From the Guidelines
A compelling clinical research question for liver surgery is: "What is the optimal strategy for liver volume optimization in patients undergoing major hepatic resection, and how does it impact post-operative liver failure and overall survival?" This question addresses a significant gap in the literature as the current guidelines for liver volume optimization, such as portal vein embolization (PVE) and associating liver partition and portal vein ligation for staged hepatectomy (ALPPS), have varying degrees of success and are not universally applicable 1. The optimal strategy for liver volume optimization would depend on various factors, including the patient's underlying liver disease, the extent of liver resection, and the presence of other comorbidities. Some of the key considerations in liver volume optimization include:
- Pre-operative evaluation of future liver remnant (FLR) volume and function 1
- Use of imaging techniques, such as CT or MRI, to assess liver volume and function 1
- Application of volume optimization strategies, such as PVE, ALPPS, or two-stage hepatectomy, to increase FLR volume and reduce the risk of post-operative liver failure 1
- Individualized approach to liver volume optimization, taking into account the patient's specific needs and underlying liver disease 1 The implementation of an optimized liver volume optimization strategy could potentially reduce post-operative complications, such as liver failure, and improve overall survival in patients undergoing major hepatic resection. However, further research is needed to determine the most effective strategy for liver volume optimization and to establish clear guidelines for its application in clinical practice 1. Some of the key areas for future research include:
- Comparative studies of different volume optimization strategies, such as PVE and ALPPS, to determine their relative efficacy and safety 1
- Investigation of the role of underlying liver disease, such as cirrhosis, in determining the optimal strategy for liver volume optimization 1
- Development of personalized approaches to liver volume optimization, using techniques such as machine learning and artificial intelligence to predict patient outcomes and optimize treatment strategies 1
From the Research
Clinical Research Question
- What is the optimal strategy for preventing postoperative liver failure in patients undergoing major liver resection, considering the potential benefits and limitations of terlipressin and other pharmacological interventions?
Rationale
- Postoperative liver failure is a significant cause of morbidity and mortality after liver resection 2
- Terlipressin has been shown to decrease portal vein pressure and improve renal function in patients undergoing liver resection 3, 4, 5
- However, the effectiveness of terlipressin in preventing postoperative liver failure is still unclear, and its use is not universally recommended 6
- Further research is needed to determine the optimal strategy for preventing postoperative liver failure, including the potential role of terlipressin and other pharmacological interventions
Potential Study Design
- A randomized controlled trial comparing the effectiveness of terlipressin versus other pharmacological interventions (e.g. somatostatin, octreotide) in preventing postoperative liver failure after major liver resection
- A prospective observational study to identify risk factors for postoperative liver failure and evaluate the effectiveness of different preventative strategies
- A systematic review and meta-analysis of existing studies on the use of terlipressin and other pharmacological interventions in preventing postoperative liver failure after liver resection
Key Outcome Measures
- Incidence of postoperative liver failure
- Mortality rate
- Length of hospital stay
- Renal function (e.g. serum creatinine, estimated glomerular filtration rate)
- Liver function (e.g. serum bilirubin, liver enzymes)