Standard Liver Volume Research Articles

Association of standardized liver volume and body mass index with outcomes of minimally invasive liver resections.

While minimally invasive liver resections (MILR) have demonstrated advantages in improved post-operative recovery, widespread adoption is hampered by inherent technical difficulties. Our study attempts to analyze the role of anthropometric measures in MILR-related outcomes. Between 2012 and 2020, 676 consecutive patients underwent MILR at the Singapore General Hospital of which 565 met study criteria and were included. Patients were stratified based on Body Mass Index (BMI) as well as Standardized Liver Volumes (SLV). Associations between BMI and SLV to selected peri-operative outcomes were analyzed using restricted cubic splines. A BMI of ≥ 29 was associated with increase in blood loss [Mean difference (MD) 69 mls, 95% CI 2 to 137] as well as operative conversions [Relative Risk (RR) 1.63, 95% CI 1.02 to 2.62] among patients undergoing MILR while a SLV of 1600cc or higher was associated with an increase in blood loss (MD 30 mls, 95% CI 10 to 49). In addition, a BMI of ≤ 20 was associated with an increased risk of major complications (RR 2.25, 95% 1.16 to 4.35). The magnitude of differences observed in these findings increased with each unit change in BMI and SLV. Both BMI and SLV were useful anthropometric measures in predicting peri-operative outcomes in MILR and may be considered for incorporation in future difficulty scoring systems for MILR.

Factors Associated With Postreperfusion Syndrome in Living Donor Liver Transplantation: A Retrospective Study.

Postreperfusion syndrome (PRS) after portal vein reperfusion during liver transplantation (LT) has been reported to cause rapid hemodynamic changes and is associated with a prolonged postoperative hospital stay, renal failure, and increased mortality. Although there are some reports on risk factors for PRS in brain-dead donor LT, there are a few reports on those in living donor LT. Therefore, we retrospectively reviewed the factors associated with PRS to contribute to the anesthetic management so as to reduce PRS during living donor LT. After approval by the ethics committee of our institution, 250 patients aged ≥20 years who underwent living donor LT at our institution between January 2013 and September 2018 were included in the study. A decrease in mean arterial pressure of ≥30% within 5 minutes after portal vein reperfusion was defined as PRS, and estimates and odds ratio (OR) for PRS were calculated using logistic regression. The backward method was used for variable selection in the multivariable analysis. Serum calcium ion concentration before reperfusion (per 0.1 mmol/L increase; OR, 0.74; 95% confidence interval (CI), 0.60-0.95; P < .001), preoperative echocardiographic left ventricular end-diastolic diameter (per 1-mm increase: OR, 0.90; 95% CI, 0.85-0.95; P < .001, men [versus women: OR, 2.45; 95% CI, 1.26-4.75; P = .008]), mean pulmonary artery pressure before reperfusion (restricted cubic spline, P = .003), anhepatic period (restricted cubic spline, P = .02), and graft volume to standard liver volume ratio (restricted cubic spline, P = .03) were significantly associated with PRS. In living donor LT, male sex and presence of small left ventricular end-diastolic diameter, large graft volume, and long anhepatic period are associated with PRS, and a high calcium ion concentration and low pulmonary artery pressure before reperfusion are negatively associated with PRS.

Dynamic changes of hepatic microenvironment related to graft function in donation after cardiac death liver transplantation

PurposeThe study aimed to evaluate dynamic changes in the liver microenvironment at 3 weeks, 3 months, and 6 months following donation after cardiac death liver transplantation (DCDLT) using multiparametric MRI, and further explore the correlation between the hepatic microenvironment and liver function after DCDLT. MethodsTwenty-seven patients after DCDLT (the LT group) at times of 3 weeks (LT-3W), 3 months (LT-3M), and 6 months (LT-6M) and 20 normal volunteers (the N group) underwent intravoxel incoherent motion (IVIM), diffusion tensor imaging (DTI), and blood oxygen level-dependent (BOLD) MR scanning. One-way repeated-measures ANOVA was used to compare MR parameters and liver volume (LV)/estimated standard liver volume (ESLV) at three follow-up times in the LT group. An independent sample t-test was used to compare MR parameters and LV/ESLV between each time of the LT group and the N group. Pearson and Spearman correlation analyses were employed to assess the correlation between MR parameters and liver blood indicators, LV/ESLV after DCDLT. ResultsAfter DCDLT, true diffusion coefficient (Dslow), pseudo diffusion coefficient (Dfast), perfusion fraction (PF), and apparent diffusion coefficient (ADC) values were increased, and fractional anisotropy (FA) and R2* values were decreased. Dfast values in the LT-3M and LT-6M were significantly higher than in the LT-3W. Compared to the LT-3W, PF and ADC values were significantly increased and R2* values were significantly decreased in the LT-6M (all P < 0.05). All MR parameters in the LT-3W were significantly different from the N group, and Dfast and ADC values in the LT-6M remained significantly higher than in the N group (all P < 0.05). In the LT group, Dslow, Dfast, PF, and ADC values were correlated with liver blood indicators and LV/ESLV (|r| = 0.364–0.561, all P < 0.05). ConclusionAfter DCDLT, the hepatic microenvironment showed an improving trend, which was correlated to the liver function. Except for the microcirculatory perfusion, the hepatic microenvironment was close to normality at six months.

Comparison of liver regeneration between donors and recipients after adult right lobe living-donor liver transplantation.

Living-donor liver transplantation (LDLT) is recognized as the standard treatment for end-stage liver diseases. The regeneration of the residual liver and graft after LDLT is important in evaluating surgical success. Previous studies have attempted to elucidate mechanisms, principles of liver regeneration after LDLT, or influencing factors. However, they have not ruled out patients with complications and reached a uniform conclusion. In this study, for the first time, we unified measurement methods of liver volumes and eliminated patients with complications to compare liver regeneration trends between donors and recipients after LDLT and search for potential influencing factors. A total of 61 donors and 62 recipients without complications after adult right lobe LDLT were included in this retrospective observational cohort study. The liver regeneration ratios (LRRs) at different time points in donors and recipients after LDLT were calculated and compared. Factors that affect LRRs include gender, age, graft with or without the middle hepatic vein (MHV), initial remnant liver (IRLV)/estimated standard liver volume (ESLV), initial graft volume (IGV)/ESLV, Child-Pugh grade, and model for end-stage liver disease (MELD) score of the recipients. Analysis of variance, independent-sample t-test, and correlation analysis were performed for statistical analyses. Significant differences were found in LRRs between the donors and recipients after LDLT (all P<0.05). The LRRs of donors at 0.5, 1, 3, and 6 months were 80.80%±24.12% (72.87%, 88.73%), 98.62%±37.47% (75.97%, 121.26%), 103.34%±23.47% (83.73%, 122.96%), and 130.18%±17.68% (102.04%, 158.32%), respectively. The LRRs of recipients at 0.5, 1, 3, and 6 months were 58.49%±26.67% (49.04%, 67.95%), 50.16%±27.25% (40.94%, 59.38%), 44.36%±26.75% (35.30%, 53.41%), and 31.19%±22.57% (20.91%, 41.47%), respectively. The former values were higher than the latter. The LRRs of recipients with the MHV was higher than those without MHV at 1 and 3 months (P<0.05). The LRRs at 1 month were 59.63%±27.48% and 41.68%±24.73%, and at 3 months were 57.25%±25.42% and 32.81%±22.79%, respectively. The IRLV/ESLV and IGV/ESLV were negatively correlated with LRRs at several times [r=-0.419 (-0.646, -0.134), -0.608 (-0.832, -0.318), respectively; P<0.05]. At 0.5 month, significant difference was found between Child-Pugh score of ≤9.55 and >9.55 (P<0.05) and MELD score of ≤14 and >14 (P<0.05). After LDLT, donors had more significant and faster liver regeneration than the recipients. Graft with or without MHV, initial liver volume, and preoperative liver function status of the recipients significantly affect liver regeneration.

Comparison of skeletal muscle index and body surface area-based formulae for estimation of standard liver volume

Comparison of skeletal muscle index and body surface area-based formulae for estimation of standard liver volume

Safety and learning curve of Da Vinci robotic single-anastomosis duodenal-ileal bypass with sleeve gastrectomy in the treatment of obesity patients

Objective: To investigate the safety and learning curve of Da Vinci robotic single-anastomosis duodenal-ileal bypass with sleeve gastrectomy (SADI-S) in the treatment of obesity patients. Methods: A descriptive case series study was performed. Clinical data of obesity patients who were treated with Da Vinci robotic SADI-S in China-Japan Union Hospital of Jilin University from March 2020 to May 2021 were analyzed retrospectively. Case inclusion criteria: (1) uncomplicated obese patients with body mass index (BMI)≥37.5 kg/m(2); (2) patients with BMI of 28 to <37.5 kg/m(2) complicated with type 2 diabetes or two metabolic syndrome components, or obesity comorbidities; (3) patients undergoing SADI-S by Da Vinci robotic surgery system. Those who received other bariatric procedures other than SADI-S or underwent Da Vince robotic SADI-S as revisional operation were excluded. A total of 77 patients were enrolled in the study, including 31 males and 46 females, with median age of 33 (18-59) years, preoperative body weight of (123.0±26.2) kg, BMI of (42.2±7.1) kg/m(2) and waistline of (127.6±16.3) cm. According to the order of operation date, the patients were numbered as 1-77. The textbook outcome (TO) and Clavien-Dindo grading standard were used to analyze the clinical outcome of each patient and to classify surgical complications, respectively. The standard of textbook outcome was as follows: the operative time less than or equal to the 75th percentile of the patient's operation time (210 min); the postoperative hospital stay less than or equal to the 75th percentile of the patient's postoperative hospital stay (7 d); complication grade lower than Clavien grade II; no readmission; no conversion to laparotomy or death. The patient undergoing robotic SADI-S was considered to meet the TO standard when meeting the above 5 criteria. The TO rate was calculated by cumulative sum analysis (CUSUM) method. The curve was drawn by case number as X-axis and CUSUM (TO rate) as Y-axis so as to understand the learning curve of robotic SADI-S. Results: The operative time of 77 robotic SADI-S was (182.9±37.5) minutes, and the length of postoperative hospital stay was 6 (4-55) days. There was no conversion to laparotomy or death. Seven patients suffered from complications (7/77, 9.1%). Four patients had grade II complications (5.2%), including one with duodeno-ileal anastomotic leakage, one with abdominal bleeding, one with peritoneal effusion and one with delayed gastric emptying; two patients were grade IIIb complications (2.6%) and both of them were diagnosed with gastric leakage; one patient was grade IV complication diagnosed with postoperative respiratory failure (1.3%), and all of them were cured successfully. A total of 51 patients met the textbook outcome standard, and the TO rate was positive and was steadily increasing after the number of surgical cases accumulated to the 46th case. Taking the 46th case as the boundary, all the patients were divided into learning stage group (n=46) and mastery stage group (n=31). There were no significant differences between the two groups in terms of gender, age, weight, body mass index, waist circumference, ASA classification, standard liver volume, operative time and morbidity of postoperative complication (all P>0.05). The percent of abdominal drainage tube in learning stage group was higher than that in mastery stage group (54.3% versus 16.1%, P<0.05). The length of postoperative hospital stay in learning stage group was longer than that in mastery stage group [6 (4-22) d versus 6 (5-55) d, P<0.05)]. Conclusion: The Da Vinci robotic SADI-S is safe and feasible with a learning curve of 46 cases.

Two hundred and fifty-one right hepatectomies for living donation: Association between preoperative risk factors, hepatic dysfunction, and complications

BackgroundDonor safety is essential in living donor liver transplantation. In this study we assessed the association among perioperative factors, liver dysfunction, and complications in 251 consecutives right hepatectomies for living donation. MethodsRetrospectively collected data from a prospectively assembled cohort of 251 consecutive living donors who underwent right hepatectomy between 1999 and 2020 were evaluated. ResultsMedian age was 36 years; 54% were men. There was a statistically significant relationship between standardized liver volume by body surface area and the volumes calculated by imaging, weighting, and volume displacement. (r2 = 0.40, r2 = 0.34, and r2 = 0.34, respectively), with the relationship between standardized liver volume and liver volume by imaging being the strongest. The median remnant liver volume was 35%. Fifty-eight donors (23%) developed postoperative hepatic dysfunction, which was associated with increased length of stay (P = .04), and complications (P < .01). Men had a 2.5 times higher chance of developing postoperative hepatic dysfunction. Age >50 years was an independent predictor of increased bilirubin at postoperative day 4 (P < .01), and remnant liver volume was inversely associated with higher peak international normalized ratio (P < .01). Eighty-one donors (32%) experienced complications. Postoperative hepatic dysfunction was associated with 2.4 times higher chances of complications (odds ratio = 2.4, P < .01). ConclusionEarly postoperative hepatic dysfunction is associated with the development of post-live liver donor complications. A thoughtful balancing of preoperative risk factors for postoperative hepatic dysfunction may indeed and by association reduce postoperative complications.

Prevention and Management of Small-for-Size Syndrome of Liver Transplantation

Small-for-size syndrome (SFSS) is a critical complication of partial liver transplantation, particularly in adult-to-adult living donor liver transplantation (ALDLT) using a small graft. Minimally required liver graft size for a successful ALDLT is classically 40% of a standard recipient’s liver volume or 0.8% of recipient body weight. Recent progress in perioperative care and technical improvement push the lower limit of safe graft size to 25% of the recipient’s standard liver volume or 0.6% of the graft versus recipient weight ratio although this is an ongoing debate. The clinical manifestations of SFSS include various symptoms and signs related to graft dysfunction and portal hypertension in patients with small grafts. The risk factors for SFSS include poor preoperative patient condition, including portal pressure, surgical techniques to reduce portal pressure, and graft quality and size. Hence, various approaches have been explored to modulate inflow and pressure to a small graft and to decrease the outflow block to alleviate this SFSS as well as the selection of a patient and graft. Additionally, recent research and efforts to prevent and treat SFSS are reviewed. (Ewha Med J 2022;45(2):29-34)

Future liver volume combined with platelet count predicts liver failure after major hepatectomy

BackgroundMajor hepatectomy is associated with high incidence of post-hepatectomy liver failure (PHLF). This study aimed to evaluate the effect of future remnant liver volume combined with liver function tests on predicting PHLF. MethodsPatients who underwent major hepatectomy from April 2009 to May 2017 were enrolled in the training cohort. Univariate and multivariate logistic regression analyses were performed to identify independent risk factors of PHLF and generate a logistic regression model for the prediction of PHLF. A conditional inference tree was generated based on the optimal cutoff value of independent predictive factors of PHLF. The precedent results were validated in an independent cohort from June 2017 to March 2018. ResultsOne hundred and eighteen patients were included in the training cohort, while another 34 in the validation cohort. Future remnant liver volume/estimated standard total liver volume (FLV/eTV) and preoperative platelet count were independent predictive factors of PHLF (P = 0.0021 and P = 0.012, respectively). The conditional inference tree showed that patients with FLV/eTV ≤0.56 and PLT count ≤145 × 109/L were at high risk of developing PHLF. ConclusionFLV/eTV combined with preoperative PLT count is effective in predicting PHLF after major hepatectomy.

The impact of preformed donor-specific antibodies in living donor liver transplantation according to graft volume.

IntroductionThe roles of preformed anti‐HLA donor‐specific antibodies (DSAs) in liver transplantation remain controversial. We evaluated the impact of preformed DSAs in living donor liver transplantation.MethodsAdults who underwent living donor liver transplantation (n = 175) in our institute were included in this study. Lymphocyte cytotoxicity test (LCT), flow cytometric crossmatch (FCXM), and single‐antigen bead assays were performed.ResultsAmong adult living donor liver transplantation recipients, 27 (16.5%) and 14 (8.5%) had pretransplant FCXM‐positive findings and LCT‐positive findings, respectively. FCXM‐positive patients displayed a significantly worse 5‐year graft survival rate (77.3%; vs. DSA‐negative, 91.6%). Six of 14 LCT‐positive patients exhibited graft loss shortly after transplantation (5‐year survival rate: 57.1%). All LCT‐positive patients with graft loss underwent left lobe living donor liver transplantation. Significantly lower ratio of graft volume relative to standard liver volume (32.9 ± 5.7%) and smaller graft size (365.3 ± 57.9 g) were observed in patients with graft loss (p < .03, vs. surviving grafts). Significantly higher DSA‐mean fluorescence intensity (MFI) values were present in patients with graft loss (p = .0012, vs. surviving grafts).ConclusionsPatients with preformed DSAs exhibited worse graft outcomes in living donor liver transplantation. Higher DSA‐MFI values and smaller graft size were associated with worse outcomes in LCT‐positive patients. High‐risk patients with preformed DSAs should be considered for appropriate graft selection and application of a desensitization protocol.

Impact of Monosegment Graft Use for Infants in Pediatric Living Donor Liver Transplantation

Left lateral segment grafts are generally used for very young pediatric patients undergoing living donor liver transplantation (LDLT). Recently, graft reduction techniques were developed for LDLT. Monosegment grafting has been used in newborns. The aim of this study was to determine the usefulness of monosegment grafting for infants. Recipients <2 years of age who underwent LDLT with a monosegment graft between 2010 and 2020 were gathered. Parents comprised all LDLT donors. A segment 2 monosegment graft was resected as a graft from the donor. Standard liver volume (SLV) was estimated using Urata's equation. Graft type, graft weight (GW), and native liver weight were assessed. Eight patients were included in the study. Original diseases consisted of biliary atresia (n=6) and fulminant hepatitis (n=2). Final graft type included monosegment (n=5) and reduced monosegment (n=3). Median final GW/body weight after reduction was 3% (range, 2%-3.4%). Median native liver weight/SLV was 134% except in patients with fulminant hepatitis. Median pre-reduction graft volume (GV)/estimated GV was 113% (range, 60%-208%). Median pre-reduction GV/SLV of monosegment grafts that required reduction (n=3) was 109% (range, 106%-121%). Median final reduced graft GV/SLV was 80% (range, 74%-91%). Complications due to large-for-size grafts were not observed. One case of bile leakage due to graft reduction occurred as a complication. Grafts were functioning well with the exception of one graft loss due to antibody-mediated rejection. Estimated GV in infants varies widely. Monosegment grafting can be useful for infants as well as newborns.

A new formula for estimation of standard liver volume using liver height and thoracic width.

PurposePrecise estimation of the standard liver volume (SLV) is crucial in decision making regarding major hepatectomy and living donor liver transplantation. This study aimed to propose an accurate and efficient formula for estimating the SLV in the Korean population.MethodsWe created a regression model for SLV estimation using a data set of 230 Korean patients with healthy livers. The proposed model was cross validated using a different data set of 37 patients with healthy livers. The total liver volume (TLV), except for the volume of liver blood vessels, was measured through computed tomography volumetry as the dependent variable. Various anthropometric variables, liver height (LH), thoracic width (TW), age, and sex (0, female and 1, male) were considered as candidates for independent variables. We conducted stepwise regression analysis to identify variables to be included in the proposed model.ResultsA new formula was established; SLV = −1,275 + 9.85 × body weight (BW, kg) + 19.95 × TW (cm) + 7.401 × LH (mm). The proposed formula showed the best performance among existing formulas over the cross-validation data set.ConclusionThe proposed formula derived using BW, TW, and LH estimated the TLV in the cross-validation data set more accurately than existing formulas.

Limited Excised Functional Liver Tissue in Hepatectomy for Large Hepatic Tumors Proved by a Three-Dimensional Reconstruction Technique

Three-dimensional (3D) reconstruction techniques have been widely used in the preoperative evaluation of hepatectomy. Here we used a 3D reconstruction technique to estimate the remnant liver volume and clarify a clinical speculation that limited functional liver tissue would be excised in hepatectomy for large hepatic tumors. Hepatectomy simulation by IQQA-Liver software was applied to 108 patients of hemihepatectomy divided into two groups (tumor diameter ≥ 10 cm vs.<10 cm). Liver volume (LV), standard liver volume (SLV), tumor volume (TV), functional liver volume (FLV), excised liver volume (ELV), excised functional liver volume (EFLV) and residual liver volume (RLV) were measured. Then we compared the rate of total liver resection (ELV/LV), the rate of functional liver resection (EFLV/FLV), and the relative rate of future liver remnant (RLV/FLV and RLV/SLV) between the two groups. The ELV calculated by the 3D reconstruction procedure were highly consistent with the actual liver excised volume (r=0.994, p<0.001), showing the accuracy of the simulation. Significantly smaller EFLV/FLV was seen in patients with a tumor diameter ≥ 10 cm than in patients with a tumor diameter<10 cm (p<0.01), in both the right and left hemihepatectomy subgroup. In contrast, significantly larger RLV/FLV was seen (p<0.01), and there was no difference of the RLV/SLV (p>0.05). Twenty-five patients had RLV/LV<30%, a recognized ratio of future liver remnant for safe hepatectomy. However, only one patient had RLV/SLV<30%. 97.2% of the patients had RLV/FLV>40%, and 98.1% had RLV/SLV>40%, accounting for the overwhelming majority of all patients. There was no hepatic failure or death within 30 days of surgery. In summary, it is better to use a 3D reconstruction method for preoperative safety assessment of liver resection for large hepatic tumors, through the hepatectomy simulation and volume calculation. In the same range of anatomical hepatectomy, a larger tumor mass meant less excised functional liver volume and more remnant liver volume. Our results indicated that neither ELV nor RLV/LV, but RLV/SLV was the better determinant of safety of hepatectomy.

Triphase contrast-enhanced CT to evaluate indications for autologous liver transplantation\xa0in patients with end-stage hepatic alveolar echinococcosis

Autologous liver transplantation (ALT) to cure end-stage hepatic alveolar echinococcosis (HAE) requires that hepatobiliary surgeons understand the invasion of intrahepatic structure and adjacent tissues or organs. Triphase contrast-enhanced CT of the liver has been widely used for diagnosis and preoperative evaluation of HAE. Three-dimensional (3D) reconstruction allows for accurate measurement of remnant liver volume (RLV). The objective of the study was to evaluate value of triphase contrast-enhanced CT together with 3D reconstruction in preoperative evaluation of indications for ALT in patients with end-stage HAE. This cohort include twenty-one consecutive patients with end-stage HAE, who preoperatively underwent triphase enhanced CT together with 3D reconstruction for ALT. To depict the indications, the 2D image data were reviewed statistically focusing on porta hepatis invasion, retrohepatic vena cava (RHVC) involvement and degrees of intrahepatic vessel invasion, and the 3D reconstruction was performed to obtain ratio of RLV to standard liver volume (SLV). The results showed that 95.24% patients (20/21) had porta hepatis invasion. When lesions located in right liver lobe, porta hepatis invasion occurred most commonly in the second and third porta hepatis (7/10), whereas the first, second and third porta hepatis were most commonly invaded by lesions in the right and caudate / left medial liver lobes (7/11) (P < 0.05). The mean value of longitudinal invasion of RHVC was 8.0 cm, and 95.2% (20/21) of patients had RHVC invasion with ≥ 180° circumferential invasion. As for the important vascular events, moderate and severe invasion occurred most commonly in the right hepatic vein, right branch of portal vein and RHVC each in 95.2% (20/21) patients (P < 0.05). We also found that preoperative CT had a good agreement with intraoperative findings in assessing intrahepatic vascular involvement by HAE (kappa index = 0.77). The estimated average ratio of RLV to SLV was 0.95 (range, 0.43–1.62). In conclusion, the 2D contrast-enhanced CT could well depict anatomic location and size of HAE, and invasion of porta hepatis and vascular by this disease, and involvement of other adjacent organs and tissues. Above all, 3D reconstruction could accurately measure RLV in patients with end-stage HAE for ALT.

Comparison of skeletal muscle index-based formula and body surface area-based formula for calculating standard liver volume

Comparison of skeletal muscle index-based formula and body surface area-based formula for calculating standard liver volume

Intraoperative Indocyanine Green Retention Test of Left Hemiliver in Decision-Making for Patients With Hepatocellular Carcinoma Undergoing Right Hepatectomy

Introduction: The aim of this study was to select qualified patients with hepatocellular carcinoma (HCC) who underwent right hepatectomy (RH) via intraoperative indocyanine green retention test at 15 min (ICG-R15) of the left hemiliver, which prevents severe posthepatectomy liver failure (PHLF).Methods: Twenty HCC patients who were preoperatively planned to undergo RH were enrolled. Intraoperative ICG-R15 of left hemiliver was measured after the right Glissonean pedicle was completely blocked. Patients then underwent RH if intraoperative ICG-R15 was ≤ 10%. Otherwise, patients underwent staged RH (SRH), either associating liver partitioning and portal vein ligation for staged hepatectomy (ALPPS) or portal vein ligation (PVL), followed by stage-2 RH. The comparison group consisted of patients with a ratio of standard left liver volume (SLLV) of > 40% and preoperative ICG-R15 ≤ 10% who underwent RH. The clinical outcomes of these two groups were compared.Results: Of the 20 patients, six underwent stage-1 RH, six underwent ALPPS, five underwent PVL followed by stage-2 RH, and three failed to proceed to stage-2 RH after PVL. No significant differences were found among the 17 patients who underwent stage-1 or stage-2 RH in the study group, the 19 patients in the comparison group, the 11 patients in the stage-2 RH group, and the six patients in the stage-1 RH group in incidences of PHLF, postoperative complications, hospital stay, and HCC recurrence within 1 year after RH. Compared with the stage-1 ALPPS group, the mean operative time and blood loss of the stage-1 PVL group were significantly less (p <0.001 and p = 0.022, respectively). The stage-1 PVL group had a significantly longer waiting-time (43.4 vs. 14.0 days, p = 0.016) than the stage-1 ALPPS group to proceed to stage-2 RH. After stage-2 RH, tumor recurrence within 1 year was 20% (1/5) in patients after PVL and 50% (3/6) after stage-1 ALPPS.Conclusions: Intraoperative ICG-R15 ≤ 10% of left hemiliver was valuable in intraoperative decision-making for patients who were planned to undergo RH. There is a possibility that stage-1 PVL might help to select patients with more favorable biological behavior to undergo stage-2 RH.

A Prospective Study of Liver Regeneration After Radiotherapy Based on a New (Su’S) Target Area Delineation

BackgroundIn this study, we designed a new (Su’S) target area delineation to protect the normal liver during liver regeneration and prospectively evaluate liver regeneration after radiotherapy, as well as to explore the clinical factors of liver regeneration and established a model and nomogram.MethodsThirty patients treated with preoperative downstaging radiotherapy were prospectively included in the training cohort, and 21 patients treated with postoperative adjuvant radiotherapy were included in the validation cohort. The cut-off points of each optimal predictor were obtained using receiver-operating characteristic analysis. A model and nomogram for liver regeneration after radiotherapy were developed and validated.ResultsAfter radiotherapy, 12 (40%) and 13 (61.9%) patients in the training and validation cohorts experienced liver regeneration, respectively. The risk stratification model based on the cutoffs of standard residual liver volume spared from at least 20 Gy (SVs20 = 303.4 mL/m2) and alanine aminotransferase (ALT=43 u/L) was able to effectively discriminate the probability of liver regeneration. The model and nomogram of liver regeneration based on SVs20 and ALT showed good prediction performance (AUC=0.759) in the training cohort and performed well (AUC=0.808) in the validation cohort.ConclusionsSVs20 and ALT were optimal predictors of liver regeneration. This model may be beneficial to the constraints of the normal liver outside the radiotherapy-targeted areas.

Accuracy of the Chula's formula for calculation of standard liver volume in Thai population

Background: Standard liver volume (SLV) is an important concept in living donor liver transplantation for treatment of end-stage liver disease. Accurate estimation of the SLV of living donor and recipient is crucial to ensure optimal graft function and avoid complications. Objective: 1) to assess the proposed formula for calculation of SLV in Thai population, using computed tomography (CT) volumetric measurement as a gold standard. 2) to evaluate the factors (e.g. age, sex, body weight and body surface area) related to differences between SLV calculated from the proposed formula and CT volumetric measurement. Materials and methods: We evaluated 497 patients underwent contrast-enhanced abdominal multi-detector CT for conditions unrelated to hepatobiliary system with normal liver radiology between October 1, 2014 and August 31, 2015 were included. Calculated SLV by the proposed formula (SLV = 20.76 x body weight) were compared to the total liver volume (TLV) measured from multi-detector CT by using computerized tool automatically. Factors related to the difference between SLV and TLV were evaluated. Result: The aforementioned formula showed a high accuracy in estimating the liver volume with some limitations in overweight or underwent patients. The mean difference between SLV and TLV is 3.36 cm3 with SD of 224.65 cm3. Conclusion: We proposed a new formula ("Chula's standard liver volume") that demonstrates a high accuracy for calculation of SLV in Thai population. Keywords: Liver volume; MDCT; standard liver volume; Thai population

Accuracy of new formula for standard liver volume using L3 skeletal muscle index

Formula-derived standard liver volume (SLV) has been clinically used for living donor liver transplantation and hepatic resection. The majority of currently available SLV formulae are based on body surface are (BSA), but they often show wide range of error. Skeletal muscle index measured at the third lumbar vertebra level (L3SMI) appears to reflect the lean body mass. We intended to establish a new SLV formula using L3SMI. The development cohort was 500 hundred living liver donors. The study cohort included 250 male and 250 female donors. The age was 25.9 ± 8.2 years. The mean values were BSA 1.70 ± 0.1 m2, L3SMI 45.4 ± 9.0 cm2/m2, and body mass index 21.8 ± 2.5 kg/m2. BSA-based SLV formula was "SLV (mL) = 969.8 × BSA (m2) - 456.3", which was previously developed. L3SMI-based SLV formula was "SLV (mL) = 23.3 × L3SMI (cm2/m2) + 133" (Spearman rho = 0.71 [p < 0.001]). The BSA-based formula showed Spearman rho = 0.69 (p < 0.001). L3SMI-based SLV formulae were "SLV (mL) = 24.0 × L3SMI (cm2/m2) + 80" (rho = 0.69 [p < 0.001]) for males and "SLV (mL) = 24.0 × L3SMI (cm2/m2) + 80" (rho = 0.26 [p = 0.15] for females. BSA-based formula showed rho = 0.65 (p < 0.001) for males and rho = 0.43 (p = 0.027). L3SMI-based SLV formula resulted in higher accuracy than BSA-based formula in male individuals, but paradoxically showed lower accuracy in female individuals, probably due to different distribution of L3SMI values. Further high-volume validation studies are necessary to use L3SMI-based SLV formulae in practice.

Comparison of skeletal muscle index-based formula and body surface area-based formula for calculating standard liver volume

Backgrounds/AimsFormula-derived standard liver volume (SLV) has been clinically used for living donor liver transplantation and hepatic resection. The majority of currently available SLV formulae are based on body surface are (BSA). However, they often show a wide range of error. Skeletal muscle index measured at the third lumbar vertebra level (L3SMI) appears to reflect lean body mass. The objective of this study was to compare the accuracy of L3SMI-based formula and BSA-based formula for calculating SLV.MethodsThe study cohort was 500 hundred living liver donors who underwent surgery between January 2010 and December 2013. Computed tomography images were used for liver volumetry and skeletal muscle area measurement.ResultsThe study cohort included 250 male and 250 female donors. Their age, BSA, L3SMI, and body mass index were 26.8±8.7 years, 1.68±0.16 m2, 45.6±9.0 cm2/m2, and 21.7±2.5 kg/m2, respectively. The BSA-based SLV formula was “SLV (ml)=−362.3+901.5×BSA (m2) (r=0.71, r2=0.50, p<0.001)”. The L3SMI-based SLV formula was “SLV (ml)=471.9+14.9×L3SMI (cm2/m2) (r=0.65, r2=0.42, p<0.001)”. Correlation coefficients were similar in subgroup analyses with 250 male donors and 250 female donors. There was a crude correlation between L3SMI and body mass index (r=0.51, r2=0.27, p<0.001).ConclusionsThe results of this study suggest that SLV calculation with L3SMI-based formula does not appear to be superior to the currently available BSA-based formulae.