Postoperative Liver Failure Research Articles

Assessment of Preoperative Liver Function in Patients with Hepatocellular Carcinoma - The Albumin-Indocyanine Green Evaluation (ALICE) Grade.

BackgroundMost patients with hepatocellular carcinoma (HCC) have underlying liver disease, therefore, precise preoperative evaluation of the patient’s liver function is essential for surgical decision making.MethodsWe developed a grading system incorporating only two variables, namely, the serum albumin level and the indocyanine green retention rate at 15 minutes (ICG R15), to assess the preoperative liver function, based on the overall survival of 1868 patients with HCC who underwent liver resection. We then tested the model in a European cohort (n = 70) and analyzed the predictive power for the postoperative short-term outcome.ResultsThe Albumin-Indocyanine Green Evaluation (ALICE) grading system was developed in a randomly assigned training cohort: linear predictor = 0.663 × log10ICG R15 (%)−0.0718 × albumin (g/L) (cut-off value: -2.20 and -1.39). This new grading system showed a predictive power for the overall survival similar to the Child-Pugh grading system in the validation cohort. Determination of the ALICE grade in Child-Pugh A patients allowed further stratification of the postoperative prognosis. This result was reproducible in the European cohort. Determination of the ALICE grade allowed better prediction of the risk of postoperative liver failure and mortality (ascites: grade 1, 2.1%; grade 2, 6.5%; grade 3, 16.0%; mortality: grade 1, 0%; grade 2, 1.3%; grade 3, 5.3%) than the previously reported model based on the presence/absence of portal hypertension.ConclusionsThis new grading system is a simple method for prediction of the postoperative long-term and short-term outcomes.

Combined in situ hypothermic liver preservation and cardioplegia for resection of hepatoblastoma with intra-atrial extension in a 3 year old child

Abstract Cure of hepatoblastoma requires complete macro- and microscopic resection of the tumor, without tumor rupture. In case of hepatoblastoma with intra-atrial tumor extension (ITE), “en bloc” resection of the hepatic tumor and ITE, with minimal risk of postoperative liver failure, constitutes a surgical challenge. We report on a 3 year old child with hepatoblastoma of the right liver lobe, and ITE through the upper Inferior Vena Cava. Initial chemotherapy (SIOPEL IV HR) induced good response, but tumor persisted inside the right atrium with tight adhesions to the cardiac wall. “En bloc” right extended hepatectomy and removal of the ITE with reconstruction of the atrial and caval wall with autologous pericardial patch was performed under normothermic extracorporeal circulation and cardioplegia, combined with in situ hypothermic liver preservation of the remaining left liver. Complete tumor resection was achieved without tumor rupture. Postoperative liver function was immediately good and adjuvant chemotherapy was resumed per protocol. Eleven months after the end of treatment the child is in complete tumor remission. In children with hepatic tumor and ITE, combination of normothermic extracorporeal circulation with cardioplegia and in situ hypothermic liver preservation allows “en bloc” extended hepatectomy and removal of ITE, with limited risk of postoperative liver failure.

A Personal Computer Freeware as a Tool for Surgeons to Plan Liver Resections.

The increase in liver surgery and the proportion of resections done on the margin to postoperative liver failure make preoperative calculations regarding liver volume important. Earlier studies have shown good correlation between calculations done with ImageJ and specimen weight as well as volume calculations done with more robust systems. The correlation to actual volumes of resected liver tissue has not been investigated, and this was the aim of this study. A total of 30 patients undergoing well-defined liver resections were included in this study. Volumes calculated with ImageJ were compared to volume measurements done after the retrieval of resected liver tissue. A strong correlation between calculated and measured liver volume was found with sample concordance correlation coefficient (ρc) = 0.9950. The knowledge on the nature of liver resections sets liver surgeons in a unique position to be able to accurately predict the volumes to be resected and, therefore, also the volume that will remain after surgery. This becomes increasingly important with the evolvement of methods to extend the boundaries of liver surgery. ImageJ is a reliable tool to preoperatively assess liver volume.

Prediction of postoperative liver failure using gadoxetic acid-enhanced magnetic resonance imaging in patients with hepatocellular carcinoma.

We intended to determine the usefulness of gadoxetic acid-enhanced magnetic resonance (MR) imaging on preoperative prediction of the risk of postoperative liver failure (PLF) using measurement of relative liver enhancement (RLE) in patients who underwent surgical resection of hepatocellular carcinoma (HCC). A total of 121 HCC patients who had underwent gadoxetic acid-enhanced MRI before surgery between January 2012 and April 2015 at our hospital was retrospectively analyzed. RLE was calculated as the ratio of signal intensity measurements of the liver parenchyma in each liver segment before and 20 min after intravenous administration of gadoxetic acid. PLF was defined based on the "50-50 criteria" (prothrombin time <50% and serum bilirubin >5 mg/dL on 5 days after surgery). Of the 121 patients, 74 (61.2%) patients had liver cirrhosis, clinically. Median tumor size 2.8 cm (range, 1-14 cm), 106 (87.6%) patients had a single HCC, and 101 (83.5%) patients had HCC within Milan criteria. Based on the "50-50 criteria", PLF was observed in 7 (5.8%) patients. Mean RLE was significantly lower in patients with PLF than those without it (55.9% vs 85.5%, P < 0.01). In a multivariate analysis, decreased RLE was a significant independent risk factor for PLF in HCC patients (odds ratio 0.97, P = 0.03). Optimal cut-off RLE value was 82.36. RLE was significantly lower in patients with PLF than those without it. Measurement of RLE using gadoxetic acid-enhanced MR imaging before surgery can be useful for prediction of PLF in HCC patients who receive surgical treatment.

Mitochondrial bioenergetics and posthepatectomy liver dysfunction.

Liver regeneration requires an enormous energy supply. Experimental evidence suggests that mitochondrial function is of paramount importance for liver regeneration. However, this has not been investigated in the clinical setting. We aimed to: (i) evaluate changes in mitochondrial function during hepatectomy, especially after hepatic pedicle clamping; and (ii) correlate these changes with postoperative hepatocellular function and clinical outcome. Prospective study of thirty patients undergoing hepatectomy. Measurement of mitochondrial membrane potential, respiration and adenosine triphosphate content in intra-operative liver biopsies performed in nonresected parenchyma. Correlation of findings with duration of hepatic pedicle clamping, postoperative markers of hepatocellular necrosis and function (aminotransferases, arterial lactate, international normalized ratio, bilirubin), and morbidity. Longer hepatic pedicle clamping was associated with worse mitochondrial depolarization (r = -0·519; P = 0·011) and longer lag phase (r = 0·568; P = 0·006). Higher postoperative peak aminotransferases, international normalized ratio and bilirubin correlated with worse mitochondrial function (P < 0·05). After major hepatectomy, mitochondrial respiration correlated with postoperative arterial lactate clearance (r = 0·756; P = 0·049). Mitochondrial bioenergetic parameters were significantly decreased in patients with liver-specific morbidity and postoperative liver failure (P < 0·05). On multivariate analysis, decrease in mitochondrial potential was an independent risk factor for liver-specific morbidity (OR = 13·7; P = 0·043). Worse lag phase was highly predictive of posthepatectomy liver failure (area under the curve: 0·933; P = 0·008). There is a relationship between mitochondrial function, duration of hepatic pedicle clamping and clinical outcome after hepatectomy. Mitochondrial bioenergetics can potentially translate into clinical practice, assisting in earlier diagnosis of postoperative liver dysfunction, and as a target for future pharmacological therapies.

Influence of Liver Disease on Perioperative Outcome After Bariatric Surgery in a Northern German Cohort.

The aim of this study was to assess the prevalence of non-alcoholic fatty liver disease (NAFLD) in morbidly obese patients and evaluate the influence on perioperative complications. Patients undergoing bariatric surgery have a high incidence of non-alcoholic steatohepatitis (NASH). Upcoming data indicates that liver disease has a significant effect on perioperative complications. However, the influence of NAFLD/NASH on perioperative outcome in bariatric patients is still controversial. We identified a total of 302 patients with concomitant liver biopsies, while performing either laparoscopic Roux-Y gastric bypass or sleeve gastrectomy. Liver biopsy was performed in case of abnormal liver appearance at time of bariatric surgery. Histological results were compared to perioperative complication rate. NAFLD is common in our patient cohort. Abnormal findings in liver histology were found in 82.3% of our patients. Liver cirrhosis was newly diagnosed in 12 patients (4%). There were no complications due to liver biopsy. The mortality rate was 0.3%, leakage rate was 1%, and postoperative bleeding occurred in 3.3%. Pulmonary complications were observed in 1.7% and cardiovascular complications in 1.3%. One patient developed portal vein thrombosis and one patient acute pancreatitis; both were treated conservatively. No patient had postoperative liver failure. We found no association between histological findings and perioperative outcomes. The prevalence of NAFLD among morbidly obese surgical patients was high, although this condition was not associated with increased risk for postoperative complications. Because of unexpected findings in intraoperative liver biopsies, the routine indication of liver biopsies in patients at high risk for liver disease should be discussed.

An updated systematic review of the evolution of ALPPS and evaluation of its advantages and disadvantages in accordance with current evidence.

The main obstacle to achieving an R0 resection after a major hepatectomy is inability to preserve an adequate future liver remnant (FLR) to avoid postoperative liver failure (PLF). Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) is a novel technique for resecting tumors that were previously considered unresectable, and this technique results in a vast increase in the volume of the FLR in a short period of time. However, this technique continues to provoke heated debate because of its high mortality and morbidity.The evolution of ALPPS and its advantages and disadvantages have been systematically reviewed and evaluated in accordance with current evidence. Electronic databases (PubMed and Medline) were searched for potentially relevant articles from January 2007 to January 2016.ALPPS has evolved into various modified forms. Some of these modified techniques have reduced the difficulty of the procedure and enhanced its safety. Current evidence indicates that the advantages of ALPPS are rapid hypertrophy of the FLR, the feasibility of the procedure, and a higher rate of R0 resection in comparison to other techniques. However, ALPPS is associated with worse major complications, more deaths, and early tumor recurrence.Hepatobiliary surgeons should carefully consider whether to perform ALPPS. Some modified forms of ALPPS have reduced the mortality and morbidity of the procedure, but they cannot be recommended over the original procedure currently. Portal vein embolization (PVE) is still the procedure of choice for patients with a tumor-free FLR, and ALPPS could be used as a salvage procedure when PVE fails. More persuasive evidence needs to be assembled to determine whether ALPPS or two-stage hepatectomy (TSH) is better for patients with a tumor involving the FLR. Evidence with regard to long-term oncological outcomes is still limited. More meticulous comparative studies and studies of the 5-year survival rate of ALPPS could ultimately help to determine the usefulness of ALPPS. Indications and patient selection for the procedure need to be determined.

Living donor liver transplantation indicated for compensated liver cirrhosis with symptomatic gallstone diseases: report of two cases.

BackgroundSurgical interventions for symptomatic gallstone disease could be dangerous in patients with severe comorbid conditions including liver cirrhosis. Here, we report our experience of living donor liver transplantation (LDLT) indicated for two patients with liver cirrhosis complicated with gallstone diseases.Case 1A 70-year-old woman with a history of hepatitis C virus infection was diagnosed as symptomatic choledocholithiasis. She had open cholecystectomy and choledochotomy with choledocholithotomy, which complicated with postoperative liver failure. Her Child-Pugh score increased from 7 to 12 points and Model for End-Stage Liver Disease (MELD) score from 11 to 36. She underwent LDLT, using the right lobe graft donated by her 47-year-old daughter. The post-transplant graft function was excellent, and the patient was discharged from the hospital on postoperative day 27.Case 2A 46-year-old man with a history of hepatitis B virus infection was diagnosed as cholecystitis. He had cholecystostomy without any complications and his Child-Pugh score remained to be 9 and MELD score 17, followed by LDLT using the right lobe graft donated by his 45-year-old wife. The post-transplant graft function was excellent, and the patient was discharged from the hospital on postoperative day 44.ConclusionLDLT is one of treatment options when patients with Child-Pugh B cirrhosis accompanied with gallstone diseases, likely to be deteriorating their liver functions in the near future.

Associating liver partition and portal vein ligation for staged hepatectomy: An emerging paradigm? Literature review apropos of the first case in Greece

Colorectal carcinoma (CRC) is the third most common cancer in the Western world. Radical resection of liver metastases remains the only curative option. Postoperative liver failure has become the main concern because of insufficient future liver remnant (FLR). Several techniques have evolved to induce liver hypertrophy of the FLR prior to hepatectomy in primarily unresectable liver tumours. An innovative two-staged technique named as associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) has shown promising results. Herein, we report the first case of ALPPS in the Greek population ever to be reported, and also provide a review of the current literature regarding this novel surgical procedure. A 70-year-old male presented with a history of altered bowel habits and haematochezia. Colonoscopy revealed a sigmoid adenocarcinoma. Computed tomography (CT) disclosed bilobar liver metastases. The initial decision of the multidisciplinary team was to use upfront chemotherapy. Magnetic resonance imaging (MRI) and CT of the abdomen showed minimal response after completion of the chemotherapy regimen. A right trisectionectomy via the ALPPS procedure and a simultaneous left hemicolectomy were performed. A systematic literature search was conducted with regard to other cases of ALPPS. The patient’s postoperative course was complicated by post hepatectomy Grade A liver failure, according to the International Study Group of Liver Surgery definition. ALPPS is a novel innovative procedure that has generated great enthusiasm in the field of hepatobiliary surgery. Indications for ALPPS should be re-evaluated and a common consensus reached among centres for a standardized surgical technique.

Impact of Perioperative Phosphorus and Glucose Levels on Liver Regeneration and Long-term Outcomes after Major Liver Resection

IntroductionThe impact of phosphorus as well as glycemic alterations on liver regeneration has not been directly examined. We sought to determine the impact of phosphorus and glucose on liver regeneration after major hepatectomy. MethodsEarly and late liver regeneration index was defined as the relative increase of liver volume (RLV) within 2[(RLV2m-RLVp)/RLVp] and 7 months[(RLV7m-RLVp)/RLVp] following surgery. The association of perioperative metabolic factors, liver regeneration, and outcomes was assessed. ResultsOn postoperative day 2, 50 (52.6 %) patients had a low phosphorus level (≤2.4 mg/dl), while 45 (47.4 %) had a normal/high phosphorus level (>2.4 mg/dl). Despite comparable clinicopathologic characteristics (all P > 0.05) and RLV/TLV at surgery (P = 0.84), regeneration index within 2 months was lower in the normal/high phosphorus group (P = 0.01) with these patients having increased risk for postoperative liver failure (P = 0.01). The inhibition of liver regeneration persisted at 7 months (P = 0.007) and was associated with a worse survival (P = 0.02). Preoperative hypoglycemia was associated only with a lower early regeneration index (P = 0.02). ConclusionsNormal/high phosphorus was associated with inhibition of early and late liver regeneration, as well as with an increased risk of liver failure and worse long-term outcomes. Immediate preoperative hypoglycemia was associated with a lower early volumetric gain. Metabolic factors may represent early indicators of liver failure that could identify patients at increased risk for worse outcomes.

Liver function assessment using 99mTc-GSA single-photon emission computed tomography (SPECT)/CT fusion imaging in hilar bile duct cancer: A retrospective study

The objective of this study was to determine the utility of Tc-99m-diethylenetriamine-penta-acetic acid-galactosyl human serum albumin ((99m)Tc-GSA) single-photon emission computed tomography (SPECT)/CT fusion imaging for posthepatectomy remnant liver function assessment in hilar bile duct cancer patients. Thirty hilar bile duct cancer patients who underwent major hepatectomy with extrahepatic bile duct resection were retrospectively analyzed. Indocyanine green plasma clearance rate (KICG) value and estimated KICG by (99m)Tc-GSA scintigraphy (KGSA) and volumetric and functional rates of future remnant liver by (99m)Tc-GSA SPECT/CT fusion imaging were used to evaluate preoperative whole liverfunction and posthepatectomy remnant liver function, respectively. Remnant (rem) KICG (=KICG×volumetric rate) and remKGSA (= KGSA×functional rate) were used to predict future remnant liver function; major hepatectomy was considered unsafe for values <0.05. The correlation of remKICG and remKGSA with posthepatectomy mortality and morbidity was determined. Although remKICG and remKGSA were not significantly different (median value: 0.071 vs 0.075), functional rates of future remnant liver were significantly higher than volumetric rates (median: 0.54 vs 0.46; P<.001). Hepatectomy was considered unsafe in 17% and 0% of patients using remKICG and remKGSA, respectively. Postoperative liver failure and mortality did not occur in the patients for whom hepatectomy was considered unsafe based on remKICG. remKGSA showed a stronger correlation with postoperative prothrombin time activity than remKICG. (99m)Tc-GSA SPECT/CT fusion imaging enables accurate assessment of future remnant liver function and suitability for hepatectomy in hilar bile duct cancer patients.

Extended liver resection

The study included 78 patients who underwent hepatic resection. The first group consisted of patients who underwent extensive liver resection – 44 (56.4%). The second group included patients with small or sparing resection – 34. Various postoperative complications occurred in 29 (37.1%) cases (of which only 1 (1.3%) patients in the group with small resections). The most frequently observed post-resection liver failure – 19 (24.35%) patients. With the expansion of the volume of intervention frequency liver dysfunction varying severity increased and reached 43%. Methodology of CT-volumetry with high precision allows to calculate the post-resection liver volume. Residual volume of liver parenchyma less than 359 cm3/m2 body surface is a predictor for the development of postoperative liver failure. Speed of the plasma elimination of ICG was sensitive (92.3%) and specificity (71.4%) by a quantitative evaluation of the functional reserves of the liver and characterized by a high potential predictor in determining postoperative liver failure in patients with chronic liver diseases, diagnosed with Class B and C by criteria Child-Pugh, as well as the residual liver volume of at least 550 cm3/m2 body surface. Critical value for extensive liver resection is the speed of the plasma elimination ICG less than 10% / min. Using the methods for determining the functional reserve of the liver resections in the planning stage, allows for a differentiated approach to individual choice of treatment based on risk factors and interventions to improve the results of resection in patients with liver volume formation.

Intraoperative evaluation of haemodynamic changes during major hepatic resections allow to predict postoperative liver failure (PLF). a prospective single-centre study

Intraoperative evaluation of haemodynamic changes during major hepatic resections allow to predict postoperative liver failure (PLF). a prospective single-centre study

Impact of postoperative liver failure on surgical and long-term outcomes after resection of colorectal liver metastases

Impact of postoperative liver failure on surgical and long-term outcomes after resection of colorectal liver metastases

Does liver kinetic growth rate predict postoperative liver failure after ALPPS?

Does liver kinetic growth rate predict postoperative liver failure after ALPPS?

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.

Albumin-bilirubin versus Child-Pugh score as a predictor of outcome after liver resection for hepatocellular carcinoma.

The Child-Pugh (CP) score is used widely to assess liver function and predict postoperative outcomes in patients with hepatocellular carcinoma (HCC). Recently, the albumin-bilirubin (ALBI) score has been validated as a predictor of overall survival in these patients. This study aimed to compare the ability of the ALBI and CP scores to predict outcomes in patients with HCC after liver resection with curative intent. Consecutive patients who underwent liver resection with curative intent for HCC between January 2007 and July 2013 were included in this retrospective study. The performance of the ALBI score in predicting postoperative liver failure (PHLF) and long-term survival was compared with that of the CP score. A total of 1242 patients were enrolled. Of these, 166 (13·4 per cent) experienced PHLF. The area under the receiver operating characteristic (ROC) curve of the ALBI score for predicting PHLF was greater than that of the CP score (0·723 versus 0·607; P < 0·001). Similar to findings for CP grade, the incidence and severity of PHLF increased with increasing ALBI grade. The ALBI grade stratified patients into at least two distinct overall survival cohorts (P < 0·001), whereas the CP grade did not. The ALBI grade also classified patients with CP grade A disease into two distinct overall survival cohorts (P < 0·001), and overall survival rates in the group with poorer survival were similar to those in the majority of patients with CP grade B disease. Both CP and ALBI scores had low power in predicting disease-free survival. The ALBI grade predicted PHLF and overall survival in patients with HCC undergoing liver resection with curative intent more accurately than the CP grade.

The many faces of ALPPS: surgical indications and techniques among surgeons collaborating in the international registry

BackgroundALPPS was developed to induce accelerated future liver remnant (FLR) hypertrophy in order to increase hepatic tumour resectability and reduce the risk of post-operative liver failure. While early studies demonstrated concerning complication rates, others reported favourable results. This inconsistency may be due to variability in surgical indications and technique. MethodsA web-based survey was sent to surgeons participating in the International ALPPS Registry in September of 2014. Questions addressed surgeon demographics and training, surgical indications and technique, and clinical management approaches. ResultsFifty six out of 85 surgeons from 78 centers responded (66%) and half (n = 30) had training in liver transplantation. Forty seven (84%) did not reserve ALPPS solely for colorectal liver metastases (CRLM) and 30 (54%) would perform ALPPS for an FLR over 30%. Neoadjuvant chemotherapy for CRLM was recommended by 37 (66%) respondents. Surgical approaches varied considerably, with 30% not preserving outflow to the middle hepatic vein and 39% believing it necessary to skeletonize the hepatoduodenal ligament. Twenty five (45%) surgeons have observed segment 4 necrosis. ConclusionThere is considerable variability in how ALPPS is performed internationally. This heterogeneity in practice patterns may explain the current incongruity in published outcomes, and highlights the need for standardization.

Attenuation of Postoperative Acute Liver Failure by Mesenchymal Stem Cell Treatment Due to Metabolic Implications.

To prevent posthepatectomy acute liver failure after extended resection by treatment with mesenchymal stem cells (MSCs). Liver tumors often require extended liver resection, overburdening metabolic and regenerative capacities of the remnant organ. Resulting dysfunction and failure may be improved by the proregenerative characteristics of MSCs. Extended liver resection was performed in (DPPIV)-deficient F344-Fischer rats. Wild-type animals served as donors of peritoneal adipose-derived MSCs. These were predifferentiated in vitro into hepatocytic cells and delivered to the liver by splenic application. Liver-related blood parameters (international normalized ratio, bilirubin, aspartate aminotransferase, alanine aminotransferase) and liver histology (hematoxylin-eosin, Sudan III) were determined to monitor liver function. Metabolic changes were assessed by metabolomic analyses in the remnant liver and the serum. Liver damage and regeneration were quantified by determination of the apoptotic and proliferation rates. MSCs supported survival after partial hepatectomy. They decreased liver-related blood parameters indicative for the improvement of liver function. The extensive lipid accumulation in hepatocytes illustrating the metabolic overload after resection was attenuated. Treatment with MSCs normalized imbalance of amino acids, acylcarnitines, sphingolipids, and glycerophospholipids in the liver and blood. Furthermore, MSCs decreased the apoptotic rate and increased the proliferation rate. The experimental time period (48 hours) was too short to allow for integration of MSCs into the host liver. Thus, the mode of action was probably indirect. MSCs ameliorated hepatic dysfunction and improved liver regeneration after extended resection by paracrine mechanisms. They may represent a new therapeutic option to treat posthepatectomy acute liver failure.

The Predictive Value of Indocyanine Green Clearance in Future Liver Remnant for Posthepatectomy Liver Failure Following Hepatectomy with Extrahepatic Bile Duct Resection.

Postoperative liver failure (PHLF) is one of the most common complications following major hepatectomy. The preoperative assessment of future liver remnant (FLR) function is critical to predict the incidence of PHLF. To determine the efficacy of the plasma clearance rate of indocyanine green clearance of FLR (ICGK-F) in predicting PHLF in cases of highly invasive hepatectomy with extrahepatic bile duct resection. Five hundred and eighty-five patients who underwent major hepatectomy with extrahepatic bile duct resection, from 2002 to 2014 in a single institution, were evaluated. Among them, 192 patients (33%) had PHLF. The predictive value of ICGK-F for PHLF was determined and compared with other risk factors for PHLF. The incidence of PHLF was inversely proportional to the level of ICGK-F. With multivariate logistic regression analysis, ICGK-F, combined pancreatoduodenectomy, the operation time, and blood loss were identified as independent risk factors of PHLF. The risk of PHLF increased according to the decrement of ICGK-F (the odds ratio of ICGK-F for each decrement of 0.01 was 1.22; 95% confidence interval 1.12-1.33; P<0.001). Low ICGK-F was also identified as an independent risk factor predicting the postoperative mortality. ICGK-F is useful in predicting the PHLF and mortality in patients undergoing major hepatectomy with extrahepatic bile duct resection. This criterion may be useful for highly invasive hepatectomy, such as that with extrahepatic bile duct resection.