Podcast
Questions and Answers
What underlying condition should be suspected when thrombocytopenia is observed?
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?
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)?
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?
Which surgical procedure is mentioned as increasing the risk for complications, particularly in biliary malignancy cases?
Which of the following factors is NOT associated with increased risk during surgery?
Which of the following factors is NOT associated with increased risk during surgery?
What is a common cause of liver dysfunction in patients undergoing chemotherapy?
What is a common cause of liver dysfunction in patients undergoing chemotherapy?
What characterizes chemotherapy-associated steatohepatitis (CASH)?
What characterizes chemotherapy-associated steatohepatitis (CASH)?
What is indicated by liver attenuation lower than that observed in the spleen on a pre-operative CT scan?
What is indicated by liver attenuation lower than that observed in the spleen on a pre-operative CT scan?
Which of the following factors does NOT increase the risk of post-hepatectomy liver failure (PHLF)?
Which of the following factors does NOT increase the risk of post-hepatectomy liver failure (PHLF)?
What does the ISGLS grading system for PHLF primarily focus on?
What does the ISGLS grading system for PHLF primarily focus on?
Which clinical symptom is least likely associated with the diagnosis of PHLF?
Which clinical symptom is least likely associated with the diagnosis of PHLF?
What is the key component in the ISGLS definition that should be standardized for PHLF risks?
What is the key component in the ISGLS definition that should be standardized for PHLF risks?
Which of the following is NOT a co-morbidity associated with an increased risk of PHLF?
Which of the following is NOT a co-morbidity associated with an increased risk of PHLF?
What is one major source of morbidity and mortality after major liver resection?
What is one major source of morbidity and mortality after major liver resection?
What is the reported mortality rate after major hepatic resection?
What is the reported mortality rate after major hepatic resection?
Which criterion has been proposed as a simple definition for post-hepatectomy liver failure?
Which criterion has been proposed as a simple definition for post-hepatectomy liver failure?
What percentage of cases report lower rates of PHLF in East Asian countries?
What percentage of cases report lower rates of PHLF in East Asian countries?
What biochemical parameters are primarily used to define post-hepatectomy liver failure?
What biochemical parameters are primarily used to define post-hepatectomy liver failure?
What was a significant advancement that improved outcomes after major liver resection?
What was a significant advancement that improved outcomes after major liver resection?
What did the International Study Group of Liver Surgery propose regarding PHLF?
What did the International Study Group of Liver Surgery propose regarding PHLF?
Why is comparison of PHLF rates between studies challenging?
Why is comparison of PHLF rates between studies challenging?
What is identified as the major source of morbidity and mortality after a major hepatectomy?
What is identified as the major source of morbidity and mortality after a major hepatectomy?
What is one of the critical aspects for optimizing patient outcomes in liver surgery?
What is one of the critical aspects for optimizing patient outcomes in liver surgery?
Which scoring system is commonly used for assessing the risk of post-hepatectomy liver failure?
Which scoring system is commonly used for assessing the risk of post-hepatectomy liver failure?
What role does the functional liver remnant (FLR) play in the context of hepatectomy?
What role does the functional liver remnant (FLR) play in the context of hepatectomy?
Which of the following is NOT a predictive factor for post-hepatectomy liver failure as implied in the article?
Which of the following is NOT a predictive factor for post-hepatectomy liver failure as implied in the article?
What level of mortality rates can be associated with major hepatectomy procedures?
What level of mortality rates can be associated with major hepatectomy procedures?
Which of the following describes an approach to prevent post-hepatic liver failure?
Which of the following describes an approach to prevent post-hepatic liver failure?
What characteristics of hepatic resections necessitate careful clinical judgement?
What characteristics of hepatic resections necessitate careful clinical judgement?
Flashcards
Post-hepatectomy Liver Failure (PHLF)
Post-hepatectomy Liver Failure (PHLF)
A serious complication following liver surgery that can lead to organ failure and death.
Model for End-Stage Liver Disease (MELD) score
Model for End-Stage Liver Disease (MELD) score
A measurement system to predict the severity of liver disease, used to assess the risk of PHLF.
Functional Liver Remnant (FLR)
Functional Liver Remnant (FLR)
The amount of healthy liver tissue remaining after a part of the liver is removed.
Pre-operative techniques
Pre-operative techniques
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Fastidious Surgical Technique
Fastidious Surgical Technique
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Post-operative management
Post-operative management
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Mortality rates
Mortality rates
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Morbidity
Morbidity
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Liver Function
Liver Function
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East Asian PHLF Rate
East Asian PHLF Rate
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PHLF Diagnostic Criteria
PHLF Diagnostic Criteria
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ISGLS PHLF Definition
ISGLS PHLF Definition
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PHLF Impact
PHLF Impact
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PHLF Definition Variability
PHLF Definition Variability
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Which imaging techniques are considered superior for pre-operative liver volume assessment?
Which imaging techniques are considered superior for pre-operative liver volume assessment?
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How are CT and MRI useful in estimating FLR?
How are CT and MRI useful in estimating FLR?
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What are the evolving methods for calculating liver volume?
What are the evolving methods for calculating liver volume?
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What surgical factors contribute to the risk of PHLF?
What surgical factors contribute to the risk of PHLF?
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Why should a clinician be cautious about thrombocytopenia in a liver surgery patient?
Why should a clinician be cautious about thrombocytopenia in a liver surgery patient?
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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.
