What is the best approach to decrease the risk of post-hepatic liver failure in a patient with a low total liver volume ratio?

Optimizing Future Liver Remnant Volume to Prevent Post-Hepatic Liver Failure

For a patient with a total liver volume ratio of 0.19, preoperative portal vein embolization (PVE) should be performed to increase the future liver remnant (FLR) volume before proceeding with hepatic resection. 1

Understanding the Risk

With a total liver volume ratio of 0.19 (19%), this patient is at high risk for post-hepatectomy liver failure (PHLF):

• For patients with normal liver, the minimum safe FLR ratio is ≥20% 1
• For patients with chronic liver disease/Child-Pugh A cirrhosis, the minimum safe FLR ratio is 30-40% 1
• For patients with severe steatosis or cholestasis, the minimum safe FLR ratio is ≥40% 1

The current ratio of 0.19 falls below even the minimum threshold for normal livers, indicating a critical need for intervention before resection.

Recommended Management Algorithm

1. Perform Portal Vein Embolization (PVE)

   • PVE is the most widely used and effective volume optimization strategy 1
   • PVE redirects portal blood flow to the FLR, inducing hypertrophy
   • Typically increases FLR volume by 40-62% after 34-37 days 1
   • Up to 80% of patients become eligible for planned resection after PVE 1

2. Reassess FLR Volume After PVE

   • Wait 4-6 weeks for optimal hypertrophy
   • Perform CT volumetry to reassess FLR volume
   • Target FLR ratio should be ≥20% for normal liver or ≥30-40% for diseased liver 1

3. Assess Liver Function

   • Consider indocyanine green (ICG) clearance test
   • ICGR15 above 15-20% indicates impaired hepatic functional reserve 1
   • Consider preoperative biopsy of FLR if underlying parenchymal disease is suspected 1

4. Additional Considerations Based on Liver Status

   • For patients with cirrhosis: aim for FLR/body weight ratio ≥1.4% 2
   • For patients undergoing extended hepatobiliary resection: aim for FLR/body weight ratio ≥0.65% 3
   • For high-risk patients (diabetes, cirrhosis): aim for FLR >40% 4

Risk Factors to Assess

Several factors increase PHLF risk that should be evaluated:

• Patient-specific factors:

  • Presence of diabetes mellitus (significant risk factor) 5, 4
  • Age ≥65 years 3
  • Cirrhosis or chronic liver disease 1, 4

• Procedure-related factors:

  • Extent of planned resection (>50% liver volume significantly increases risk) 1, 6
  • Anticipated blood loss (≥25 mL/kg increases risk) 3
  • Prolonged operative time 6

Potential Complications to Monitor

After optimization and during/after surgery, monitor for:

• Small-for-size syndrome with hyperperfusion of the remnant liver 6
• Cholestatic pattern with impaired bilirubin conjugation and excretion 6
• The "50-50 criteria" (prothrombin time <50% and bilirubin >50 μmol/L on day 5) which predicts mortality risk 6

Common Pitfalls to Avoid

• Underestimating FLR requirements: Different liver conditions require different minimum FLR volumes
• Relying solely on volumetry: Volume is a surrogate for function; consider functional assessment tests like ICG clearance 1
• Inadequate waiting time after PVE: Allow sufficient time (4-6 weeks) for optimal hypertrophy before reassessment
• Overlooking underlying liver disease: Cirrhosis, steatosis, and cholestasis all require higher FLR thresholds 1
• Failing to account for intraoperative blood loss: Excessive blood loss (>1000 mL) can contribute to PHLF 6

By following this approach and ensuring adequate FLR volume before proceeding with hepatic resection, the risk of post-hepatic liver failure can be significantly reduced in this high-risk patient.