Abstract
ObjectivesTo compare the value of functional future liver remnant (functFLR) to established clinical and imaging variables in prediction of post-hepatectomy liver failure (PHLF) after major liver resection.MethodsThis retrospective, cross-sectional study included 62 patients, who underwent gadoxetic acid enhanced MRI and MDCT within 10 weeks prior to resection of ≥ 4 liver segments. Future liver remnant (FLR) was measured in MDCT using semi-automatic software. Relative liver enhancement for each FLR segment was calculated as the ratio of signal intensity of parenchyma before and 20 min after i.v. administration of gadoxetic acid and given as mean (remnantRLE). Established variables included indocyanine green clearance, FLR, proportion of FLR, weight-adapted FLR and remnantRLE. functFLR was calculated as FLR multiplied by remnantRLE and divided by patient’s weight. The association of measured variables and PHLF was tested with univariate and multivariate logistic regression analysis and receiver operator characteristics (ROC) curves compared with the DeLong method.ResultsSixteen patients (25.8%) experienced PHLF. Univariate logistic regression identified FLR (p = 0.015), proportion of FLR (p = 0.004), weight-adapted FLR (p = 0.003), remnantRLE (p = 0.002) and functFLR (p = 0.002) to be significantly related to the probability of PHLF. In multivariate logistic regression analysis, a decreased functFLR was independently associated with the probability of PHLF (0.561; p = 0.002). Comparing ROC curves, functFLR showed a significantly higher area under the curve (0.904; p < 0.001) than established variables.ConclusionsfunctFLR seems to be superior to established variables in prediction of PHLF after major liver resection.Key Points• functFLR is a parameter combining volumetric and functional imaging information, derived from MDCT and gadoxetic acid enhanced MRI.• In comparison to other established methods, functFLR is superior in prediction of post-hepatectomy liver failure.• functFLR could help to improve patient selection prior major hepatic surgery.
Highlights
Liver resection is an established method to prolong patient survival and which possibly results in a curative treatment option in selected patients with primary and metastatic liver tumours [1, 2]
Recent clinical guidelines base the indication for surgery on volume analysis and recommend that the future liver remnant (FLR) should be at least one-third of the total liver volume and 40–50% in patients with parenchymal liver disease [4, 5]
post-hepatectomy liver failure (PHLF) was classified by the grading system of the International Study Group of Liver Surgery (ISGLS) [18]
Summary
Liver resection is an established method to prolong patient survival and which possibly results in a curative treatment option in selected patients with primary and metastatic liver tumours [1, 2]. The possibility of liver resection is determined by the technical feasibility of radical surgery and the capacity of the future liver remnant (FLR) to functionally compensate for tissue loss. While an overly conservative approach might exclude individuals from curative surgery, a more aggressive strategy might put others at risk of post-hepatectomy liver failure (PHLF), which remains the major cause of perioperative morbidity and mortality [3]. Recent clinical guidelines base the indication for surgery on volume analysis and recommend that the FLR should be at least one-third of the total liver volume and 40–50% in patients with parenchymal liver disease [4, 5]. The relationship between liver volume and functional capacity is unpredictable and substantiates the inclusion of functional tests into the preoperative work-up. Previous exploratory work suggested this marker as a potential predictor of PHLF [10,11,12,13,14]
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