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 current guidelines for liver volume optimization are largely based on expert opinion and limited high-quality evidence 1. While portal vein embolization (PVE) and associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) are commonly used strategies for liver volume optimization, there is limited comparative data on their effectiveness in reducing post-operative liver failure and improving overall survival 1. To investigate this, researchers should conduct a randomized controlled trial comparing different liver volume optimization strategies, including PVE, ALPPS, and two-stage hepatectomy with portal vein ligation (PVL), in patients undergoing major hepatic resection. The study should include outcomes such as post-operative liver failure, overall survival, and quality of life, and should be guided by the most recent and highest quality evidence, such as the 2023 guidelines for perioperative care for liver surgery: enhanced recovery after surgery (ERAS) society recommendations 1. The development of an evidence-based strategy for liver volume optimization has the potential to significantly improve outcomes for patients undergoing major hepatic resection, and reduce morbidity and mortality associated with post-operative liver failure. Some key considerations for the study include:
- The use of standardized criteria for liver volume optimization, such as the future liver remnant (FLR) volume and the functional liver volume 1
- The comparison of different liver volume optimization strategies, including PVE, ALPPS, and two-stage hepatectomy with PVL 1
- The inclusion of outcomes such as post-operative liver failure, overall survival, and quality of life 1
- The use of multimodal perioperative care pathways, such as ERAS protocols, to minimize the stress response to surgery and optimize post-operative recovery 1.
From the Research
Clinical Research Question
- What is the effectiveness of preoperative dynamic liver function tests in predicting post-hepatectomy liver failure (PHLF) in patients undergoing liver resection, and can these tests be used to identify patients at high risk of PHLF who may benefit from alternative treatment strategies?
Rationale
- Post-hepatectomy liver failure (PHLF) is a major cause of morbidity and mortality following liver resection, with reported incidence rates ranging from 8-12% 2.
- Current methods for predicting PHLF, such as static liver function tests, have limitations, and dynamic liver function tests may provide a more accurate assessment of liver function 3.
- Identifying patients at high risk of PHLF is crucial to mitigate the risk of this complication, and preoperative dynamic liver function tests may be a useful tool in this regard 4, 2.
Gap in the Literature
- While there is evidence on the use of dynamic liver function tests in predicting liver function after resection, there is a need for further studies to evaluate the effectiveness of these tests in predicting PHLF specifically 3, 2.
- The current literature on PHLF highlights the importance of identifying risk factors and preventative strategies, but there is a lack of studies on the use of preoperative dynamic liver function tests in this context 5, 6.