Monitoring of liver function in a 73-year old patient undergoing 'Associating Liver Partition and Portal vein ligation for Staged hepatectomy': case report applying the novel liver maximum function capacity test.
BACKGROUND
The two-stage liver resection combining in situ liver transection with portal vein ligation, also referred to as ALPPS (Associating Liver Partition and Portal vein ligation for Staged hepatectomy), has been described as a promising method to increase the resectability of liver tumors. However, one of the most important issues regarding the safety of this procedure is the optimal timing of the second stage at the point of sufficient hypertrophy of the future liver remnant. The recently developed liver maximum function capacity test (LiMAx) can be applied to monitor the liver function postoperatively and hence could be a useful tool for decision-making regarding the timing of the second stage of ALPPS.


METHODS
A 73-year-old female patient presented with metachronous colorectal liver metastasis comprising the complete right liver lobe as well as segment IV. Due to an insufficient future liver remnant (19.3 %; segments II and III of the liver) and a low future liver remnant:body weight ratio (0.28 %) the decision was made to perform an ALPPS-procedure in order to avoid development of postoperative small-for-size syndrome. Despite a formally sufficient increase of the FLR to 30.8 % within 7 days after the first step of ALPPS, the liver function was seen to only slowly increase as expressed by a LiMAx value of 245 μg/h/kg (baseline of 282 μg/h/kg prior to surgery). By means of the LiMAx test, sufficient increase of liver function eventually was detected by postoperative day 11 (LiMAx value of 371 μg/h/kg; FLR 35.2 %) so that the second step of ALPPS (completion of hepatectomy) was performed with no signs of liver failure during further clinical course.


CONCLUSIONS
Performing ALPPS we have observed a significant difference between the increase in future liver remnant volume and function applying the LiMAx test. The latter tool thus might proof valuable for application in two-stage liver resection to avoid postoperative small-for-size syndrome.
Regenerative Medicine & Experimental Surgery (ReMediES); Department of General, Visceral and Transplant Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany.
Felix
F
Oldhafer
Department of Diagnostic and Interventional Radiology, Hannover Medical School, Hannover, Germany.
Kristina I
KI
Ringe
Regenerative Medicine & Experimental Surgery (ReMediES); Department of General, Visceral and Transplant Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany.
Kai
K
Timrott
Regenerative Medicine & Experimental Surgery (ReMediES); Department of General, Visceral and Transplant Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany.
Moritz
M
Kleine
Regenerative Medicine & Experimental Surgery (ReMediES); Department of General, Visceral and Transplant Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany.
Wolf
W
Ramackers
Regenerative Medicine & Experimental Surgery (ReMediES); Department of General, Visceral and Transplant Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany.
Sebastian
S
Cammann
Regenerative Medicine & Experimental Surgery (ReMediES); Department of General, Visceral and Transplant Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany.
Mark D
MD
Jäger
Regenerative Medicine & Experimental Surgery (ReMediES); Department of General, Visceral and Transplant Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany.
Juergen
J
Klempnauer
Regenerative Medicine & Experimental Surgery (ReMediES); Department of General, Visceral and Transplant Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany.
Hueseyin
H
Bektas
Regenerative Medicine & Experimental Surgery (ReMediES); Department of General, Visceral and Transplant Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany.
Florian W R
FW
Vondran
ALPPS; In situ split; LiMAx; Liver; Liver resection; Surgery