Portal Venous Pressure Variation during Hepatectomy: A Prospective Study

Abstract

Introduction: Excessive portal venous pressure in the liver remnant is an independent factor in the occurrence of posthepatectomy liver failure and small-for-size syndrome. The baseline portal pressure prior to hepatectomy was not considered previously. The aim of this study is to assess the impact of portal pressure change during hepatectomy on the patient outcome.Material and Methods: Prospective observational study including 30 patients subjected to intraoperative measurement of portal pressure before and after hepatectomy. This variation was related to the patient outcome. Control group evaluation was assessed. Patient, disease and procedure features were considered. The optimal cut-off of portal pressure variation was determined. Linear regression or logistic regression was applied to identify predictors of the outcome.Results: The univariate analysis showed that portal pressure increase after hepatectomy was associated with coagulation impairment in the first 30 postoperative days (p < 0.05), and with the occurrence of major complications (p = 0.01), namely hepatic failure (p = 0.041). The multivariate analysis showed that portal venous pressure increase ≥ 2 mmHg is an independent factor for worse outcomes.Discussion: As in previous studies, this study concludes that, after hepatectomy, in addition to the functional liver remnant, other factors are responsible for deterioration of liver function and patient outcome, such as the portal pressure increase and the exposure to chemotherapy prior to hepatectomy. This work may influence the definition of future indications for portal influx modulation.Conclusion: Patient outcomes are influenced by the portal venous pressure increase: an increment ≥ 2 mmHg after hepatectomy seems to increase the risk of major complications.

A systematic review of the impact of portal vein pressure changes on clinical outcomes following hepatic resection

“…See Table 2. Following the original literature search 10 studies (with 712 patients) from a pool of 68 studies were selected [6][7][8][9][10][11][12][13][14][15] [Fig. 1].…”

“…Three prospective studies and two RCTs were excluded for not having recorded postresection direct PVP measurement [26][27][28][29][30] Only two studies reported the Future Liver Remnant volumes. 13,14 Pre-and post-resection PVP The definition of elevated PVP, results of PVP and definitions and relationship of PVP to outcomes evaluated are shown in Tables 3 and 4. The overall median (range) baseline PVP was 11.4 mmHg (7.3-16.4) with 50% of patients with cirrhosis.…”

“…Following resection, nine out of ten studies reported [6][7][8][9][10][11][12]14,15 absolutes values for PVP (n = 682 patients) and one study (n = 30) reported a delta increment. 13 These data included patients with minor (n = 162) and major resections (n = 550) and with or without cirrhosis (424/682 no cirrhosis).…”

“…6,7,10,11,15 Morbidity, mortality and PVP See Table 4. Six studies 6,9,[11][12][13]15 reported significantly increased morbidity (Clavien Dindo complications III or higher) when post-resection PVP was elevated, for example ascites, 9,15 hyperbilirubinemia 13,15 or a prolonged INR. 13 Others 12 reported less bleeding and reduced transfusion requirement when Deltaincrement was <2 mmHg (p < .05) or even reported elevated post-resection to be PVP an independent predictor factor for 90 day-mortality after surgery.…”

“…4,5 More recently, in patients without cirrhosis elevated post-resection PVP has been shown to predict PLF, death and other complications after a major liver resection. 6,7 Intraoperative measurement of PVP therefore might contribute to accurate risk assessment of PLF and provides a potential therapeutic target for pharmacological [6][7][8][9][10][11][12][13][14][15] or surgical (reversible PV diameter modulation, splenic artery ligation, shunting or splenectomy) [16][17][18][19] PVP modulation. The aim of the present study was to systematically review the relationship between post-resection PVP and clinical outcomes, specifically, PLF in patients undergoing LR.…”