Preoperative Assessment Of Liver Function Research Articles

Perioperative Non-Invasive Indocyanine Green-Clearance Testing to Predict Postoperative Outcome after Liver Resection.

BackgroundPostoperative liver dysfunction may lead to morbidity and mortality after liver resection. Preoperative liver function assessment is critical to identify preexisting liver dysfunction in patients prior to resection. The aim of this study was to evaluate the predictive potential of perioperative indocyanine green (ICG)-clearance testing to prevent postoperative liver dysfunction and morbidity using standardized outcome parameters in a routine Western-clinical-setting.Study Design137 patients undergoing partial hepatectomy between 2011 and 2013, at the general hospital of Vienna, were included. ICG-clearance was recorded one day prior to surgery as well as on the first and fifth postoperative day. Postoperative liver dysfunction was defined according to the International Study Group of Liver Surgery and evaluation of morbidity was based on the Dindo-Clavien classification. Statistical analyses were based on non-parametric tests.ResultsPreoperative reduced ICG—plasma disappearance rate (PDR) as well as increased ICG—retention rate at 15 min (R15) were able to significantly predict postoperative liver dysfunction (Area under the curve = PDR: 0.716, P = 0.018; R15: 0.719, P = 0.016). Furthermore, PDR <17%/min. or R15 >8%, were able to accurately predict postoperative complications prior to surgery. In addition to this, ICG-clearance on postoperative day 1 comparably predicted postoperative liver dysfunction (Area under the curve = PDR: 0.895; R15: 0.893; both P <0.001), specifically, PDR <10%/min or R15 >20% on postoperative day 1 predicted poor postoperative outcome.ConclusionPDR and R15 may represent useful parameters to distinguish preoperative high and low risk patients in a Western collective as well as on postoperative day 1, to identify patients who require closer monitoring for potential complications.

Liver Function Assessment by Magnetic Resonance Imaging

Liver function assessment by hepatocyte-specific contrast-enhanced magnetic resonance imaging is becoming a new biomarker. Liver function can be assessed by T1 mapping (reduction rate) and signal intensity measurement (relative enhancement ratio) before and after GD-EOB-DTPA (gadoxetic acid) administration, as alternative to Tc-99m galactosyl serum albumin scintigraphy, 99m Tc-labeled mebrofenin scintigraphy, and indocyanine green clearance test. Magnetic resonance imaging assessment of liver function can enable diagnosis of cirrhosis, nonalcoholic fatty liver disease associated fibrosis and steatohepatitis, primary sclerosing cholangitis, toxic hepatitis, and chemotherapy and radiotherapy-related changes, which may be only visible on hepatobiliary phase images. Simple visual assessment of signal intensity at hepatobiliary phase images is important for the diagnosis of different patterns of liver dysfunction including diffuse, lobar, segmental, and subsegmental forms. Furthermore, preoperative assessment of liver function is feasible before oncologic hepatic surgery, which may be important to prevent posthepatectomy liver failure and to estimate future remnant volume. Functional magnetic resonance cholangiography obtained by T1-weighted images at hepatobiliary phase can allow diagnosis of acalculous cholecystitis, biliary leakage, bile reflux to the stomach, sphincter of oddi dysfunction, and lesions with communication to biliary tree. Functional information can be easily obtained when Gd-EOB-DTPA is used for liver magnetic resonance imaging.

Indocyanine green retention is a potential prognostic indicator after splenectomy and pericardial devascularization for cirrhotic patients

Splenectomy and pericardial devascularization (SPD) is an effective treatment of upper gastrointestinal bleeding and hypersplenism in cirrhotic patients with portal hypertension. Indocyanine green retention at 15 minutes (ICGR15) was reported to offer better sensitivity and specificity than the Child-Pugh classification in hepatectomy, but few reports describe ICGR15 in SPD. The present study was to evaluate the prognostic value of ICGR15 for cirrhotic patients with portal hypertension who underwent SPD. From January 2012 to January 2015, 43 patients with portal hypertension and hypersplenism caused by liver cirrhosis were admitted in our center and received SPD. The ICGR15, Child-Pugh classification, model for end-stage liver disease (MELD) score, and perioperative characteristics were analyzed retrospectively. Preoperative liver function assessment revealed that 34 patients were Child-Pugh class A with ICGR15 of 13.6%-43.0% and MELD score of 7-20; 8 patients were class B with ICGR15 of 22.8%-40.7% and MELD score of 7-17; 1 patient was class C with ICGR15 of 39.7% and MELD score of 22. The optimal ICGR15 threshold for liver function compensation was 31.2%, which offered a sensitivity of 68.4% and a specificity of 70.8%. Univariate analysis showed preoperative ICGR15, MELD score, surgical procedure, intraoperative blood loss, and autologous blood transfusion were significantly different between postoperative liver function compensated and decompensated groups. Multivariate regression analysis revealed that ICGR15 was an independent risk factor of postoperative liver function recovery (P=0.020). ICGR15 has outperformed the Child-Pugh classification for assessing liver function in cirrhotic patients with portal hypertension. ICGR15 may be a suitable prognostic indicator for cirrhotic patients after SPD.

Assessment of preoperative liver function in patients with hepatocellular carcinoma: The albumin-indocyanine green evaluation (ALICE) grade.

4066Background: Most patients with hepatocellular carcinoma (HCC) have underlying liver disease, therefore, precise preoperative evaluation of the patient’s liver function is essential. Methods: We...

Preoperative Assessment of Liver Function after Hepatectomy Using Hepatobiliary Scintigraphy and Indocyanine Green Clearance

RESULTS: The SFRP2 contrast agent detected tumor vasculature with greater signal intensity (SI) using 5e7 vs 5e6 microbubbles (21.2 vs 2.4 SI, p<0.001) and contrast with 3-fold greater antibody conjugation (27.6 vs 14.8 SI, p<0.001). Using these optimizations, SFRP2 contrast agent detected a 2.8-fold greater tumor vasculature SI compared with control (22.1 vs 7.92 SI, p<0.001). Peritumoral vasculature showed minimal SI for both the SFRP2 and control contrast agents, (3.2 vs 1.6, p1⁄40.16), confirming specificity of the SFRP2 contrast for tumor vasculature.

Imaging-Based Liver Function Tests--Past, Present and Future.

Preoperative assessment of liver function and prediction of postoperative functional reserve are important in patients scheduled for liver resection. While determination of absolute liver function currently mostly relies on laboratory tests and clinical scores, postoperative remnant liver function is estimated volumetrically using imaging data obtained with computed tomography (CT) or magnetic resonance imaging (MRI). Accurate estimation of hepatic function is also relevant for intensive care patients, oncologic patients, and patients with diffuse liver disease. The indocyanine green (ICG) test is still the only established test for estimating true global liver function. However, more recent tools such as the LiMAx test also allow global assessment of hepatic function. These tests are limited when liver function is inhomogeneously distributed, which is the case in such conditions as unilateral cholestasis or after portal vein embolization. Imaging-based liver function tests were first developed in nuclear medicine and, compared with laboratory tests, have the advantage of displaying the spatial distribution of liver function. Nuclear medicine scans are obtained using tracers such as 99mTc galactosyl and 99mTc mebrofenin. Liver function is typically assessed using planar scintigraphy. However, three-dimensional volumetry is possible with single-photon emission computed tomography (SPECT-CT). Another technique for image-based liver function estimation is Gd-EOB-enhanced MRI. While metabolization of Gd-EOB in the body is similar to that of ICG and mebrofenin, its distribution in the liver can be displayed by MRI with higher temporal and spatial resolution. Moreover, MRI-based determination of liver function can be integrated into routine preoperative imaging. This makes MRI an ideal candidate for preoperative determination of liver function, though the best pulse sequence and the parameter to be derived from the image information remain to be identified. Another question to be answered is how the results may be affected by renal function and the presence of hyperbilirubinemia. As more results from clinical evaluation including comparison with postoperative liver function data become available, image-based liver function tests, especially with use of Gd-EOB as the contrast medium, have the potential to add another dimension to preoperative imaging. Liver function consists of a multitude of subfunctions such as biotransformation, excretion and storage. Global liver function tests are score-based tests such as Child-Pugh or MELD as well as the ICG- and LiMAx-test. Imaging-based liver function tests add spatial information. Current clinical standard is the 99mTc-Mebrofenin-scintigraphy. MRI-based function tests with Gd-EOB-DTPA have the potential to integrate seamlessly into clinical workup, feature a higher temporal and spatial resolution and do not rely on ionizing radiation.

Update in management of hepatocellular carcinoma in Eastern population.

Hepatocellular carcinoma (HCC) is one of the commonest malignant tumours in the East. Although the management of HCC in the West is mainly based on the Barcelona Clinic for Liver Cancer staging, it is considered too conservative by Asian countries where the number of HCC patients is huge. Scientific and clinical advances were made in aspects of diagnosis, staging, and treatment of HCC. HCC is well known to be associated with cirrhosis and the treatment of HCC must take into account the presence and stage of chronic liver disease. The major treatment modalities of HCC include: (1) surgical resection; (2) liver transplantation; (3) local ablation therapy; (4) transarterial locoregional treatment; and (5) systemic treatment. Among these, resection, liver transplantation and ablation therapy for small HCC are considered as curative treatment. Portal vein embolisation and the associating liver partition with portal vein ligation for staged hepatectomy may reduce dropout in patients with marginally resectable disease but the midterm and long-term results are still to be confirmed. Patient selection for the best treatment modality is the key to success of treatment of HCC. The purpose of current review is to provide a description of the current advances in diagnosis, staging, pre-operative liver function assessment and treatment options for patients with HCC in the east.

CT/99mTc-GSA SPECT fusion images demonstrate functional differences between the liver lobes

To evaluate the functional differences between the 2 liver lobes in non-cirrhotic patients by using computed tomography/(99m)Tc-galactosyl human serum albumin (CT/(99m)Tc-GSA) single-photon emission computed tomography (SPECT) fusion images. Between December 2008 and March 2012, 264 non-cirrhotic patients underwent preoperative liver function assessment using CT/(99m)Tc-GSA SPECT fusion images. Of these, 30 patients, in whom the influence of a tumor on the liver parenchyma was estimated to be negligible, were selected. Specifically, the selected patients were required to meet either of the following criteria: (1) the presence of an extrahepatic tumor; or (2) presence of a single small intrahepatic tumor. These 30 patients were retrospectively analyzed to calculate the percentage volume (%Volume) and the percentage function (%Function) of each lobe. The ratio between the %Function and %Volume (function-to-volume ratio) of each lobe was also calculated, and the ratios were compared between the 2 lobes. Furthermore, the correlations between the function-to-volume ratio and each of 2 liver parameters [lobe volume and diameter ratio of the left portal vein to the right portal vein (LPV-to-RPV diameter ratio)] were investigated. The median values of %Volume and %Function were 62.6% and 67.1% in the right lobe, with %Function being significantly higher than %Volume (P < 0.01). The median values of %Volume and %Function were 31.0% and 28.7% in the left lobe, with %Function being significantly lower than %Volume (P < 0.01). The function-to-volume ratios of the right lobe (1.04-1.14) were significantly higher than those of the left lobe (0.74-0.99) (P < 0.01). The function-to-volume ratio showed no significant correlation between the lobe volume in either lobe. In contrast, the function-to-volume ratio showed significant correlations with the LPV-to-RPV diameter ratio in both lobes (right lobe: negative correlation, r s = -0.37, P = 0.048; left lobe: positive correlation, r s = 0.71, P < 0.001). The function-to-volume ratio in the left lobe tended to be higher, and that in the right lobe tended to be lower, in accordance with the increase in the LPV-to-RPV diameter ratio. CT/(99m)Tc-GSA SPECT fusion images demonstrated that the function of the left lobe was significantly decreased compared with that of the right lobe in non-cirrhotic livers.

Predictive factors for liver dysfunction and failure after hepatectomy: Analysis of 467 patients with hepatocellular carcinoma

The aim of our study was to analyze hepatic dysfunction and failure after hepatocellular carcinoma (HCC) resection and relationship of clinical and pathological factors. Clinical and pathological data of 467 HCC patients was retrospectively reviewed, who underwent liver resection from January 2002 to December 2008 in the Affiliated Hospital of Medical College, Qingdao University, and the post-resectional liver dysfunction and failure risk factors were analyzed by univariate and multivariate analysis. The morbidity of post-resectional liver dysfunction and failure was 1.7% and 2.1%. The post-resectional liver dysfunction and failure after HCC hepatectomy into the statistical analysis: univariate analysis revealed preoperative platelet level ( 64 U/L), Child-Pugh classification (B), MELD score (≥ 9), intraoperative bleeding (≥ 1000 mL), blood transfusion were positive factors, multivariate analysis (Logistic) revealed that preoperative platelet level (0.983, 95% CI = 0.971–0.995) and intraoperative blood transfusion (3.145, 95% CI = 1.027–12.028) were independent risk factors for post-resectional liver dysfunction and failure. Prevented liver failure and liver dysfunction occurring after liver resection, it is the key to accurate preoperative assessment of liver function and the patient’s reserved liver functional, precise hepatectomy and reasonable blockage of hepatic inflow.

Beyond the body surface area vauthey formula to identify the minimal donor volume for right-lobe living-donor liver transplantation

Several studies have reported on the preoperative assessment of liver function as a predictor of postresection liver failure. Recently, the impact of volumetric data on the outcome of liver resections and, in particular, graft function in living-donor liver transplantation1 has been emphasized. The majority of Western centers involved in adult-to-adult living-related liver transplantation have adopted the Vauthey formula to calculate liver volumes, including the minimal donor volume. This formula, published by Vauthey et al.2 zref validated in a meta-analysis as a precise and unbiased approach to estimating the total liver volume, was derived from linear regression by calculation of the total liver volume based on the body surface area (BSA) in a total of 292 patients in centers in the United States and Europe. This formula is considered more reliable than the Urata formula, which has been found to have limitations in Western patients because of autopsy findings indicating that liver weight in Japanese adults is lower than that in European and American adults.4 With this BSA Vauthey formula [total liver volume (cm3) = −794.41 + 1267.28 × BSA (m2)], it is possible to identify a minimal donor volume sufficient for avoiding postresection liver failure. In our experience with 75 right hepatectomies (Couinaud segments 5–8) performed for adult-to-adult living-related liver transplantation, in 21 (28%) cases, we used the donor's right lobe, even though the minimal donor volume according to the BSA Vauthey formula was higher than the real left-lobe volume calculated with a computed tomography (CT) scan. In those 21 patients, the difference between the minimal donor volume identified by the BSA Vauthey formula and the CT scan–calculated left-lobe volume ranged from 14.57 to 134.29 cm3 (median, 64.33 cm3). This difference was below 50 cm3 in 8 patients, between 51 and 100 cm3 in 8 patients, and above 101 cm3 in 5 patients. The 75 donors, who were completely homogeneous for gender and age, were divided into 2 groups: A (minimal donor volume according to the BSA Vauthey formula) and B (minimal donor volume below the cutoff in the BSA Vauthey formula), and potential differences were analyzed. Comparing group A with group B, we found no statistically significant difference in the total length of stay (P = 0.635) or onset of surgical complications (occurring within 90 days of surgery and stratified according to the most recent version of the Clavien classification of postoperative surgical complications; P = 0.132). There was no mortality in either group The trends of the total serum bilirubin, international normalized ratio, and transaminases (alanine aminotransferase/aspartate aminotransferase) were examined in a further analysis during the first postoperative week in groups A and B. Those liver function tests showed no statistically significant differences in the 2 groups (P > 0.05), with the peak on postoperative day 3 and normalization on postoperative day 7. Right-lobe living donation can be safely accomplished when the difference between the minimal donor volume identified by the BSA Vauthey formula and the real remnant volume calculated by a CT scan is below 150 cm3. Salvatore Gruttadauria*, Fabrizio di Francesco*, James Wallis Marsh*, Amadeo Marcos*, Bruno Gridelli*, * Istituto Mediterraneo Trapianti e Terapie ad, Alta Specializzazione, Palermo, Italy.

Assessment of liver function for safe hepatic resection

The preoperative assessment of liver function is extremely important for preventing postoperative liver failure and mortality after hepatic resection. Liver function tests may be divided into three types; conventional liver function tests, general scores, and quantitative liver function tests. General scores are based on selected clinical symptoms and conventional test results. Child-Turcotte-Pugh score has been the gold standard for four decades, but the Child-Turcotte-Pugh score has difficulty discriminating a good risk from a poor risk in patients with mild to moderate liver dysfunction. The model for end-stage liver disease score has also been applied to predict short-term outcome after hepatectomy, but it is only useful in patients with advanced cirrhosis. Quantitative liver function tests overcome the drawbacks of general scores. The indocyanine green retention rate at 15 minutes (ICG R15) has been reported to be a significant predictor of postoperative liver failure and mortality. The safety limit of the hepatic parenchymal resection rate can be estimated using the ICG R15, and a decision tree (known as the Makuuchi criteria) for selecting patients and hepatectomy procedures has been proposed. Hepatic resection can be performed with a mortality rate of nearly zero using this decision tree. If the future remnant liver volume does not fulfill the Makuuchi criteria, preoperative portal vein embolization should be performed to prevent postoperative liver failure. Galactosyl human serum albumin-diethylenetriamine-pentaacetic acid scintigraphy also provides data that complement the ICG test. Other quantitative liver function tests, however, require further validation and simplification.

Three-Port laparoscopic partial hepatectomy using an ultrasonically activated device (USAD)

We provide an initial report of the indications and procedure for three-port laparoscopic partial hepatectomy. Three-port laparoscopic partial hepatectomy was performed in nine patients (age, 49 to 73 years) at our department. Eight patients (seven men and one woman) had hepatocellular carcinoma (HCC); six of these patients had liver cirrhosis (LC) and two had chronic hepatitis (CH). The ninth patient, a woman had a single metastatic liver tumor from colon cancer. The tumors were located in regons S(2), S(3), S(4), S(5), S(6), and S(8). Preoperative liver function assessment revealed Child-Pugh classification A or B. All the tumors were located superficially, and their diameter averaged approximately 3 cm. Hepatectomy was performed laparoscopically, using an ultrasonically activated device (USAD) with or without microwave coagulation therapy (MCT). The operative time was 50 to 168 min, and the intraoperative blood loss ranged from 32 to 158 g. The postoperative hospital stay was 5 to 17 days. No recurrences, including local relapse, were observed. Three-port laparoscopic partial hepatectomy is safe and feasible for patients with Child-Pugh liver function classification A or B if the tumor is located superficially and is less than 3 cm in diameter.

Liver resection in the treatment of hepatocellular carcinoma

Hepatocellular carcinoma is a leading cause of cancer death worldwide. Liver resection and liver transplantation remain the only options for cure. Since the indications for orthotopic liver transplantation are limited, partial liver resection is the more common treatment. Recently, indications for liver resection have been expanded and there have been advances in the associated surgical techniques. This review describes the state-of-the-art of liver resection for hepatocellular carcinoma. Topics covered include: new indications, such as treatment of large tumors, bilobar tumors and those associated with vascular invasion; preoperative assessment of liver function; and surgical strategies. An overview of the most common staging systems, which are useful in predicting prognosis after liver resection for hepatocellular carcinoma, is given.

Assessment of hepatic reserve for indication of hepatic resection: decision tree incorporating indocyanine green test

Preoperative assessment of liver function and prediction of postoperative remaining functional liver parenchymal mass and reserve is of paramount importance to minimize surgical risk, especially in patients with hepatocellular carcinoma (HCC), the majority of whom have liver cirrhosis as a complication. We have established a decision tree for deciding the safe limit of hepatectomy based on three variables: whether ascites is present, the serum total bilirubin level, and the indocyanine green retention rate at 15 minutes (ICGR-15), an indicator of sinusoidal capillarization. In patients who show a sign of decompensated cirrhosis as reflected by an elevated bilirubin value or uncontrollable ascites, hepatectomy is not indicated. In patients without ascites and with normal bilirubin level, the ICGR-15 value becomes the main determinant for the resectability and hepatectomy procedure. Incorporation of ICGR-15 into the decision tree enables patients conventionally classified into Child-Turcotte-Pugh class A or score 5-6 to be subdivided into several groups in which various hepatectomy procedures are feasible: enucleation, limited resection, segmentectomy, mono- to bisectoriectomy, and trisectriectomy. During strict application of this decision tree to 1429 consecutive hepatectomies, of which 685 were performed on HCC patients, during the last 10 years, we encountered only a single mortality.

Hepatocellular carcinoma: Current surgical management

At present the only potentially curative treatment for hepatocellular carcinoma (HCC) is either partial hepatectomy or total hepatectomy with orthotopic liver transplantation (OLT). Underlying liver reserve and regenerative capacity are the most important determinants of the risk of postoperative hepatic failure after partial hepatectomy; thus, careful preoperative assessment of liver function is mandatory. In specialized centers perioperative mortality is less than 5%, although cirrhotic patients are at increased risk. Various neoadjuvant and adjuvant therapies are under investigation, but as yet there are no data that demonstrate benefit from adjuvant systemic chemotherapy. The use of OLT is limited by the difficulty of obtaining donor livers. Patients selected for transplantation and partial hepatectomy represent two distinct subgroups, but their survival after treatment is comparable. Despite the progress in the management of HCC by surgical resection, the fact remains that the majority of these patients will experience local recurrences. This has led to the development of a variety of novel new treatments that require further evaluation.

7105 Laparoscopic hepatectomy for liver tumor as a new surgical alternative.

The development of laparoscopic hepatectomy has been impeded by unsolved technical difficulties. However, a variety of laparoscopic instruments and devices have been developed, leading us to establish laparoscopic hepatectomy. Results of a clinical series of 23 patients are reported. Surgical procedure: A microwave tissue coagulator was used in combination with an ultrasonic surgical aspirator or a laparoscopic coagulating shears to divide hepatic parenchyma by using abdominal wall lift without pneumoperitoneum. Branched vessels and ducts were clipped and transected. The endoscopic linear stapler was used to transect the Glisson's pedicle and left hepatic vein. Patients: The indications were hepatocellular carcinoma in 12 cases, isolated metastatic tumor in 4 cases, hemangioma in 4 cases, others in 3 cases. The underlying liver diseases was liver cirrhosis in 9 cases and chronic hepatitis in 5 cases. Result: Six patients underwent left lateral segmentectomy and seventeen patients underwent partial hepatectomy. The 22 procedures were performed safely. There were notable difference in blood loss and operating time compared with open hepatectomy. No postoperative complication including no bile leakage and abscess, except ascitis and pneumonia in one case was observed. The postoperative recovery such as oral intake and ambulatory was faster and pain was minimal. Indication: The preoperative assessment of liver function for laparoscopic and open hepatectomy is the same. Tumors smaller than 5 cm, and nodular types, especially extrahepatic growth types, are the best candidates for laparoscopic resection. Concerning location, tumors in the lower segment and left lateral segment were good indication. Conclusion: The laparoscopic hepatectomy, especially partial or left lateral segmentectomy, appears to be a viable surgical alternative in selected patients as minimal invasive surgery.

Magnetic resonance imaging and hepatic hemodynamics: correlation with metabolic function in liver transplantation candidates.

Preoperative assessment of orthotopic liver transplantation candidates requires definition of both the anatomy and metabolic function of the native liver. Current evaluation techniques combine computed tomographic scanning, duplex ultrasonography with blood chemistry analysis, and physical stigmata of end-stage liver disease. Recently, magnetic resonance imaging (MRI) has emerged as an alternative method for delineation of hepatic and portal venous anatomy. In addition, MRI accurately measures hepatic volume and portal venous blood flow. To examine the role of MRI-derived indexes of hepatic hemodynamics in the preoperative assessment of liver function, 39 consecutive liver transplantation candidates were studied in a prospective manner. Liver function (aspartate aminotransferase), alanine aminotransferase, alkaline phosphatase, total bilirubin, and albumin levels), hematologic indexes (complete blood cell count, prothrombin time), and Child's classification were determined at the time of evaluation. Axial breath-held multiplanar spoiled-gradient echo MRI measured hepatic volume, whereas a cine phase-contrast sequence perpendicular to the portal vein measured flow. Hepatic index, defined as hepatic mass corrected for body surface area, was found to correlate with prothrombin time (p < 0.04) and platelet count (p < 0.03) by multivariate regression analysis. Portal flow index (PFI), defined as portal flow corrected for hepatic mass), was associated with aspartate aminotransferase (p < 0.02), alanine aminotransferase (p < 0.04), and albumin (p < 0.03) by multivariate regression analysis. In addition, PFI was closely correlated with the patients' functional status as determined by Child's classification system. Increasing values of PFI were associated with declining hepatic functional reserve. Child's class A patients had a mean PFI that was two times less than that of Child's class B patients (0.26 +/- 0.04 versus 0.04 +/- 0.06 ml/min/gm; p < 0.02) and five times less than that of Child's class C patients (0.26 +/- 0.04 versus 1.05 +/- 0.14 ml/min/gm; p < 0.001). Similarly, the mean PFI associated with Child's class B was two times less than that of Child's class C (0.46 +/- 0.06 versus 1.05 +/- 0.14 ml/min/gm; p < 0.01). These data show that MRI-derived indexes of portal hemodynamics and hepatic mass (1) correlate well with biochemical indexes of hepatic dysfunction and (2) serve as anatomic and hemodynamic correlates to Child's functional classification. We conclude that MRI may serve to noninvasively delineate preoperative hepatic vascular anatomy and metabolic dysfunction in candidates undergoing examination for liver transplantation.

Surgical Management of Gastric Cancer Patients with Liver Cirrhosis.

From 1966 to 1992, a total of 3,118 gastric cancer (GC) patients were referred to the First Department of Surgery, Kurume University Hospital. Fifty-six (0.02%) of these patients also had liver cirrhosis (LC). Forty-nine (87.5%) of these patients with LC underwent GC resection. Postoperative complications occurred in 32.7%, but the operative mortality rate was zero using our preoperative assessment of liver function to decide the operation. The 5-year survival rate following curative resection was 69% in early cancer and 17% in advanced cancer. Deaths were mainly cirrhosis-related in the early cancer cases, while cancer recurrence and hepatic failure were the main causes of mortality in the advanced cancer cases.

Surgical management of portal hypertension and esophageal varices: 10 year experience

The results of 157 operations performed for portal hypertension and esophageal varices on 148 patients at the Cleveland Clinic in the 10 year period between 1970 and 1980 are reported. One hundred four shunt procedures and 53 ligation procedures were performed. The overall operative mortality rate of 13 percent did not differ significantly from the 11 percent rate reported from this institution in 1971. A comparatively higher rate of recurrent variceal hemorrhage and a lower rate of encephalopathy reflected our increased use of selective shunts and ligation procedures. There was no improvement in overall long-term survival, which was approximately 50 percent. The two most important factors in predicting the results of all operations for esophageal varices continue to be assessment of preoperative liver function and the timing of the operation. The best results were obtained in patients with good liver function who had an elective operation. Our data suggest that the portacaval shunt is associated with a higher incidence of late mortality, largely as a result of liver failure; therefore, our preference now is to perform a distal selective splenorenal shunt procedure whenever possible. If a selective shunt procedure cannot be performed, we advocate either a mesocaval shunt or a ligation procedure, depending on patient risk and the suitability of veins for a shunt procedure.