Discrepancy between volume and functional recovery in early phase liver regeneration following extended hepatectomy with extrahepatic bile duct resection

Abstract

Aim To elucidate the clinical factors having an impact on liver regeneration rate following preoperative portal vein embolization (PVE) and subsequent extended hepatectomy. The correlation between liver volume and functional recovery after extended hepatectomy was also investigated. Methods Records of patients who underwent extended hepatectomy with extrahepatic bile duct resection following PVE for perihilar cholangiocarcinoma were reviewed retrospectively with attention to liver regeneration. All patients underwent computed tomography before PVE, after PVE (immediately before surgery), and on postoperative day (POD) 7. The kinetic growth rate (KGR) was calculated as the percent increase in liver volume relative to the future liver remnant volume per day after PVE (KGRPVE) and after POD 7 (KGRPOD7) using the computed tomography images before PVE, after PVE, and on POD 7. Results In the 289 study patients, the median of KGRPVE was 1.35%/day whereas that of KGRPOD7 was 5.56%/day. The extent of liver resection had the greatest impact on both KGRPVE and KGRPOD7 and the impacts of other factors were less. There was a significant negative correlation between KGRPVE and KGRPOD7 (P = 0.002). No correlations were observed between KGRPVE or KGRPOD7 and serum total bilirubin and prothrombin time – international normalized ratio on POD 7, nor in the incidence of liver failure after surgery. Conclusions Early phase liver regeneration after extended hepatectomy was largely influenced by the extent of liver resection and showed no correlation with the indices of liver failure. There was a discrepancy between volume and functional recovery in early phase liver regeneration.

In search of a pathogenesis for impaired liver regeneration after major hepatectomy with extrahepatic bile duct resection: The plot thickens!

“…The study of Maeda et al . showed in multivariate analysis that postoperative vLR significantly correlated only with preoperative albumin plasma levels and the extent of hepatic resection . While surely confirming the already established clinical evidence in major hepatectomy cases without EBR, the present investigation was actually unable to identify the specific pathogenic mechanism sustaining the increased risk associated with EBR.…”

“…10 The study of Maeda et al showed in multivariate analysis that postoperative vLR significantly correlated only with preoperative albumin plasma levels and the extent of hepatic resection. 4 While surely confirming the already established clinical evidence in major hepatectomy cases without EBR, the present investigation was actually unable to identify the specific pathogenic mechanism sustaining the increased risk associated with EBR. Although this might be considered as a limitation, we believe that the present study still provided an interesting setting of analysis for those factors that theoretically could, but actually did not, play a role in the pathogenesis of EBR-related postoperative LR impairment.…”

“…The suspected underlying trigger was the development of cholangitis induced by jejunobiliary reflux, as a previous study also noted that experimentally‐induced segmental cholangitis in rats impaired LR . However in the study of Maeda et al ., neither the grade of surgical invasiveness defined by operative time, intraoperative blood loss, or combined pancreatoduodenectomy or vascular resection, nor early postoperative complications were found to be significantly correlated with vLR …”

“…The study performed by Maeda et al . retrospectively analyzed the clinical determinants of volumetric LR (vLR) and the risk factors for post‐hepatectomy liver failure, specifically in patients submitted to major hepatectomy combined with extrahepatic bile duct resection (EBR) for perihilar cholangiocarcinoma . This investigation represented the logical consequence of a previous study reported by the same group showing that EBR was the only independent risk factor for impaired early vLR (regeneration rate of future liver remnant <10%) and one the independent risk factors for post‐hepatectomy liver failure, together with male sex and intraoperative blood transfusion .…”

“…In conclusion, the mechanism underlying compensatory LR is complex, and depends on multiple signaling pathways induced both by local and systemic triggers. The study of Maeda et al . surely offered an interesting scenario where evidence from experimental animal models and real‐life clinical practice could be confronted and reciprocally explored.…”