Three hundred and one consecutive extended right hepatectomies: evaluation of outcome based on systematic liver volumetry.
OBJECTIVE
This study aimed to determine the effect of preoperative liver volumetry on postoperative outcomes after extended right hepatectomy. Primary end point was to evaluate whether future liver remnant (FLR)/standardized liver volume ratio (sFLR) >20% is sufficient for a safe hepatic resection. Secondary end point was to assess whether preoperative portal vein embolization (PVE) is associated with improved outcome in patients with initial sFLR ≤ 20%.


BACKGROUND
An sFLR >20% of the total liver volume has been proposed as sufficient for safe hepatic resection, but this concept has not been validated in a large series. In addition, recent reports suggest preoperative PVE is indicated for sFLR <30%.


METHODS
The impact of sFLR and PVE on short-term outcomes (postoperative complications, liver insufficiency, and 90-day mortality) was analyzed in 301 consecutive patients after extended right hepatectomy. Liver volumetry accounted for partial resection of segment IV. Liver insufficiency was defined as peak postoperative serum bilirubin >7 mg/dL. Predictors of liver insufficiency were identified by multivariate logistic regression.


RESULTS
Postoperative liver insufficiency occurred in 45 patients (15%) and accounted for 61% of deaths. Among 290 patients who underwent liver volumetry, sFLR was <20% in 38 patients, 20.1% to 30% in 144, and ≥ 30% in 108. Rates of postoperative liver insufficiency and death from liver failure were similar between patients with sFLR 20.1% to 30% and sFLR ≥ 30% but higher in patients with sFLR ≤ 20% (P 0.05). Postoperative outcomes were similar between patients with increase in sFLR from ≤ 20% to >20% after PVE and patients with initial sFLR >20%. Multivariate analysis revealed that body mass index >25 kg/m2, intraoperative blood transfusion, and sFLR ≤ 20% (odds ratio = 3.18; 95% CI, 1.34-7.54) independently predicted postoperative liver insufficiency.


CONCLUSIONS
Systematic measurement of FLR volume is important to select patients for PVE and extended right hepatectomy. A sFLR >20% is sufficient for safe hepatic resection and sFLR 20.1% to 30% is not an indication for preoperative PVE.
Kishi
Yoji
Y
Department of Surgical Oncology, Unit 444, The University of Texas MD Anderson Cancer Center, Houston, TX 77030–4009, USA.
Abdalla
Eddie K
EK
Chun
Yun Shin
YS
Zorzi
Daria
D
Madoff
David C
DC
Wallace
Michael J
MJ
Curley
Steven A
SA
Vauthey
Jean-Nicolas
JN
D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001663:Bilirubin / Q000097:blood; D016009:Chi-Square Distribution; D002648:Child; D004621:Embolization, Therapeutic; D023381:Endpoint Determination; D005260:Female; D006498:Hepatectomy / Q000379:methods* / Q000401:mortality; D006801:Humans; D008099:Liver / Q000033:anatomy & histology* / Q000601:surgery*; D008111:Liver Function Tests; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D010043:Outcome and Process Assessment, Health Care; D018579:Patient Selection; D011169:Portal Vein; D011183:Postoperative Complications / Q000401:mortality; D011300:Preoperative Care; D012189:Retrospective Studies; D012307:Risk Factors; D018709:Statistics, Nonparametric
D001663:Bilirubin