Post-Hepatectomy Liver Failure Review (2014) PDF
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2014
Rondi Kauffmann, Yuman Fong
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Summary
This review article examines post-hepatectomy liver failure (PHLF), a significant complication of liver surgery. It discusses definitions, predictive factors, prevention strategies, and management approaches. The article highlights the varying definitions used and emphasizes the importance of pre-operative assessment and post-operative care for optimal patient outcomes.
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Review Article Post-hepatectomy liver failure Rondi Kauffmann, Yuman Fong Department of Surgery, City of Hope National Medical Center, Duarte, CA, USA Correspondence to: Yuman Fong, MD. Department of Surgery, City of Hope National Medical Center, 1500 East Duarte Rd, Duarte, CA 91010-8113, USA. Em...
Review Article Post-hepatectomy liver failure Rondi Kauffmann, Yuman Fong Department of Surgery, City of Hope National Medical Center, Duarte, CA, USA Correspondence to: Yuman Fong, MD. Department of Surgery, City of Hope National Medical Center, 1500 East Duarte Rd, Duarte, CA 91010-8113, USA. Email: [email protected]. Abstract: Hepatectomies are among some of the most complex operative interventions performed. Mortality rates after major hepatectomy are as high as 30%, with post-hepatic liver failure (PHLF) representing the major source of morbidity and mortality. We present a review of PHLF, including the current definition, predictive factors, pre-operative risk assessment, techniques to prevent PHLF, identification and management. Despite great improvements in morbidity and mortality, liver surgery continues to demand excellent clinical judgement in selecting patients for surgery. Appropriate choice of pre-operative techniques to improve the functional liver remnant (FLR), fastidious surgical technique, and excellent post-operative management are essential to optimize patient outcomes. Keywords: Post-hepatectomy liver failure (PHLF); prevention of liver failure; predictive factors for liver failure Submitted Aug 01, 2014. Accepted for publication Aug 21, 2014. doi: 10.3978/j.issn.2304-3881.2014.09.01 View this article at: http://dx.doi.org/10.3978/j.issn.2304-3881.2014.09.01 Introduction obscure laboratory tests, such as hepaplastin or hyaluronic acid levels, limiting their utility (6). The Model for End- Hepatic resections are among some of the most complex Stage Liver Disease (MELD) score is one such definition operative interventions performed, and are fraught with that is widely used. The MELD score is calculated using risk and the potential for complications. Mortality rates serum creatinine, INR, and bilirubin, but requires a complex after major hepatic resection have been reported to be mathematical formula computation (7). The ‘50-50 criterion’ as high as 30% (1,2) with post-hepatectomy liver failure (PT 50 µmL/L) have also been (PHLF) representing the major source of morbidity and proposed as a simple definition for PHLF (8). However, mortality after liver resection. Despite great improvements this definition does not account for any clinical parameters, in outcomes after major liver resection due to refinements and relies only on two laboratory values. In 2011, the in operative technique and advances in critical care, PHLF International Study Group of Liver Surgery (ISGLS) remains one of the most serious complications of major liver proposed a standardized definition and severity of grading resection, and occurs in up to 10% of cases (3,4). Several of PHLF. After evaluating more than 50 studies on PHLF studies report a lower rate of PHLF in East Asian countries after hepatic resection, the consensus conference committee (1-2%), but when present, PHLF represents a significant defined PHLF as “a post-operatively acquired deterioration source of morbidity and mortality (5). in the ability of the liver to maintain its synthetic, excretory, and detoxifying functions, which are characterized by an increased INR and concomitant hyperbilirubinemia on or Definition after postoperative day 5” (2). While other definitions of The definition of PHLF has varied widely among groups, PHLF utilizing biochemical or clinical parameters are used making comparison of rates between studies challenging. by some centers, the ease with which the ISGLS definition Numerous definitions of PHLF exist in the literature, with can be calculated and used for comparison renders it the variations by country and between hospitals within the same definition that ought to be standardized and used. country. Many definitions include complicated formulas or While PHLF is the most feared complication, the © Hepatobiliary Surgery and Nutrition. All rights reserved. www.thehbsn.org Hepatobiliary Surg Nutr 2014;3(5):238-246 HepatoBiliary Surgery and Nutrition, Vol 3, No 5 October 2014 239 Table 1 ISGLS definition and grading of PHLF (2) Grade Clinical description Treatment Diagnosis Clinical symptoms Location for care A Deterioration in liver None UOP >0.5 mL/kg/h None Surgical ward function BUN 90% O2 saturation INR 25% of liver remaining after the same immune function, and hepatic steatosis contributing to post-operative liver dysfunction (10). operation (24). Furthermore, the percentage of remaining Chemotherapy-associated steatohepatitis (CASH) is an liver, as determined by volumetric analysis, was more increasing challenge in the era of novel chemotherapeutic specific in predicting PHLF than the anatomic extent of and biologic agents. Many commonly-used chemotherapy resection (24). agents cause damage to hepatocytes, including 5-fluorouracil, Careful evaluation of pre-operative CT scan imaging irinotecan, oxaliplatin, cituximab, and bevacizumab should focus on liver attenuation. Liver attenuation that (11-14). Additionally, pre-operative malnutrition or renal is lower than that observed in the spleen indicates fatty insufficiency, hyperbilirubinemia, thrombocytopenia, infiltration indicative of steatohepatitis (11,24,25) (Figure 1). presence of co-morbidities (lung disease), and advanced age Similarly, splenomegaly, varices, ascites, or consumptive are associated with increased risk of PHLF (15-18). thrombocytopenia should prompt the clinician to suspect underlying cirrhosis (11) (Figure 2A,B). Although ultrasound and 3-dimensional ultrasound has Surgical factors been advocated by some as a means by which to assess the In addition to patient-specific factors, the performance pre-operative volume of the liver, CT or MRI provide more of the surgical procedure itself influences risk of PHLF. objective data that is less subject to operator-error. Both CT Factors associated with increased risk are shown in Table 2 and MRI show excellent accuracy and precise quantification and include operative estimated blood loss >1,200 mL of hepatic volume (26-28), and are particularly useful in (19,20), intra-operative transfusion requirement, need for estimating the future liver remnant (FLR) (29). vena caval or other vascular resection (21), operative time Numerous methods have been developed for calculating >240 minutes (13), resection of >50% of liver volume, major liver volume, using either CT or MRI images. The first hepatectomy including right lobe (22), and skeletonization of technique involved manual tracing of the outline of the the hepatoduodenal ligament in cases of biliary malignancy liver (30), but has been criticized its time-intensity. Most (23). In patients for whom