Predicting the trajectory of post-hepatectomy liver dysfunction (PHLD)

Abstract

Objective: PHLD is an expected outcome with more extensive liver resections, and it remains a major cause of morbidity. Early recognition of severe cases may be beneficial. The International Study Group of Liver Surgery (ISGLS) consensus criteria for post-hepatectomy liver failure serve to identify individuals with significant liver dysfunction. However, because the diagnostic criteria comprise liver dysfunction persisting more than 4 days after hepatectomy, the ISGLS definition is of limited use to a clinician. Our objective was to identify factors that inform the clinician whether PHLD is likely to be accompanied by an adverse clinical course. Methods: Liver resections between 2006 and 2014 were retrospectively reviewed. Patients with bilirubin ≥40 μmol/L and/or prothrombin time ≥1.5 at any time after surgery were identified. Factors associated with severe complications, ICU admission and death were identified. Results: During the study period, 1010 liver resections were performed and 110 patients (10.9%) had PHLD. Of those, 76 (69%) met the ISGLS criteria for liver failure. Clavien-Dindo complication grades ≥4 (ICU admission or mortality) occurred in 25 patients (22.7%). Factors associated with those adverse outcomes included patient age (P=0.015), duration of surgery (P=0.030), estimated blood loss (P=0.010), and the need for intraoperative blood transfusions (P < 0.001). The extent of liver resection and presence of cirrhosis did not predict clinical trajectory. Conclusion: Intraoperative events leading to prolonged surgery and excessive blood loss had the greatest influence on the clinical trajectory of PHLD.