Making sense of the liver volume/function relationship in health and disease will lead to safer liver surgery

Here is my highlight for the february edition of the journal HPB

CT scan based liver volume analysis has become a standard technique for complex or extended liver resections as a means of estimating likelihood of liver failure and improving patient safety. Volume analysis of the predicted future liver remnant is known to work well for patients with normal or near normal liver function with predicted minimum liver volumes of around 25%, reliably avoiding post-operative liver failure.

Where volume analysis falls down is in patients with abnormal liver function and particularly cirrhosis. The problem is essentially that the liver function can be highly variable at the dysfunctional end of the scale and the volume function relationship becomes unpredictable.

Kim and colleagues from South Korea have presented an analysis combining conventional hepatic volumetry w ith retention of indocyanine green (ICG) at 15 minutes. In this study, they have confirmed that in healthy liver, volume measurement alone can reliably identify patients at risk of developing post operative liver failure. In patients with underlying liver disease or cirrhosis, expressing the future liver remnant volume in relation to the ICG15 retention time also provided a clear cut off value that identified a safe level at which resection could proceed. This ratio of future liver remnant volume to ICG15 was >1.9. This therefore provides a useful and practical approach to estimate patient safety in patients undergoing major resection. Patients with healthy liver probably only need to undergo volume analysis and if the future liver remnant is greater than 25%, resection can proceed. Those with cirrhosis or marked fibrosis should undergo both volume analysis and measurement of ICG retention at 15 minutes. If the ratio of these measurements (FLR : ICG15) is >1.9, resection can proceed safely but if less than this then a modified approach should be used or there will be significant risk of liver failure.

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