Major liver resections, perioperative issues and posthepatectomy liver failure: A comprehensive update for the anesthesiologist

Table 3 Perioperative risk factors for posthepatectomy liver failure (adapted from Sparrelid et al[3])

Patient-associated
Sex	Risk double in males, especially males with HCC
	Female hormones show proliferative effect in animal models, inhibiting effect of testosterone on immune system
	NAFLD, lower postoperative risk than other chronic liver diseases, higher incidence in postmenopausal women
Age	Still unclear, possible changes in bile flow and acute-phase protein production
	Age-related sinusoidal pseudocapillarization, rescue in animal models through serotonin agonist injection
Sepsis	Bacterial endotoxins decrease cytokine production needed for liver regeneration
	Kupffer cell and hepatocyte function in liver regeneration inhibited
Metabolism	Insulin induces expression of IGF and HGF
	High BMI and malnutrition associated with PHLF
Other	Serum bilirubin, low platelets, insufficient renal function, cardiopulmonary disease, associated with PHLF
Liver-associated
Steatosis	Leads to changes in the hepatic microenvironment and higher risk for ischaemia–reperfusion injury
Neoadjuvant chemotherapy	Chemotherapy-associated liver injury and steatohepatitis are known complications after neoadjuvant chemotherapy
Fibrosis grade	Functional liver tissue reserve is reduced, patients often present with several comorbidities
Cholestasis	Jaundice increases morbidity after surgery; in animal models, bile duct ligation leads to reduced growth factor expression
Portal hypertension	High preoperative portal pressure in cirrhosis associated with increased risk of PHLF
Surgery-associated
Future liver remnant	‘Small-for-flow’ syndrome negatively impacts hepatic haemodynamics
	Increase in portal pressure leads to altered hepatic microcirculation and hepatocyte damage
Blood loss	Leads to intravascular fluid shifts, introduction of bacterial endotoxins into the hepatic microenvironment
	Increased risk of sepsis, coagulopathy and PHLF
Surgical technique	Vascular occlusion can cause ischaemia–reperfusion injury and in increases PHLF risk
	Long Pringle manoeuvre leads to increased oxidative stress and overshooting inflammatory response
	Extensive vascular resection can cause PHLF

HCC: Hepatocellular carcinoma; NAFLD: Non-alcoholic fatty liver disease; IGF: Insulin-like growth factor; HGF: Hepatocyte growth factor; PHLF: Posthepatectomy liver failure.