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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Age is no barrier to tolerability or efficacy of radioembolization for colorectal liver metastases

Here is my highlight from the december issue of HPB

Radioembolization is still searching for its precise niche in the armoury of treatments for colorectal liver metastases. The majority of protocols advise its use in patients who have non-resectable and chemotherapy-resistant liver metastases with some requiring failure of first line chemotherapy and some second line chemotherapy. Guidance on its use in patients with extrahepatic sites of disease is also somewhat variable. Economic considerations influence patient selection in a number of healthcare models in addition to outcome data.

In this edition of HPBTohme and colleagues from the University of Pittsburgh explore outcomes of older patients treated with radioembolization. They have reported outcomes of more than 100 patients older or younger than 70 years treated with one or more episodes of radioembolization for non-resectable liver metastases which have proved resistant to one or two chemotherapy regimens. Fatigue is a frequently reported complicating symptom of radioembolization. It might be considered that elderly patients have less physical reserve. However, the Pittsburgh group found no difference in either frequency or severity of fatigue in treated patients based on age. Other side effect profiles were also similar suggesting that this treatment modality is well tolerated by the elderly. In terms of patient survival, again there was no difference in outcome based on patient age. The major determinant of poor outcome appeared to be the presence of extrahepatic disease but this was the same irrespective of age.

This article provides evidence that radioembolization is effective and reasonably well tolerated in patients with colorectal liver metastases and should be considered in motivated patients regardless of age.

Survival and tolerability of liver radioembolization: a comparison of elderly and younger patients with metastatic colorectal cancer

  1. Samer Tohme1,
  2. Daniel Sukato1,
  3. Gary W Nace1,
  4. Albert Zajko2,
  5. Nikhil Amesur2,
  6. Philip Orons2,
  7. Didier Chalhoub3,
  8. James W Marsh1,
  9. David A Geller1 and
  10. Allan Tsung


Volume 16Issue 12pages 1110–1116December 2014

SIRT copyPicture from Macmillan cancer organisation

Further patient information at

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Fools rush in where angels fear to tread: damage control surgery for severe pancreatic trauma

Here is my highlight from the Journal HPB for November which relates to an analysis of damage control surgery for major pancreas trauma. This is a must read paper on the very difficult problem of major pancreas trauma from South Africa.

The pancreas is usually considered to be well protected however, it’s anatomical relationships mean that when the head of the gland is injured there are frequently severe associated injuries to vasculature or important structures such as the bile duct and duodenum. Major trauma to the pancreatic head therefore, represents a life-threatening situation for the patient and a complex management issue for the surgeon.

In this issue of HPB, Krige and colleagues from Cape Town, South Africa present a wealth of experience of pancreatic trauma. The article refers to a cohort of more than 400 pancreatic trauma cases with focus on 19 with the most severe grade 5 injuries. The mechanism of injury included penetrating trauma from gunshot and stab wounds as well as blunt trauma from road traffic accidents. Approaches to management were tailored to the individual patient needs. A number of these cases were associated with major haemorrhage from vena cava or portal vein injuries which required control prior to dealing with pancreatic injury itself.

The concept of damage control surgery originated in South Africa and this series includes a number of patients who had two or more stage procedures after initial damage control of the pancreatic injury. This measured approach seems entirely sensible given the potential difficulties of reconstruction after pancreaticoduodenectomy in an unstable patient. This approach is a good learning point and must have contributed to the excellent survival rate of 84% in these patients at the extreme end of the pancreatic trauma scale.


Emergency pancreatoduodenectomy for complex injuries of the pancreas and duodenum (pages 1043–1049)

Jake E. Krige, Andrew J. Nicol and Pradeep H. Navsaria

Article first published online: 19 MAY 2014 | DOI: 10.1111/hpb.12244

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Greetings to medical colleagues in china 问候医疗在中国的同事

Some WordPress blog sites seem to be accessible now for the first time from China and so welcome to Chinese colleagues. I will try to make some of my blogs accessible in Mandarin but apologies for the many errors likely.

欢迎来到医疗读者在中国。我希望你觉得我的文章对肝脏手术,移植和学术手术对您有价值。   我会努力让我的一些普通话的博客.     道歉对我的翻译错误

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Donor age is no bar to successful liver transplantation unless the recipient has untreated hepatitis C virus disease

Here is my highlight from the current issue of HPB.

The disparity between supply and demand of donor livers for transplantation remains an ever-present challenge and drives the use of extended criteria donor organs. Donor age is one criterion that has been moving steadily upwards but changes have often been based on anecdote rather than evidence. In addition much of what we know about using older donor livers relates to short-term outcomes but there is clearly interest in how an already old liver will do in a recipient who may be expected to have a long post-transplant life expectancy. In this edition of HPB, Chedid et al. explore the Mayo Clinic experience of transplanting livers from 70 and 80 year old cadaveric donors. In their experience, 107 donor livers (14 % of the total series) were from this older population. Fewer livers from older donors were transplanted into recipients with hepatitis C, which concurs with their institutional policy based on evidence of better outcomes in hepatitis C recipients for liver transplantation from younger donors. They found no difference in graft or patient survival for the overall population based on donor age being greater or less than 70 years. In the hepatitis C recipients, there was a clear disadvantage both in terms of patient and graft survival to patients receiving a graft from an over 70 years donor. Although there is undoubtedly a need for careful selection of livers in the older populations with the avoidance of steatosis, there is clear evidence of benefit from using older livers from brainstem dead heart-beating donors. The introduction of new effective antiviral therapies for Hepatitis C may negate the observed adverse outcome association of transplanting older livers into hepatitis C recipients. Older individuals in society should be afforded the possibility of donating their livers, where appropriate, as it is clear that recipients will benefit.

The full article is 

Excellent long-term patient and graft survival are possible with appropriate use of livers from deceased septuagenarian and octogenarian donors

  1. Marcio F. Chedid, 
  2. Charles B. Rosen*
  3. Scott L. Nyberg and
  4. Julie K. Heimbach

Article first published online: 28 JAN 2014

DOI: 10.1111/hpb.12221



Volume 16Issue 9pages 852–858September 2014

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Challenging epidural analgesia as the preferred route for postoperative analgesia in liver surgery

Here is my highlight from the July issue of HPB.

Good post-operative pain control is a central part of recovery after surgery. ERAS programmes, in particular, have heavily promoted the use of epidural analgesia for abdominal surgery. This probably owes something to the roots of ERAS in colorectal surgery however many of the studies on which these recommendations were made are outdated and relate to very different operative procedures. Epidural analgesia is known to offer good dynamic and static pain control but does have drawbacks in terms of hypotension, immobility and rare but life threatening complications of epidural abscess or epidural haematoma. The liver surgery group in Basingstoke have been one of the major centres pioneering local anaesthetic wound catheter infiltration of upper abdominal wounds combined with patient controlled opiates as an alternative to epidural analgesia. In this edition of HPB, Wong-Lu-Hing and colleagues report the Basingstoke experience of wound catheter analgesia after liver resection in a retrospective comparative cohort analysis including a small group of contemporaneous patients receiving epidural analgesia (analgesic selection based on surgeon preference). Although not a randomized trial they clearly show some important benefits from wound catheter analgesia. These were equivalency of analgesia combined with reduced overall complication rates, reduced opiate requirement and a shorter length of stay compared with patients receiving epidural analgesia. Further refinements to local anaesthetic protocols such as additional transversus abdominis plane blocks may improve the effectiveness of this analgesic approach and it seems certain that this will remain an effective alternative if not a preferred alternative to epidural analgesia in liver surgery.


Postoperative pain control using continuous i.m. bupivacaine infusion plus patient-controlled analgesia compared with epidural analgesia after major hepatectomy (pages 601–609)
Edgar M. Wong-Lun-Hing, Ronald M. van Dam, Fenella K. S. Welsh, John K. G. Wells, Timothy G. John, Adrian B. Cresswell, Cornelis H. C. Dejong and Myrddin Rees
Article first published online: 23 OCT 2013 | DOI: 10.1111/hpb.12183

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What drives altruism in living liver donors – a risk-decision analysis?

Here is my editorial highlight from the June edition of HPB the official journal of the IHPBA, A-HPBA and EA-HPBA

Living organ donation is unusual in medical practice because for the donor there is a significant health risk incurred through donation which is only offset by a sense of well being from helping another human who is in clinical need. In his contemporary analysis of Darwinist theory ‘The Selfish Gene’, Richard Dawkins explains altruism in terms of protecting lines of inheritance and in this analysis he questions the illogicality of altruistic acts outside of this framework.

This issue of HPB contains an analysis by Molinari and colleagues of the drivers for living liver donors to donate. The paper acknowledges the balance between risk and benefit and there is a several log order increased risk of serious harm or death to otherwise healthy individuals compared with for example living kidney donation. Molinari et al. did find that altruism wasn’t given completely freely. Apart from the obvious need for a biological or close emotional relationship between donor and recipient, donors had an expectation of reasonable prospects of survival for the recipient at one and 3 years. Donors were likely to donate if there was an expectation that the recipient would have a protracted wait for a cadaveric graft.

Interestingly donors were prepared to accept a greater level of risk than clinicians. This study provides an important insight into the decision-making processes of potential liver donors. The authors conclude that living donors are ‘risk takers’, while this may be true, the risks are calculated and the donors in this study seemed well equipped to make the decisions underpinning the risk.

Based on the following original article in the June issue of HPB

Live liver donors’ risk thresholds: risking a life to save a life (pages 560–574) Michele Molinari, Jacob Matz, Sarah DeCoutere, Karim El-Tawil, Bassam Abu-Wasel and Valerie KeoughArticle first published online: 20 NOV 2013 | DOI: 10.1111/hpb.12192
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