Safe standard remnant liver volume after hepatectomy in HCC patients in different stages of hepatic fibrosis

Background To determine the standard remnant liver volume (SRLV) threshold to avoid postoperative hepatic insufficiency inpatients in different stages of hepatic fibrosis who undergo right hemi-hepatectomy. Methods Data for 85 patients at our single medical center were analysed prospectively to examine whether the following factors differed significantly between those who experienced postoperative hepatic insufficiency and those who did not: height, prothrombin time, remnant liver volume, SRLV or hepatic fibrosis stage. Results Logistic regression showed SRLV and hepatic fibrosis stage to be independent risk factors for postoperative hepatic insufficiency. The threshold SRLV for predicting insufficiency was 203.2 ml/m2 across all patients [area under receiver operating characteristic curve (AUC) 0.778, sensitivity 66.67%, specificity 83.64%, p<0.0001), 193.8 ml/m2 for patients with severe hepatic fibrosis (AUC 0.938, sensitivity 91.30%, specificity 85.71%, p<0.0001), and 224.3 ml/m2 for patients with cirrhosis (AUC 0.888, sensitivity 100%, specificity 64.29%, p<0.0001). Conclusions Right hemi-hepatectomy may be safer in Chinese patients when the standard remnant liver volume is more than 203.2 ml/m2 in the absence of hepatic fibrosis or cirrhosis, 193.8 ml/m2 in the presence of severe hepatic fibrosis or 224.3 ml/m2 in the presence of cirrhosis.

Utility of remnant liver volume for predicting posthepatectomy liver failure after hepatectomy with extrahepatic bile duct resection

Background Hepatectomy with extrahepatic bile duct resection is associated with a high risk of posthepatectomy liver failure (PHLF). However, the utility of the remnant liver volume (RLV) in cholangiocarcinoma has not been studied intensively. Methods Patients who underwent major hepatectomy with extrahepatic bile duct resection between 2002 and 2018 were reviewed. The RLV was divided by body surface area (BSA) to normalize individual physical differences. Risk factors for clinically relevant PHLF were evaluated with special reference to the RLV/BSA. Results A total of 289 patients were included. The optimal cut-off value for RLV/BSA was determined to be 300 ml/m2. Thirty-two patients (11.1 per cent) developed PHLF. PHLF was more frequent in patients with an RLV/BSA below 300 ml/m2 than in those with a value of 300 ml/m2 or greater: 19 of 87 (22 per cent) versus 13 of 202 (6.4 per cent) (P &lt; 0.001). In multivariable analysis, RLV/BSA below 300 ml/m2 (P = 0.013), future liver remnant plasma clearance rate of indocyanine green less than 0.075 (P = 0.031), and serum albumin level below 3.5 g/dl (P = 0.015) were identified as independent risk factors for PHLF. Based on these risk factors, patients were classified into three subgroups with low (no factors), moderate (1–2 factors), and high (3 factors) risk of PHLF, with PHLF rates of 1.8, 14.8 and 63 per cent respectively (P &lt; 0.001). Conclusion An RLV/BSA of 300 ml/m2 is a simple predictor of PHLF in patients undergoing hepatectomy with extrahepatic bile duct resection.

Comment on surgical approaches for definitive treatment of hepatic alveolar echinococcosis: results of a survey in 178 patients

Echinococcus multilocularis causes alveolar echinococcosis which is a chronic, progressive zoonotic disease that mainly affects the liver. Hepatic alveolar echinococcosis is insidious and the patients are asymptomatic most of the time. Generally, it is incidentally found on imaging studies performed for other reasons. Specific symptoms may evolve if the vascular and biliary structures of the liver are affected. Hepatic alveolar echinococcosis shows a similar pattern to malignancies in terms of radiologic and clinical features. For this reason, oncological surgical principles should be applied during the resection of hepatic alveolar echinococcosis. The gold standard surgical treatment is resection with negative surgical margin. However, in patients whose radical resection is not possible other therapeutic options include palliative resection which has no benefit to the patient, and other curative major surgical options such as ex vivo liver resection, and autotransplantation and ultimately liver transplantation. The remnant liver volume has paramount importance if resection is going to be performed. For this reason, occasionally, remnant liver volume hypertrophy is induced by employing either two-stage hepatectomy or associating liver partition and portal vein ligation for staged hepatectomy.

ALPPS in overcoming small remnant liver volume in alveolar echinococcosis

Aim.To evaluate the possibilities and indications for ALPPS, immediate and long-term results of surgical treatment of alveolar echinococcosis including great vessels invasion in case of small remnant liver volume.Material and methods. There were 30 ALPPS procedures. Seven patients had small future liver remnant (FLR) — 24.5% (22.4—26.7%). Bile ducts repair with Roux-en-Y procedure for biliodigestive anastomosis during the first surgical stage was performed in 5 patients (71.4%). ALPPS combined with great vessels resection (portal vein or portal vein and left hepatic vein) was required in 4 patients (57.1%). RO-resections were carried out in all patients.Results.Mean duration of ALPPS stage I was 365 (330—415) min, intraoperative blood loss — 800 (700—1000) ml. Time of stage II was 85 (70—110) min, intraoperative blood loss — 200 (100—300) ml. The second stage of ALPPS was performed in 6—7 days (max 8 days) after preliminary assessment of FLR volume according to CT-volumetry, which was 570 (430—630) ml (37.9% (31.9—52.4%) in relation to FLR volume before the first stage of ALPPS. Augmentation of FLR volume was 200 (150—290) ml (60.9% (48.3—80.6%)). The daily increase of FLR volume was 29 (23—46) ml. Overall postoperative morbidity was 42.9% (complications grade I were noted in 2 patients (28.6%), grade IV — in 1 patient (14.3%). Incidence of post-hepatectomy liver failure grade A (ISGLS, 2011) after ALPPS stage II was 42.9% (n = 3). Bile leakage grade A (ISGLS, 2011) occurred in 28.6% of cases (n = 2). Mortality was absent. Postoperative hospital-stay after stage II was 22 (18—35) days. Maximum follow-up was 50 months. Long-term disease-free survival was 100%, median survival — 29 months.Conclusion.ALPPS technique is feasible, followed by desired increase of FLR volume and safe hepatectomy. The procedure leads to good immediate and long-term postoperative results in patients with alveolar echinococcosis and small FLR volume regard less invasion of afferent and/or efferent liver vessels.