How Much Remnant Is Enough in Liver Resection?

Abstract

Background: Liver resection represents the first choice of treatment for primary and secondary liver malignancies, offering the patient the best chance of long-term survival. The extensive use of major hepatectomy increases the risk of post-hepatectomy liver failure (PHLF), which is associated with a high frequency of postoperative complications, mortality and increased length of hospital stay. Aims: The aim of this review is to investigate the different risk factors related to the occurrence of PHLF and to identify the limits for a safe liver resection in patients with normal liver and injured liver (cirrhosis, cholestasis, steatosis and post-chemotherapy liver injury). Methods: A literature search was undertaken in PubMed and related search engines, looking for articles relating to hepatic failure following hepatectomy in normal liver or injured liver. Results: In spite of improvements in surgical and postoperative management, the parameters determining how much liver can be resected are still largely undefined. A number of preoperative, intraoperative and postoperative factors all contribute to the likelihood of liver failure after surgery. The safe limits for liver resection can be estimated from the data of the literature for patients with normal liver and for those with different types of liver injury. Conclusions: Preoperative assessment that includes evaluation of liver volume and function of the remnant liver is a mandatory prerequisite before major hepatectomy. The critical residual liver volume for patients able to predict PHLF is mainly related to the presence of pre-existing liver disease and liver function. Among patients with normal liver, the limit for safe resection ranges from 20 to 30% future remnant liver of total liver volume. In patients with injured liver (cirrhosis, cholestasis or steatosis), preoperative assessment of the risk of PHLF should include future remnant liver volumetry and accurate liver function evaluation, including different dynamic liver function tests.

Liver volumetry: Is imaging reliable? Personal experience and review of the literature

“…The remnant liver must therefore be able to overcome the necrosis, preserving or recovering an adequate synthetic ability [22] ; as a consequence, there must be an adequate and functional FLRV to avoid PHLF [23] . Despite this, there is no uniform consensus among hepatic surgeons on the amount of liver volume that can be safely resected, with a wide range of reported values [24,25] . Guglielmi et al [24] reported that in patients with "healthy" liver (absence of hepatic diffuse disease, normal functionality tests) the limit of FLRV% for a safe resection varies between 20% and 30%, while in patients with underlying hepatic disease (cirrhosis, cholestasis, steatosis) the critical FLRV% value rise up to 30%-40%.…”

Liver Status Assessment by Spectrally and Time Resolved IR Detection of Drug Induced Breath Gas Changes

“…The predicted LiMAx value after surgery is approximately 31% of 639 µ g/kg/h. This value of 198 µ g/kg/h is below the normal liver capacity, but in a range in which the recovery of the liver is expected without complications [21,30,[32][33][34][35][36]. Thus, it is possible to predict this operation is safe.…”

Liver tissue engineering: From implantable tissue to whole organ engineering

“…However, in order to replace the vital functions of a human liver and allow patient survival, a much larger mass (>25%) is needed 43. This ambitious goal is the core aim of the whole organ decellularization–recellularization technology that is covered in the next section.…”