Institute of Surgical Gastroenterology & Liver Transplant, Govt. Stanley Medical College, India
Submission: September 10, 2018;Published: October 05, 2018
*Corresponding author: Sugi RV Subramaniam, Surgical Gastroenterology Resident, Institute of Surgical Gastroenterology & Liver Transplant, Govt Stanley Medical College & Hospital, 601, Old Jail Road, Chennai, Royapuram, Tamil Nadu, India, Pin Code: 600001, Tel: +97299058581;Email: email@example.com
How to cite this article:Sugi RV S, Senthil K P, Kamalakannan R, Sugumar C, Jeswanth S, Ravichandran P. Post Hepatectomy Liver Failure in Nutshell. Adv Res Gastroentero Hepatol. 2018; 11(1): 555804. DOI:10.19080/ARGH.2018.11.555804.
Hepatic resections are the most complex operative interventions that we do today with a mortality rate as high as 30%. Post-Hepatectomy Liver Failure (PHLF) is a major source of morbidity and mortality after hepatectomies with an incidence of up to 10% of cases. Lower rate of PHLF are reported in East Asian countries (1-2%), but when present, PHLF leads to significant morbidity and mortality.
Keywords: Post hepatectomy liver failure; 50-50 criterion; Hepatic resection
Defining what is PHLF and criteria to diagnose it were equally difficult as treating a PHLF. The International Study Group of Liver Surgery: considering the normal postoperative course of serum bilirubin concentration and International Normalized Ratio defined PHLF as the impaired ability of the liver to maintain its synthetic, excretory, and detoxifying functions, which are characterized by an increased INR and concomitant hyperbilirubinemia on or after postoperative day 5 .
This does not account for any clinical parameters and relies only on two laboratory values namely Prothrombin Time [PT] and serum bilirubin on post-operative day 5. The association of PT < 50% and SB >50 μml/L on POD 5 was a simple, early, and accurate predictor of more than 50% mortality rate after hepatectomy. These criteria could be identified early enough, before clinical evidence of complications, for specific interventions to be applied in due time .
CT-based volumetric analysis: A helical CT scan to assess the volume of resection by semi-automated contouring of the liver. Shoup et al observed that the percentage of remaining liver was closely correlated with increasing prothrombin time (>18 seconds) and bilirubin level (>3 mg/dL). PHLF was noted more often in patients undergoing trisegmentectomy especially those with ≤25% of liver remaining.
Indocyanine green (ICG) clearance and ICG retention rate (ICG R15): All ICG administered is cleared by normal liver. ICG reflects intra-hepatic blood flow which can be used to assess liver functional reserve in patients with cirrhosis. Application of ICG and ICG R15 to estimating functional hepatic reserve after resection of normal livers in the setting of malignancy is an effective method. ICG elimination is measured by pulse spectrophotometry & indocyanine green plasma disappearance rate (ICG PDR) is determined. The foremost advantage of ICG is that it is a noninvasive tool for prediction of PHLF . When the pre-operative ICG PDR was less than 17.6%/min and the pre-operative serum bilirubin was >17 μmol/L, the positive predictive value for post-operative liver dysfunction was 75%, and the negative predictive value was 90%.
Galactosyl human serum albumin (GSA) scintigraphy: 99mTc diethylenetriamine-pentaacetic acid-Galactosyl human Serum Albumin (GSA) scintigraphy for the pre-operative evaluation of cirrhotic patients is a valid method for pre-operative
risk assessment. The molecule is taken up by the liver, reflecting the
volume of functional liver. Uptake corresponds to bilirubin level,
INR, and ICG clearance. GSA is unaffected by hyperbilirubinemia
and offers a highly accurate estimation of FLR. In nearly 20% of
patients, the severity of liver disease is underestimated by ICG
clearance testing, and better represented by GSA scintigraphy.
99mTc-mebrofenin: 99mTc-mebrofenin is excreted into
the bile by adenosine triphosphate–dependent export pumps
namely the multidrug-resistance-associated proteins 1 and 2,
without undergoing biotransformation during transit through
the hepatocytes. This preoperative total hepatic uptake rate of
99mTc-mebrofenin correlates well with the indocyanine green
(ICG) clearance rate. In patients with parenchymal disease and
hilar cholangiocarcinoma 99mTc-mebrofenin uptake in the future
remnant liver on functional hepatobiliary scintigraphy has been
proved to be more valuable than measurement of the volume of
the future remnant in the assessment of the posthepatectomy risk
of liver failure and liver failure–related mortality.
*To avoid irreversible injury to the liver, the Pringle maneuver
should be applied in an intermittent manner, and the duration
should not exceed a total of 120 minutes. *Pringle maneuver
during liver transection is safe and effective and can be employed,
in an intermittent manner, during hepatectomy of whatever
histology of nontumorous liver  (Table 1).
Bismuth et al proposed a formula to estimate amount of
functional parenchyma remaining after resection (Mr), Where Me
is the quantity of functional liver removed and Mt the total quantity
of functional liver. PBC the Paul Brousse Hospital classification.
Mr = Me/Mt X PBC
Postoperative mortality or complications are not dependent
on the amount of resected parenchyma alone. There was a 5%
mortality even after minimal resection. Postoperative liver failure
is precipitated in over 50% of patients by sepsis, hemorrhage or
portal thrombosis. Incidence of late liver failure is rare [< 5%]
with almost nil mortality when estimated postoperative liver
volume > 35%. Normal livers regenerate completely within 3
months, while in cirrhosis or chronic hepatitis it may take up to
9–12 months or even longer to reach preoperative liver volume.
The speed of hepatic regeneration appears to be a function of the
Goal-directed therapy: Human albumin, fresh frozen plasma
or AT III to cover the liver function
Liver support systems have been available for some years
now: Molecular absorbent recirculating system (MARS), Modified
fractionated plasma separation and adsorption (Prometheus)and
Bioartificial liver and extracorporeal liver assist device
Liver transplantation: Salvage transplantation as the last
PHLF is a severe deadly complication. Mild hepatic
insufficiency with a transient hyperbilirubinemia that does
not alter the expected post-operative course is quite common.
Multi-system failure requiring invasive treatment in ICU and
multiple factors increase the risk of mortality. Obesity, diabetes,
neoadjuvant treatment with chemotherapy, underlying cirrhosis,
increased age, male gender, need for extended liver resection,
and long operation with high intra-operative Estimated Blood
Loss. Risk of PHLF can be minimized by accurate preoperative
assessment of FLR, induction of hypertrophy of the liver remnant
via PVE if the expected FLR is < 20% for a normal liver, < 30% for
a steatotic liver and < 40% for a cirrhotic liver. PHLF is rather easy
to prevent than to treat .