The majority of patients who undergo liver resection come through their operation with little or no problems. Occasionally people develop jaundice after liver resection and this can usually be explained by one of two reasons.
1. There is a problem with liver synthetic function
2. There is a problem with biliary drainage
Liver synthetic function
The healthy liver has a huge metabolic capacity that far exceeds what is required to survive on a day to day basis. Previous studies have shown a clear relation between postoperative functional liver volume and likelihood of developing clinically evident liver failure. In patients with healthy liver up to 75% of the liver volume can be resected with little disturbance of liver function. In patients with diseased liver the volume of liver resected which will precipitate liver dysfunction or failure is considerably less. You can read an article about liver volume and function here.
After major liver resection the liver can struggle and this can result in the development of clinical jaundice. The pattern of liver function test abnormalities after major liver resection is interesting and for the majority of patients very predictable. The liver transaminase enzymes ALT or AST are immediately elevated because of ischemic injury and damage at the time of surgery. Usually these fall progressively day by day after surgery as in the figure.
Prolonged elevation of the AST and ALT enzymes is sometimes seen particularly if there has been prolonged inflow occlusion because of ongoing liver injury. Clotting abnormalities (INR or PTR) become evident within 12 hours of surgery and peak around 36 to 48 hours usually. These resolve fairly rapidly after surgery. Bilirubin only becomes elevated later in the picture and often peaks around day 4-6. depending on the size of the liver remnant and the degree of injury. The development of sepsis often exacerbates post operative jaundice as does major transfusion or enteral bleeding such as may occur from haemobilia.
Clinical signs of encephalopathy, clinically evident as confusion or liver flap, are seen from around 12 hours post surgery but usually only last 48-72 hours and resolve as liver function improves.
Abnormal liver function after liver resection is more likely in the presence of:
1. An abnormal liver–
A. chemotherapy associated sinusoidal obstruction syndrome or steatohepatitis
B. cirrhosis or fibrosis
C. steatosis or steatohepatitis of any cause
D. longstanding biliary obstruction
2. Massive liver resection- resection of 75% or more liver constitutes a massive liver resection and runs a high risk of inducing liver failure or small for size syndrome (more about this later).
4. Poor nutrition
Problem with biliary drainage after liver resection?
Problems with biliary drainage leading to postoperative jaundice are thankfully uncommon. There may be an issue with compromise of biliary drainage arising from occlusion of the bile duct during transection of the portal pedicle. This will cause immediate unremitting jaundice with radiological signs of biliary dilatation. Bile leak and intra-abdominal collection may cause mild jaundice due to resorption of bile via the peritoneum. A collection will usually be evident radiologically and should be drained. Late jaundice weeks to months after liver resection is again unusual but can herald the onset of a late biliary stricture associated with either ischemia of the bile duct or fibrosis and scarring from a low grade collection or leak.
Rare causes of jaundice after liver resection.
Antibiotic associated jaundice- Intrahepatic cholestasis is a well recognized but rare complication of the use of certain drugs particularly antibiotics (e.g flucloxacillin or amoxycillin). The presence of jaundice with no biliary dilatation and in the presence of resolving or normal liver function may suggest this.
Gilbert’s syndrome. Most patients know that they have Gilbert’s syndrome when they are quite young and long before they ever need to undergo liver resection, but this operation can unmask this syndrome which usually resolves spontaneously with no requirement for intervention.