Liver failure after major hepatic resection

Introduction  The consequence of excessive liver resection is the inexorable development of progressive liver failure characterised by the typical stigmata associated with this condition, including worsening coagulopathy, hyperbilirubinaemia and encephalopathy. The focus of this review will be to investigate factors contributing to hepatocyte loss and impaired regeneration. Methods  A literature search was undertaken of Pubmed and related search engines, examining for articles relating to hepatic failure following major hepatectomy. Results  In spite of improvements in adjuvant chemotherapy and increasing surgical confidence and expertise, the parameters determining how much liver can be resected have remained largely unchanged. A number of preoperative, intraoperative and post-operative factors all contribute to the likelihood of liver failure after surgery. Conclusions  Given the magnitude of the surgery, mortality and morbidity rates are extremely good. Careful patient selection and preservation of an obligate volume of remnant liver is essential. Modifiable causes of hepatic failure include avoidance of sepsis, drainage of cholestasis with restoration of enteric bile salts and judicious use of portal triad inflow occlusion intra-operatively. Avoidance of post-operative sepsis is most likely to be achieved by patient selection, meticulous intra-operative technique and post-operative care. Modulation of portal vein pressures post-operatively may further help reduce the risk of liver failure.     

肝切除术后肝功能衰竭:病理生理、危险因素与临床治疗

肝功能衰竭是肝切除术后最严重的致命性并发症.本文主要论述部分肝切除术后肝功能衰竭(PLF)的发生机理、危险因素和防治措施.肝切除后剩余肝组织数量和功能不足是发生PLF的关键致病机理.主要的危险因素是残余肝体积过小、术中失血和输血过多、15分钟吲哚氰绿滞留试验(ICGR15)＞20%、肝纤维化程度Metavir评分F4/F3.PLF的可供选择的治疗方案是有限的,因此应该采取适当的预防措施.人工肝或联合肝移植对PLF的治疗有着极其重要的作用.     

肝切除术后肝功能衰竭:病理生理、危险因素与临床治疗

肝功能衰竭是肝切除术后最严重的致命性并发症.本文主要论述部分肝切除术后肝功能衰竭(PLF)的发生机理、危险因素和防治措施.肝切除后剩余肝组织数量和功能不足是发生PLF的关键致病机理.主要的危险因素是残余肝体积过小、术中失血和输血过多、15分钟吲哚氰绿滞留试验(ICGR15)＞20%、肝纤维化程度Metavir评分F4/F3.PLF的可供选择的治疗方案是有限的,因此应该采取适当的预防措施.人工肝或联合肝移植对PLF的治疗有着极其重要的作用.

Abstract：

Liver failure is a dreaded and often fatal complication that sometimes follows partial hepatectomy.This article reviews the pathophysiology, risk factors and treatment of post-resectional liver failure (PLF). An inadequate quantity or quality of residual liver mass are the key event in its pathogenesis. The major risk factors are small remnant liver volume (RLV), excessive blood loss or transfusion, ICGR15 of greater than 20%, and F4/F3 liver cirrhosis. It is essential to identify these risk factors during the pre-operative assessment. Preventive measures should be applied whenever possible as options of curative treatment for PLF are limited. Artificial liver and/or liver transplantation are the important treatment alternatives for hepatic failure after hepatectomy.     

Liver blood flow after major hepatic resection

The factors involved in liver regeneration are poorly understood, but it has been suggested that blood flow plays a role. This paper documents the changes in liver blood flow (LBF) that occur after major hepatic resection. Eight patients, ranging in age from 37 to 76 years, underwent liver resection. Liver blood flow was measured preoperatively and on days 1, 4 and 7 postoperatively by low-dose galactose clearance. There was a significant (p less than 0.01) fall in LBF on day 1 compared with the baseline value, followed by a significant (p less than 0.01) rise from the baseline value by day 4. By day 7, LBF had returned to baseline levels and was significantly (p less than 0.01) lower than on day 4. These changes in LBF may be related to the stimulus for liver regeneration and increased functional demands during the early regenerative phase.     

急性肝功能衰竭肝细胞移植后的肝再生研究进展

急性肝功能衰竭（acute liver failure，ALF）的治疗十分棘手。自1985年开始采用急诊行原位肝移植治疗以来，术后一年生存率已提高至83％。但是急诊行原位肝移植存在供体短缺等缺点，其应用受到一定限制。近年肝细胞移植的研究取得很大进展。有望成为治疗ALF的另一种有效手段。由于肝脏的再生潜力很大．移植肝细胞所提供的暂时、有效的肝功能支持．为受体肝脏的再生恢复赢得了时间，从而可使ALF病人有时间等待肝移植，甚至有可能避免肝移植。研究ALF肝细胞移植后的肝再生及其机制．探讨其影响因素．对肝细胞移植的临床应用具有重要的意义。本文就有关ALF肝细胞移植后肝再生的研究进展综述如下。     

Liver resection for primary hepatic neoplasms

Summary Subtotal hepatic resection was performed in 356 patients; 87 had primary hepatic malignancies, 108 had metastatic tumors, and 161 had benign lesions including 8 traumatic injuries. The global mortality was 4.2%. The experience has elucidated the role of subtotal hepatic resection both for benign and malignant neoplasms. Vorgetragen bei der 28. Jahrestagung der ?sterreichischen Gesellschaft für Chirurgie in Linz, 18.–20. Juni 1987.     

Liver resection for hepatic adenoma.

Between 1970 and 1978, eight hepatic adenomas were resected. Four of the eight patients took oral contraceptive pills before the hepatic adenoma was identified; one patient was male. Four patients had evidence of bleeding at the time of presentation. The original histologic diagnosis in the first five patients was malignant hepatoma. There has been no known recurrence of tumor and all patients are well. The use of oral contraceptives in these patients has been prohibited. Formal anatomic resection is recommended for hepatic adenoma when this procedure can be done without mortality or serious morbidity; however, in the future, less drastic treatments, such as occlusion of the hepatic arterial circulation to the tumor or discontinuation of oral contraceptives, may prove as effective as tumor resection.     

Acute respiratory failure after hepatic resection in canine biliary obstruction model

Acute respiratory failure after hepatic resection, especially in case of concomitant liver dysfunction, is the most troublesome postoperative complication. In order to clarify the pathophysiological mechanism of acute respiratory failure, EVLW (extravascular lung water) was measured by double indicator dilution method in canine model. Mongrel dogs underwent laparotomy and the common bile duct was ligated and divided. After 6 weeks, EVLW was significantly elevated compared with that of normal dogs (p less than 0.05). From 4 hours after 70% hepatic resection dextran-40 was loaded to increase PWP (pulmonary wedge pressure). EVLW was increased accompanying the elevation of PWP in all groups, but in the group with biliary obstruction EVLW was significantly increased for the same elevation of PWP. These results suggest that permeability of pulmonary capillary was highly increased after hepatic resection in biliary obstruction group. Pulmonary edema in this canine model seems to resemble ARDS in human and the pathophysiological mechanism was thought to be related with depression of RES phagocytic function, activation of complement system and pulmonary vascular plugging by aggregates of degenerating granulocytes and endothelial injury. Gabexate mesilate blocked the increase of the lung vascular permeability and was thought to be effective to protect the lung from postoperative acute respiratory failure.     

原发性肝癌切除术后肝功能衰竭的防治

原发性肝癌是我国常见的消化系统恶性肿瘤之一,肝切除术仍是目前治疗肝癌最有效的方法.然而,原发性肝癌患者尤其是合并严重肝硬化、门静脉高压者,容易发生术后肝功能衰竭等严重并发症,其发生率为0.7%～9.1%,占术后死亡总数的18%～75%.因此,对原发性肝癌术后肝功能衰竭进行有效防治具有十分重要的意义.     

Liver transplantation for acute hepatic failure

INTRODUCTION: The mortality rate of acute hepatic failure (AHF) with conservative treatment is 40% to 90%, depending on the etiology. Hepatitis B infection is the major cause of AHF in Asia. In this study, we examined the role of liver transplantation for adult patients with AHF. METHODS: Sixteen patients with AHF received liver transplants in the past 6 years. Eight patients received cadaveric donor and another 8 living-related donor grafts. Fifteen patients suffered from hepatitis B-related disease and 1 had drug-induced AHF. Extracorporeal charcoal hemoperfusion was used as a bridge to liver transplantation in the first 2 patients and plasma exchange was used in the following patients. RESULTS: One patient died 1 month after the operation due to primary nonfunction. The other 15 patients are alive with good graft function at 2 months to 6 years follow-up. The success rate is 94%. Postoperative complications included infection in 10 patients (62.5%), acute rejection in 4 patients (25%), and biliary complication in 2 patients (12.5%). No neurological complications were noted. CONCLUSION: Liver transplantation is the most effective treatment for patients with AHF. Living donors may be considered due to the organ shortage and the critical patient disease.     

Liver transplant for fulminant hepatic failure

Fulminant hepatic failure is a challenging indication for liver transplantation because of associated multiple organ failure, profound neurologic abnormalities and coagulopathy. Sixteen patients have undergone emergent orthotopic liver transplantation for this indication at the University of Michigan, Ann Arbor, Michigan. Despite the associated problems, patient survival (68.2% at 2 years), intra-operative blood product utilization and duration of surgery were comparable to patients receiving liver transplants for other indications. All patients experienced complete recovery from preoperative neurologic abnormalities. Recurrent viral hepatitis did occur but did not result in allograft loss. For selected patients, orthotopic liver transplantation is excellent therapy for patients presenting with fulminant hepatic failure.     

Liver resection with repair of major hepatic veins

BACKGROUND: Liver resections for tumors adjacent to major hepatic veins often require reconstruction of venous wall defects. We describe a new operative approach that facilitates repair of major hepatic veins during hepatectomies. METHODS: In 3 cases of liver tumors, the resection line had to include partially the wall of the right hepatic vein, middle hepatic vein and left hepatic vein of the preserved liver. The procedure was carried out by employing portal triad clamping combined with extrahepatic occlusion of the hepatic veins. Venous grafts for vascular repair were harvested from the inferior mesenteric vein. RESULTS: In all 3 patients, histology showed tumor-free resection margins. Follow-up of 32 to 42 months revealed no recurrence and excellent liver function. CONCLUSIONS: Combination of selective hepatic vascular exclusion with venous repair techniques, facilitates extensive liver resections in patients with tumors adjacent to the major hepatic veins and maximizes preservation of healthy liver tissue.     

Bile leakage after hepatic resection

OBJECTIVE: To identify the perioperative risk factors for postoperative bile leakage after hepatic resection, to evaluate the intraoperative bile leakage test as a preventive measure, and to propose a treatment strategy for postoperative bile leakage according to the outcome of these patients. SUMMARY BACKGROUND DATA: Bile leakage remains a common cause of major complications after hepatic resection. METHODS: Between January 1985 and June 1999, 781 hepatic resections without bilioenteric anastomosis were performed at the authors' institution. Perioperative risk factors related to postoperative bile leakage were identified using univariate and multivariate analysis. The characteristics of patients with intractable bile leakage and the effect of intraoperative bile leakage test were also examined. Management was evaluated in relation to the outcomes and the clinical characteristics of the patients with bile leakage. RESULTS: Bile leakage developed in 31 (4.0%) of 781 hepatic resections. This complication carried high risks for surgical death (two patients [6.5%] died). The stepwise logistic regression analysis identified high-risk surgical procedure, in which the cut surface exposed the major Glisson's sheath and included the hepatic hilum (i.e., anterior segmentectomy, central bisegmentectomy, or total caudate lobectomy), as the independent predictor of the development of postoperative bile leakage. None of the 102 cases in which an intraoperative bile leakage test was performed were subsequently complicated by postoperative bile leakage, and the preventive effect of the test was statistically significant. Patients with fisterographically demonstrable leakage from the hepatic hilum and with postoperative uncontrollable ascites had poor outcomes. CONCLUSION: Patients with bile leakage from the hepatic hilum and postoperative uncontrollable ascites tend to have a poor prognosis. Therefore, especially when a high-risk surgical procedure is performed in patients with liver cirrhosis, more careful surgical procedures and use of an intraoperative bile leakage test are recommended.     

Infectious complications after hepatic resection

The purpose of this study was to assess the characteristics of surgical infections after hepatic resection (HR) to identify factors accounting for increased postoperative mortality. Advances in operative technique and care have decreased morbidity and mortality after HR. However, infections after HR continue to be a major contributor to postoperative morbidity and mortality. All HR done during a 7-year period were analyzed and compared to our prospective surgical infection database. Factors contributing to infectious complications and mortality were identified. HR (n = 207) were performed with an overall mortality of 5.8 per cent. Nine patients (3.3%) had 18 infections; 6 (60%) had multiple infection sites, most commonly the peritoneum, blood, or wound. Three infected patients died. Lung and line infections occurred in 2 (67%) infection-related deaths. No single comorbidity increased postoperative infection risk, but an average of 6.7 comorbid conditions were present. All infection-related deaths were associated with ventilator-dependence. All infection-related deaths occurred after resection of a mean of four segments. Additional procedures at the time of HR, operative drains, or transfusion requirements did not impact infectious complications or mortality. Methicillin-resistant Staphylococcus sp. was isolated in all infection-related deaths. The mean time from HR to initiation of treatment was 8 days for infection survivors and 13.3 days for infection-related deaths. Infectious mortality after HR remains significant. Contributing risk factors are advanced age, multiple comorbid conditions, and extent of HR. Ventilator-dependence and delays in antibiotic therapy were associated with infectious mortality. Although gram-negative enteric infections were more common, abdominal, lung, and line infections with gram-positive cocci had higher associated mortality; especially when antibiotic resistant strains were present.     

肝细胞癌经皮穿刺肝动脉化疗栓塞缩小后切除及疗效分析

作者为探讨不能切除的肝细胞癌经肝动脉化疗栓塞（ＴＡＣＥ）缩小后行肿瘤切除的疗效,总结了５９例肝细胞癌患者的经验。本组患者首次ＴＡＣＥ前肿瘤直径５．６～２０．０ｃｍ,平均９．４３ｃｍ,每人接受ＴＡＣＥ１～６次,平均２．９次,手术前肿瘤直径缩小至３．２９ｃｍ,末次ＴＡＣＥ距手术时间１～７个月,平均２．５个月。ＡＦＰ阳性３５例,ＴＡＣＥ治疗后１３例转为正常。５９例患者中行肝段、联合肝段或肝部分切除５６例,左三叶切除２例,左半肝切除１例。切除的肿瘤各有４０％～１００％坏死,其中９例１００％坏死。ＴＡＣＥ后１３例ＡＦＰ转为正常的患者中,９例镜下仍见癌细胞。５９例患者１、３、５年生存率分别为７９．７％、６５％和５６％。作者认为ＴＡＣＥ可为一期不能切除的肝癌患者争取手术切除的机会,且可获得满意疗效。