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.