Risk Assessment of Posthepatectomy Liver Failure Using Hepatobiliary Scintigraphy and CT Volumetry

Abstract

A major part of morbidity and mortality after liver resections is caused by inadequate remnant liver function leading to liver failure. It is therefore important to develop accurate diagnostic tools that can predict the risk of liver resection-related morbidity and mortality. In this study, preoperative hepatobiliary scintigraphy of the future remnant liver and CT volumetric measurement of the future remnant liver were performed on patients who were to undergo liver resection. The accuracy of risk assessment for postoperative morbidity, liver failure, and mortality was evaluated. Methods: Forty-six patients who were scheduled for liver resection because of hepatobiliary tumors, including 17 patients with parenchymal disease (37%) and 13 patients with hilar cholangiocarcinoma (28%), were assessed preoperatively. Hepatobiliary scintigraphy was performed by drawing regions of interest around the future remnant to calculate 99m Tc-mebrofenin uptake in it. CT volumetry was used to measure the volume of the total liver, the tumors, and the future remnant. Receiver-operatingcharacteristic analysis was performed to assess cutoff values for risk assessment of morbidity, liver failure, and mortality. Furthermore, univariate and multivariate analyses were performed to determine factors related to morbidity and mortality. Results: Morbidity and mortality rates were 61% and 11%, respectively. Liver failure occurred in 6 patients (13%). Significantly decreased uptake in the future remnant was found in patients in whom liver failure and liver failure-related mortality developed (P 5 0.003 and 0.02, respectively). The volume of the future remnant was not significantly associated with any of the outcome parameters. In receiver-operating-characteristic analysis, uptake cutoff values for liver failure and liver failure-related mortality were 2.5%/min/ body surface area and 2.2%/min/body surface area, respectively. In multivariate analysis, uptake was the only significant factor associated with liver failure. Conclusion: Preoperative measurement of 99m Tc-mebrofenin uptake in the future remnant liver on hepatobiliary scintigraphy proved more valuable than measurement of the volume of the future remnant on CT in assessing the risk of liver failure and liver failure-related mortality after partial liver resection.

Measurement of liver function using hepatobiliary scintigraphy improves risk assessment in patients undergoing major liver resection

“…Although we cannot ascertain what the postoperative results would have been if these patients would have undergone resection without preoperative PVE, we know from our previous studies that FRL-function rather than FRL-volume is predictive for the occurrence of postoperative liver failure. 7,13 There were no significant differences in the occurrence of postoperative liver failure or liver failure related mortality between the PVE and the non-PVE patients, suggesting that unilateral embolization of the portal vein in these patients has contributed to the prevention of postoperative liver failure. Furthermore, in nine patients suspected of PHC, HBS was used as a diagnostic tool to identify patients who might benefit from additional procedures prior to the operation such as additional biliary drainage.…”

Nuclear Imaging Techniques for the Assessment of Hepatic Function in Liver Surgery and Transplantation

“…Therefore, a single cutoff value for the prediction of liver failure suffices for both patients with a compromised liver and patients with a normal liver. In patients with an unknown quality of liver parenchyma, preoperative dynamic HBS proved more valuable then CT volumetry for the prediction of postoperative liver failure (75,84).…”

“…FRL uptake function is calculated by dividing counts within the ROI of the FRL by the total liver counts and multiplying this factor by total liver 99m Tc-mebrofenin uptake and is expressed as %/min/m 2 . Regional uptake and FRL uptake of 99m Tc-mebrofenin can be assessed with little intra-and interobserver variation (74,75). Single-head g-cameras permit anterior or posterior projections of the liver only.…”

“…Dinant et al investigated the value of preoperative FRL function, measured by 99m Tc-mebrofenin HBS, in predicting short-term outcome after partial liver resection (75). Forty-six patients with and without parenchymal disease were included in this study.…”

Effect of portal vein embolisation on the growth rate of colorectal liver metastases

“…At present, selection of patients for PVE is based on CT/MRI volumetry, and 30% of future liver remnant volume is considered adequate in patients with normal liver and 40% in patients with abnormal liver function (Abdalla et al, 2001). Incorporating hepatic functional studies, such as hepatic scintigraphy (Dinant et al, 2007) and biopsy of normal liver, to evaluate histological abnormality (steatosis, steatohepatitis and cholestasis) in patients with borderline future liver remnant will provide further information on the quality of the residual liver and may avoid unnecessary PVE.…”