The small remnant liver after major liver resection: How common and how relevant?

Abstract

The maximum extent of hepatic resection compatible with a safe postoperative outcome is unknown. The study goal was to determine the incidence and impact of a small remnant liver volume after major liver resection in patients with normal liver parenchyma. Among 265 major hepatectomies performed at our institution (1998 to 2000), 138 patients with normal liver and a remnant liver volume (RLV) systematically calculated from the ratio of RLV to functional liver volume (FLV) were studied. Patients were divided into five groups based on RLV-FLV ratio from <30% to >60%. Kinetics of postoperative liver function tests were correlated with RLV. Postoperative complications were stratified by RLV-FLV ratios. Ninety patients (65%) underwent resection of up to four Couinaud segments. The RLV-FLV ratio was <60% in 94 patients (68%) including only 13 (9%) with RLV-FLV <30%. There was no linear correlation between the number of resected segments and the RLV-FLV. Postoperative serum bilirubin but not prothrombin time correlated with extent of resection. The incidence of complications including liver failure was not different among groups. Analysis of the four groups with a RLV-FLV ratio <60% showed a trend toward more complications and a longer intensive care unit stay in patients with the smallest RLVs. After major hepatectomy in patients with normal livers, the proportion of patients with a small remnant liver is low and not directly related to the number of segments resected. Although the rate of postoperative complications, including liver failure, did not directly correlate with the volume of remaining liver, the postoperative course was more difficult for patients with smaller remnants. Therefore preoperative portal vein embolization should be considered in patients who will undergo extended liver resection who have (1) injured liver or (2) normal liver when the planned procedure will be complex or when the anticipated RLV-FLV will be <30%. (Liver Transpl 2003;9:S18-S25.)

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

“…CT volumetric analysis of the future remnant correlated with outcome after resection in 3 studies (7,18,32). These and other studies have determined that a minimal remnant volume of 25%-30% is necessary to maintain adequate function after partial resection of healthy livers (9,33).…”

“…The 3 mentioned studies dealt with homogeneous groups of patients. In 2 of the studies (7,18), only patients without parenchymal disease were evaluated. In the third study (32), only patients with hepatocellular carcinoma who underwent large (no less than bisegmentectomy) resections were evaluated.…”

“…Liver failure is an important cause of mortality after partial liver resection (2,6). For patients with healthy livers, a resection of 70%-75% of the liver is assumed to be safe (7). For patients with parenchymal disease, this safety limit is more variable and lies between 40% and 60%.…”

“…CT volumetry can be used to calculate the volume of the future remnant liver (8) and is widely used to exclude patients from liver resection or to select patients who will benefit from a procedure to increase the volume of the future remnant, such as portal vein embolization (9). However, the function of the future remnant is decreased in patients with parenchymal disease, despite a future-remnant volume that is equal to that in patients with healthy livers (7,10,11). Therefore, one can argue that determining the functional capacity of the future remnant is more important than determining the volume, especially in patients with parenchymal disease.…”

Risk of venous congestion in live donors of extended right liver graft

“…RVBWR was also found to be more specific than RV/TLV as a predictor of postoperative outcomes in hepatic resections with SFS remnants [6] . Yigitler et al [42] observed a poor correlation between RV/TLV ≤ 30% and RVBWR < 0.6 for SFS remnants after major hepatic resections. In a retrospective analysis by Yaprak et al [11] , remnants with marginal RVBWR < 0.6 and RV/TLV ≤ 30% constellation had the highest (52.2%) donor morbidity.…”