Expanded Makuuchi's criteria using estimated indocyanine green clearance rate of future liver remnant as a safety limit for maximum extent of liver resection

Abstract

Background: Recent advances in liver surgery have dramatically improved the safety of hepatectomy for hepatocellular carcinoma (HCC). The aim of this study was to compare outcomes for patients fulfilling an extended criteria vs. those fulfilling the conventional criteria based on the bilirubin and indocyanine green (ICG) clearance (Makuuchi's criteria). Methods:The short term outcomes of patients undergoing hepatectomy for HCC and who fulfilled the expanded criteria (ICG clearance of future remnant liver [ICG-Krem] ! 0.05 estimated using 3-D volumetry) were retrospectively reviewed and were compared between those fulfilling the conventional criteria. Postoperative hepatic insufficiency (PHI) was defined as peak total bilirubin >7 mg/dL.Results: A total of 323 patients undergoing resection of whom 269 (83%) met conventional criteria (In-M) and 54 (17%) extended criteria (Ex-M). The overall morbidity rates were not significantly different. The incidence of PHI was 0.37% in In-M and 3.7% in Ex-M (P = 0.074), with no liver-related deaths. When the ICG-Krem ! 0.05 criterion was included, major hepatectomy was performed in 24 patients (41%) in Ex-M with no significant increase in major morbidity (13%), PHI(3.3%), or liver-related death (0%) compared with minor hepatectomy (n = 30) in Ex-M(10%, 4% and 0%, respectively).Conclusions: Objective criteria using ICG clearance rate and 3-D volumetry may offer opportunities for safe surgical resection in selected patients exceeding the conventional criteria.

Development and Validation of a Nomogram Based on Perioperative Factors to Predict Post-hepatectomy Liver Failure

“…However, within each category of Makuuchi’s criteria, there is a relatively wide range of hepatic function reserve and it does not take into account the individual variation in the FLR volume. 27 …”

“…However, within each category of Makuuchi's criteria, there is a relatively wide range of hepatic function reserve and it does not take into account the individual variation in the FLR volume. 27 MELD, 8 ALBI 10,28 and PALBI 29 scores were previously reported to be accurate for the prediction of PHLF in patients with hepatocellular carcinoma. However, the ALBI score and PALBI score were based on a relatively low proportion of 727 (28.0%) patients undergoing hepatectomy.…”

“…In the Zhongshan cohort, hospital stay of patients without PHLF (median [IQR]: 8 [7-10] days) was shorter than that of grade A (10 [8-13] days), grade B (10 [8-13] days) and grade C (16.5 [10][11][12][13][14][15][16][17][18][19][20][21][22][23][24][25][26][27][28][29] days) PHLF patients (p<0.001 for all).…”

A novel scoring system for evaluating the difficulty of lysis of adhesion and surgical risk at repeat hepatectomy

“…Details of our surgical indications are reported elsewhere . Briefly, surgery with curative intent was considered for those who fulfilled the following three criteria: (a) no or controllable ascites; (b) serum total bilirubin level of ≤2.0 mg/dL; and (c) estimated indocyanine green clearance rate of the full‐functioning future liver remnant (ICG‐Krem) ≥0.05.…”

Japanese experience with hepatic resection of KRAS-mutated colorectal liver metastases

“…For risk estimation of postoperative hepatic insufficiency, we have used original criteria, expanding conventional Makuuchi's criteria (29). In short, (I) serum bilirubin level <2.0 mg/dL, II) no or controllable ascites, and (III) estimated indocyanine green disappearing rate of the future liver remnant (ICG-Krem) ≥0.05 which is calculated with ICG clearance test and three-dimensional volumetry of the liver (30). When a patient does not meet the volume criteria, portal vein embolization or two stage hepatectomy is considered.…”