NIRCO med‎ > ‎periop‎ > ‎assessment‎ > ‎03 abdomen‎ > ‎

liver

Epidemiology:
  • Morbidity: risk of development of an organ-failure in patients with cirrhosis: acute on chronic liver failure score calculator (1).
  • Risk factors:
    • for postoperative liver failure: older age (e.g. >=70y), cirrhosis, fibrosis, hepatitis, intraoperative blood loss, ischemia, obstructive cholestasis, preoperative chemotherapy (e.g., irinotecan, oxaliplatin, bevacizumab (a window of 6-8 weeks between administration of bevacizumab and surgery may NOT increase the risk of perioperative complications after liver resection (4))), steatosis. Removal of up to 75% of the total liver volume is feasible in a patient <=40y with normal hepatic parenchyma (2).
    • Steatosis: mild steatosis (<=30% of hepatocytes containing fat) represents a minimal additional risk or none, whereas patients with severe steatosis (>60%) should undergo only limited resection (e.g., 1 or 2 segments) (2). In patients with moderate steatosis (30-60%), caution is necessary, particularlyif macrosteatosis is present, and conservative resection should be favored over major resection (3).
Indication (2):
  • An allograft mass that is 35-40% of a normal liver, often expressed as a ratio of the graft to the total body weight of the recipient (0.8-1%), must be obtained to ensure successful and viable transplantation. Recipients with more severe disease require a higher graft volume.
  • Major hepatectomy in patients with normal liver parenchyma: potential liver remnant >30% volume?
    • yes -> resection
    • no -> portal-vein embolization. Potential liver remnant >30%?
      • yes -> resection
      • no -> no resection
  • Major hepatectomy in patients with cirrhosis: cirrhotic liver:
    • Child-Turcotte-Pugh score B or C -> no resection
    • Child-Turcotte-Pugh score A: portal hypertension?
      • yes -> no resection
      • no -> potential liver remnant >50%?
        • yes -> resection
        • no -> retention of indocyanine green (0.5 mg/kg) at 15 minutes?
          • <14% -> resection
          • 14-20% -> portal-vein embolization. Potential liver remnant >50%?
            • yes -> resection
            • no -> no resection
          • >20% -> resection
Contraindications (5): platelets <100000/mm3 or the presence of large varices rule out patients with cirrhosis for major liver resection.

Measurments (2): in patients with cirrhosis -> Child-Turcotte-Pugh classification (albumin, bilirubin, prothrombin time, ascites, encephalopathy).

Complications (1):
  • There is no rationale to avoid thrombotic prophylaxis in patients with hepatic failure.
  • There is no evidence that the use of nasogastric tube or TEE in patients with varices adds an additional risk of bleeding.
  • Abdominal surgery is high risk even with mild liver disease.
  • Preoperative TIPS at least 3 months before elective surgery.
References:
  1. G. Wagener. Session II: Shall we operate on patients with cirrhosis? SGAR-Kongress. 2014.
  2. Pierre-Alain Clavien et al. Strategies for safer liver surgery and partial liver transplantation. N Engl J Med. 2007. 356;15:1545-1559: full text | pdf.
  3. Mc Cormack L et al. Hepatic steatosis is a risk factor for postoperative complications after major hepatectomy: a case-matched control study. Ann Surg. 2007;245(6):923-930: full text | pdf.
  4. D'Angelica M et al. Lack of evidence for increased operative morbidity after hepatectomy with perioperative use of bevacizumab: a matched case-control study. Ann Surg Oncol. 2007;14:759-65: full text | pdf.
  5. Poon RT et al. Assessment of hepatic reserve for indication of hepatic resection: how I do it. J Hepatobiliary Pancreat Surg. 2005;12:31-7: full text | pdf.