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

Table 1 Indications for liver resection

Benign solid tumors (selected cases)

Adenoma (single/multiple)

Hemangioma

Focal nodular hyperplasia

Inflammatory pseudotumor

Malignant solid tumors

Liver metastasis

Primary tumors of the liver and biliary tract

Hepatocarcinoma

Cholangiocarcinoma

Cholecystic tumor

Primary hepatic sarcoma

Angiosarcoma

Cystic lesions

Cystadenoma/cystadenosarcoma

Simple epithelial cyst

Hepatic polycystosis

Pyogenic liver abscess

Amoebic abscess

Echinococcus cyst

Biliary tract diseases

Primary sclerosing cholangitis

Caroli’s disease

Table 2 Overview of preoperative tests to estimate adequate remnant liver function Adapted from Sparrelid et al[3]

Test	Agent used	FLR volume	TL function	FLR function	Distribution	FLR function after	Complexity	Validated for PHLF
Volumetry		Yes	No	No	No	–	–	++
Laboratory scores		No	No1	No	No	–	–	+
ICG test	Indocyanine green	No	Yes	No	No	–	+	++
LIMAX	13C-methacetin	No	Yes	No	No	–	+	+
LIMAX+volumetry	13C-methacetin	Yes	Yes	Yes	No	+	++	+
ICG+volumetry	Indocyanine green	Yes	Yes	Yes	No	+	++	++
HBS	99mTc-Mebrofenin	Yes	Yes	Yes	Yes	++	++	++
RLE-MRI	Gadoxetic Acid	Yes	Limited2	Limited2	Yes	+2	+	+
DCE-MRI	Gadoxetic Acid	Yes	Yes	Yes	Yes	++	+++	–

¹Only sensitive in low liver function/cirrhosis.

²Not absolute.

ICG: Indocyanine green; HBS: Hepatobiliary scintigraphy; RLE: Relative liver enhancement; MRI: Magnetic resonance imaging; DCE: Dynamic contrast-enhanced; FLR: Future liver remnant; TL: Total liver; PHLF: Posthepatectomy liver failure; +: Low; ++: Medium; +++: High.

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.