Hepatectomy Liver Research Articles

Usefulness of functional remnant liver volume assessment using EOB-MRI to predict posthepatectomy liver failure in hepatectomy of more than one segment

Introduction: Several reports described Gd-EOB-DTPA-enhanced MRI (EOB-MRI) can be potentially used for evaluation of liver function. This modality has better versatility and spatial resolution compared with 99mTc-GSA scintigraphy. We assessed whether functional remnant liver volumetry (FRLV) using EOB-MRI predicted post hepatectomy liver failure (PHLF). Method: We retrospectively analyzed 114 cases performed hepatectomy of more than one segment (MOS). Signal intensity (SI) of remnant liver were measured by putting region of interest in T1WI image. SI of spinal erector muscle and spleen were calculated for standardization of SI value. Functional remnant liver score was derived in division of average SI of liver by average SI of muscle (or spleen) as liver-muscle ratio(LMR) and liver-spleen ratio(LSR), respectively. Future remnant volume was calculated by volume analyzer, then FRLV was calculated by multiplying LMR(or LSR) and remnant volume. Standardized FRLV(sFRLV) was calculated by dividing FRLV by body surface area. Definition of PHLF is used ISGLS classification. Results: LMR correlated with ICG-R15(p=0.004), but not LSR, FRLV or sFRLV. PHLF(≥GradeB) occurred in 5 patients (4.4%). In univariate analysis, predictive factors of PHLF were operative time(p=0.010), blood loss(p=0.013), FRLV(LMR) (p=0.021), sFRLV(LMR)(p=0.015), FRLV(LSR)(p=0.040), and sFRLV(LSR)(p=0.044). In multivariate analysis, only sFRLV(LMR) was independent predictive factor of PHLF(p=0.042). ROC analysis revealed that cut-off value of sFRLV(LMR) predicting PHLF was 599ml/m2(AUC: 0.913). In analysis of PTPE cases (n=17), 10 cases over cut-off of sFRLV did not occur PHLF, but 7 cases lower than cut-off occurred PHLF in 4 patients (57%) (p=0.019). Conclusion: sFRLV using EOB-MRI predicts PHLF in hepatectomy of MOS.

Is HCC associated with worse surgical outcomes compared to CRLM?

Purpose: The purpose of this study is to understand the incidence of complications associated with open liver resections for liver tumors with respect to regional variation and disease specific incidence. Methods: A systematic literature review of the incidence (weighted average) of complications and correlating factors during open liver resection published during the past five years were analyzed. Results: In total, 139 manuscripts and 29 abstracts met the study criteria providing data on 540,397 [MG1] liver resections. 46% of studies were conducted in Asia Pac, 27%-Europe, and 23%-North America. 78% of studies focusing on HCC were from Asia Pacific whereas 77% of focusing on CRLM were from Europe/North America. The average mortality was 3.8% and morbidity 36.4%. Ascites (25.6%), post hepatectomy liver failure (11.9%), bile leak (7.7%) and SSI (7.1%) were the most common non-hemorrhagic complications. Disease specific surgical mortality was 3.6 % for CRLM and 1.7% for HCC. Morbidity was also slightly higher in CRLM (38.1%) versus studies of HCC alone (30.9%). The specific transfusion rate for CRLM was 29.4% and for HCC 19.7%. Conclusions: Bleeding, bile leak, ascites, and PHLF remain prominent complications in liver resection procedures and contribute to a mortality rate of approximately 4%. Findings from this study may challenge traditional beliefs that cirrhosis is the most important contributor to mortality and transfusion after liver surgery; that rates of transfusion are greater in the Asia Pacific region; and that cirrhosis (HCC) is associated with worse surgical outcomes than CRLM.

Post hepatectomy liver failure - A comprehensive review of current concepts and controversies.

Post hepatectomy liver failure (PHLF) comprises of a conundrum of symptoms and signs following major hepatic resections. The pathophysiology essentially revolves around disruption of the normal hepatocyte regeneration and disturbed liver homeostasis. Prompt identification of the pre-operative predictors of PHLF in the form of biochemical parameters and imaging features are of paramount importance for any hepatic surgeon and forms the cornerstone of its management. Treatment revolves around a goal-directed resuscitation of the systemic organ failure. Auxiliary support systems such as liver dialysis devices and stem cell therapy are still under investigational trials for treatment of the same. Orthotopic liver transplantation (OLT) is the last resort in most cases not responding to other measures.

Modeling the Dynamics of Human Liver Failure Post Liver Resection.

Liver resection is an important clinical intervention to treat liver disease. Following liver resection, patients exhibit a wide range of outcomes including normal recovery, suppressed recovery, or liver failure, depending on the regenerative capacity of the remnant liver. The objective of this work is to study the distinct patient outcomes post hepatectomy and determine the processes that are accountable for liver failure. Our model based approach shows that cell death is one of the important processes but not the sole controlling process responsible for liver failure. Additionally, our simulations showed wide variation in the timescale of liver failure that is consistent with the clinically observed timescales of post hepatectomy liver failure scenarios. Liver failure can take place either instantaneously or after a certain delay. We analyzed a virtual patient cohort and concluded that remnant liver fraction is a key regulator of the timescale of liver failure, with higher remnant liver fraction leading to longer time delay prior to failure. Our results suggest that, for a given remnant liver fraction, modulating a combination of cell death controlling parameters and metabolic load may help shift the clinical outcome away from post hepatectomy liver failure towards normal recovery.

12. Expanding the donor pool for living donor liver transplantation: experience with nash and fibrosis

Background and Aims: Living donor liver transplantation carries small but real risk to live donor. Donor steatosis, fibrosis and NASH in donor are common cause of rejection in Living donor liver transplantation. Hereby we report our experience of LDLT in donors with NASH and fibrosis. Methods: 394 patients underwent living donor liver transplantation from August 2011 to January 2018. Liver steatosis was seen in 47 patients. All these patients underwent donor optimization protocol, involving dietary modification, exercise regimen and targeted weight reduction. Results: Of the 47 patients with liver steatosis, 8 patients had NASH and fibrosis. After lifestyle change, dietary modification and exercise regimens, repeat biopsies were done in 6 patients. All 6 patients showed resolution of NASH and fibrosis. 5 donors underwent right hepatectomies and 1 underwent left hepatectomy. 2 patients did not undergo liver biopsy, they underwent emergency left lobectomy and left lateral sectionectomy for ALF. No donor had post hepatectomy liver failure (50-50 criteria). 2 patients had grade 3a complications needing PCD for pleural effusion. Analyzing the recipient outcomes, 1 patient had mortality (not related to graft function). Conclusions: NASH and fibrosis can be reversed with carefully selected motivated donors, with lifestyle modification, diet and exercise planning. This increases the donor pool for living donor liver transplantation. The authors have none to declare.

Protective Effects of Liu Wei Di Huang Wan on the Liver, Orbitofrontal Cortex Nissl Bodies, and Neurites in MSG+PH-Induced Liver Regeneration Rat Model.

Introduction. To examine the protective effects of Liu Wei Di Huang Wan formula (LWDH) on liver and orbitofrontal cortex (OFC) injuries in monosodium glutamate (MSG) and partial hepatectomy (PH) rat model. Methods. Neonatal Wistar rats were given MSG or saline on postnatal days 2, 4, 6, 8, and 10. The rats were caged into five groups and treated accordingly at six weeks old as follows: Saline group, Saline+PH group, MSG group, MSG+PH group, and LWDH group (MSG+PH+LWDH). The PH was performed during week 8 by excision of the left and median hepatic lobes (occupying about 68% of whole liver).On day 8 after the PH, the rats were subjected to an inner OFT before being sacrificed. The liver and OFC were stained using H&E, ORO, or Nissl staining. The expression of neurotrophic factors (β-NGF, BDNF) was examined in the OFC lysates by ELISA. Serum levels of cytokines (IL-1β, VEGF) were examined using the Bio-Plex suspension array. Results. LWDH increased the total distance traveled by the animals (p<0.05), and LWDH improved the integrity of the Nissl bodies in the OFC (mean area of the Nissl bodies, p<0.01; mean diameter, p<0.05; mean density, p<0.05; and IOD, p<0.01). There were less white area in the liver (p>0.05) and decreased hepatic steatosis (p<0.01) in LWDH group. LWDH administration decreased the expression of serum levels of IL-1β (p>0.05), while it increased VEGF (p>0.05) expression. LWDH administration increased the expression of BDNF (p>0.05) and β-NGF (p>0.05) in the OFC, all as compared to the MSG+PH group. Conclusion. LWDH partly protected the animals from depressive-like behaviors in the MSG+PH-induced liver regeneration neonatal rat model. LWDH alleviated hepatic injury and steatosis and, furthermore, protected the Nissl body integrity and the growth of neurites.

Prospective evaluation of the International Study Group for Liver Surgery definition of post hepatectomy liver failure after liver resection: an international multicentre study

BackgroundThe International Study Group for Liver Surgery (ISGLS) definition of post hepatectomy liver failure (PHLF) was developed to be consistent, widely applicable, and to include severity stratification. This international multicentre collaborative study aimed to prospectively validate the ISGLS definition of PHLF. Methods11 HPB centres from 7 countries developed a standardised reporting form. Prospectively acquired anonymised data on liver resections performed between 01 July 2010 and 30 June 2011 was collected. A multivariate analysis was undertaken of clinically important variables. ResultsOf the 949 patients included, 86 (9%) met PHLF requirements. On multivariate analyses, age ≥70 years, pre-operative chemotherapy, steatosis, resection of >3 segments, vascular reconstruction and intraoperative blood loss >300 ml significantly increased the risk of PHLF. Receiver operator curve (ROC) analysis of INR and serum bilirubin relationship with PHLF demonstrated post-operative day 3 and 5 INR performed equally in predicting PHLF, and day 5 bilirubin was the strongest predictor of PHLF. Combining ISGLS grades B and C groups resulted in a high sensitivity for predicting mortality compared to the 50-50 rule and Peak bilirubin >7 mg/dl. ConclusionsThe ISGLS definition performed well in this prospective validation study, and may be the optimal definition for PHLF in future research to allow for comparability of data.

ALPPS as a salvage procedure after insufficient future liver remnant hypertrophy following portal vein occlusion

BackgroundA minimum future liver remnant (FLR) of 30% is required to avoid post hepatectomy liver failure (PHLF). Portal vein occlusion (PVO) is the main strategy to induce hypertrophy of the FLR, but some patients will not reach sufficient FLR hypertrophy to enable resection. Recently ALPPS has emerged as a “Salvage Procedure” for PVO failure. The aim of this study was to report the short term outcomes of ALPPS following PVO failure. MethodsA retrospective analysis of patients enrolled within the international ALPPS Registry between October 2012 and November 2015 (NCT01924741) was performed. Patients with documented PVO failure were included. The outcomes reported included feasibility, FLR growth rate and safety of ALPPS. Complications were recorded as per Clavien-Dindo classification. ResultsFrom 510 patients enrolled in the Registry there were 22 patients with previous PVO failure. Two patients were excluded due to missing data and twenty patients were analysed. All of them completed the proposed ALPPS with a medium FLR increase of 88% (23–115%) between two stages and no 90-day mortality. ConclusionIn experienced centers, ALPPS following PVO failure is feasible and safe. The FLR hypertrophy was similar to other ALPPS series. ALPPS is a potential rescue strategy after PVO failure.

Preoperative regional maximal removal rate of technetium-99m-galactosyl human serum albumin is correlated with liver functional parameters, but did not predict postoperative morbidity.

Recently, posthepatectomy complications have been predicted by advances of new liver functional parameters, and the technetium-99m-galactosyl human serum albumin (GSA) liver scintigraphy has been applied widely for this purpose. We evaluated the clinical significance of the regional maximal removal rate (GSA-Rmax) in patients with various liver diseases as predictors of posthepatectomy complications. Between 2012 and March 2016, we examined 200 patients who underwent hepatectomy for liver and biliary diseases. The patients' background liver conditions included chronic viral liver diseases in 147 patients, normal liver in 44 patients, and others in nine patients. Hepatectomy-related postoperative complications (i.e. long-term ascites, intra-abdominal infection, and hepatic failure) occurred in 69 (35%) patients. A multivariate logistic analysis was carried out to detect the predictive parameters for complications. The median and mean preoperative GSA-Rmax was 0.420 and 0.448±0.148 mg/min, respectively. The GSA-Rmax was significantly correlated with liver functional parameters of ICGR15, LHL15, HH15, platelet count, prothrombin activity, and serum hyaluronic acid level (P<0.01), and was significantly correlated with postoperative total bilirubin level and C-reactive protein level (P<0.05). With respect to patient outcomes, GSA-Rmax was significantly lower in patients with long-term ascites (P<0.05). The predictive cutoff value for posthepatectomy long-term ascites for GSA-Rmax was 0.421 mg/min. However, the multivariate logistic regression analysis identified that a higher serum hyaluronic acid level and a lower platelet count were significant, independent factors, but not lower GSA-Rmax. GSA-Rmax is one of the liver functional parameters and is a complementary parameter to predict postoperative hyperbilirubinemia, inflammatory responses, and ascites when Tc-GSA scintigraphy is performed.

Hepatobiliary scintigraphy to evaluate liver function in associating liver partition and portal vein ligation for staged hepatectomy: Liver volume overestimates liver function

Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) induces a rapid and extensive increase in liver volume. The functional quality of this hypertrophic response has been called into question because ALPPS is associated with a substantial incidence of liver failure and high perioperative mortality. This multicenter study aimed to evaluate functional liver regeneration in contrast to volumetric liver regeneration in ALPPS, using technetium-99m hepatobiliary scintigraphy and computed tomography volumetry, respectively. Patients who underwent ALPPS and hepatobiliary scintigraphy in 6 centers were included. Hepatobiliary scintigraphy data were analyzed centrally at the Academic Medical Center in Amsterdam according to established protocols. Increase in liver function as measured by hepatobiliary scintigraphy after stage 1 of ALPPS was compared with the increase in liver volume. In addition, we analyzed the impact of liver function and volume on postoperative outcomes including liver failure, morbidity, and mortality. In 60 patients, future liver remnant volume increased by a median 78% (interquartile range 48-110) during a median 8 (interquartile range 6-14) days after stage 1, while function as measured by hepatobiliary scintigraphy increased by a median 29% (interquartile range 1-55) throughout 7days (interquartile range 6-10) in the 27 patients with paired measurements. After stage 2 of ALPPS, liver failure occurred in 5/60 (8%) patients, severe complications in 24/60 (40%), and mortality occurred in 4/60 (7%). In ALPPS, volumetry overestimates liver function as measured by hepatobiliary scintigraphy and may be responsible for the high rate of liver failure. Quantitative liver function tests are highly recommended to avoid post hepatectomy liver failure.

Circulating tumor DNA (ctDNA) utilizing a high-sensitivity panel to detect minimal residual disease post liver hepatectomy and predict disease recurrence.

3522 Background: Preliminary data suggests that ctDNA can serve as a marker of minimal residual disease following colorectal cancer (CRC) tumor resection. Applicability of current ctDNA testing is limited by the requirement of sequencing known individual tumor mutations. We explored the applicability of a multi-gene panel ctDNA detection technology in CRC. Methods: Plasma was prospectively collected from CRC patients (pts) undergoing hepatic resections with curative intent between 1/2013 to 9/2016. In a blinded manner 5ml of preoperative (preop) and immediate post-operative (postop) plasma were tested using a novel 30kb ctDNA digital sequencing panel (Guardant Health) covering SNVs in 21 genes and indels in 9 genes based on the landscape of genomic alterations in ctDNA from over 10,000 advanced cancer pts with a high theoretical sensitivity (96%) for CRC. Median unique molecule coverage for this study is 9000 for cfDNA inputs ranging from 10 – 150 ng (media input preop = 27 ng, median input postop = 49 ng) with 120,000X sequencing depth on an IIlumina HiSeq2500. Results: A total of 54 pts underwent liver metastectomies with curative intent with a median follow-up of 33 months. Preop blood was a median of 49 days from last systemic chemotherapy and 3 days prior to surgery; postop blood was a median of 17 days after resection. Tumor mutations from standard of care hotspot multigene panel testing (at MDACC) were identified in 46 of 54 pts (85%). Preop ctDNA mutation detection rate was 80% (43/54) and 44% (24/54) in postop setting, with postop median allele frequency of 0.16% (range 0.01% to 20%). In pts with a minimum of 1 year follow up, sensitivity of postop ctDNA for residual disease was 58% (95%CI; 41%-74%), and specificity was 100% (66%-100%). In 43 patients who underwent successful resection of all visible disease, postop detection of ctDNA significantly correlated with RFS (P = 0.002, HR 3.1; 95% CI 1.7-9.1) with 2-year RFS of 0% vs. 47%. Recurrence was detected in ctDNA a median of 5.1 months prior to radiographic recurrence. Conclusions: The detection of postop ctDNA using an NGS panel-based approach is feasible and is associated with a very high rate of disease recurrence.

Isolated IgG4-related sclerosing cholangitis misdiagnosed as malignancy in an area with endemic cholangiocarcinoma: a case report

BackgroundThe most common cause of perihilar obstruction is cholangiocarcinoma, especially in Thailand. Benign perihilar stricture represents less than 20% of cases. IgG4-related disease and IgG4-related sclerosing cholangitis, however, have been receiving increased recognition. Isolated IgG4-related sclerosing cholangitis is less common. The preoperative diagnosis of IgG4-related sclerosing cholangitis without pancreatic involvement is very difficult because the clinical presentation and preoperative evaluation are extremely difficult to distinguish from perihilar cholangiocarcinoma.Case presentationWe report the case of a 56-year-old man who presented with obstructive jaundice with preoperative imaging showing proximal common bile duct obstruction. He underwent right lobe liver hepatectomy with extrahepatic bile duct resection and regional lymph node dissection due to high suspicion of malignancy. The pathological report showed severe acute and chronic inflammation of the bile duct with morphology and immunohistochemistry suggestive of IgG4-related sclerosing cholangitis.ConclusionsIgG4-related sclerosing cholangitis with perihilar obstruction should be considered even in areas where cholangiocarcinoma is endemic.

Clinical values of multimodal preventive analgesia in patients with partial hepatectomy for liver cancer

Objective: To investigate the clinical values of multimodal preventive analgesia in patients with partial hepatectomy for liver cancer. Methods: A perspective study was conducted to collect data of patients with liver cancer who underwent partial hepatectomy from March 2014 to March 2015.The 90 patients involved in the study were randomly divided into two groups as multimodal analgesia and control groups, and each group had 45 cases. In multimodal analgesia group, 40 mg parecoxib sodium was injected intravenously 30 minutes before anesthetic induction, and 0.375% ropivacaine 150 mg combined with dexamethasone 5 mg were applied to transversus abdominis plane block before closing abdomen.The patients in control group without above treatment. Patient controlled intravenous analgesia was used in all patients. Three days after surgery, 40 mg parecoxib sodium was injected intravenously, twice a day for all patients.Visual analogue scales (VAS) was used to evaluate postoperative pain, and postoperative adverse events were observed.The number of cases of postoperative ambulation (>6 h for every day), time of flatus and defecation, and duration of hospital stay were recorded in two groups.Pearson chi-square test was used to compare the rate or constituent ratio between two groups.Independent sample t test or Mann-Whitney U was used to analyzed the measurement data between two groups. Results: There were no difference between two groups in aging, gender, weight, body mass index, ASA classification, blood loss volume, time of operation(all P>0.05). The scores of VAS in multimodal analgesia group was significantly lower than that in control group(3.0±0.8 vs. 4.6±1.1, t=7.814, P<0.01 for day 1; 2.2±1.0 vs. 3.6±1.2, t=5.825, P<0.01 for day 2; 1.6±0.8 vs. 2.4±1.2, t=3.894, P<0.01 for day 3). The number of cases of postoperative ambulation(>6 h) in multimodal analgesia group was significantly more than that in control group (10 cases vs. 0 case, χ(2)=11.250, P<0.01 for day 1; 21 cases vs. 5 cases, χ(2)=13.846, P<0.01 for day 2; 28 cases vs. 17 cases, χ(2)=5.378, P =0.020 for day 3). The time of flatus and defecation, and duration of hospital stay were significantly shorter than that in control group((30.2±7.3) hours vs. (36.4±7.0)hours, t=4.115, P<0.01 for flatus; (50.9±5.2)hours vs. (60.7±7.3)hours, t=7.346, P<0.01 for defecation; (6.2±0.8)days vs. (9.6±1.1)days, t=16.615, P<0.01 for hospital stay). Conclusion: Multimodal preventive analgesia effectively alleviate the postoperative pain, benefits early ambulation, improves recovery of gastrointestinal function, and shortens duration of hospital stay in patients with partial hepatectomy for liver cancer.

Albumin-Bilirubin Score: Predicting Short-Term Outcomes Including Bile Leak and Post-hepatectomy Liver Failure Following Hepatic Resection

IntroductionPost-operative bile leak (BL) and post hepatectomy liver failure (PHLF) are the major potential sources of morbidity among patients undergoing liver resection. We sought to define the incidence of BL and PHLF among a large cohort of patients, as well as examine the prognostic impact of model for end-stage liver disease (MELD) and albumin-bilirubin (ALBI) scores to predict these short-term outcomes. Materials and MethodsPatients who underwent a hepatectomy between January 1, 2014 and December 31, 2014 were identified using the National Surgical Quality Improvement Program (NSQIP) liver-targeted database. Risk factors for BL and PHLF were identified using multivariable logistic regression. ResultsAmong the 3064 patients identified, median age was 60 years (IQR 50–68). Most patients underwent surgery (78.9 %) for malignant lesions. Post-operatively, 250 (8.5 %) patients experienced a BL while PHLF occurred in 149 cases (4.9 %). Both MELD (MELD <10 4.9 %; MELD ≥10, 10 %; P = 0.001) and ALBI (grade 1, 4.0 %; grade 2, 7.2 %; grade 3, 10.0 %; P = 0.001) were associated with PHLF occurrence, while only ALBI predicted PHLF severity (P = 0.008). Moreover, ALBI was associated with BL (grade 1, 7.1 %; grade 2, 11.5 %; grade 3, 14.0 %; P < 0.001), whereas MELD was not (MELD <10, 8.4 %; MELD ≥10, 11.2 %; P = 0.13). On multivariable analysis, ALBI grade 2/3 was associated with PHLF (OR 1.57, 95 % CI 1.08–2.27; P = 0.02), PHLF severity (OR 3.06, 95 % CI 1.50–6.23; P = 0.003), and the development of a BL (OR 1.35, 95 % CI 1.02–1.80; P = 0.04). ConclusionThe ALBI score was associated with short-term post-operative outcomes following hepatic resection and represents a useful pre-operative risk-assessment tool to identify patients at risk for adverse post-operative outcomes.

435. Application of a three-dimensional print of a liver in hepatectomy

435. Application of a three-dimensional print of a liver in hepatectomy

Prospective blinded study on INTRAOPEATIVE ICG retention test for major hepatectomy – A direct functional measurement of future liver remnant

Background: PRE-hepatectomy ICG study estimate overall liver function but does not measure the function of future liver remnant. Objective: This prospective single-centre study aims to evaluate the safe limited of ICG retention at 15 minutes during major hepatectomy after clamping of the hemi-liver inflow. Patients and methods: 98 patients had major liver resection for liver cancer and INTRA-operative ICG evaluation since 2010. All patients had preoperative ICG15 < 23%. The ICG retention rate of the future liver remnant was measured by LiMON pulse densitometry during major hepatectomy. Surgeon were blinded from ICG measurement. Result: 78 male and 20 females were included. 74 patients had hepatectomy for HCC and 11 patients had liver metastases. 71 Patients had Right hepatectomy, 18 patients had left hepatectomy, 6 patients and 3 patients had right trisectionectomy and left trisectionectomy respectively, 12 patients had ALPPS procedures. The median operation time was 351 minutes. The median blood loss was 0.8L. Despite good preoperative ICG15 measurement, 4 patients developed post hepatecotmy liver failure. 2 patients end up in mortality and 1 patient received rescue liver transplant. All of them had intraoperative ICG15 >50%. The risk of hospital mortality and postoperative morbidity increased from 1.1%% to 50% (P < 0.001) and from 20.2% to 100% (P = 0.002) respectively if the intraoperative ICG15> 50%. Conclusion: Intraoperative ICG measurement is a quick and simple study that provide accurate functional measurement of future liver remnant. It provides surgeons a good last chance to adjust treatment plan in order to prevent post hepatectomy liver failure.

Over 75 year olds undergoing right hemihepatectomy are at a higher risk of post hepatectomy liver failure

Over 75 year olds undergoing right hemihepatectomy are at a higher risk of post hepatectomy liver failure

Reducing mortality in liver surgery by introduction of the dynamic liver function test LiMAx

Aims: The LiMAx-Algorithm – a clinical decision tree based on the preoperative prediction of actual postoperative liver function with the dynamic liver function test LiMAx – was introduced 2008/9 in our high volume liver center succeeding conventional CT-scan based volume planning as standard tool for risk evaluation in patients undergoing partial liver resection. We hereby report the impact of the new standard procedure on postoperative outcome in patients undergoing partial liver resection. Methods: All patients undergoing liver resection of at least one segment between the years 2006 to 2011 (n = 1170) were analyzed for this retrospective study. Primary case data were retrieved from the administrative medical controlling department. Clinical characteristics, operative data and postoperative outcome were compared between the years. Additionally a propensity score based matched analysis of the years 2006/2007 (n = 313) to 2010/2011 (n = 313) was carried out. Results: While the amount patients undergoing partial liver resection in cirrhosis (p = 0.039) and the proportion of complex partial liver resection (p = 0.034) significantly increased within the years, the rate of post hepatectomy liver failure (p < 0.001) and liver related death (p = 0.014) decreased significantly. The matched pair analysis between 2006/2007 and 2010/2011 showed no difference regarding age, ASA score and surgical procedure between the groups. However the comparison yielded a significant decline in postoperative liver dysfunction from 24.7 % to 11.2 % (p < 0.001) and liver related death from 3.8% to 1.0% (p = 0.035). Conclusions: The rate of postoperative liver failure and liver failure related death could be reduced significantly due to the introduction of the dynamic liver function test LiMAx in our high volume liver center. The LiMAx-Algorithm is capable to evaluate risks of complex surgical procedures making partial liver resection safer.

Portal Vein Embolization and ALPPS for Prevention of Post-Hepatectomy Liver Failure

Aim. To estimate early and remote outcomes of portal vein embolization and ALPPS for prevention of post-hepatectomy liver failure. Material and Methods. 358 liver resections were performed for the period 2008–2016. There were 132 (36.9%) advanced resections (over 4 segments). Cholangiocelullar carcinoma was diagnosed in 48 cases (36.4%), hepatocellular carcinoma – in 23 (17.4%) cases, colorectal liver metastases – in 19 (14.4%), parasitic liver diseases (hydatid disease, alveococcosis) – in 31 (23.5%) cases and others – in 11 (8.3%) cases. Vascular resection was performed in 42 (31.8%) patients, common bile and (or) common hepatic duct resection – in 76 (57.6%) cases. In this article 41 cases of portal vein embolization with staged liver resection and 6 cases of ALPPS are described. Control group included 85 advanced liver resections without portal vein embolization. Results. Portal vein embolization was effective in 41 (66%) cases: FLR growth was 52% (33;61) within average terms of 5.0 (4.0; 6.5) weeks. In ALPPS FLR growth was 70% (60; 77) after 11 (7; 17) days, in 1 case it was uneffective (FLR% – 30% after 24 days). The grade B+C of post hepatectomy liver failure was observed in 66 (50%) cases, infectious complications – in 39 (29.5%) cases, biliary complications – in 29 (21.9%) cases, post hepatectomy bleeding (grade C, ISGLS) – in 5 (3,8%) cases. In-hospital mortality was 8,3 %. Portal vein embolization decreased grade C post hepatectomy liver failure (7.3% vs 20%) (p = 0.07). Conclusion. Two-stage liver resection with primary embolization or ligation of the portal vein can reduce the frequency of post-resection liver failure. For certain patients ALPPS is the only method that allows to perform radical surgery and preserve necessary amount of hepatic parenchyma. However long-term results are unpredictable

Hepatic Hemodynamic Changes Following Stepwise Liver Resection

AimExtended liver resection has increased during the last decades. However, hepatic hemodynamic changes after resection and the consequent complications like post hepatectomy liver failure are still a challenging issue. The aim of this study was to systematically evaluate the role of stepwise liver resection on hepatic hemodynamic changes. MethodsTo evaluate this effect we performed 25, 50, and 75 % sequential liver resections in 10 pigs. Before and after each resection, the hepatic artery flow and portal vein flow in relation to the remnant liver volume (RLV) as well as hepatic vascular pressures were measured and compared between the groups. ResultsFollowing sequential liver resection, the hepatic artery flow /100 g decreases and the portal vein flow increases up to 17 and 167 % following extended liver resection (75 %), respectively. Also, during stepwise liver resection, the portal vein pressure increases gradually up to 33 % following extended hepatectomy (75 %). ConclusionSequential decrease in the RLV decreases the hepatic artery flow /100 g and increases the portal vein flow /100 g and portal vein pressure. As the consequence, the liver goes under more poor-oxygenated blood supply and higher pressure. This may be one of the most important mechanisms of the post hepatectomy liver failure in case of extended liver resection.