Post-Hepatectomy Liver Failure Overview

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Questions and Answers

What underlying condition should be suspected when thrombocytopenia is observed?

Underlying cirrhosis (correct)

Acute pancreatitis

Hepatic steatosis

Gallbladder disease

Which imaging modalities provide more objective data for assessing liver volume?

CT or MRI (correct)

Fluoroscopy

3-dimensional ultrasound

Ultrasound

What surgical factor is associated with an increased risk of Post Hepatectomy Liver Failure (PHLF)?

Resection of less than 30% of liver volume

Estimated blood loss less than 800 mL

Intra-operative transfusion requirement (correct)

Operative time less than 120 minutes

Which surgical procedure is mentioned as increasing the risk for complications, particularly in biliary malignancy cases?

Skeletonization of the hepatoduodenal ligament Signup and view all the answers

Which of the following factors is NOT associated with increased risk during surgery?

Patient age over 70 years Signup and view all the answers

What is a common cause of liver dysfunction in patients undergoing chemotherapy?

Hepatocyte damage from chemotherapy agents Signup and view all the answers

What characterizes chemotherapy-associated steatohepatitis (CASH)?

Increased risk of post-operative liver failure Signup and view all the answers

What is indicated by liver attenuation lower than that observed in the spleen on a pre-operative CT scan?

Presence of fatty infiltration indicative of steatohepatitis Signup and view all the answers

Which of the following factors does NOT increase the risk of post-hepatectomy liver failure (PHLF)?

Liver volume assessment Signup and view all the answers

What does the ISGLS grading system for PHLF primarily focus on?

Clinical deterioration of liver function Signup and view all the answers

Which clinical symptom is least likely associated with the diagnosis of PHLF?

Fever Signup and view all the answers

What is the key component in the ISGLS definition that should be standardized for PHLF risks?

Calculation of liver volume percentage Signup and view all the answers

Which of the following is NOT a co-morbidity associated with an increased risk of PHLF?

Asthma Signup and view all the answers

What is one major source of morbidity and mortality after major liver resection?

Post-hepatectomy liver failure (PHLF) Signup and view all the answers

What is the reported mortality rate after major hepatic resection?

As high as 30% Signup and view all the answers

Which criterion has been proposed as a simple definition for post-hepatectomy liver failure?

PT of 50 µmL/L Signup and view all the answers

What percentage of cases report lower rates of PHLF in East Asian countries?

1-2% Signup and view all the answers

What biochemical parameters are primarily used to define post-hepatectomy liver failure?

Increased INR and hyperbilirubinemia Signup and view all the answers

What was a significant advancement that improved outcomes after major liver resection?

Refinements in operative technique Signup and view all the answers

What did the International Study Group of Liver Surgery propose regarding PHLF?

A standardized definition and severity grading for PHLF Signup and view all the answers

Why is comparison of PHLF rates between studies challenging?

Variability in definitions of PHLF among different groups Signup and view all the answers

What is identified as the major source of morbidity and mortality after a major hepatectomy?

Post-hepatic liver failure (PHLF) Signup and view all the answers

What is one of the critical aspects for optimizing patient outcomes in liver surgery?

Excellent post-operative management Signup and view all the answers

Which scoring system is commonly used for assessing the risk of post-hepatectomy liver failure?

Model for End-Stage Liver Disease (MELD) score Signup and view all the answers

What role does the functional liver remnant (FLR) play in the context of hepatectomy?

Improving FLR is vital to prevent post-hepatectomy complications Signup and view all the answers

Which of the following is NOT a predictive factor for post-hepatectomy liver failure as implied in the article?

Post-operative activities Signup and view all the answers

What level of mortality rates can be associated with major hepatectomy procedures?

Up to 30% Signup and view all the answers

Which of the following describes an approach to prevent post-hepatic liver failure?

Selecting patients carefully for surgery Signup and view all the answers

What characteristics of hepatic resections necessitate careful clinical judgement?

Complexity and associated risks Signup and view all the answers

Study Notes

Post-Hepatectomy Liver Failure (PHLF)

PHLF is a significant source of morbidity and mortality after major liver resections.
The mortality rate for major hepatic resection can be as high as 30%.
PHLF is a post-operative complication where the liver's ability to perform its synthetic, excretory, and detoxifying functions deteriorates.
It typically presents with increased prothrombin time (INR) and hyperbilirubinemia after postoperative day 5.

Definition of PHLF

The definition of PHLF varies widely.
The International Study Group of Liver Surgery (ISGLS) proposed a standardized definition for PHLF.
The ISGLS definition defines PHLF as a post-operative acquired decline in the liver's ability to function (synthetic, excretory, and detoxifying) characterized by an increasing INR and hyperbilirubinemia after postoperative day 5.

Predictive Factors for PHLF

Patient-related factors: Diabetes mellitus, obesity, chemotherapy-related steatohepatitis, hepatitis B/C, malnutrition, renal insufficiency, hyperbilirubinemia, thrombocytopenia, lung disease, and cirrhosis (age >65).
Surgical factors: Estimated blood loss > 1200mL, intraoperative transfusions, resection of >50% of liver volume, major hepatectomy (including right lobectomy), operative time > 240 minutes.

Pre-operative Risk Assessment

CT-based volumetric analysis is used to assess the volume of the functional liver remnant (FLR).
Lower liver attenuation compared to the spleen suggests fatty infiltration (steatohepatitis).
Other signs of cirrhosis (splenomegaly, varices, ascites, thrombocytopenia) are also relevant.
Semi-automated contouring of the liver on CT scans helps determine the percentage of remaining liver, correlating with prothrombin time and bilirubin levels. The percentage of remaining liver is more predictive of PHLF than the extent of resection.
Serum C-reactive protein (CRP), pre-operative prothrombin time, hyaluronic acid, and bilirubin levels can be indicative of risk.

Prevention of PHLF

Portal vein embolization (PVE): used to direct blood flow to the spared liver, leading to FLR hypertrophy.
PVE can reduce risk of PHLF, especially in patients with cirrhosis and a predicted FLR of ≤40%.
Minimizing intraoperative blood loss, avoidance of blood transfusion if possible, close attention to hemostasis, early recognition and treatment of post-operative complications (like hemorrhage and biliary obstruction/leaks), and good postoperative management are essential for minimizing risk.
Pre-operative liver hypertrophy procedures can help reduce risk.

Identification and Management of PHLF

PHLF manifests as multi-system organ failure, with persistent hyperbilirubinemia, coagulopathy, renal insufficiency, encephalopathy, requiring ventilation and pressor support.
Early identification and supportive care are critical in improving survival.
Laboratory tests to confirm presence of PHLF, and MELD and APACHE III scores used in risk assessment for severe cases.
Liver transplantation is a last resort, offered to those who have not responded to other methods.

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Description

This quiz covers the critical aspects of Post-Hepatectomy Liver Failure (PHLF), including its definition, mortality rates, and predictive factors. Understand the importance of recognizing PHLF as a significant post-operative complication and the standardized definitions provided by the International Study Group of Liver Surgery.