title: Post-hepatectomy hyperbilirubinemia: The point of no return.
abstract: BACKGROUND
  Post-hepatectomy hyperbilirubinemia is associated with liver insufficiency and failure. The highest survivable peak total bilirubin (ptbili) is not defined. This study aimed to identify the postop ptbili beyond which survival is improbable or impossible.
  
  
  METHODS
  An institutional database of major hepatectomies (≥3 segments, no biliary resections), 2000-2012 was reviewed. Data were analyzed to find ptbili in the first 45 postop days. Factors associated with 90-day mortality (90 DM) and those predictive of ptbili were determined.
  
  
  RESULTS
  603 pts were analyzed with 90DM of 4.5%. 90 DM for a ptbili ≥ 18 (n = 15) was 86.6%, but only 2.5% for a ptbili < 18. All 6 pts with a ptbili ≥ 30 died. On multivariate analysis, postop ptbili ≥ 18 (HR34.95, CI 3.8-324; p = 0.002) and cirrhosis (HR6.4, CI 1.2-33.2; p = 0.027) were associated with 90DM. Factors associated with a ptbili ≥ 18 were age >65 (HR14.24, CI 2.9-70.5; p = 0.001), preop chemotherapy (HR4.77, CI 1.3-18.2; p = 0.02) and postop FFP (HR12.5, CI 2.6-56.2; p = 0.001).
  
  
  CONCLUSIONS
  Postop ptbili ≥ 18 after major hepatectomy has an 86.6% risk of 90DM; there are no survivors for tbili ≥ 30. These values may guide postop counseling for prognosis. Future studies may evaluate tbili ≥ 18 as an indication for hepatic replacement therapy.
authors.affiliation: Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA, USA.
authors.forename: Jessica Y
authors.initials: JY
authors.lastname: Liu
authors.affiliation: Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA, USA.
authors.forename: Lauren M
authors.initials: LM
authors.lastname: Postlewait
authors.affiliation: Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA, USA.
authors.forename: Joanna W
authors.initials: JW
authors.lastname: Etra
authors.affiliation: Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA, USA.
authors.forename: Malcolm H
authors.initials: MH
authors.lastname: Squires
authors.affiliation: Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA, USA.
authors.forename: Kenneth
authors.initials: K
authors.lastname: Cardona
authors.affiliation: Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA, USA.
authors.forename: Joshua H
authors.initials: JH
authors.lastname: Winer
authors.affiliation: Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA, USA; Division of General Surgery, Department of Surgery, Emory University, Atlanta, GA, USA.
authors.forename: Juan M
authors.initials: JM
authors.lastname: Sarmiento
authors.affiliation: Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA, USA.
authors.forename: Charles A
authors.initials: CA
authors.lastname: Staley
authors.affiliation: Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA, USA.
authors.forename: Shishir K
authors.initials: SK
authors.lastname: Maithel
authors.affiliation: Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA, USA.
authors.forename: David A
authors.initials: DA
authors.lastname: Kooby
authors.affiliation: Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA, USA. Electronic address: maria.c.russell@emory.edu.
authors.forename: Maria C
authors.initials: MC
authors.lastname: Russell
mesh_terms: D000328:Adult; D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D001663:Bilirubin / Q000097:blood*; D017024:Chemotherapy, Adjuvant / Q000009:adverse effects; D005260:Female; D005845:Georgia / Q000453:epidemiology; D006498:Hepatectomy / Q000009:adverse effects*; D006801:Humans; D006932:Hyperbilirubinemia / Q000401:mortality*; D008103:Liver Cirrhosis / Q000401:mortality; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D020360:Neoadjuvant Therapy / Q000009:adverse effects; D010949:Plasma; D011183:Postoperative Complications; D012189:Retrospective Studies; D055815:Young Adult
chemical_list: D001663:Bilirubin
keywords: ELAD; Hyperbilirubinemia; MARS; Post hepatic insufficiency