Impact of Future Liver Remnant Volume on Outcome in 301 Consecutive Extended Right Hepatectomies
*Jean-Nicolas Vauthey, *Yoji Kishi, *Yun S Chun, *David C Madoff, *Martin Palavecino, *Michael J Wallace, *Eddie K Abdalla, Steven A Curley
The University of Texas M. D. Anderson Cancer Center, Houston, TX
The safe minimum amount of remnant liver after extensive hepatectomy remains unclear. We aimed to determine the impact of future liver remnant (FLR) volume on outcomes.
301 patients who underwent extended right hepatectomy during 1993-2008 were analyzed. FLR volumetry was performed preoperatively and accounted for partial resection of segment IV. Liver insufficiency was defined as postoperative peak serum bilirubin >7 mg/dl. Predictors of liver insufficiency were identified by multivariate analysis.
Overall morbidity and 90-day mortality were 40% and 6%, respectively. Postoperative liver insufficiency occurred in 45 patients (15%), and liver failure accounted for 61% of perioperative deaths. Among 290 patients who underwent liver volumetry, FLR was <20% in 38, 20.1%-30% in 144, and >30% in 108. Rates of postoperative liver insufficiency and death from liver failure were similar between patients with FLR 20.1%-30% and >30% but higher in patients with FLR ≤20% (figure). Postoperative outcomes were similar with FLR increase from ≤20% to >20% after portal vein embolization (PVE) and with initial FLR >20%. In multivariate analysis body mass index >25 kg/m2, intraoperative blood transfusion, and FLR ≤20% (odds ratio=3.18; 95% CI=1.34-7.54) independently predicted postoperative liver insufficiency.
FLR volumetry is important in the selection of patients for PVE and extended right hepatectomy. FLR >20% is sufficient for safe hepatic resection, and FLR 20.1%-30% is not an indication for preoperative PVE.