Morbidity of major hepatic resections: a 100-case prospective study

Central bisectionectomy for centrally located hepatocellular carcinoma

BACKGROUND

Central bisectionectomy, which involves the removal of the central hepatic segments (IVA, IVB, V, VIII) for hepatocellular carcinoma (HCC), is performed to reduce the volume of resected liver and to overcome the problem of insufficient future residual volume.

METHODS

Twenty-seven patients with HCC underwent central bisectionectomy from January 1998 to April 2007 in one hospital. The surgical techniques, clinicopathological characteristics and outcomes were reviewed.

RESULTS

The median operating time was 330 min. Twelve patients developed postoperative complications and two died. The most common complication, occurring in five patients, was bile duct injury leading to biloma or bile leakage. Median follow-up was 19.1 (range 1.4-102.2) months and eight patients developed a recurrence. Twenty-four patients were alive at the time of writing.

CONCLUSION

Although biliary complications occur somewhat frequently, central bisectionectomy in centrally located HCC can be performed safely to preserve liver volume.

Precautions in caudate lobe resection: Report of 11 cases

AIM: To find the precautions against the safety in caudate lobe resection.

METHODS: The clinical data obtained from 11 cases of primary liver cancer in caudate lobe who received hepatectomy successfully were retrospectively analyzed. Four safe procedures were used in resection of primary liver cancer in caudate lobe: (1) selection of appropriate skin incision to obtain excellent exposure of operative field; (2) adequate mobilization of the liver to allow the liver to be displaced upwards to the left or to the right; (3) preparatory placement of tapes for total hepatic vascular exclusion, so that this procedure could be used to control the fatal bleeding of the liver when necessary; (4) selection of the ideal route for hepatectomy based on the condition of the tumor and the combined removal of multiple lobes if necessary. Among the 11 cases, simple occlusion of vessels of porta hepatis was used in caudate lobectomy for 6 cases, while in the other cases, the vessels were intermittently occluded several times or total hepatic vascular isolation was used in the caudate lobectomy. Combined partial right hepatectomy was done for 3 cases, combined left lateral lobectomy for 2 cases and caudate lobectomy alone for 6 cases.

RESULTS: Operation was successful for all the 11 cases. Intermittent inflow occlusion was performed for all patients for 15 min at 5-min intervals. Blockade was performed twice in 3 patients and total hepatic vascular exclusion was performed in one of the three patients. Blockade was performed three times in one patient, including a total hepatic vascular exclusion. Total hepatic vascular exclusion was performed only in one patient. The mean blood loss was 300 mL. Ascites and pleural effusion occurred in 4 patients, jaundice in 1 patient. Six patients died of tumor recurrence in 6, 11, 12, 13, 15, 19 mo after operation, respectively. The other 5 patients have survived more than 16 mo since the operation.

CONCLUSION: Caudate lobectomy for liver cancer in candidate lobe can be safely performed with the above procedures.

Operative mortality after hepatic resection: are literature-based rates broadly applicable?

INTRODUCTION

Literature-based data on mortality after hepatectomy may be misleading, as poor outcomes are less likely to be published. The objective of the current study was to compare published vs public, nationally available mortality rates after hepatic resection.

MATERIALS AND METHODS

A systematic MEDLINE review was conducted to identify reports of hepatectomy outcome between January 1998-December 2004. Data were analyzed to calculate literature-based mortality rate and then compared with population-based mortality rate for hepatectomy using the Nationwide Inpatient Sample (NIS) dataset.

RESULTS

Twenty-three publications fulfilled screening criteria. The studies included 7,073 patients who had undergone hepatic resection (46.1% within USA vs 53.9% outside USA). Most patients were male (58.6%) with median age of 56 years. Indications for hepatic resection included hepatocellular carcinoma (47.7%), metastatic disease (34.3%), or other (18.1%). Cirrhosis was present in 23.2% of patients; 46.9% patients underwent either a hemi-hepatectomy or extended resection. The literature-based mortality rate was 3.6% (US centers only, 2.8%). Analysis of NIS revealed 11,429 hepatectomy cases. After controlling for gender, age, extent of hepatectomy, hepatocellular cancer diagnosis, and presence of cirrhosis, the adjusted NIS-based perioperative mortality rate for hepatectomy was 5.6% (95% CI, 5.0-6.2%). The relative mortality after hepatectomy was 1.6-fold higher based on population-based data compared with reports from the literature (P<0.05).

CONCLUSION

Actual population-based mortality rates for major liver resections may be higher than those reported in the literature. Informed consent should reflect actual local and national mortality rates rather than selective reports from the literature.

Sonographic preoperative assessment of liver volume before major liver resection

OBJECTIVE

The use of ultrasonography is widespread for both the diagnosis and treatment of liver tumors. However, the measurement of liver volume by ultrasonography is not commonly done. We report an original method of liver volumetry using ultrasonography and an investigation into the usefulness of ultrasonography in this context.

METHODS

The data for 50 patients undergoing various types of major hepatectomy were collected. We preoperatively measured liver volume using ultrasonography, dividing the liver into three main compartments according to precise anatomical landmarks, and then made comparisons with the volume of the actual specimen after hepatectomy, for all of the study participants.

RESULTS

Total volume correlation between the two groups was good (r = 0.916, P < 0.001). However, the correlation was weaker in cases of right hepatectomy compared with other types of hepatectomy.

CONCLUSION

This study demonstrates the possibility of doing liver volumetry using an ultrasound device. Further investigation to establish the reliability of this easily available and noninvasive approach is needed.

The benefit of the supplementation of perioperative branched-chain amino acids in patients with surgical management for hepatocellular carcinoma: a preliminary study

The aim of this work was to study the benefit of supplementation with a branched chain amino acids enriched nutrient mixture on the physical and mental condition following hepatic surgery in patients with hepatocellular carcinoma (HCC). A total of 41 patients with HCC who underwent hepatic surgery (36 hepatic resection and five radiofrequency ablation therapy) were enrolled in this comparative study. These patients were divided into two groups: 13 patients received perioperative supplementation of a branched chain amino acids enriched nutrient mixture (AEN group) and 28 patients did not (control group). Between these two groups, laboratory data, postoperative complications and the length of hospital stay were analyzed comparatively. Restoration of peripheral lymphocyte count and serum total cholesterol level at 3 months after the operation was significantly faster in the AEN group than in the control group (P < 0.05). The length of hospitalization in the AEN group was significantly shorter than in the control group (P < 0.05). This preliminary case control study suggested that the perioperative supplementation of a branched chain amino acids enriched nutrient mixture is of clinical benefit for nutritional support of patients surgically managed for HCC in chronic liver disease.

Outcomes and prognostic factors of cirrhotic patients with hepatocellular carcinoma after radical major hepatectomy

BACKGROUND

Radical major hepatectomy (RMH) has been suggested as one of main options for cure of large/advanced hepatocellular carcinoma (HCC). However, its operative risk remains high and its effectiveness is still controversial, especially for patients with liver cirrhosis. The present study aims to investigate short- and long-term outcomes and to identify prognostic factors for cirrhotic patients with HCC after RMH.

MATERIALS AND METHODS

Prospectively collected clinicopathological data of 81 consecutive cirrhotic HCC patients who underwent RMH were reviewed retrospectively. The Kaplan-Meier method was adopted for evaluating long-term survival. Prognostic factors were identified by univariate and multivariate analyses.

RESULTS

After RMH, perioperative mortality, overall morbidity, and life-threatening morbidity were 1.2%, 24.7%, and 12.3%, respectively. Overall and disease-free 5-year survival rates were 39.4% and 28.1%, respectively. Univariate analysis showed that presence of portal vein tumor thrombosis (PVTT) and satellite nodules, late TNM staging, high Edmondson-Steiner grading, and blood transfusion was associated with worsened prognosis. Of them, Edmondson-Steiner grading was identified as the sole independent prognostic factor for both overall and disease-free survival by multivariate analysis, whereas blood transfusion and the presence of PVTT independently predicted unfavorable overall or disease-free survival, respectively.

CONCLUSIONS

These data indicated that RMH was safe and appeared to be effective in treating cirrhotic patients with HCC. Some tumor-related and clinical variables influenced long-term outcome of these patients after RMH.

Effect of major liver resection on hepatic ureagenesis in humans

Changes in hepatic ureagenesis following major hepatectomy are not well characterized. We studied the relation between urea synthesis and liver mass before and after major hepatectomy in humans. Fifteen patients scheduled for resection of malignancies in otherwise healthy livers were studied. Pre- and postoperative liver volume was assessed by computerized tomography-volumetry. During surgery, a primed, continuous infusion of [(13)C]urea was administered intravenously, and arterial blood samples were obtained hourly. Indocyanine green clearance was determined before and after resection. Seven patients underwent major hepatectomy, and eight patients underwent minor [<5% functional liver volume (total volume -- tumor volume)] or no resection, serving as controls. Resected functional liver volume in the major hepatectomy group averaged 60%. Urea synthesis per gram of functional liver tissue increased 2.6-fold following major hepatectomy, maintaining whole body urea synthesis. Arterial ammonia remained unchanged throughout the study, whereas following hepatectomy a hyperaminoacidemia occurred. In conclusion, immediately following major hepatectomy, urea synthesis per gram of functional liver tissue increases rapidly and proportionately to the amount of liver tissue resected, maintaining whole body urea synthesis at preoperative levels. This rapid and complete adaptation suggests that the capacity of urea synthesis is not limiting the maximum resectable volume in otherwise healthy livers.

Prognostic factors after resection for hepatocellular carcinoma in nonfibrotic or moderately fibrotic liver. A 116-case European series

The purpose of this study was to identify factors influencing prognosis after resection for hepatocellular carcinoma in the noncirrhotic liver and to measure the impact of moderate fibrosis on presentation and prognosis. A series of 116 primary procedures were performed for hepatocellular carcinoma in the noncirrhotic liver. These cases accounted for 42% of hepatic resections performed for hepatocellular carcinoma during the study period (1987-2005). Seventy-seven cases (58%) occurred in patients with nonfibrotic livers (Metavir score F0). The mean age was 61 years. The sex ratio was 3.5, with a female predominance before 50 years. Hepatitis B virus (HBV) or hepatitis C virus infection was found in 30% of patients. Symptoms were present in 64% of cases. Elevated serum alpha fetoprotein levels were observed in 44% of cases. Procedures involved minor hepatectomy in 40 cases, major hepatectomy in 72 cases, and transplantation in 4 cases. Postoperative mortality was 6% and morbidity was 31%. Complete resection was achieved in 90% of cases. The tumor was isolated in 72% of cases. The mean tumor diameter was 10.6 cm. Vascular invasion was observed in 48% of cases. Hepatocellular carcinoma in the nonfibrotic liver was associated with younger age and female sex, but there was no difference with other hepatocellular carcinoma with regard to histological or prognostic features. With a median follow-up of 79 months, overall survival was 40% for a median of 41 months. Multivariate analysis identified incomplete resection, vascular invasion, and HBV infection as independent factors of poor prognosis. In case of recurrence, repeat resection was feasible in 30% of cases with 69% survival at 5 years. Although hepatocellular carcinoma in the noncirrhotic liver is generally diagnosed at an advanced stage, its resectability remains high. As a result, hepatocellular carcinoma in the noncirrhotic liver accounts for a large proportion of cases in surgical series and has a better prognosis than hepatocellular carcinoma in the cirrhotic liver. Vascular invasion, incomplete resection, and HBV infection are independent factors of poor prognosis.

Small remnant liver volume after right lobe living donor hepatectomy

BACKGROUND

Right lobe living donor liver transplantation has become a viable option for adult patients with end-stage liver disease, however, the safety of the donor is of paramount importance. One of the key factors in donor safety is ensuring adequate donor remnant liver volume.

METHODS

We retrospectively examined donors who had less than 30% remnant liver volume after right graft procurement. Eighty-six right lobe living donor transplants were carried out in Chang Gung Memorial Hospital, Kaohsiung Medical Center, from January 1999 to December 2004.

RESULTS

Eight donors had less than 30% remnant liver volume (Group 1) after graft procurement and 78 donors had remnant liver volume greater than 30% (Group 2). There were no differences in donor characteristics, types of graft, operative parameters, and post-operative liver and renal function as well as liver volume at 6 months post-donation between the 2 groups. The graft weight obtained in Group 1 donors was significantly greater compared with that from Group 2 (P<.005). The overall donor complication rate was 6.98%, and all the complications occurred among group 2 donors.

CONCLUSIONS

The judicious use of donors with less than 30% remnant liver volume is safe as a last resort.

Resection of hepatocellular carcinoma with tumor thrombus in the major vasculature. A European case-control series

Tumor thrombus in major vasculature is a frequent finding with a poor long-term prognosis in patients with hepatocellular carcinoma (HCC). The utility of surgical resection is still controversial. This study compared morbidity and survival after resection for HCC with and without tumor thrombus. Data of 108 patients who underwent major hepatic resection for HCC were prospectively recorded. Patients were divided into two groups. The venous thrombectomy (VT) group included 26 patients who had HCC with tumor thrombus in the portal or hepatic veins. The matched control group included 82 patients who had HCC without tumor thrombus. Surgical technique, early outcome, and late survival were analyzed in each group. Multivariate analysis was performed to assess the prognostic value of this feature. Surgical technique was comparable in the VT and control group with regard to extent of hepatectomy, procedure duration, and transfusion requirements. Early postoperative outcome was also comparable. Actuarial survival at 1, 3, and 5 years was 38%, 20%, and 13%, respectively, in the VT group (median: 9 months) versus 74%, 56%, and 33%, respectively, in the control group (median: 41 months). In the subgroup of patients with tumor thrombus limited to the portal vein, actuarial survival at 1, 3, and 5 years was 50%, 26%, and 17%, respectively, (median: 12 months) and two patients lived longer than 5 years. Multivariate analysis showed that incomplete resection, alphafetoprotein level greater than 100 N, more than two tumor nodules, and tumor thrombus in major vasculature were independent factors of poor prognosis. Survival after resection for HCC with tumor thrombus in the major vasculature is poorer than after resection for HCC without tumor thrombus. However, an aggressive surgical strategy can provide significant survival with comparable morbidity in selected cases, that is, tumor thrombus located in the portal vein only and expected complete resection of the lesions.

Clinicopathological features, post-surgical survival and prognostic indicators of elderly patients with hepatocellular carcinoma

AIM

Comprehensive data regarding elderly patients with hepatocellular carcinoma (HCC) were limited. The present study aims to widen the knowledge based on patients in China.

METHODS

Fifty-four elderly (> or =65 years) and 125 non-elderly HCC patients undergoing hepatectomy were enrolled in this retrospective study. Clinicopathological features and post-surgical survival were compared between two groups. Prognostic indicators of elderly patients were defined by uni- and multivariate analyses.

RESULTS

Contrast to non-elderly patients, the elderly presented significantly lower rates of HBsAg positivity, Child-Pugh grade A, alpha-fetoprotein (AFP) marked elevation, portal vein tumour thrombosis (PVTT), satellite nodule, and intrahepatic recurrence, smaller tumour sizes, earlier TNM staging and better histological differentiation. No significant differences were found in perioperative mortality rate and post-surgical survival between two groups. PVTT and Edmondson-Steiner grading were identified as independent prognostic indicators of both overall and disease-free survival by multivariate analysis, whereas Child-Pugh grading independently affected the overall survival.

CONCLUSIONS

HCC in the elderly seemed to be less HBV-associated, less progressive and less aggressive than that in the non-elderly. Hepatectomy for the elderly could make a satisfactory prognosis and be well tolerated. Some tumour-related factors independently predict the prognosis of elderly HCC patients, and their liver function status should be further valued.

Predictive indices of morbidity and mortality after liver resection

OBJECTIVE

To determine if use of Model for End-Stage Liver Disease (MELD) scores to elective resections accurately predicts short-term morbidity or mortality.

SUMMARY BACKGROUND DATA

MELD scores have been validated in the setting of end-stage liver disease for patients awaiting transplantation or undergoing transvenous intrahepatic portosystemic shunt procedures. Its use in predicting outcomes after elective hepatic resection has not been evaluated.

METHODS

Records of 587 patients who underwent elective hepatic resection and were included in the National Surgical Quality Improvement Program Database were reviewed. MELD score, CTP score, Charlson Index of Comorbidity, American Society of Anesthesiology classification, and age were evaluated for their ability to predict short-term morbidity and mortality. Morbidity was defined as the development of one or more of the following complications: pulmonary edema or embolism, myocardial infarction, stroke, renal failure or insufficiency, pneumonia, deep venous thrombosis, bleeding, deep wound infection, reoperation, or hyperbilirubinemia. The analysis was repeated with patients divided according to their procedure and their primary diagnosis. Parametric or nonparametric analyses were performed as appropriate. Also, a new index was developed by dividing the patients into a development and a validation cohort, to predict morbidity and mortality in patients undergoing elective hepatic resection. ROC curves were also constructed for each of the primary indices.

RESULTS

CTP and ASA scores were superior in predicting outcome. Also, patients undergoing resection of primary malignancies had a higher rate of mortality but no difference in morbidity.

CONCLUSION

MELD scores should not be used to predict outcomes in the setting of elective hepatic resection.

Respiratory Complications: A Major Concern after Right Hepatectomy in Living Liver Donors

BACKGROUND

One of the main concerns after living donor liver transplantation is the risk of morbidity and/or mortality that it imposes on the donors. Respiratory postoperative complications in living liver donors have already been reported but their frequency seems to be underestimated. We designed a prospective study to evaluate the rate and the nature of postoperative pulmonary complications in 112 consecutive donors.

METHODS

The medical records of the 112 living liver donors operated on at our center from 1998 to 2003 were reviewed and all the cases of respiratory complications were retrieved. Moreover, since 2000, all patients had a computed tomography angiography of the thorax at day 7 on a prospective basis.

RESULTS

In all, 112 hepatectomies (44 right and 68 left) for adult-to-adult or adult-to-child liver donation were performed in our center. No postoperative mortality was recorded. Fourteen major respiratory complications developed in of 11 of 112 donors (9.8%), in all cases after right hepatectomy, and included nonsevere pulmonary embolism (n=7), right pleural empyema (n=3), and bacterial pneumonia (n=3). Minor respiratory complications (7.1% of the donors) included iatrogenic pneumothorax (n=3) and pleural effusion requiring thoracocentesis (n=5). Abdominal complications (mainly biliary leak) developed in 10 donors (8.9%), who in the vast majority remained free of pulmonary complications.

CONCLUSIONS

In our series, pulmonary complications are frequent in living liver donors. These complications are mainly observed after right hepatectomy. The particular prevalence of pulmonary embolism should lead to focus on its early diagnosis and prevention.

Incidence of benign pathology in patients undergoing hepatic resection for suspected malignancy

BACKGROUND

Confirming the presence of hepatic or proximal bile duct malignancy pre-operatively remains difficult and some patients may undergo surgical resection for suspected malignant lesions which subsequently turn out to be benign. The aim of this study was to establish whether improvements in pre-operative staging might better identify this patient population.

METHODS

Analysis of a prospectively collected database, which has been maintained in our unit since 1988.

RESULTS

Of 250 consecutive patients undergoing hepatic resection for presumed malignancy, 18 (7.2%) were shown to have benign pathology. These "false positive" rates were 4 out of 160 (2.5%) resections for colorectal metastases, 4 out of 49 (8.2%) resections for other solid hepatobiliary tumours and 10 out of 41 (24.4%) resections for hilar cholangiocarcinoma. Four of the 18 patients (22%) developed post-operative complications but there was no postoperative mortality.

CONCLUSION

Although hepatic resection remains a potentially curative procedure for patients with tumours involving the liver parenchyma or proximal bile ducts, pre-operative confirmation of malignancy remains difficult. Despite appropriate investigation a subset of patients with benign disease will still be subjected to major hepatic resection which should be undertaken in a specialist unit.

Factors affecting outcome in liver resection

BACKGROUND

Studies demonstrate an inverse relationship between institution/surgeon procedural volumes and patient outcomes. Similar studies exist for liver resections, which recommend referral of patients for liver resections to 'high-volume' centers. These studies did not elucidate the factors that underlie such outcomes. We believe there exists a complex interaction of patient-related and perioperative factors that determine patient outcomes after liver resection. We sought to delineate these factors.

METHODS

Retrospective review of 114 liver resections by a single surgeon from 1993-2003: Records were reviewed for demographics; diagnosis; type/year of surgery; American Society of Anesthesiologists (ASA) score; preoperative albumin, creatinine, and bilirubin; operative time; intraoperative blood transfusions; epidural use; and intraoperative hypotension. Main outcome measurements were postoperative morbidities, mortalities and length of stay (LOS). Data were analyzed using a multivariate linear regression model (SPSS v10.1 statistical analysis program).

RESULTS

Primary indications for resections were hepatocellular carcinoma (HCC) (N=57), metastatic colorectal cancer (N=25), and benign disease (N=18). There were no intraoperative mortalities and 4 perioperative (30-day) mortalities (3.5%). Mortality occurred in patients with malignancies who were older than 50 years. Morbidity was higher in malignant (15.6%) versus benign (5.5%) disease. Complications included bile leak/stricture (N=6), liver insufficiency (N=3), postoperative bleeding (N=2), myocardial infarction (N=2), aspiration pneumonia (N=1), renal insufficiency (N=1), and cancer implantation into the wound (N=1). Average LOS for all resections was 8.6 days. Longer operative time (p=0.04), lower albumin (p<0.001), higher ASA score (p<0.001), no epidural use (p=0.04), and higher creatinine (p<0.001) all correlated positively with longer LOS. ASA score and creatinine were the strongest predictors of LOS. LOS was not affected by patient age, sex, diagnosis, presence of malignancy, intraoperative transfusion requirements, intraoperative hypotension, preoperative bilirubin, case volume per year or year of surgery.

CONCLUSIONS

Liver resections can be performed with low mortality/morbidity and with acceptable LOS by an experienced liver surgeon. Outcome as measured by LOS is most influenced by patient comorbidities entering into surgery. Annual case volume did not influence LOS and had no impact on patient safety. Length of stay may not reflect surgeon/institution performance, as LOS is multifactorial and likely related to patient population, patient selection and increased high-risk cases with a surgeon's experience.

Risk factors for postoperative delirium after liver resection for hepatocellular carcinoma

We investigated risk factors for delirium in 100 patients who underwent liver resection for hepatocellular carcinoma. Postoperative delirium developed in 17 (17%). Univariate analysis revealed that advanced age (especially = 70 years old), a history of smoking, a decreased serum albumin concentration (especially < 3.8 g/dl), advanced cancer stage (II-IV), major hepatectomy, prolonged operating time, and large intraoperative blood loss were possible risk factors for postoperative delirium. When patients' preoperative condition and laboratory test results were subjected to multivariate analysis, only advanced age [odds ratio (OR) 1.201; confidence interval (CI) 1.063-1.357] and a decreased serum albumin concentration (OR 0.151; CI 0.025-0.900) were independent risk factors for the delirium. The percentages of patients with high aspartate and alanine aminotransferase activities, a high indocyanine green retention rate at 15 minutes, a low platelet count, and advanced cancer stage (II-IV) were higher in patients with a low (< 3.8 g/dl), rather than high (= 3.8 g/dl) serum albumin concentration. These findings indicate that multiple factors, including advanced age, impaired liver function, and advanced cancer stage, affect the development of postoperative delirium after liver resection for hepatocellular carcinoma.

Correlation between preoperative serum concentration of type IV collagen 7s domain and hepatic failure following resection of hepatocellular carcinoma

OBJECTIVE

To determine the predictive value of the preoperative serum concentration of type IV collagen 7s domain (7s collagen) for postoperative hepatic failure in patients undergoing liver resection for hepatocellular carcinoma.

SUMMARY BACKGROUND DATA

Clear and reliable criteria for predicting hepatic failure after liver resection are needed. The serum 7s collagen concentration correlates with the histologic degree of active hepatitis and hepatic fibrosis and may predict the regenerative potential of the liver.

METHODS

Potential risk factors for postoperative hepatic failure, including the serum 7s collagen concentration, were evaluated in 251 patients who underwent liver resection for hepatocellular carcinoma. Prognostic significance was determined by univariate and multivariate analyses.

RESULTS

Hepatic failure developed postoperatively in 25 patients, 4 of whom died. The serum 7s collagen concentration correlated with the histologic degree of hepatitis activity and hepatic fibrosis. The serum 7s collagen concentration was a risk factor for postoperative hepatic failure by univariate analysis and was the only risk factor on multivariate analysis. No patient with a serum 7s collagen concentration <12 ng/mL died of postoperative hepatic failure, and all 4 patients who died had a serum 7s collagen concentration >or=12 ng/mL.

CONCLUSIONS

The preoperative serum 7s collagen concentration correlated independently with hepatic failure following liver resection for hepatocellular carcinoma. Patients whose serum 7s collagen is >or=12 ng/mL are poor candidates for hepatic resection.

Preoperative galactose elimination capacity predicts complications and survival after hepatic resection

OBJECTIVE

To analyze a single center's 6-year experience with 258 consecutive patients undergoing major hepatic resection for primary or secondary malignancy of the liver, and to examine the predictive value of preoperative liver function assessment.

SUMMARY BACKGROUND DATA

Despite the substantial improvements in diagnostic and surgical techniques that have made liver surgery a safer procedure, careful patient selection remains mandatory to achieve good results in patients with hepatic tumors.

METHODS

In this prospective study, 258 patients undergoing hepatic resection were enrolled: 111 for metastases, 78 for hepatocellular carcinoma (HCC), 21 for cholangiocellular carcinoma, and 48 for other primary hepatic tumors. One hundred fifty-eight patients underwent segment-oriented liver resection, including hemihepatectomies, and 100 had subsegmental resections. Thirty-two clinical and biochemical parameters were analyzed, including liver function assessment by the galactose elimination capacity (GEC) test, a measure of hepatic functional reserve, to predict postoperative (60-day) rates of death and complications and long-term survival. All variables were determined within 5 days before surgery. Data were subjected to univariate and multivariate analysis for two patient subgroups (HCC and non-HCC). The cutoffs for GEC in both groups were predefined. Long-term survival (>60 days) was subjected to Kaplan-Meier analysis and the Cox proportional hazard model.

RESULTS

In the entire group of 258 patients, a GEC less than 6 mg/min/kg was the only preoperative biochemical parameter that predicted postoperative complications and death by univariate and stepwise regression analysis. A GEC of more than 6 mg/min/kg was also significantly associated with longer survival. This predictive value could also be shown in the subgroup of 180 patients with tumors other than HCC. In the subgroup of 78 patients with HCC, a GEC less than 4 mg/min/kg predicted postoperative complications and death by univariate and stepwise regression analysis. Further, a GEC of more than 4 mg/min/kg was also associated with longer survival.

CONCLUSIONS

This prospective study establishes the preoperative determination of the hepatic reserve by GEC as a strong independent and valuable predictor for short- and long-term outcome in patients with primary and secondary hepatic tumors undergoing resection.

Major liver resection results in a changed plasma amino acid pattern as reflected by a decreased Fischer ratio which improves by bactericidal/permeability increasing protein

BACKGROUND/AIMS

Major liver resection results in a high morbidity and mortality, and endotoxin plays a role in post-resection hepatic failure. Severe hepatic failure as seen in hepatitis and cirrhosis may be accompanied by hepatic encephalopathy and is characterized by a typical plasma amino acid pattern reflected by a decreased Fischer ratio. This study was performed to evaluate the plasma amino acid pattern in patients undergoing major liver surgery receiving placebo or the endotoxin-neutralizing agent bactericidal/permeability-increasing protein (rBPI21).

PATIENTS AND METHODS

Forty-eight patients were randomized in this phase II, dose escalation, multicenter trial. Plasma amino acid profiles were determined preoperatively, and on the first (day 1) and third (day 3) postoperative day.

RESULTS

In the placebo group the Fischer ratio decreased significantly on both postoperative days. Administration of rBPI21 also resulted in a decreased Fischer ratio on day 1, but not on day 3. Highly elevated alanine plasma levels were observed on day 1 in placebo-treated patients, whereas rBPI21 prevented this elevation. Plasma alanine levels on day 1 correlated with the duration of post-resection hepatic failure.

CONCLUSIONS

Major liver resection results in a decreased Fischer ratio and a rise in plasma alanine levels. Plasma levels of alanine on the first postoperative day correlated with the duration of the post-resection hepatic failure. rBPI21 improved the Fischer ratio and prevented the rise of plasma alanine levels.

Selection and outcome of living donors for adult to adult right lobe transplantation

BACKGROUND

The shortage of cadaveric livers has sparked an interest in adult-to-adult living donor transplantation. Right lobe donor hepatectomy is frequently required to obtain a graft of adequate size for adult recipients. Careful donor selection is necessary to minimize complications and assure a functional graft.

METHODS

A four-step evaluation protocol was used for donor selection and satisfactory results of all tests in each step were required before proceeding to the next. Donors were selected based on a battery of laboratory studies chosen to exclude unrecognized infection, liver disease, metabolic disorders, and conditions representing undue surgical risk. Imaging studies included ultrasonography, angiography, magnetic resonance imaging, and intraoperative cholangiography and ultrasonography. The information obtained from liver biopsy was used to correct the estimated graft mass for the degree of steatosis.

RESULTS

From March 1998 to August 1999, 126 candidates were evaluated for living donation. A total of 35 underwent donor right lobectomy with no significant complications. Forty percent of all donors that came to surgery were genetically unrelated to the recipient. A total of 69% of those evaluated were excluded. ABO incompatibility was the primary reason for exclusion after the first step (71%) and the presence of steatosis yielding an inadequate estimated graft mass after the second step (20%).

CONCLUSIONS

Donor selection limits the application of living donor liver transplantation in the adult population. Unrelated individuals increase the size of the donor pool. Right lobe hepatectomy can be performed safely in healthy adult liver donors. Preoperative liver biopsy is an essential part of the evaluation protocol, particularly when the estimated graft mass is marginal.

Right lobe living donor liver transplantation: a review

The continuing shortage of organs for adult transplant recipients has generated enthusiasm for adult-to-adult living donor liver transplantation (LDLT). The major concern has been the ability to resect a graft of adequate size without subjecting the donor to undue risk. The right hepatic lobe is generally large enough for adult recipients, but because of the real and perceived risks of right lobe (RL) resection, surgeons have been hesitant to offer this option to their patients. The first series of RL resections that included a significant number of patients was reported in 1999, and the results were encouraging. Only minor complications occurred in donors, and the recipients fared quite well. Enthusiasm for these donor resections is growing, and more centers are beginning to perform them. There is a good deal of global experience with pediatric LDLT but little with adults, and there are unique considerations in this population. This review examines donor selection criteria for adult recipients, highlights technical points critical for good outcome, and examines the early results and complications in both donors and recipients. If the preliminary results continue to be reproduced, RL LDLT could have significant impact on the worsening organ shortage.