Systematic review of MARS treatment in post-hepatectomy liver failure

Abstract

Background: Post-hepatectomy liver failure (PHLF) remains a serious complication after major liver resection with severe 90-day mortality. Molecular adsorbent recirculating system (MARS) is a potential treatment option in PHLF. This systematic review sought to analyze the experiences and results of MARS in PHLF.Methods: Following the PRISMA guidelines, a systematic literature review using PubMed and Embase was performed. Non-randomized trials were assessed by the MINORS criteria.Results: 2884 records were screened and 22 studies were extracted (no RCT). They contained 809 patients including 82 patients with PHLF. Five studies (n = 34) specifically investigated the role of MARS in patients with PHLF. In these patients, overall 90-day survival was 47%. Patients with primary PHLF had significantly better 90-day survival compared to patients with secondary PHLF (60% vs 14%, p = 0.03) and treatment was started earlier (median POD 6 (range 2-21) vs median POD 30 (range 15-39); p < 0.001). Number of treatments differed non-significantly in these groups. Safety and feasibility of early MARS treatment following hepatectomy was demonstrated in one prospective study. No major adverse events have been reported. Conclusion:Early MARS treatment is safe and feasible in patients with PHLF. Currently, MARS cannot be recommended as standard of care in these patients. Further prospective studies are warranted.

Role of liver support systems in the management of post hepatectomy liver failure: A systematic review of the literature

“… 39 The results of this review show promise, with the 90-day mortality rates by both modalities being less than those suggested by the Balzan criteria, which may suggest some benefit in the use of LSS as a treatment option for PHLF, however, with a caveat that the Balzan definition is not used for PHLF in all the studies. Similar results are reported by Gilg et al 40 in a review that evaluated only MARS as a treatment option for PHLF.…”

Expert consensus of perioperative intensive care and management of critically ill cancer patients (2021)

“…Primary PHLF refers to liver failure caused by small-for-size situation, coupled with intraoperative bleeding or not. Secondary PHLF refers to liver failure caused by late complications (32). According to definition and grading of International Study Group of Liver Surgery (ISGLS), PHLF was divided into three groups.…”

“…The outcome of ECLS was related to the etiology of PHLF. In a meta-analysis in 2020, of 34 PHLF patients who received ECLS, ninetyday mortality was 60% and 17% respectively for primary PHLF (n=25) and secondary PHLF (n=7) patients (32). Liver transplantation may be the only treatment measure for primary PHLF which was refractory to conventional measures.…”

Liver resection in Cirrhotic liver: Are there any limits?

“…With regard to management, Grade A PHLF usually resolved on conservative management while a more aggressive treatment approach for grade B PHLF in the form of fresh-frozen plasma, albumin infusion, diuretics and branch-chained amino acids supplementation were indicated. Postoperative somatostatin infusion to reduce the portal pressure should also be considered providing the portal pressure was > 20mHg [95]. On the other hand, the evidence to support the use of molecular adsorbent recirculating system (MARS) was still lacking [95].…”

“…Postoperative somatostatin infusion to reduce the portal pressure should also be considered providing the portal pressure was > 20mHg [95]. On the other hand, the evidence to support the use of molecular adsorbent recirculating system (MARS) was still lacking [95]. For grade C PHLF, a timely referral for liver transplantation before occurrence of septicaemia should be considered in order to improve the outlook of the patient [96].…”