Chronic-On-Acute Post-Hepatectomy Liver Failure: A New Entity of Liver Failure?

Abstract

Introduction: Post-hepatectomy liver failure (PHLF) has been widely studied, but little is known about patients who survive the acute, initial phase. Thus, we sought to investigate prolonged liver decompensation in PHLF patients surviving >30 days post-operatively. Here we describe the incidence, clinical presentation, and impact on long-term outcomes. Methods: A bi-institutional, retrospective analysis of sequential patients undergoing major hepatectomy was performed. Patients with PHLF per ISGLS criteria and with persistent ascites/hydrothorax, thrombocytopenia, esophageal varices and hypoalbuminemia > post-operative day 30 were included in the final analysis. Vascular and biliary complications were excluded. Results: A total of 972 patients who had undergone major hepatectomy were identified, 202/972 (20%) developed PHLF per ISGLS criteria. There were 31/202 (5%) patients with signs of persistent liver failure on or after post-operative day 30, of whom 26/31 (84%) died during follow up (median 664 days, range 90-3766). The majority of these patients underwent extended right hepatectomy (18/31, 58%), with significant estimated blood loss (estimated blood loss median 1000 mL, range 300-20,500). ). Signs of prolonged liver failure included 24/31 (77%) with mild to severe ascites, 27/31 (87%) with elevated bilirubin (>1 mg/dL) , 4/31 (13%) with esophageal varices, and 4/31 (13%) with thrombocytopenia . Of note, INR was only moderately elevated (median 1.3, range 1.2-5.1). Conclusion: PHLF is a known cause of short-term mortality, but also can progress to become prolonged or chronic liver failure/decompensation. For adequate treatment and classification of these patients, we propose a new clinical entity of liver failure, Chronic-on-Acute PHLF.