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Semin Liver Dis 2013; 33(03): 204-212
DOI: 10.1055/s-0033-1351777
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Assessment of Hepatic Function, Operative Candidacy, and Medical Management after Liver Resection in the Patient with Underlying Liver Disease

Gebhard Wagener
1   Department of Anesthesiology, College of Physicians and Surgeons, Columbia University, New York
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Publication History

Publication Date:
13 August 2013 (online)

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Abstract

Liver resection in patients with underlying liver disease remains a formidable challenge. It requires adequate patient selection, a precise surgical plan, and avoidance of additional ischemic insults during surgery. Precise estimation of the residual liver volume using computed tomography or magnetic resonance imaging and computer-assisted volumetry allows the calculation of residual to total liver volume (RLV/TLV) ratios. Although RLV/TLV ratios over 20 to 25% are considered sufficient in healthy livers, patients with cirrhosis may only tolerate resections that result in RLV/TLV ratios over 40% and higher. Conventional laboratory tests may not be able to sufficiently predict liver reserve after resection. Dynamic tests such as indocyanine green clearance have been used to assess residual liver function and assist in deciding about operability of patients with underlying liver disease undergoing extensive resections. Intraoperative management should focus on avoiding blood loss and ischemic injury to the liver. Low central venous pressure may reduce blood loss and is recommended if tolerated without impeding renal perfusion. Portal vein and hepatic artery occlusion during resection can reduce blood loss, but will cause ischemic insult to the liver that may jeopardize residual liver function and induce postoperative hepatic failure. When feasible, vascular occlusion should be avoided in patients with underlying liver disease. The postoperative recovery is usually fast if sufficient liver remains. However, vigilance is required to detect liver dysfunction and treat its complications.

Keywords

hepatectomy - liver function - cirrhosis - liver tumors - dynamic liver tests - liver injury
 

  • References

  • 1 Pomposelli JJ, Tongyoo A, Wald C, Pomfret EA. Variability of standard liver volume estimation versus software-assisted total liver volume measurement. Liver Transpl 2012; 18 (9) 1083-1092
    CrossrefPubMedSearch in Google Scholar
  • 2 Siriwardana RC, Chan SC, Chok KS, Lo CM, Fan ST. Effects of the liver volume and donor steatosis on errors in the estimated standard liver volume. Liver Transpl 2011; 17 (12) 1437-1442
    CrossrefPubMedSearch in Google Scholar
  • 3 Tucker ON, Heaton N. The 'small for size' liver syndrome. Curr Opin Crit Care 2005; 11 (2) 150-155
    CrossrefPubMedSearch in Google Scholar
  • 4 Truant S, Oberlin O, Sergent G , et al. Remnant liver volume to body weight ratio > or =0.5%: A new cut-off to estimate postoperative risks after extended resection in noncirrhotic liver. J Am Coll Surg 2007; 204 (1) 22-33
    CrossrefPubMedSearch in Google Scholar
  • 5 Chun YS, Ribero D, Abdalla EK , et al. Comparison of two methods of future liver remnant volume measurement. J Gastrointest Surg 2008; 12 (1) 123-128
    CrossrefPubMedSearch in Google Scholar
  • 6 Vauthey JN, Zorzi D, Pawlik TM. Making unresectable hepatic colorectal metastases resectable—does it work?. Semin Oncol 2005; 32 (6) (Suppl. 09) S118-S122
    CrossrefPubMedSearch in Google Scholar
  • 7 Vauthey JN, Dixon E, Abdalla EK , et al; American Hepato-Pancreato-Biliary Association; Society of Surgical Oncology; Society for Surgery of the Alimentary Tract. Pretreatment assessment of hepatocellular carcinoma: expert consensus statement. HPB (Oxford) 2010; 12 (5) 289-299
    CrossrefPubMedSearch in Google Scholar
  • 8 Vauthey JN, Klimstra D, Franceschi D , et al. Factors affecting long-term outcome after hepatic resection for hepatocellular carcinoma. Am J Surg 1995; 169 (1) 28-34 , discussion 34–35
    CrossrefPubMedSearch in Google Scholar
  • 9 Teh SH, Christein J, Donohue J , et al. Hepatic resection of hepatocellular carcinoma in patients with cirrhosis: Model of End-Stage Liver Disease (MELD) score predicts perioperative mortality. J Gastrointest Surg 2005; 9 (9) 1207-1215 , discussion 1215
    CrossrefPubMedSearch in Google Scholar
  • 10 Cucchetti A, Ercolani G, Vivarelli M , et al. Impact of model for end-stage liver disease (MELD) score on prognosis after hepatectomy for hepatocellular carcinoma on cirrhosis. Liver Transpl 2006; 12 (6) 966-971
    CrossrefPubMedSearch in Google Scholar
  • 11 Delis SG, Bakoyiannis A, Biliatis I, Athanassiou K, Tassopoulos N, Dervenis C. Model for end-stage liver disease (MELD) score, as a prognostic factor for post-operative morbidity and mortality in cirrhotic patients, undergoing hepatectomy for hepatocellular carcinoma. HPB (Oxford) 2009; 11 (4) 351-357
    CrossrefPubMedSearch in Google Scholar
  • 12 Teh SH, Sheppard BC, Schwartz J, Orloff SL. Model for end-stage liver disease score fails to predict perioperative outcome after hepatic resection for hepatocellular carcinoma in patients without cirrhosis. Am J Surg 2008; 195 (5) 697-701
    CrossrefPubMedSearch in Google Scholar
  • 13 Hemming AW, Scudamore CH, Shackleton CR, Pudek M, Erb SR. Indocyanine green clearance as a predictor of successful hepatic resection in cirrhotic patients. Am J Surg 1992; 163 (5) 515-518
    CrossrefPubMedSearch in Google Scholar
  • 14 Seyama Y, Kokudo N. Assessment of liver function for safe hepatic resection. Hepatol Res 2009; 39 (2) 107-116
    CrossrefPubMedSearch in Google Scholar
  • 15 Hashimoto M, Watanabe G. Hepatic parenchymal cell volume and the indocyanine green tolerance test. J Surg Res 2000; 92 (2) 222-227
    CrossrefPubMedSearch in Google Scholar
  • 16 Scheingraber S, Richter S, Igna D, Flesch S, Kopp B, Schilling MK. Indocyanine green disappearance rate is the most useful marker for liver resection. Hepatogastroenterology 2008; 55 (85) 1394-1399
    PubMedSearch in Google Scholar
  • 17 Lorf T, Schnitzbauer AA, Schaefers SK , et al. Prognostic value of the monoethylglycinexylidide (MEGX)-test prior to liver resection. Hepatogastroenterology 2008; 55 (82–83) 539-543
    PubMedSearch in Google Scholar
  • 18 Hemming AW, Gallinger S, Greig PD , et al. The hippurate ratio as an indicator of functional hepatic reserve for resection of hepatocellular carcinoma in cirrhotic patients. J Gastrointest Surg 2001; 5 (3) 316-321
    CrossrefPubMedSearch in Google Scholar
  • 19 Emond JC, Kelley SD, Heffron TG, Nakagawa T, Roberts JP, Lim Jr RC. Surgical and anesthetic management of patients undergoing major hepatectomy using total vascular exclusion. Liver Transpl Surg 1996; 2 (2) 91-98
    CrossrefPubMedSearch in Google Scholar
  • 20 Sakka SG, van Hout N. Relation between indocyanine green (ICG) plasma disappearance rate and ICG blood clearance in critically ill patients. Intensive Care Med 2006; 32 (5) 766-769
    CrossrefPubMedSearch in Google Scholar
  • 21 Schneider L, Spiegel M, Latanowicz S , et al. Noninvasive indocyanine green plasma disappearance rate predicts early complications, graft failure or death after liver transplantation. Hepatobiliary Pancreat Dis Int 2011; 10 (4) 362-368
    CrossrefPubMedSearch in Google Scholar
  • 22 Mandell MS, Wachs M, Niemann CU, Henthorn TK. Elimination of indocyanine green in the perioperative evaluation of donor liver function. Anesth Analg 2002; 95 (5) 1182-1184 table of contents.
    CrossrefPubMedSearch in Google Scholar
  • 23 Sakka SG, Reinhart K, Meier-Hellmann A. Prognostic value of the indocyanine green plasma disappearance rate in critically ill patients. Chest 2002; 122 (5) 1715-1720
    CrossrefPubMedSearch in Google Scholar
  • 24 Bargetzi MJ, Aoyama T, Gonzalez FJ, Meyer UA. Lidocaine metabolism in human liver microsomes by cytochrome P450IIIA4. Clin Pharmacol Ther 1989; 46 (5) 521-527
    CrossrefPubMedSearch in Google Scholar
  • 25 Wang JS, Backman JT, Wen X, Taavitsainen P, Neuvonen PJ, Kivistö KT. Fluvoxamine is a more potent inhibitor of lidocaine metabolism than ketoconazole and erythromycin in vitro. Pharmacol Toxicol 1999; 85 (5) 201-205
    CrossrefPubMedSearch in Google Scholar
  • 26 Shiffman ML, Luketic VA, Sanyal AJ , et al. Hepatic lidocaine metabolism and liver histology in patients with chronic hepatitis and cirrhosis. Hepatology 1994; 19 (4) 933-940
    CrossrefPubMedSearch in Google Scholar
  • 27 Elin RJ, Fried MW, Sampson M, Ruddel M, Kleiner DE, DiBisceglie AM. Assessment of monoethylglycinexylidide as measure of liver function for patients with chronic viral hepatitis. Clin Chem 1997; 43 (10) 1952-1957
    PubMedSearch in Google Scholar
  • 28 Meyer-Wyss B, Renner E, Luo H, Scholer A. Assessment of lidocaine metabolite formation in comparison with other quantitative liver function tests. J Hepatol 1993; 19 (1) 133-139
    CrossrefPubMedSearch in Google Scholar
  • 29 Zotz RB, von Schönfeld J, Erhard J , et al. Value of an extended monoethylglycinexylidide formation test and other dynamic liver function tests in liver transplant donors. Transplantation 1997; 63 (4) 538-541
    CrossrefPubMedSearch in Google Scholar
  • 30 Olinga P, Maring JK, Groothuis GM , et al. Value of the in vitro or in vivo monoethylglycinexylidide test for predicting liver graft function. Transplantation 1997; 64 (1) 60-65
    CrossrefPubMedSearch in Google Scholar
  • 31 Schütz E, Luy-Kaltefleiter M, Kaltefleiter M , et al. The value of serial determination of MEGX and hyaluronic acid early after orthotopic liver transplantation. Eur J Clin Invest 1996; 26 (10) 907-916
    CrossrefPubMedSearch in Google Scholar
  • 32 Schröter J, Wandel C, Böhrer H, Schmidt H, Böttiger BW, Martin E. Lignocaine metabolite formation: an indicator for liver dysfunction and predictor of survival in surgical intensive care patients. Anaesthesia 1995; 50 (10) 850-854
    CrossrefPubMedSearch in Google Scholar
  • 33 Blakley RL. The metabolism and antiketogenic effects of sorbitol; sorbitol dehydrogenase. Biochem J 1951; 49 (3) 257-271
    PubMedSearch in Google Scholar
  • 34 Molino G, Avagnina P, Belforte G, Bircher J. Assessment of the hepatic circulation in humans: new concepts based on evidence derived from a D-sorbitol clearance method. J Lab Clin Med 1998; 131 (5) 393-405
    CrossrefPubMedSearch in Google Scholar
  • 35 Fleisher LA, Beckman JA, Brown KA , et al. ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery) Developed in Collaboration With the American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, and Society for Vascular Surgery. J Am Coll Cardiol 2007; 50 (17) 1707-1732
    CrossrefPubMedSearch in Google Scholar
  • 36 Lee TH, Marcantonio ER, Mangione CM , et al. Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery. Circulation 1999; 100 (10) 1043-1049
    CrossrefPubMedSearch in Google Scholar
  • 37 Shippy CR, Appel PL, Shoemaker WC. Reliability of clinical monitoring to assess blood volume in critically ill patients. Crit Care Med 1984; 12 (2) 107-112
    CrossrefPubMedSearch in Google Scholar
  • 38 Marik PE, Baram M, Vahid B. Does central venous pressure predict fluid responsiveness? A systematic review of the literature and the tale of seven mares. Chest 2008; 134 (1) 172-178
    CrossrefPubMedSearch in Google Scholar
  • 39 Smyrniotis V, Kostopanagiotou G, Theodoraki K, Tsantoulas D, Contis JC. The role of central venous pressure and type of vascular control in blood loss during major liver resections. Am J Surg 2004; 187 (3) 398-402
    CrossrefPubMedSearch in Google Scholar
  • 40 Jones RM, Moulton CE, Hardy KJ. Central venous pressure and its effect on blood loss during liver resection. Br J Surg 1998; 85 (8) 1058-1060
    CrossrefPubMedSearch in Google Scholar
  • 41 Wang WD, Liang LJ, Huang XQ, Yin XY. Low central venous pressure reduces blood loss in hepatectomy. World J Gastroenterol 2006; 12 (6) 935-939
    PubMedSearch in Google Scholar
  • 42 Chen H, Merchant NB, Didolkar MS. Hepatic resection using intermittent vascular inflow occlusion and low central venous pressure anesthesia improves morbidity and mortality. J Gastrointest Surg 2000; 4 (2) 162-167
    CrossrefPubMedSearch in Google Scholar
  • 43 Gozzetti G, Mazziotti A, Grazi GL , et al. Liver resection without blood transfusion. Br J Surg 1995; 82 (8) 1105-1110
    CrossrefPubMedSearch in Google Scholar
  • 44 Sugiyama Y, Ishizaki Y, Imamura H, Sugo H, Yoshimoto J, Kawasaki S. Effects of intermittent Pringle's manoeuvre on cirrhotic compared with normal liver. Br J Surg 2010; 97 (7) 1062-1069
    CrossrefPubMedSearch in Google Scholar
  • 45 Fan ST. Methods and related drawbacks in the estimation of surgical risks in cirrhotic patients undergoing hepatectomy. Hepatogastroenterology 2002; 49 (43) 17-20
    PubMedSearch in Google Scholar
  • 46 Kloek JJ, Marsman HA, van Vliet AK, Gouma DJ, van Gulik TM. Biliary drainage attenuates postischemic reperfusion injury in the cholestatic rat liver. Surgery 2008; 144 (1) 22-31
    CrossrefPubMedSearch in Google Scholar
  • 47 Peralta C, Hotter G, Closa D, Gelpí E, Bulbena O, Roselló-Catafau J. Protective effect of preconditioning on the injury associated to hepatic ischemia-reperfusion in the rat: role of nitric oxide and adenosine. Hepatology 1997; 25 (4) 934-937
    CrossrefPubMedSearch in Google Scholar
  • 48 Clavien PA, Selzner M, Rüdiger HA , et al. A prospective randomized study in 100 consecutive patients undergoing major liver resection with versus without ischemic preconditioning. Ann Surg 2003; 238 (6) 843-850 , discussion 851–852
    CrossrefPubMedSearch in Google Scholar
  • 49 Clavien PA, Yadav S, Sindram D, Bentley RC. Protective effects of ischemic preconditioning for liver resection performed under inflow occlusion in humans. Ann Surg 2000; 232 (2) 155-162
    CrossrefPubMedSearch in Google Scholar
  • 50 Gurusamy KS, Kumar Y, Pamecha V, Sharma D, Davidson BR. Ischaemic pre-conditioning for elective liver resections performed under vascular occlusion. Cochrane Database Syst Rev 2009; (1) CD007629
    PubMedSearch in Google Scholar
  • 51 Jeon J, Watkins A, Wagener G , et al. Complex hepatectomy under total vascular exclusion of the liver: impact of ischemic preconditioning on clinical outcomes. World J Surg 2013; 37 (4) 838-846
    CrossrefPubMedSearch in Google Scholar
  • 52 Jarnagin WR, Gonen M, Fong Y , et al. Improvement in perioperative outcome after hepatic resection: analysis of 1,803 consecutive cases over the past decade. Ann Surg 2002; 236 (4) 397-406 , discussion 406–407
    CrossrefPubMedSearch in Google Scholar
  • 53 Saner F. Kidney failure following liver resection. Transplant Proc 2008; 40 (4) 1221-1224
    CrossrefPubMedSearch in Google Scholar
  • 54 Halimi C, Bonnard P, Bernard B , et al. Effect of terlipressin (Glypressin) on hepatorenal syndrome in cirrhotic patients: results of a multicentre pilot study. Eur J Gastroenterol Hepatol 2002; 14 (2) 153-158
    CrossrefPubMedSearch in Google Scholar
  • 55 Wrighton LJ, O'Bosky KR, Namm JP, Senthil M. Postoperative management after hepatic resection. J Gastrointest Oncol 2012; 3 (1) 41-47
    PubMedSearch in Google Scholar
  • 56 Lisman T, Bakhtiari K, Pereboom IT, Hendriks HG, Meijers JC, Porte RJ. Normal to increased thrombin generation in patients undergoing liver transplantation despite prolonged conventional coagulation tests. J Hepatol 2010; 52 (3) 355-361
    CrossrefPubMedSearch in Google Scholar
  • 57 Geerts WH, Pineo GF, Heit JA , et al. Prevention of venous thromboembolism: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest 2004; 126 (3, Suppl): 338S-400S
    CrossrefPubMedSearch in Google Scholar
  • 58 Golse N, Bucur PO, Adam R, Castaing D, Sa Cunha A, Vibert E. New paradigms in post-hepatectomy liver failure. J Gastrointest Surg 2013; 17 (3) 593-605
    CrossrefPubMedSearch in Google Scholar
  • 59 Friedman LS. Surgery in the patient with liver disease. Trans Am Clin Climatol Assoc 2010; 121: 192-204 , discussion 205
    PubMedSearch in Google Scholar
  • 60 Malinchoc M, Kamath PS, Gordon FD, Peine CJ, Rank J, ter Borg PC. A model to predict poor survival in patients undergoing transjugular intrahepatic portosystemic shunts. Hepatology 2000; 31 (4) 864-871
    CrossrefPubMedSearch in Google Scholar
  • 61 Northup PG, Wanamaker RC, Lee VD, Adams RB, Berg CL. Model for End-Stage Liver Disease (MELD) predicts nontransplant surgical mortality in patients with cirrhosis. Ann Surg 2005; 242 (2) 244-251
    CrossrefPubMedSearch in Google Scholar
  • 62 Farnsworth N, Fagan SP, Berger DH, Awad SS. Child-Turcotte-Pugh versus MELD score as a predictor of outcome after elective and emergent surgery in cirrhotic patients. Am J Surg 2004; 188 (5) 580-583
    CrossrefPubMedSearch in Google Scholar
  • 63 Perkins L, Jeffries M, Patel T. Utility of preoperative scores for predicting morbidity after cholecystectomy in patients with cirrhosis. Clin Gastroenterol Hepatol 2004; 2 (12) 1123-1128
    CrossrefPubMedSearch in Google Scholar
  • 64 Befeler AS, Palmer DE, Hoffman M, Longo W, Solomon H, Di Bisceglie AM. The safety of intra-abdominal surgery in patients with cirrhosis: model for end-stage liver disease score is superior to Child-Turcotte-Pugh classification in predicting outcome. Arch Surg 2005; 140 (7) 650-654 , discussion 655
    CrossrefPubMedSearch in Google Scholar