Residual Liver Function Research Articles

Turning points in the practice of liver surgery: A historical review.

The history of liver surgery is a tale of progressive resolution of issues presenting one after another from ancient times to the present days when dealing with liver ailments. The perfect knowledge of human liver anatomy and physiology and the development of a proper liver resective surgery require time and huge efforts and, mostly, the study and research of giants of their own times, whose names are forever associated with anatomical landmarks, thorough descriptions, and surgical approaches. The control of parenchymal bleeding after trauma and during resection is the second issue that surgeons have to resolve. A good knowledge of intra and extrahepatic vascular anatomy is a necessary condition to develop techniques of vascular control, paving the way to liver transplantation. Last but not least, the issue of residual liver function after resection requires advanced techniques of volume redistribution through redirection of blood inflow. These are the same problems any young surgeon would face when approaching liver surgery for the first time. Therefore, obtaining a wide picture of historical evolution of liver surgery could be a great starting point to serve as an example and a guide.

Differential liver function at cessation of atezolizumab-bevacizumab versus lenvatinib in HCC: a multicenter, propensity-score matched comparative study.

Atezolizumab+bevacizumab (AB) and lenvatinib have been proposed as first-line treatment options for patients with advanced hepatocellular carcinoma (HCC), but comparative efficacy and associated factors are controversial. This real-world multicenter study analysed patients with HCC who received AB (n=169) or lenvatinib (n=177). First, 1:1 propensity score matching (PSM) was performed, resulting in 141 patients in both the AB and lenvatinib groups. After PSM, overall survival (OS) was better in the AB group than in the lenvatinib group [hazard ratio (HR)=0.642, P=0.009], but progression-free survival (PFS) did not vary between the two groups (HR=0.817, P=0.132). Objective response rate (ORR) was also similar between AB and lenvatinib (34.8% vs. 30.8%, P=0.581). In a subgroup of patients with objective responses (OR, n=78), OS (HR=0.364, P=0.012) and PFS (HR=0.536, P=0.019) were better in the AB group (n=41) than in the lenvatinib group (n=37). Time-to-progression from time of OR was also better in the AB group (HR=0.465, P=0.012). Importantly, residual liver function was a significant factor related to OS in both treatments. Child-Pugh score following cessation of the respective treatments was better in the AB group (n=105) than in the lenvatinib group (n=126) (median 6 versus 7, P=0.008), and proportion of salvage treatment was also higher in the AB group (52.4% versus 38.9%, P=0.047). When we adjusted for residual liver function or salvage treatment, there was no difference in OS between the two treatments. Our study suggests that residual liver function and subsequent salvage treatments are major determinants of clinical outcomes in patients treated with AB and lenvatinib; these factors should be considered in future comparative studies.

Remnant liver function is associated with long-term survival in patients with hepatocellular carcinoma undergoing hepatectomy

It is important to assess the prognosis and intervene before and after surgery in patients with hepatocellular carcinoma. This study aims to elucidate the association of outcomes and residual liver function after hepatectomy. A total of 176 patients who underwent the initial resection for hepatocellular carcinoma between January 2011 and March 2021 at Jichi Medical University were included. Hepatic clearance of the remnant liver was measured using 99mTc-galactosyl serum albumin scintigraphy. The log-rank test was used to analyze survival using the Kaplan–Meier method. Hazard ratios (HR) and 95% confidence intervals (CI) for overall survival were calculated using Cox’s proportional hazard model. In multivariate analysis, microvascular invasion, intraoperative blood loss, and hepatic clearance of the remnant liver were independently associated with overall survival. Hepatic clearance of the remnant liver was independently associated with recurrence free survival. This is the first report to show that lower residual liver function is associated with shorter survival in patients with hepatocellular carcinoma undergoing hepatectomy. Preoperative determination of remnant liver function may allow assessment of prognosis in patients planned to undergo resection of hepatocellular carcinoma. Preservation of liver functional reserve may be crucial for improved long-term outcomes after hepatectomy.

Is an intraoperative liver function assessment possible? Application of the 13C-methacetin-breath-test during major liver resections – a pilot study

BackgroundAs prevention of posthepatectomy-liver-failure is crucial, there is need of dynamic assessment of liver function, even intraoperatively. 13C-methacetin-breath-test estimates the organ's microsomal functional capacity. This is its first intraoperative evaluation in major liver surgery. Methods30 patients planed for resection of ≥3 liver segments, between March-November 2019, were prospectively enrolled in this “single-center”, pilot study. Using the 13C-methacetin-breath-test, liver function was assessed four times: preoperatively, intraoperatively before and after resection and postoperatively. The resulted maximum-liver-function-capacity (LiMAx)-values and delta-over-baseline (DOB)-curves were compared, further analyzed and correlated to respective liver volumes. ResultsThe intraoperative LiMAx-values before resection were mostly lower than the preoperative ones (-11.3% ± 28%). The intraoperative measurements after resection resulted to mostly higher values than the postoperative ones (42.35% ± 46.19%). Pharmacokinetically, an interference between the two intraoperative tests was observed. There was no strong correlation between residual liver volume and function with a percentual residual-LiMAx mostly lower than the percentual residual volume (-17.7% ± 4.1%). ConclusionsIntraoperative application of the 13C-methacetin-breath-test during major liver resections seems to deliver lower values than the standard preoperative test. As multiple intraoperative tests interfere significantly to each other, a single intraoperative measurement is suggested. Multicentric standardized measurements could define the “normal” range for intraoperative measurements and control their predictive value.

Holistic management of hepatocellular carcinoma: The hepatologist's comprehensive playbook.

Hepatocellular carcinoma (HCC) is a common complication in patients with chronic liver disease and leads to significant morbidity and mortality. Liver disease and liver cancer are preventable by mitigating and managing common risk factors, including chronic hepatitis B and C infection, alcohol use, diabetes, obesity and other components of the metabolic syndrome. The management of patients with HCC requires treatment of the malignancy and adequate control of the underlying liver disease, as preserving liver function is critical for successful cancer treatment and may have a relevant prognostic role independent of HCC management. Hepatologists are the ideal providers to guide the care of patients with HCC as they are trained to identify patients at risk, apply appropriate surveillance strategies, assess and improve residual liver function, evaluate candidacy for transplant, provide longitudinal care to optimize and preserve liver function during and after HCC treatment, survey for cancer recurrence and manage its risk factors, and prevent and treat decompensating events. We highlight the need for a team-based holistic approach to the patient with liver disease and HCC and identify necessary gaps in current care and knowledge.

Real-World Single-Center Clinical Data on Sorafenib in Patients with Unresectable Hepatocellular Carcinoma

"Introduction. Hepatocellular carcinoma (HCC) is a malignant tumor that frequently develops in conjunction with chronic liver disease and cirrhosis, and is often identified late in its course, with a median survival of around 6 to 20 months following diagnosis. Although surgical excision is the gold standard of treatment, most patients are ineligible due to tumor size or underlying liver dis-ease. The hepatic reserve of the patient, as determined by the Child-Turcotte-Pugh classification, frequently influences treatment options. Method. Between January 2016 and June 2018, 42 patients admitted to Fundeni Clinical Institute's Department of Medical Oncology who had previously been treated with Sorafenib for more than two months were recruited in this retrospective analysis. We evaluated the etiology and stage of illness (BCLC), residual liver function (CHILD), performance status (ECOG), treatment response and side effects, progression-free survival, and overall survival. Results. The study group had good short and long-term outcomes: median progression-free survival was 7.7 months and median overall survival was 11.6 months. The most frequently reported adverse effects were skin rashes, diarrhea, hypertension, and hand-foot skin reaction. Conclusion. This retrospective, single-center study confirmed the benefit of sorafenib in the treatment of advanced HCC, particularly in patients with good liver function and performance status. Method. Between January 2016 and June 2018, 42 patients admitted to Fundeni Clinical Insti-tute's Department of Medical Oncology who had previously been treated with Sorafenib for more than two months were recruited in this retrospective analysis. We evaluated the etiology and stage of illness (BCLC), residual liver function (CHILD), performance status (ECOG), treatment response and side effects, progression-free survival, and overall survival. Results. The study group had good short and long-term outcomes: median progression-free survival was 7.7 months and median overall survival was 11.6 months. The most frequently-re-ported adverse effects were skin rashes, diarrhea, hypertension, and hand-foot skin reaction. Conclusion. This retrospective, single-center study confirmed the benefit of sorafenib in the treatment of advanced HCC, particularly in patients with good liver function and performance sta-tus"

Uridine alleviates carbon tetrachloride-induced liver fibrosis by regulating the activity of liver-related cells.

At present, liver fibrosis is a major challenge of global health. When hepatocyte regeneration cannot compensate for hepatocyte death, it will develop into liver fibrosis in chronic liver disease. Initially, collagen produced by myofibroblasts plays a role in maintaining liver integrity, but excessive collagen accumulation can inhibit the residual liver function, leading to liver failure. At present, many scientists are actively looking for drugs to alleviate liver fibrosis. In the current study, we investigated the potential role of uridine in the treatment of liver fibrosis (uridine is a plant/animal‐derived pyrimidine nucleoside, therefore uridine can also be ingested and absorbed by the body, accompanied by the process of food intake). For this, we systematically studied the effect of uridine on CCl4‐induced liver fibrosis in vitro and in vivo through a series of technologies, such as Western blot, laser confocal scanning microscope, ELISA and immunohistochemistry. The experimental results showed that uridine can effectively reduce the accumulation of collagen in liver. Furthermore, uridine can improve the activity of liver cells and alleviate CCl4‐induced liver injury. Furthermore, uridine can significantly alleviate the risk factors caused by hepatic stellate cell activation, uridine treatment significantly down‐regulated the expression of α‐SMA, collagen type‐I and fibronectin. In conclusion, the current research shows that uridine can alleviate CCl4‐induced liver fibrosis, suggesting that uridine can be used as a potential drug to alleviate liver fibrosis.

Hepatocellular CarcinomaPost Viral Hepatitis B and C:Application of the PrognosticScore of Singapore

Surgical resection of hepatocellular carcinoma (HCC) is a major curative option in patients with adequate residual liver function. The risk of recurrence is extremely high. The Singapore liver cancer recurrence (SLICER) is a nomogram that evaluates the 3-year and 5-year recurrence-free survival (RFS) of patients operated for HCC. The objectives of our study were: To apply the SLICER prognostic score to a series of patients operated for a CHC To compare the results found with specific evolutionary data in our patients

Expression of MMP-2 in residual VX2 liver tumor after transcatheter arterial embolization combined with portal venous embolization in an animal model

ObjectiveThis study aimed to analyze the effects of transcatheter arterial embolization (TAE) combined with portal venous embolization (PVE) on the expression of MMP-2 in residual VX2 liver tumor tissues, liver function and non-embolic lobe regeneration. MethodsA total of 72 rabbits were randomly divided into Sham, TAE, PVE and TAE ​+ ​PVE groups (n ​= ​18/group). The tissue samples from each group were taken at 6 ​h, 3 days and 7 days after interventional operation, respectively. MMP-2 expression was detected by immunohistochemistry, Real-time PCR, and Western-blotting. The main indicators (such as AST, ATL, and TBIL) of liver function and the volume of non-embolized hepatic lobes were measured in each group after operation. One-way ANOVA and Kruskal-wallis method were used for statistical analysis. ResultsThe expression of MMP-2 mRNA and protein remained the highest in the Sham group, and the expression of MMP-2 mRNA and protein in TAE, PVE and TAE ​+ ​PVE groups were successively increased, and the expression of MMP-2 in TAE ​+ ​PVE group was always significantly higher than TAE group. The AST and ALT levels in each group on day 7 after operation showed a significant declination, and all groups have recovered to the preoperative baseline level and TBIL has a slight fluctuation in each group after operation with no statistical difference. On day 7 after operation, the increasing volume of non-embolized liver lobes in TAE ​+ ​PVE group showed a more significant effect than those in PVE group, but there was no statistical significance (37.62 ​± ​1.54 ​ml VS 36.18 ​± ​1.15 ​ml, P ​= ​0.881), and its volume was significantly higher than those in the sham group (27.03 ​± ​1.11 ​ml). ConclusionTAE ​+ ​PVE is considered to be an efficient and safe approach for treating rabbit VX2 liver transplantation tumor, but the expression of MMP-2 increased fastest after TAE ​+ ​PVE, which might promote tumor cell invasion and metastasis.

Role of residual liver volumetry and function in prediction of liver tolerability after transarterial chemoembolization for hepatocellular carcinoma in cirrhotic patients: deriving a clinical decision support score

BackgroundTransarterial chemoembolization (TACE) is the recommended treatment modality for non-resectable intermediate-stage hepatocellular carcinoma; however, this stage has wide variable levels of liver functions and tumor burden making a challenge as regards the tolerability of the functioning residual liver to this type of therapy. Further stratification of this intermediate stage may help the clinical decision for the suitability of TACE, so we tried to derive a clinical decision support tool to predict the tolerability of the functioning residual liver to TACE using pre-intervention liver reserve function and liver residual volume as well as tumor burden.ResultsTwo hundred and fifty-two patients with non-resectable intermediate-stage hepatocellular carcinoma (HCC) were consecutively included in this cohort study; all patients were blindly followed up for 6 weeks after TACE for manifestation of liver decompensation. For univariate logistic regression analysis, the significant predictors were age, s.albumin, s.bilirubin, prothrombin concentration (PC), tumor volume (TV), residual liver volume (RLV), and residual to liver volumetric ratio (RLVR) (sig, 0.007, 0.000, 0.000, 0.000, 0.000, 0.002, and 0.000, respectively). Multivariate logistic regression analysis illustrated that s.albumin, s.bilirubin, PC, and RLVR were the most independent significant predictors (sig, 0.000 for all with adjusted OR 0.002, 22.692, 0.827, and 0.000, respectively). The discriminatory performance of our proposed decision support score (liver tolerability score) was evaluated using the receiver operating characteristics that identified two cutoff points (≤ 0.30 and ≥ 0.83) to rule out or rule in the possibility of liver decompensation after TACE, respectively (AUC, 0.942 and sig. 0.000). Liver tolerability score stratified the intermediate stage of HCC to 3 risk grades (low, medium, and high) with significant difference as regards hazard distribution.ConclusionComputed tomography image-based assessment of RLVR may have a possible role in predicting future tolerability of the functioning residual tissue to TACE of HCC. Liver tolerability score (LTS) could stratify the intermediate stage HCC to 3 risk grades, so LTS may have a role in clinical decision for the suitability of TACE for intermediate stage HCC.

Radiomics model based on preoperative gadoxetic acid-enhanced MRI for predicting liver failure.

BACKGROUNDPostoperative liver failure is the most severe complication in cirrhotic patients with hepatocellular carcinoma (HCC) after major hepatectomy. Current available clinical indexes predicting postoperative residual liver function are not sufficiently accurate.AIMTo determine a radiomics model based on preoperative gadoxetic acid-enhanced magnetic resonance imaging for predicting liver failure in cirrhotic patients with HCC after major hepatectomy.METHODSFor this retrospective study, a radiomics-based model was developed based on preoperative hepatobiliary phase gadoxetic acid-enhanced magnetic resonance images in 101 patients with HCC between June 2012 and June 2018. Sixty-one radiomic features were extracted from hepatobiliary phase images and selected by the least absolute shrinkage and selection operator method to construct a radiomics signature. A clinical prediction model, and radiomics-based model incorporating significant clinical indexes and radiomics signature were built using multivariable logistic regression analysis. The integrated radiomics-based model was presented as a radiomics nomogram. The performances of clinical prediction model, radiomics signature, and radiomics-based model for predicting post-operative liver failure were determined using receiver operating characteristics curve, calibration curve, and decision curve analyses.RESULTSFive radiomics features from hepatobiliary phase images were selected to construct the radiomics signature. The clinical prediction model, radiomics signature, and radiomics-based model incorporating indocyanine green clearance rate at 15 min and radiomics signature showed favorable performance for predicting postoperative liver failure (area under the curve: 0.809-0.894). The radiomics-based model achieved the highest performance for predicting liver failure (area under the curve: 0.894; 95%CI: 0.823-0.964). The integrated discrimination improvement analysis showed a significant improvement in the accuracy of liver failure prediction when radiomics signature was added to the clinical prediction model (integrated discrimination improvement = 0.117, P = 0.002). The calibration curve and an insignificant Hosmer-Lemeshow test statistic (P = 0.841) demonstrated good calibration of the radiomics-based model. The decision curve analysis showed that patients would benefit more from a radiomics-based prediction model than from a clinical prediction model and radiomics signature alone.CONCLUSIONA radiomics-based model of preoperative gadoxetic acid–enhanced MRI can be used to predict liver failure in cirrhotic patients with HCC after major hepatectomy.

Advanced fibrosis of non-alcoholic steatohepatitis affects the significance of lipoprotein(a) as a cardiovascular risk factor

Background and aimsLipoprotein(a) [Lp(a)] is an important independent cardiovascular risk factor. However, Lp(a) levels are lower in patients with chronic liver disease than in healthy subjects. Furthermore, Lp(a) levels decrease as residual liver function declines. Although non-alcoholic fatty liver disease (NAFLD), especially advanced non-alcoholic steatohepatitis (NASH), increases the risk of cardiovascular diseases, the relationship between serum Lp(a) level and NASH is unknown. Thus, we examined the relationship between serum Lp(a) levels and biopsy-proved NAFLD and clarified the significance of Lp(a) measurements for cardiovascular disease screening in patients with NAFLD. MethodsA total of 176 patients with NAFLD were enrolled. Comprehensive blood chemistry tests and histological examinations of liver samples were conducted. The relationship between serum Lp(a) levels and NAFLD was analyzed. ResultsSerum Lp(a) levels in advanced fibrosis (stage 3–4) were lower than those in non-advanced fibrosis (stage 0–2) (p < 0.05). After adjustment for age, sex, body mass index, alanine aminotransferase (ALT), creatinine (Cre), HbA1c level, high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), triglycerides (TG), and the use of lipid-lowering agents, the significant inverse association between advanced fibrosis and serum Lp(a) levels remained (p < 0.01). Although the Lp(a) level was inversely associated with an NAFLD Activity Score (NAS) of 5–8, there was no significant association between Lp(a) levels and NAS adjusted for age, sex, body mass index, ALT, Cre, HbA1c level, HDL-C, LDL-C, TG, and the use of lipid-lowering agents. ConclusionsAdvanced NASH is associated with low serum Lp(a) levels; therefore, Lp(a) levels may not be useful in evaluating cardiovascular risk.

Novel liver fibrosis model in Macaca fascicularis induced by thioacetamide

Although transplantation is the only definitive treatment for liver cirrhosis, there remains a shortage of donors, necessitating that novel treatments be developed. We aimed to establish a liver fibrosis model in Macaca fascicularis that can help accelerate preclinical research. Liver fibrosis was induced by administering thioacetamide (TAA) and carbon tetrachloride (CCl4). Analysis of residual liver function and fibrosis progression was based on clinical indices, such as the Child–Pugh score or fibrotic markers, besides histology. TAA-induced marked fibrosis, whereas CCl4 did not induce fibrosis. Concerning residual liver function, both of TAA and CCl4 worsened the indices of the Child–Pugh score, but only the TAA model increased the retention ratio of indocyanine green. The TAA-induced fibrosis model in Macaca fascicularis worsens fibrosis and residual liver function, mimicking Child–Pugh grade B. Given that our model was evaluated by clinical indices, it could be applicable to preclinical research.

Increment of plasma glucose by exogenous glucagon is associated with present and future renal function in type 2 diabetes:a retrospective study from glucagon stimulation test

BackgroundGlucagon stimulation test (GST) is often employed to assess the insulin reserve of the pancreatic beta cells in diabetic subjects. The clinical significance of the increment of plasma glucose (Δglucose) by exogenous glucagon during GST has not been elucidated. We investigated the relationship between Δglucose and clinical parameters including the liver and renal function in type 2 diabetic subjects, since we hypothesized that Δglucose is associated with the liver and renal function reflecting the capacity for gluconeogenesis in the organs.MethodsA total of 209 subjects with type 2 diabetes who underwent GST during admission were included in this cross-sectional study. We defined the difference between plasma glucose at fasting and 6 min after intravenous injection of 1 mg glucagon as Δglucose. We assessed correlations between Δglucose and clinical parameters such as diabetic duration, BMI, HbA1c, beta cell function, serum free fatty acids (FFA) which is known to stimulate gluconeogenesis, liver function, the indices of liver function, renal function, and urinary albumin excretion (UAE).ResultsIn correlation analysis, Δglucose positively correlated to FFA and estimated glomerular filtration rate (eGFR), but inversely to serum creatinine and cystatin C, although Δglucose showed no correlation with both liver function and the indices of residual liver function. Multiple regression analysis revealed that Δglucose was an independent determinant for the eGFR after 1 year, equally BMI, HbA1c, serum lipids, and UAE, which are known as the predictors for the development of chronic kidney disease.ConclusionOur results suggest that Δglucose during GST might be related to gluconeogenesis in the kidney and could be the determinant of future renal function in type 2 diabetes.

Efficacy and safety of dacron patch in surgical treatment of congenital disease by echocardiography

To evaluate the efficacy and safety of a new domestic dacron patch in the surgical treatment of congenital heart disease (CHD) with infective endocarditis (IE), a clinical controlled trial is conducted. 48 patients with CHD complicated with IE are selected and randomly divided into two groups. 26 patients in the experimental group are treated with a new domestic dacron patch, while 22 patients in the control group are treated with an imported cardiac polyester patch. By echocardiography, collecting chest X-ray, echocardiography and laboratory examination before and after operation, the residual shunt, cardiac function, liver function, renal function, coagulation function and other related indicators are observed after operation in the two groups, and the therapeutic effect and safety of the new dacron patch are evaluated. The results showed that there is no significant difference in C/T (cardiothoracic ratio), LAD (Left atrial diameter), LVSD (left ventricular end systolic diameter) and LVDD (left ventricular end diastolic diameter) between the two groups before operation, before discharge and 1, 3 and 6 months after discharge (P>0.05). The C/T, LAD and LVDD of the two groups decrease 6 months after operation, and the size of atrioventricle decreases significantly. There is a decreasing trend in the experimental group compared with the control group, but there is no significant difference (P>0.05). There are no significant differences in cardiac function classification, echocardiography, electrocardiogram, patch performance evaluation and blood compatibility between the two groups before operation and 6 months after discharge. ConclusionThe new domestic dacron patch has good clinical efficacy and safety.

Elevated apolipoprotein B predicts poor postsurgery prognosis in patients with hepatocellular carcinoma.

AimsTo date, curative resection remains to be the most optimal therapeutic choice of hepatocellular carcinoma (HCC), though the overall survival (OS) remains extremely unsatisfactory. To better manage the HCC patients, we evaluated the prognosis predicting values of apolipoprotein B (ApoB) and low-density lipoprotein cholesterol (LDL-C) on the long-time survival of patients who underwent surgical treatment in this study.MethodsA subgroup of 164 patients from our previously described follow-up cohort were enrolled in this study, of whom the pre-surgery ApoB and LDL-C measurements were available. They had been followed until January 2017, with a 19.5 months median survival time. The prognosis predicting values of serum ApoB, LDL-C, and other clinical variables were evaluated through Cox univariate and multivariate analyses, meanwhile, Kaplan–Meier analysis was conducted to obtain the OS curves.ResultsPre-surgery ApoB was an independent prognosis predicting factor with HR as 1.396 (P=0.033), elevated ApoB was associated with worse postsurgery prognosis in HCC patients. Concordantly, Spearman’s correlation analysis revealed that value of pre-surgery ApoB was to some extent correlated with tumor size (r=0.355, P<0.001). In line with this, further univariate and multivariate logistic regression analysis revealed that patients with higher ApoB value were more likely to have larger tumor size (≥5 cm), with the OR value as high as 2.221 (95% CI: 1.288–3.830, P=0.004). Additionally, level of ApoB was found to be highly correlated with the serum level of LDL-C (r=0.686, P<0.001).ConclusionApoB could be a valuable novel prognosis predicting marker for HCC patients who underwent curative liver resection. Moreover, elevated ApoB level could indicate worse outcome in HCC patients, which could be explained by the relationship between ApoB and residual liver function.

A randomized controlled trial for enhanced recovery in liver surgery: improved perioperative management using the LiMAx test

Background: The LiMAx test can validly determine liver maximal capacity and has been successfully integrated in clinical management in liver surgery. However, no prospective randomized trials have been available to judge its actual clinical impact. Methods: A randomized controlled trial (RCT) was conducted from January 2013 to September 2015 in six recruiting hospitals. Patients prior open liver resection of at least one segment were included. Patients were randomly assigned to LiMAx group (pre-, and postoperative LiMAx test) or control group (standard-of-care). Stable patients with sufficient residual liver function (LiMAx >150 μg/kg/h) were directly transferred to general ward after surgery. Results: A total of 148 patients were randomized. Patients in LiMAx group were more frequently directly transferred to general ward after surgery (62.1% vs. 1.7%; p<0.0001), the risk of severe postoperative complications was lower (≥ grade IIIa; 14% vs. 28%; p<0.02) and the length of post-operative stay was shorter (10 vs. 13 days; p=0.01). No patient in LiMAx group was admitted to intensive care after primary transfer to general ward. Conclusion: The LiMAx test distinctively improves perioperative management in liver surgery. The valid identification of low risk patients skipping intensive care enables enhanced recovery.

A randomized controlled trial for enhanced recovery in liver surgery: Improved perioperative management using the LiMAx test

Background: The LiMAx test can validly determine liver maximal capacity and has been successfully integrated in clinical management in liver surgery. However, no prospective randomized trials have been available to judge its actual clinical impact. Methods: A randomized controlled trial (RCT) was conducted from January 2013 to September 2015 in six recruiting hospitals. Patients prior open liver resection of at least one segment were included. Patients were randomly assigned to LiMAx group (pre-, and postoperative LiMAx test) or control group (standard-of-care). Stable patients with sufficient residual liver function (LiMAx >150 μg/kg/h) were directly transferred to general ward after surgery. Results: A total of 148 patients were randomized. Patients in LiMAx group were more frequently directly transferred to general ward after surgery (62.1% vs. 1.7%; p<0.0001), the risk of severe postoperative complications was lower (≥ grade IIIa; 14% vs. 28%; p<0.02) and the length of post-operative stay was shorter (10 vs. 13 days; p=0.01). No patient in LiMAx group was admitted to intensive care after primary transfer to general ward. Conclusion: The LiMAx test distinctively improves perioperative management in liver surgery. The valid identification of low risk patients skipping intensive care enables enhanced recovery.

Hepatobiliary scintigraphy combined with SPECT/CT in predicting liver failure before major hepatectomy: preliminary results of the HIBA-index at a single center

Introduction: Hepatobiliary scintigraphy (HBS) is able to estimate future liver remnant function (FLR-F) and may be useful to predict post-hepatectomy liver failure (PHLF) before major hepatectomy. Existing cut-off values for PHLF (FLR-F < 2.69%/min/m2) were previously set using only planar acquisitions but not combined with single photon emission computed tomography (SPECT/CT). A new index, the so-called Hospital Italiano De Buenos Aires index (HIBA-i), has been recently used to measure sectorial liver function in two-stage hepatectomy setting. Method: All consecutive patients submitted to major hepatectomy between November 2016 and November 2017 at Sant'Orsola-Malpighi Hospital (Bologna, Italy), were analyzed. Patients were resected according to their preoperative volumetry. Data regarding preoperative HBS were retrospectively reviewed. FLR-F and HIBA-i were calculated as previously described. PHLF was defined according to the International Study Group of Liver Surgery criteria. Results: Twenty-seven patients were submitted to major hepatectomy (13 right hepatectomies, 8 left hepatectomies, 5 right trisectionectomies, 1 left trisectionectomy). PHLF (grade A/B/C) was observed in 9 out of 27 patients (33.3%). The HIBA-i differed significantly (p=0.002) between patients with (14.37%, IQR 8.64-16.14) and without PHLF (24.31%, IQR 15.74-39.53). Eight of 16 patients with a preoperative FLR-F < 2.69 %/min/m2 did not experienced PHLF. FLR volumes between the two groups did not show any statistical significance. Conclusions: The HIBA-i seems a promising tool able to estimate residual liver function. Prospective clinical trial are warranted to define more precise cut-offs of FLR-F when SPECT/CT is associated.

Prediction of Posthepatectomy Liver Failure Proposed by the International Study Group of Liver Surgery: Residual Liver Function Estimation With 99mTc-Galactosyl Human Serum Albumin Scintigraphy.

The International Study Group of Liver Surgery (ISGLS) proposed a definition and grading system for posthepatectomy liver failure (PHLF). We evaluated the usefulness of residual liver function estimation using Tc-galactosyl human serum albumin (Tc-GSA) for the prediction of PHLF. Patients with liver tumors (n = 136) and scheduled for hepatectomy underwent Tc-GSA scintigraphy. Based on their imaging data, the maximal GSA removal rate (GSA-Rmax)was calculated using multicompartment analysis. We also calculated GSA-Rmax in the predicted residual liver (GSA-RL) whose volume was determined on computed tomography (CT) scans. We compared the age, sex, 15-minute indocyanine green retention rate; albumin, bilirubin, hyaluronic acid, and type 4 collagen levels; the Child-Pugh classification; residual liver volume; residual liver percentage; GSA-Rmax; and GSA-RL in patients with and without PHLF. Univariate and multivariate logistic analyses were used for statistical assessments. Of 136 patients, 17 (12.5%) met the ISGLS criteria for PHLF (ISGLS-PHLF). There was a statistically significant difference in the age, albumin level, Child-Pugh classification, residual liver volume, residual liver percentage, GSA-Rmax, and GSA-RL between patients with and without PHLF. Based on multivariate analysis, GSA-RL and the residual liver volume were significant independent predictors of ISGLS-PHLF (P = 0.004 and P = 0.038, respectively). The odds ratio was 149423 for GSA-RL and 1.003 for the residual liver volume. GSA-RL calculated using Tc-GSA scintigraphy was the most useful independent predictor for ISGLS-PHLF.