Monitoring of liver function using the novel liver maximum function capacity test (LiMAx) in a patient undergoing ALPPS

Abstract

Background: ALPPS has been described as a promising method to increase the resectability of liver tumors. Optimal timing of hepatectomy at the point of sufficient hypertrophy of the future liver remnant (FLR) is essential for the morbidity and mortality of this procedure. The recently developed LiMAx-test can be applied to monitor postoperative liver function and hence might represent a useful tool for decision-making regarding the timing of the second step of ALPPS. Methods: A 73-year-old female patient presented with metachronous colorectal liver metastasis comprising the complete right liver lobe as well as segment IV. Due to an insufficient FLR (19.3%) and a low FLR: body weight ratio (0.28%) the decision was made to perform ALPPS. Results: Despite a formally sufficient increase of the FLR to 30.8% within 7 days after the first step of ALPPS, the liver function was seen to only slowly increase as expressed by a LiMAx value of 245 μg/h/kg. By means of the LiMAx-test, sufficient increase of liver function eventually was detected by postoperative day 11 (LiMAx value of 371 μg/h/kg; FLR 35.2%) so that second step of ALPPS was performed with no signs of liver failure during further clinical course. Conclusion: Applying LiMAx during ALPPS, we have found a significant difference between increase in volume and function of the FLR. LiMAx hence might proof valuable for application in two-stage liver resection to avoid postoperative small-for-size syndrome.