What is the recommended management for adult hepatectomies?

Management of Adult Hepatectomies

Hepatectomy requires comprehensive multiparametric preoperative assessment incorporating liver function, portal hypertension, remnant liver volume, and patient comorbidities to achieve perioperative mortality <3% and morbidity <20%. 1

Preoperative Risk Stratification

Essential Assessment Components

All hepatectomy candidates require multiparametric evaluation including at minimum: 1

• Volumetric assessment of future liver remnant
• Indocyanine green (ICG) retention test for functional reserve
• Laboratory-based scoring (Child-Pugh, MELD, ALBI, or APRI)
• Scintigraphy when major hepatectomy is planned

Cirrhotic vs. Non-Cirrhotic Liver

For non-cirrhotic livers: Liver resection is the preferred treatment regardless of tumor size, with more aggressive resections permissible due to preserved function and lower post-hepatectomy liver failure (PHLF) risk. 1

For cirrhotic livers: Assessment must evaluate: 1

• Severity of portal hypertension (HVPG measurement)
• Extent of planned hepatectomy
• Volume of future liver remnant (minimum 40% of total liver volume required)
• Performance status and comorbidity profile

Absolute contraindications to resection in cirrhosis: 1

• Clinically significant portal hypertension (HVPG >10 mmHg)
• Child-Pugh class B or C cirrhosis (with rare exceptions for highly selected Child-Pugh B7 patients undergoing minimally invasive surgery)

Special Population Considerations

Metabolic dysfunction-associated steatotic liver disease (MASLD): These patients experience 32% major morbidity vs. 24% in non-MASLD patients, requiring thorough preoperative metabolic assessment and optimization of modifiable risk factors (diabetes, obesity, dyslipidemia) before surgery. 1

Elderly patients (>75 years): Age alone should not be an absolute contraindication. Higher perioperative complications relate primarily to comorbidities and blood loss rather than age itself, with elderly patients benefiting equally from minimally invasive approaches. 1

Preoperative Optimization

Nutritional Management

Malnourished patients (weight loss >10% or >5% over 3 months, reduced BMI, or low fat-free mass index) require: 1

• Enteral supplementation for 7-14 days preoperatively
• Surgery postponement for at least 2 weeks in severely malnourished patients

All patients should receive: 1

• Carbohydrate loading the evening before surgery and 2-4 hours before anesthesia
• Preoperative fasting limited to 6 hours for solids, 2 hours for liquids

Biliary Drainage

For cholestatic liver disease with bilirubin >50 mmol/L, biliary drainage is mandatory with surgery ideally postponed until bilirubin drops below this threshold. 1 For perihilar cholangiocarcinoma, percutaneous drainage is preferred over endoscopic approaches. 1

Substance Cessation

• Smoking cessation: Counsel at least 4 weeks preoperatively 1
• Alcohol cessation: Required for heavy drinkers (>24 g/day women, >36 g/day men) for 4-8 weeks before surgery 1

Medication Management

Avoid preoperatively: 1, 2

• Long-acting anxiolytics (especially in elderly—worsen hepatic encephalopathy)
• Preoperative gabapentinoids and NSAIDs

Administer: 1

• Methylprednisolone 500 mg preoperatively (except in diabetic patients)
• Acetaminophen dose-adjusted according to resection extent
• Antibiotic prophylaxis (cefazolin) within 60 minutes of incision

Intraoperative Management

Surgical Approach

Minimally invasive liver surgery (MILS) is strongly recommended when feasible, particularly for anterolateral and superficial tumors, as it reduces postoperative length of stay and complication rates compared to open surgery. 1 Laparoscopic approaches benefit elderly patients equally or more than younger patients. 1

Hemodynamic Management

Low central venous pressure (CVP <5 cm H₂O) during hepatic transection significantly reduces blood loss. 1, 3 Stroke volume variation (SVV) monitoring demonstrates superior results to CVP monitoring in laparoscopic procedures. 3

Goal-directed fluid therapy optimizes cardiac output and end-organ perfusion, particularly beneficial after transection to restore tissue perfusion in patients with comorbidities or reduced cardiac function. 1 Balanced crystalloids are preferred over 0.9% saline or colloids. 1

Bleeding Management

Critical pitfall: Traditional coagulation tests (INR, PT) overestimate bleeding risk and do not reliably predict procedural bleeding. 3 Prophylactic blood product transfusion based solely on laboratory values increases complications without reducing bleeding. 3

Appropriate strategies: 3

• Restrictive transfusion (transfuse when hemoglobin <7 g/dL, target 7-9 g/dL)
• Avoid routine tranexamic acid in cirrhotic patients
• Treat underlying conditions (infections, acute kidney injury) that contribute more to bleeding than coagulation abnormalities

Analgesia

For open hepatectomy: Thoracic epidural provides excellent analgesia but causes hypotension and mobility issues detrimental to recovery. Multimodal analgesia (including potential intrathecal opiates) or continuous local anesthetic wound infiltration is preferred. 1

For laparoscopic hepatectomy: Regional anesthesia is unnecessary; multimodal analgesia with judicious IV opiates provides adequate pain control. 1

Postoperative Management

Thromboprophylaxis

Low molecular weight heparin or unfragmented heparin should be started postoperatively (not preoperatively) unless exceptional circumstances make this unsafe. 1, 3 Intermittent pneumatic compression devices provide additional thromboembolic risk reduction. 1

Nutritional Support

Early oral intake with normal diet should be implemented immediately after hepatectomy. 1 Individualized artificial nutrition assessment is needed only for malnourished patients, those with complications causing prolonged fasting, or cirrhotic patients. 1 When artificial nutrition is required, enteral administration is preferred. 1

Glycemic Control

Insulin therapy maintaining normoglycemia (<8.3 mmol/L) is recommended. 1

Mobilization

Early mobilization (out of bed) should begin on the operative day and continue until discharge. 1

Prophylactic Measures NOT Recommended

• Nasogastric intubation: Routine use increases hospital length of stay without benefit 1
• Abdominal drainage: Not indicated for hepatectomy without biliary reconstruction 1

Adjuvant and Neoadjuvant Therapy

Neoadjuvant therapies should only be considered in prospective studies, as evidence of survival advantage with pre-surgical treatments is lacking. 1

Adjuvant treatment after resection or ablation is not recommended based on current evidence. 1 However, recent data on atezolizumab plus bevacizumab shows improved recurrence-free survival, though longer follow-up is required. 1

Quality Metrics

Target outcomes for hepatectomy programs: 1

• Perioperative mortality <3%
• Major morbidity <20%

These benchmarks are achievable through proper patient selection, multiparametric risk assessment, and adherence to enhanced recovery protocols. 1