Risk Of Postoperative Liver Failure Research Articles

The preoperative fibrosis score 4 predicts posthepatectomy liver failure in patients with hepatocellular carcinoma

Introduction and ObjectivesThe fibrosis score 4 (FIB-4) has been identified as a biochemical surrogate for histological fibrogenesis and fibrosis in cirrhosis. This study investigates the impact of preoperative FIB-4 on postoperative liver failure of patients with hepatocellular carcinoma (HCC). Materials and methodsData from 205 patients who underwent curative resection for HCC were retrospectively analyzed. The receiver operating characteristic (ROC) curve analysis was performed to determine the cutoff value of the FIB-4. Univariate analysis and multivariate analysis were performed to identify risk factors for postoperative liver failure. The clinical outcomes were compared between patients with high FIB-4 and low FIB-4. ResultsThe optimal cutoff value of the FIB-4 was set at 5.92 for postoperative liver failure according to ROC curve. By univariate and multivariate analysis, the number of resected segments, FIB-4, and model for end-stage liver disease score were identified as independent risk factors for postoperative liver failure. Patients with preoperative FIB-4>5.92 had poorer liver function and higher occurrence of postoperative liver failure. ConclusionsPreoperative FIB-4 was associated with postoperative liver failure. Patients with preoperative FIB-4>5.92 carry a high risk of postoperative liver failure.

Surgery for Hilar cholangiocarcinoma: the Newcastle upon Tyne Liver Unit experience

Hilar cholangiocarcinoma (HCCA) arises from the confluence of the common hepatic duct and has a poor prognosis. If resectable, an extended left (eLH) or right hemihepatectomy (eRH) is usually required to provide oncological clearance. We reviewed outcomes for patients with HCCA managed at our centre. Electronic records of patients referred to our centre for HCCA were retrospectively reviewed. The Kaplan–Meier method was used to estimate overall survival (OS) with the log rank test used for significance (p 0.05). Patients undergoing an eLH for HCCA have significantly better long-term outcomes compared to those undergoing eRH, independent of other pathological variables. The functional liver remnant (FLR) is usually smaller following eRH, resulting in a higher risk of post-operative liver failure. Combining CT volumetry with PVE may result in better prediction and optimisation of the FLR in the context of eRH for HCCA. An extended left hemihepatectomy is an independent predictor of survival; investigation into the precise interaction between left- and right-sided resections and pre- and post-embolization liver volume is warranted.

Preoperative Evaluation of Liver Function in Patients with Hepatocellular Carcinoma using the LiMAx Test

Background: Besides liver transplantation, resection surgery provides the best long term survival in patients with hepatocellular carcinoma. To properly select patients for surgery an adequate estimation of liver function is of great clinical importance. Methods: We performed a retrospective analysis of patients diagnosed with HCC that had received the LiMAx test for evaluation of surgical treatment in our department. LiMAx is a non-invasive 13C-breath-test for specific measurement of cytochrom P450 capacity by intravenous administration of 2mg/kg 13C-Methacetin. This system can be purchased commercially. Results: A total of 47 patients were identified. After evaluation of liver function 24 patients received resection surgery. The LiMAx results were higher in resected patients (392 vs. 247 μg/kg/h; P=0,022). Patients diagnosed with liver cirrhosis had significantly lower results (242 vs. 450 μg/kg/h; P<0,006). In 10 patients surgical treatment was cancelled due to reduced liver function (mean LiMAx 181 μg/kg/h). After surgery 7 patients presented with postoperative liver failure (5 patients grade A, 1 grade B and 1 grade C). Histologic assessment revealed complete liver cirrhosis in 5 resected patients not influencing their risk for postoperative liver failure. Conclusion: Evaluation of preoperative liver function by the LiMAx test allows patient selection to reduce severe postoperative liver decompensation. In appropriate patients mortality and morbidity remains low, even in the presence of liver cirrhosis.

Laparoscopic left lateral liver resection is a safe procedure in cirrhotic patients

Background: Patients suffering from liver cirrhosis have a higher risk for postoperative liver failure and other complications. Methods: We retrospectively analyzed the postoperative course of all consecutive patients undergoing laparoscopic left lateral liver resection between July 2009 and September 2016 in our center and compared patients suffering from Child A liver cirrhosis with non-cirrhotic patients. Results: Five of 31 patients suffered from Child A cirrhosis at the time of resection. 8 patients were excluded due to multivisceral resections. Cirrhotic patients were significantly more often male (p=0.027) and significantly older (median 75 years vs. 48 years; p=0.009) compared to non-cirrhotic patients. Length of operation was not significantly different in both groups (non-cirrhotic: median 193 min. vs. non cirrhotic: median 222 min.; p=0.752). While five non-cirrhotic patients (19.2%) had a postoperative complication (grade II (n=3), grade 3a (n=1), grade IIIb (n=1), no complications were observed in the cirrhotic group. No morbidity was observed in neither of the groups. Length of stay did not significantly differ between the two groups (median 6 days vs. median 7 days; p=0.129). Conclusion: Laparoscopic left lateral liver resection is feasible and safe in patients suffering from Child A liver cirrhosis. Although patients in this group were significantly older compared to non cirrhotic patients, the length of operation, postoperative morbidity and length of hospital stay did not significantly differ.

Laparoscopic left lateral liver resection is a safe procedure in cirrhotic patients

Background: Patients suffering from liver cirrhosis have a higher risk for postoperative liver failure and other complications. Methods: We retrospectively analyzed the postoperative course of all consecutive patients undergoing laparoscopic left lateral liver resection between July 2009 and September 2016 in our center and compared patients suffering from Child A liver cirrhosis with non-cirrhotic patients. Results: Five of 31 patients suffered from Child A cirrhosis at the time of resection. 8 patients were excluded due to multivisceral resections. Cirrhotic patients were significantly more often male (p=0.027) and significantly older (median 75 years vs. 48 years; p=0.009) compared to non-cirrhotic patients. Length of operation was not significantly different in both groups (non-cirrhotic: median 193 min. vs. non cirrhotic: median 222 min.; p=0.752). While five non-cirrhotic patients (19.2%) had a postoperative complication (grade II (n=3), grade 3a (n=1), grade IIIb (n=1), no complications were observed in the cirrhotic group. No morbidity was observed in neither of the groups. Length of stay did not significantly differ between the two groups (median 6 days vs. median 7 days; p=0.129). Conclusion: Laparoscopic left lateral liver resection is feasible and safe in patients suffering from Child A liver cirrhosis. Although patients in this group were significantly older compared to non cirrhotic patients, the length of operation, postoperative morbidity and length of hospital stay did not significantly differ.

Laparoscopic right hepatectomy after portal vein ligation: second step of two stage hepatectomy for colorectal liver metastases

Background: Hepatic resection is the treatment of choice for patients with colorectal liver metastases but 75- 85% of patients are unresectable at diagnosis. Many patients with multiple bilobar metastases are not eligible for surgery because of the small future remnant liver (FRL). Patients with impaired hepatic function, scheduled for extended hepatectomy are at greater risk of liver failure. Methods: Two stage hepatectomy (TSH) is a strategy designed to increase the number of patients who may benefit from liver surgery while reducing the risk of postoperative liver failure. Right hepatectomy is now frequently performed laparoscopically, but it may be challenging in the setting of two stage hepatectomy, after left liver clearance and portal vein ligation. Results: The video shows the case of a patient in whom TSH is completed with a laparoscopic right hepatectomy after laparoscopic left liver clearance and PVL. FLR had increased to 49% after portal vein alcohol injection and PLV performed during the first stage. Right hepatic vein is dissected at the caval confluence. Dissection of the right side of the liver pedicle is rather difficult because of the previous PVL. Right hepatic artery and right portal vein are clipped and divided. Parenchimal section is performed with ultrasound dissector. Right bile duct is stapled intraparenchimally. Right hepatectomy is concluded with section of the right hepatic vein. Conclusion: Two stage hepatectomy can performed entirely in laparoscopy in selected patients.

Laparoscopic right hepatectomy with portal vein reconstruction for hepatocelular carcinoma with tumoral portal vein thrombosis in a cirrhotic patient

Background: Performing a hepatectomy to treat a hepatocarcinoma in a cirrhotic patient is associated with improved survival, but may ba a challenging task due to the risk of postoperative liver failure.[1] The use of the laparosopic approach has been widely adopted as it presents lower mortality and postoperative liver failure rates when compared to the open approach.[2] Nevertheless, the use of the laparoscopic approach to treat hepatocarcinomas with advanced vein thrombosis is rarely reported because of the technical challenges involved.[3] Methods: The video presents a totally laparoscopic right hepatectomy with tumor thrombectomy and portal vein reconstruction to treat a large right liver hepatocarcinoma with tumor thrombosis of the right portal vein extending to the main vascular trunk in a chirrotic patient. Results: Operative time was 500 minutes.Estimated blood loss was 275 mililiters. Patient develooped mild ascitis that was managed with diuretics for one month. Patient was discharged on the tenth postoperative day. Eight months after the procedure he was submitted to a CT-scan that disclosed a patent portal vein and no signs of tumor recurrence. Conclusion: In selected patients, the laparoscopic approach may be an effective technique to treat primary liver tumors even in patients with cirrhosis and advanced portal vein tumour thrombosis.

Preoperative evaluation of liver function in patients with hepatocellular carcinoma using the LiMAx Test

Background: Besides liver transplantation, resection surgery provides the best long term survival in patients with hepatocellular carcinoma. To properly select patients for surgery an adequate estimation of liver function is of great clinical importance. Methods: We performed a retrospective analysis of patients diagnosed with HCC that had received the LiMAx test for evaluation of surgical treatment in our department. LiMAx is a non-invasive 13C-breath-test for specific measurement of cytochrom P450 capacity by intravenous administration of 2mg/kg 13C-Methacetin. This system can be purchased commercially. Results: A total of 47 patients were identified. After evaluation of liver function 24 patients received resection surgery. The LiMAx results were higher in resected patients (392 vs. 247 μg/kg/h; P=0,022). Patients diagnosed with liver cirrhosis had significantly lower results (242 vs. 450 μg/kg/h; P<0,006). In 10 patients surgical treatment was cancelled due to reduced liver function (mean LiMAx 181 μg/kg/h). After surgery 7 patients presented with postoperative liver failure (5 patients grade A, 1 grade B and 1 grade C). Histologic assessment revealed complete liver cirrhosis in 5 resected patients not influencing their risk for postoperative liver failure. Conclusion: Evaluation of preoperative liver function by the LiMAx test allows patient selection to reduce severe postoperative liver decompensation. In appropriate patients mortality and morbidity remains low, even in the presence of liver cirrhosis.

Assessment of preoperative liver function in patients undergoing liver resection – The ALICE grade

Objective: Precise preoperative evaluation of the patient's liver function is essential for surgical decision making in patients with hepatocellular carcinoma (HCC) and colorectal liver metastasis (CRLM). The aim of the study is to validate the usefulness of the new preoperative liver function evaluation system, Albumin-Indocyanine Green Evaluation (ALICE) grading system, for predicting the postoperative outcomes after liver resection in both HCC and CRLM patients. Methods: The ALICE grading system, incorporating only serum albumin level and the indocyanine green retention rate at 15 minutes (ICG R15), was developed based on the overall survival of 1868 HCC patients: linear predictor = 0.663 × log10ICG R15 (%) - 0.0718 × albumin (g/L) (cut-off value: -2.20 and -1.39). We analyzed the predictive power for the postoperative short-term outcome after liver resection in 1025 patients with HCC and 348 patients with CRLM. Results: Determination of the ALICE grade allowed better prediction of the risk of postoperative liver failure than the previously reported model based on the presence/absence of portal hypertension (PH). A combination of ALICE grade and PH further predicted the risk of postoperative liver failure. Determination of the ALICE grade also allowed prediction of the risk of postoperative complications and ascites in patients with CRLM, which was also significant in multivariate analysis. Pathological examination revealed chemotherapy related liver damage in high ALICE grade CRLM patients. Conclusions: This new grading system is a simple method for prediction of the postoperative short-term outcomes in both HCC and CRLM patients.

Portal Inflow Modulation by Somatostatin During Major Liver Resection With a High Risk of Postoperative Liver Failure.

Portal Inflow Modulation by Somatostatin During Major Liver Resection With a High Risk of Postoperative Liver Failure.

Laparoscopic extended posterior sectorectomy for metastatic adrenocortical carcinoma: a minimally invasive approach to parenchymal preservation

Background: Parenchymal preservation contributes to improved morbidity and mortality after hepatic resection. Additionally, randomized data supports minimally invasive (MIS) approaches to hepatic resection, resulting in shortened hospitalization, reduced postoperative morbidity, and improved quality of life. The Wakabayashi complexity index for laparoscopic hepatectomy guides patient selection, but the combination of MIS and parenchymal preservation for complex hepatic resections is seldom performed. Methods: A 65-year old male with adrenocortical carcinoma was treated with a laparoscopic left adrenalectomy in 2012. Surveillance MRI 5 years later identified a new 1.7 cm lesion located adjacent to the right hepatic vein in segment 7 (Figure). Percutaneous biopsy was consistent with metastatic adrenocortical carcinoma. Given the prolonged disease-free interval, extended right posterior sectorectomy was recommended. Results: The patient was placed in a split leg French position. A 3-D laparoscope was used and 4 port sites were required. Taking advantage of patient anatomy, the right posterior hepatic artery and portal vein were ligated and divided within the porta hepatis. The translation of open parenchymal transection techniques with crush-clamping, energy, and staplers facilitated safe laparoscopic dissection between the anterior and posterior sectors, with control of intrahepatic vascular structures and ultimate division of the right hepatic vein at its origin. Conclusion: Parenchymal preservation leveraging MIS technique facilitated complete resection of an isolated adrenocortical carcinoma metastasis. Laparoscopic extended posterior sectorectomy allowed for rapid progression through postoperative milestones with early discharge and salvage of the majority of the anterior sector, thereby reducing this patient’s risk for postoperative liver failure and mortality.

Two-stage hepatectomy aiming for the development of intrahepatic venous collaterals for multiple colorectal liver metastases

BackgroundAggressive hepatectomy with venous resection has a higher risk of postoperative liver failure (POLF) than hepatectomy without venous reconstruction; however, venous reconstruction is technically demanding. We performed a novel two-stage hepatectomy (TSH) without venous reconstruction in a patient with bilobar multiple colorectal liver metastases located near the caval confluence, waiting for the development of intrahepatic venous collaterals between procedures.Case presentationA 60-year-old man was referred to our hospital with sigmoid colon cancer accompanied by intraabdominal abscess and two synchronous liver metastases. One of the liver tumors (tumor 1) was located in segment 8 near the caval confluence and was attached to both the right hepatic vein (RHV) and middle hepatic vein (MHV). The other tumor (tumor 2) in the left lobe invaded the umbilical portion of the portal vein. Both liver metastases decreased in size after four cycles of panitumumab/5-fluorouracil, leucovorin, and oxaliplatin (FOLFOX) therapy. Radical liver resection was planned because tumor 1 had not invaded the MHV. However, three-dimensional volumetric software showed that the non-congested volume of the future liver remnant was estimated at 354 ml, which corresponded to 26.3% of the total liver volume. TSH was scheduled to avoid POLF. We first performed limited resection of segment 8 with resection of the RHV root. After the first hepatectomy, the development of intrahepatic venous collaterals between the RHV and MHV was seen on computed tomography and magnetic resonance imaging. The estimated non-congested future liver remnant was 1242 ml, 78.5% of the total liver volume. Therefore, the patient underwent left hemihepatectomy 58 days after the first hepatectomy. We saw no adhesions around the porta hepatis, and the left hepatic artery and left branch of the portal vein were safely exposed and divided. Intraoperative Doppler ultrasonography revealed intrahepatic venous collaterals arising from RHV to MHV. The patient’s postoperative course was uneventful, and he underwent eight cycles of panitumumab/FOLFOX therapy for 5 months after the second hepatectomy.ConclusionsOur TSH strategy helped avoid POLF by waiting for the development of intrahepatic venous collaterals.

Computational Modeling in Liver Surgery.

The need for extended liver resection is increasing due to the growing incidence of liver tumors in aging societies. Individualized surgical planning is the key for identifying the optimal resection strategy and to minimize the risk of postoperative liver failure and tumor recurrence. Current computational tools provide virtual planning of liver resection by taking into account the spatial relationship between the tumor and the hepatic vascular trees, as well as the size of the future liver remnant. However, size and function of the liver are not necessarily equivalent. Hence, determining the future liver volume might misestimate the future liver function, especially in cases of hepatic comorbidities such as hepatic steatosis. A systems medicine approach could be applied, including biological, medical, and surgical aspects, by integrating all available anatomical and functional information of the individual patient. Such an approach holds promise for better prediction of postoperative liver function and hence improved risk assessment. This review provides an overview of mathematical models related to the liver and its function and explores their potential relevance for computational liver surgery. We first summarize key facts of hepatic anatomy, physiology, and pathology relevant for hepatic surgery, followed by a description of the computational tools currently used in liver surgical planning. Then we present selected state-of-the-art computational liver models potentially useful to support liver surgery. Finally, we discuss the main challenges that will need to be addressed when developing advanced computational planning tools in the context of liver surgery.

Predicting the risk of postoperative liver failure and overall survival using liver and spleen stiffness measurements in patients with hepatocellular carcinoma.

Postoperative liver failure (PLF) is the primary cause of morbidity and mortality after hepatic resection for hepatocellular carcinoma (HCC). In this study, we evaluated the efficacy of liver stiffness (LS) and spleen stiffness (SS), as measured by transient elastography (TE), for predicting the risk of PLF and overall survival (OS) in these patients.This prospective cohort study included 54 patients diagnosed with HCC who underwent hepatic resection between March 2013 and March 2014. Preoperative measurement of LS and SS using TE was performed on all patients underwent. The predictivity of LS and SS for PLF was assessed by receiver operating characteristic curve analysis. OS according to LS and SS was analyzed using the Kaplan–Meier method and compared using the log-rank test.PLF developed in seven (12.96%) patients. LS was significantly higher in patients with than in those without PLF (P = .03). The area under the curve of LS for predicting PLF was 0.76 (95% confidence interval, 0.62–0.86; P = .02). However, there was no significant difference in SS between patients with and without PLF (P = .36). Moreover, patients with an LS <16.2 kPa had significantly better OS than those with an LS ≥16.2 kPa (P = .028). No significant difference in OS was observed between patients with an SS of <22.3 and ≥22.3 kPa (P = .378).LS measured by TE can be used to predict the risk of PLF as well as OS in patients with HCC who have undergone hepatic resection. However, SS obtained using TE was not found to be a significant predictor for PLF and OS in our patients.

Liver Stiffness Assessed by Shear Wave Elastography Predicts Postoperative Liver Failure in Patients with Hepatocellular Carcinoma

BackgroundCirrhosis increases a patient’s risk of developing postoperative liver failure (PLF). Liver stiffness (LS), assessed by two-dimensional shear wave elastography (SWE), indicates liver fibrosis with high accuracy. Whether LS is superior to portal hypertension (PHT) in predicting PLF remains to be studied. MethodsThe study enrolled 280 patients who underwent hepatectomy for hepatocellular carcinoma from July 2015 to July 2016. All patients received preoperative assessments for LS, PHT, and serum markers of liver fibrosis in addition to other clinicopathological tests. Risk factors for grade A and grade B (or greater) PLF were subjected to univariate and multivariate analysis and receiver operating characteristic curve analysis. ResultsFifty-five patients (19.6%) experienced PLF. The cutoff value of LS for predicting cirrhosis was 10.1 kPa. Multivariate analysis identified LS, hyaluronic acid, IV collagen, and the presence of splenomegaly as independent predictors of PLF. The cutoff value of LS for predicting PLF and grade B (or greater) PLF was 11.75 and 11.9 kPa, respectively. LS was superior to PHT in predicting PLF or greater than grade B PLF (0.72 vs. 0.60, 0.76 vs. 0.59, P < 0.05). ConclusionLS measured by SWE can predict risk of PLF with greater accuracy than PHT.

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.

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.

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.

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.