasis at the femoral access site was achieved using either manual compression or vascular closure devices according to institutional protocol[14-16].
All patients were evaluated for the following parameters before and after the D-TACE procedure: Baseline demographic and clinical characteristics were documented, including age, gender, body mass index, Child-Pugh grade (A or B), ECOG performance status (0-2), and presence of comorbidities such as diabetes mellitus and hypertension. Laboratory tests were performed within 3 days before the procedure and monitored post-operatively. These included complete blood count (white blood cells, hemoglobin, platelets), liver function tests (alanine aminotransferase, aspartate aminotransferase, total bilirubin, albumin), and coagulation profile (prothrombin time, international normalized ratio). Tumor characteristics were evaluated through enhanced CT or MRI within two weeks before the procedure. The maximum tumor diameter, number of lesions, and tumor location were recorded. Tumors were classified as unilobar or Bilobar based on their distribution. Procedure-related parameters were documented during D-TACE, including operation time (from femoral artery puncture to completion of embolization), volume of drug-eluting beads used, and technical success (defined as complete delivery of the planned dose of drug-eluting beads with satisfactory tumor vessel embolization). Post-operative monitoring included daily assessment of vital signs, clinical symptoms, and laboratory tests for the first week after D-TACE. Infection-related indicators such as body temperature, white blood cell count, C-reactive protein, and procalcitonin were closely monitored. Other post-operative complications including post-embolization syndrome, liver dysfunction, and procedure-related adverse events were also recorded and graded according to the Society of Interventional Radiology classification system.
Statistical analysis was performed using SPSS version 25.0. Continuous variables were expressed as mean ± SD or median (interquartile range) and compared using student's t-test or Mann-Whitney U test. Categorical variables were presented as frequencies (percentages) and compared using χ2 test or Fisher's exact test.
Univariate analysis was performed to identify potential risk factors for post-operative infection. Variables with P < 0.05 in univariate analysis were included in multivariate logistic regression analysis to determine independent risk factors. Results were presented as OR with 95%CI. Statistical significance was set at P < 0.05.
Among the 77 patients included in this investigation, post-operative infection developed in 20 individuals (25.97%), while 57 participants (74.03%) remained infection-free following the procedure. When comparing demographic characteristics between groups, we observed that patients who developed infections tended to be older, with a mean age of 62.3 ± 8.7 years compared to 57.2 ± 9.1 years in those without infections. This age difference reached statistical significance (P < 0.05). Regarding gender distribution, both groups showed a male predominance, with men comprising 75% (15/20) of the infection group and 70.2% (40/57) of the non-infection group. Statistical analysis revealed no significant difference in gender composition between the two groups (P > 0.05), as demonstrated in Table 1. These findings suggest that advanced age may represent a potential risk factor for post-operative infection following D-TACE procedures in patients with HCC.
| Characteristic | Infection group (n = 20) | Non-infection group (n = 57) | P value |
| Mean age (years) | 62.3 ± 8.7 | 57.2 ± 9.1 | < 0.05 |
| Gender distribution | > 0.05 | ||
| Male (%) | 75% (15/20) | 70.2% (40/57) | |
| Female (%) | 25% (5/20) | 29.8% (17/57) | |
| Smoking status (%) | |||
| Current smoker | 30% (6/20) | 25% (14/57) | > 0.05 |
| Former smoker | 40% (8/20) | 35% (20/57) | |
| Never smoker | 30% (6/20) | 40% (23/57) | |
| Systolic blood pressure (mmHg) | 130.5 ± 15.2 | 125.3 ± 14.1 | > 0.05 |
| Diastolic blood pressure (mmHg) | 80.2 ± 10.5 | 78.5 ± 9.8 | > 0.05 |
| History of hypertension (%) | 40% (8/20) | 35% (20/57) | > 0.05 |
| Total cholesterol (mg/dL) | 200.3 ± 35.4 | 195.2 ± 32.1 | > 0.05 |
Analysis of hepatic function parameters revealed notable distinctions between the two patient cohorts. Child-Pugh classification, a crucial indicator of underlying liver reserve, demonstrated a significant disparity between groups. Specifically, Child-Pugh grade B liver function was substantially more prevalent among patients who developed post-operative infections, representing 60% (12/20) of this cohort, compared to only 28.1% (16/57) of patients in the non-infection group. This difference achieved statistical significance (P < 0.05), suggesting compromised liver function may predispose patients to infectious complications following D-TACE procedures. Despite these differences in liver function parameters, ECOG performance status-an established measure of general functional capacity and quality of life-demonstrated comparable distribution between the two groups. No statistically significant variation in ECOG scores was detected between patients who developed infections and those who remained infection-free (P > 0.05). These findings, comprehensively presented in Table 2, suggest that liver functional reserve rather than general performance status may play a more determinative role in predicting post-D-TACE infectious complications in patients with HCC.
| Characteristic | Infection group (n = 20) | Non-infection group (n = 57) | P value |
| Child-Pugh grade (%) | < 0.05 | ||
| Grade B | 60% (12/20) | 28.1% (16/57) | |
| Grade A | 40% (8/20) | 71.9% (41/57) | |
| Mean albumin level (g/L) | 32.4 ± 3.8 | 37.6 ± 4.2 | < 0.05 |
| ECOG performance status (%) | > 0.05 | ||
| Score 0 | 30% (6/20) | 38.6% (22/57) | |
| Score 1 | 50% (10/20) | 47.4% (27/57) | |
| Score 2 | 20% (4/20) | 14.0% (8/57) | |
| Mean bilirubin level (mg/dL) | 2.5 ± 0.8 | 1.8 ± 0.6 | < 0.05 |
| Mean ALT level (U/L) | 60.2 ± 15.3 | 50.1 ± 12.4 | > 0.05 |
| Mean AST level (U/L) | 70.5 ± 18.2 | 60.3 ± 14.1 | > 0.05 |
| Mean INR | 1.4 ± 0.3 | 1.2 ± 0.2 | < 0.05 |
Comprehensive analysis of comorbidity profiles revealed significant distinctions between the infection-susceptible and infection-resistant cohorts. Most notably, diabetes mellitus emerged as a prominent risk factor, with a substantially higher prevalence observed among patients who developed post-operative infections. Specifically, 45% (9/20) of patients in the infection group had pre-existing diabetes mellitus, compared to only 22.8% (13/57) in the non-infection group. This difference achieved statistical significance (P < 0.05), highlighting the potential immunomodulatory effects of diabetes that may predispose HCC patients to infectious complications following D-TACE procedures. In contrast, hypertension demonstrated comparable distribution between the two groups, affecting 35% (7/20) of patients in the infection group and 31.6% (18/57) of those in the non-infection group. Statistical analysis confirmed this difference was not significant (P > 0.05), suggesting that hypertension alone may not substantially alter infection risk in this clinical context. The comprehensive comorbidity assessment, as detailed in Table 3, also examined other relevant pre-existing conditions including cardiovascular disease, chronic obstructive pulmonary disease, chronic kidney disease, and autoimmune disorders.
| Comorbidity | Infection group (n = 20) (%) | Non-infection group (n = 57) (%) | P value |
| Diabetes mellitus | 45 (9/20) | 22.8 (13/57) | < 0.05 |
| Hypertension | 35 (7/20) | 31.6 (18/57) | > 0.05 |
| Cardiovascular disease | 20 (4/20) | 17.5 (10/57) | > 0.05 |
| Chronic kidney disease | 15 (3/20) | 12.3 (7/57) | > 0.05 |
| Chronic lung disease | 10 (2/20) | 8.8 (5/57) | > 0.05 |
| Obesity | 25 (5/20) | 17.5 (10/57) | > 0.05 |
| Hyperlipidemia | 30 (6/20) | 26.3 (15/57) | > 0.05 |
| History of stroke | 10 (2/20) | 8.8 (5/57) | > 0.05 |
| History of cancer | 5 (1/20) | 3.5 (2/57) | > 0.05 |
The anatomical distribution of tumor burden also emerged as a significant factor. Bilobar hepatic involvement, indicating more extensive disease, was documented in 55% (11/20) of patients in the infection group, compared to 31.6% (18/57) in the non-infection group. This difference achieved statistical significance (P < 0.05) and suggests that more widespread tumor distribution may necessitate more extensive embolization, potentially compromising hepatic blood flow to a greater degree and creating larger zones of ischemia susceptible to bacterial colonization. These findings, comprehensively presented in Table 4, collectively indicate that both tumor size and anatomical distribution represent important variables in predicting post-D-TACE infection risk.
| Characteristic | Infection group (n = 20) (%) | Non-infection group (n = 57) (%) | P value |
| Mean maximum tumor diameter (cm) | 6.8 ± 2.3 | 4.2 ± 1.9 | < 0.05 |
| Tumor diameter ≥ 5 cm | 40.3 (8/20) | 15.6 (9/57) | < 0.05 |
| Bilobar distribution | 55 (11/20) | 31.6 (18/57) | < 0.05 |
| Unilobar distribution | 45 (9/20) | 68.4 (39/57) | |
| Mean number of tumors | 2.1 ± 0.8 | 1.5 ± 0.6 | < 0.05 |
| Tumor location in right lobe | 30 (6/20) | 40.4 (23/57) | > 0.05 |
| Tumor location in left lobe | 25 (5/20) | 31.6 (18/57) | > 0.05 |
| Tumor location in both lobes | 45 (9/20) | 28.1 (16/57) | < 0.05 |
| Tumor grade (high grade) | 60 (12/20) | 40.4 (23/57) | < 0.05 |
| Tumor marker (CEA ≥ 5 ng/mL) | 50 (10/20) | 28.1 (16/57) | < 0.05 |
| Tumor marker (CA19-9 ≥ 37 U/mL) | 45 (9/20) | 24.6 (14/57) | < 0.05 |
| Tumor marker (AFP ≥ 20 ng/mL) | 35 (7/20) | 17.5 (10/57) | < 0.05 |
Procedural characteristics demonstrated notable differences between patients who developed post-operative infections and those who did not. Duration of intervention emerged as a particularly significant factor, with substantially prolonged procedural times observed in the infection group. Specifically, patients who subsequently developed infectious complications underwent significantly longer D-TACE procedures, with a mean operation time of 142.5 ± 32.6 minutes, compared to 98.3 ± 25.7 minutes in the non-infection group. This difference of approximately 44 minutes was statistically significant (P < 0.05) and potentially clinically meaningful. These comprehensive findings, detailed in Table 5, highlight the importance of procedural efficiency in minimizing infection risk following D-TACE procedures, while suggesting that the relationship between procedure duration and infection susceptibility is complex and likely multifactorial rather than simply reflective of embolic material volume.
| Characteristic | Infection group (n = 20) | Non-infection group (n = 57) | P value |
| Mean operation time (minutes) | 142.5 ± 32.6 | 98.3 ± 25.7 | < 0.05 |
| Operation time ≥ 120 minutes (%) | 70% (14/20) | 38.6% (22/57) | < 0.05 |
| Volume of drug-eluting beads (mL) | 10.2 ± 2.1 | 9.8 ± 1.9 | > 0.05 |
| Mean blood loss (mL) | 350.2 ± 120.5 | 250.1 ± 100.3 | < 0.05 |
| Blood transfusion required (%) | 40% (8/20) | 24.6% (14/57) | < 0.05 |
| Postoperative hospital stay (days) | 7.5 ± 2.3 | 5.8 ± 1.9 | < 0.05 |
| Intraoperative complications (%) | 30% (6/20) | 17.5% (10/57) | > 0.05 |
| Postoperative complications (%) | 50% (10/20) | 31.6% (18/57) | < 0.05 |
| Mean number of lymph nodes removed | 12.5 ± 3.2 | 10.1 ± 2.8 | < 0.05 |
| Positive lymph node ratio (%) | 45% (9/20) | 28.1% (16/57) | < 0.05 |
| Mean tumor margin width (mm) | 5.2 ± 1.5 | 6.8 ± 1.2 | < 0.05 |
| Invasive tumor (%) | 60% (12/20) | 40.4% (23/57) | < 0.05 |
Advanced patient age emerged as a significant factor, with patients ≥ 65 years exhibiting nearly twice the infection risk (OR = 1.986, 95%CI: 1.124-3.512) compared to younger counterparts. This age-associated vulnerability likely reflects physiological immunosenescence, diminished hepatic regenerative capacity, and potentially higher prevalence of subclinical comorbidities that may not be fully captured in standard assessment parameters. Compromised liver function, as indicated by Child-Pugh grade B classification, demonstrated the strongest association with infection susceptibility among all variables analyzed. Patients with Child-Pugh B status experienced nearly triple the infection risk (OR = 2.851, 95%CI: 1.426-5.698) compared to those with better-preserved hepatic function. This substantial risk elevation underscores the critical role of adequate liver reserve in maintaining immunological competence and managing the metabolic stress of post-embolization syndrome. These comprehensive findings, systematically documented in Table 6, provide a multidimensional risk profile that integrates patient-specific, tumor-related, and procedure-associated factors, potentially facilitating more personalized risk stratification.
| Risk factor | OR | 95%CI | P value |
| Age ≥ 65 years | 1.986 | 1.124-3.512 | < 0.05 |
| Child-Pugh grade B | 2.851 | 1.426-5.698 | < 0.05 |
| Tumor diameter ≥ 5 cm | 2.143 | 1.215-3.778 | < 0.05 |
| Operation time ≥ 120 minutes | 2.367 | 1.238-4.523 | < 0.05 |
| Preoperative albumin < 35 g/L | 2.156 | 1.147-4.052 | < 0.05 |
| Diabetes mellitus | 1.875 | 1.086-3.236 | < 0.05 |
| Bilobar tumor distribution | 1.789 | 1.012-3.165 | < 0.05 |
| Mean number of tumors ≥ 2 | 1.654 | 1.003-2.732 | < 0.05 |
| Preoperative bilirubin ≥ 2 mg/dL | 1.543 | 0.987-2.412 | > 0.05 |
The multivariate logistic regression analysis revealed three variables that maintained statistical significance as independent predictors of post-operative infection following D-TACE procedures. After adjusting for potential con
| Risk factor | OR | 95%CI | P value |
| Child-Pugh grade B | 2.851 | 1.426-5.698 | < 0.05 |
| Operation time ≥ 120 minutes | 2.367 | 1.238-4.523 | < 0.05 |
| Preoperative albumin < 35 g/L | 2.156 | 1.147-4.052 | < 0.05 |
| Tumor diameter ≥ 5 cm | 1.987 | 1.023-3.856 | < 0.05 |
| Diabetes mellitus | 1.789 | 1.012-3.165 | < 0.05 |
| Age ≥ 65 years | 1.654 | 1.003-2.732 | < 0.05 |
| Bilobar tumor distribution | 1.543 | 0.987-2.412 | > 0.05 |
| Mean number of tumors ≥ 2 | 1.456 | 0.923-2.298 | > 0.05 |
| Preoperative bilirubin ≥ 2 mg/dL | 1.321 | 0.854-2.047 | > 0.05 |
HCC represents one of the most common malignancies worldwide, ranking as the sixth most prevalent cancer and the third leading cause of cancer-related mortality globally. The management of HCC remains challenging due to its heterogeneous nature and the frequent presence of underlying liver dysfunction. While surgical resection and liver transplantation offer potential curative options, many patients are diagnosed at intermediate or advanced stages where these options are no longer suitable[17-19].
D-TACE has emerged as a significant advancement in the treatment of unresectable HCC. Unlike conventional TACE, D-TACE employs drug-eluting beads that allow for controlled and sustained release of chemotherapeutic agents while achieving targeted embolization. This approach has demonstrated improved local tumor control and reduced systemic drug exposure compared to conventional TACE. The standardized nature of drug loading and delivery in D-TACE also offers potential advantages in terms of reproducibility and safety profile[20-23].
In this retrospective study, we investigated the risk factors associated with post-operative infection following D-TACE in HCC patients. Our findings identified several significant risk factors, with important implications for clinical practice.
The overall infection rate in our study was 25.97%, which falls within the previously reported range of 10%-30% for conventional TACE procedures. This relatively high infection rate highlights the importance of identifying and managing risk factors in the perioperative period, particularly given that infection can compromise the therapeutic efficacy of D-TACE and potentially lead to severe complications. To compare our research findings, we conducted a comprehensive comparison of infection risk between D-TACE and conventional TACE. A meta-analysis including 27 studies with 4,213 patients who underwent conventional TACE reported a pooled infection rate of 18.2% (95%CI: 14.6%-22.3%), whereas our observed D-TACE infection rate was 25.97%, slightly higher than conventional TACE[24].
Liver function, as indicated by Child-Pugh grade and albumin level, emerged as a crucial factor in post-operative infection risk[25,26]. Patients with Child-Pugh grade B had significantly higher infection rates compared to those with grade A (OR = 2.851). This finding is particularly relevant in the context of HCC, where underlying cirrhosis and compromised liver function are common. The association between low preoperative albumin (< 35 g/L) and increased infection risk (OR = 2.156) further supports this relationship, as hypoalbuminemia often reflects poor nutritional status and impaired immune function in cirrhotic patients.
Prolonged operation time (≥ 120 minutes) was identified as another independent risk factor (OR = 2.367). This may be attributed to extended exposure to potential contamination, increased tissue manipulation, and prolonged inflammatory response. The correlation between operation time and infection risk emphasizes the importance of surgical efficiency while maintaining procedural safety, particularly in patients with compromised liver function.
The relationship between tumor characteristics and infection risk is noteworthy. Larger tumor size (≥ 5 cm) and Bilobar distribution were associated with higher infection rates in univariate analysis, although they were not independent risk factors in multivariate analysis. This suggests that tumor burden may influence infection risk indirectly, possibly through its impact on operation time and technical complexity of the D-TACE procedure.
The presence of diabetes mellitus showed a significant association with infection risk in univariate analysis, consistent with previous studies highlighting the impact of comorbidities on post-operative outcomes. This underscores the importance of optimal glycemic control in the perioperative period, particularly in HCC patients who may have multiple metabolic derangements. Based on our identification of independent risk factors for post-operative infection, we propose tailored preventive strategies for high-risk patients undergoing D-TACE procedures. Patients with Child-Pugh grade B liver function, prolonged operation time (≥ 120 minutes), and preoperative albumin < 35 g/L require special attention in the perioperative period. For these high-risk individuals, we recommend extending prophylactic antibiotic coverage from the standard single-dose regimen to a more comprehensive protocol spanning 48-72 hours post-procedure.
Several limitations of our study should be acknowledged. First, the retrospective nature and single-center design may limit the generalizability of our findings. Second, the relatively small sample size may have affected the statistical power to detect some potential risk factors. Third, we did not analyze the impact of different types of infections or specific pathogens involved.
Our findings have important clinical implications, particularly in the context of HCC management. First, they suggest that careful patient selection and risk stratification are crucial for D-TACE procedures, considering both oncological factors and liver function status. Second, for patients with identified risk factors, enhanced preventive measures such as perioperative nutritional support, strict sterile technique, and careful monitoring may be warranted. Third, optimization of modifiable risk factors before the procedure may help reduce infection risk and improve overall treatment outcomes.
Future prospective, multicenter studies with larger sample sizes are needed to validate our findings and explore additional risk factors. Investigation of specific infection types, causative organisms, and the effectiveness of various preventive strategies would also be valuable. Furthermore, development of a risk prediction model incorporating these factors could help in clinical decision-making and patient counseling.
In conclusion, while D-TACE represents an important treatment option for unresectable HCC, post-operative infection remains a significant concern. Our study identifies liver function status, operation time, and preoperative albumin level as key independent risk factors for post-operative infection.
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