Issues to be considered to address the future liver remnant prior to major hepatectomy
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REVIEW ARTICLE
Issues to be considered to address the future liver remnant prior to major hepatectomy Yoji Kishi1 · Jean‑Nicolas Vauthey2 Received: 9 June 2020 / Accepted: 8 July 2020 © Springer Nature Singapore Pte Ltd. 2020
Abstract An accurate preoperative evaluation of the hepatic function and application of portal vein embolization in selected patients have helped improve the safety of major hepatectomy. In planning major hepatectomy, however, several issues remain to be addressed. The first is which cut-off values for serum total bilirubin level and prothrombin time should be used to define posthepatectomy liver failure. Other issues include what minimum future liver remnant (FLR) volume is required; whether the total liver volume measured using computed tomography or the standard liver volume calculated based on the body surface area should be used to assess the adequacy of the FLR volume; whether there is a discrepancy between the FLR volume and function during the recovery period after portal vein embolization or hepatectomy; and how best the function of a specific FLR can be assessed. Various studies concerning these issues have been reported with controversial results. We should also be aware that different strategies and management are required for different types of liver damage, such as cirrhosis in hepatocellular carcinoma, cholangitis in biliary tract cancer, and chemotherapy-induced hepatic injury. Keywords Major hepatectomy · Future liver remnant · Portal vein embolization · Post-hepatectomy liver failure
Introduction Major hepatectomy has become a common procedure in patients with large hepatocellular carcinoma (HCC) or cholangiocarcinoma. Over the past decade, in parallel with improvements in systemic chemotherapy for liver tumors, the indications for major hepatectomy have expanded to include metastases in the liver, especially colorectal liver metastases (CRLM). At the same time, the safety of hepatectomy has improved owing to the appropriate preoperative assessment of the liver function and advances in surgical techniques, leading to decreased intraoperative blood loss. The risk of post-hepatectomy liver failure (PHLF) has fallen over the past decade, but remains high for several types of procedures; a nationwide survey of board-certified training institutions by the Japanese Society of Hepato-Biliary-Pancreatic Surgery showed 90-day mortality rates of * Yoji Kishi ykishi‑[email protected] 1
Department of Surgery, National Defense Medical College, Namiki 3‑2, Tokorozawa, Saitama 359‑8513, Japan
Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
2
10.3% after left trisectionectomy and 6.7% after hepatopancreatectomy [1]. One of the most extensive types of hepatectomy, associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) [2], which was initially introduced to induce rapid hypertrophy of the future liver remnant (FLR) before second-stage major hepatectomy [3], was still associated with a mortality rate
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