What are the recommendations for prevention and management of Postoperative Hepatic Liver Failure (PHLF)?

Prevention and Management of Post-Hepatectomy Liver Failure (PHLF)

Prevention: Preoperative Risk Assessment and Patient Selection

The cornerstone of PHLF prevention is comprehensive multiparametric preoperative assessment to ensure perioperative mortality remains below 3% and morbidity below 20%. 1, 2

Mandatory Preoperative Assessments

All hepatectomy candidates require the following evaluations 1, 2:

• Volumetric assessment of future liver remnant (FLR) using CT or MRI 1
• Indocyanine green (ICG) retention test (ICG-R15) for functional hepatic reserve 1
• Laboratory-based scoring including at minimum one of: ALBI grade, Child-Pugh score, MELD score, or APRI 1
• Scintigraphy (99mTc-GSA or 99mTc-IDA) when major hepatectomy (>2 segments) is planned 1, 3
• Functional MRI (Gd-EOB-DTPA-enhanced) as an alternative that simultaneously evaluates volume and function 3, 4

Absolute Contraindications to Major Resection

Clinically significant portal hypertension (HVPG >10 mmHg) and Child-Pugh class B cirrhosis are absolute contraindications to major hepatectomy (>2 segments). 1

For limited resections (<2 segments) using minimally invasive techniques, these factors are not absolute contraindications but require careful risk-benefit analysis against alternatives like locoregional therapy or liver transplantation 1.

Preoperative Optimization Strategies

When FLR is inadequate or borderline, implement volume optimization strategies 1:

• Portal vein embolization (PVE) - standard approach with 37% FLR hypertrophy and 77% completion rate 1
• Two-stage hepatectomy with portal vein ligation (PVL) 1
• Yttrium-90 radioembolization 1
• ALPPS (Associating Liver Partition and Portal vein ligation for Staged hepatectomy) - achieves 76% FLR hypertrophy with 100% completion rate but carries significantly higher morbidity (73% vs 59%) and mortality (14% vs 7%) compared to PVE 1

Critical caveat: ALPPS should be reserved for highly selected cases given its substantially elevated risk profile compared to traditional PVE 1.

Nutritional Optimization

Malnourished patients (weight loss >10% or >5% over 3 months with reduced BMI or low fat-free mass index) require enteral supplementation for 7-14 days preoperatively. 1, 2

Surgery should be delayed at least 2 weeks in severely malnourished patients 2. All patients should receive carbohydrate loading the evening before surgery and 2-4 hours before anesthesia 2.

Lifestyle Modifications

• Smoking cessation at least 4 weeks before surgery reduces respiratory and wound complications 1
• Alcohol cessation for heavy drinkers (>24 g/day for women, >36 g/day for men) 4-8 weeks preoperatively 1

Intraoperative Prevention Strategies

Surgical Technique

Minimally invasive liver surgery (MILS) is strongly recommended when feasible, particularly for anterolateral and superficial tumors, as it reduces postoperative complications and length of stay. 2

Judicious use of intermittent hepatic inflow occlusion (Pringle maneuver) decreases blood loss without increasing PHLF risk, even in cirrhotic patients. 1

However, avoid excessive and prolonged venous inflow occlusion in cirrhotics with borderline FLR, as prolonged ischemia impairs hepatocyte function and regeneration 1.

Hemodynamic Management

Maintain low central venous pressure (CVP <5 cm H₂O) during hepatic transection to significantly reduce blood loss. 2, 5

Implement goal-directed fluid therapy to optimize cardiac output and end-organ perfusion 2. Excessive intraoperative blood loss is an important determinant of PHLF 1.

Management of Established PHLF

Definition and Recognition

PHLF is defined by the 50-50 criteria: PT index <50% (INR >1.7) and serum bilirubin >50 μmol/L (2.9 mg/dL) on postoperative day 5, which predicts 59% mortality risk versus 1.2% when criteria are not met 1.

The ISGLS grading system stratifies severity 1:

• Grade A: Laboratory abnormalities without clinical impact
• Grade B: Requires deviation from standard postoperative care
• Grade C: Requires intensive care support

Treatment Principles

Management of PHLF relies on supportive care strategies identical to those for acute liver failure, acute-on-chronic liver failure, and sepsis, focusing on end-organ support rather than specific therapeutic interventions. 1

Key management components include 1, 6, 7, 8:

• Hemodynamic support to maintain adequate perfusion
• Prevention and aggressive treatment of sepsis - the leading cause of PHLF-related mortality 7
• Metabolic support including correction of hypoglycemia, coagulopathy, and electrolyte abnormalities 1
• Nutritional support tailored to metabolic demands 8
• Renal replacement therapy if acute kidney injury develops 7
• Minimizing hepatic insult by avoiding hepatotoxic medications 1

Rescue Options

Rescue hepatectomy and liver transplantation can be considered in highly selected PHLF patients who meet transplantation criteria. 1

Liver transplantation is generally contraindicated in patients with metastatic hepatic disease, with rare exceptions for select patients with metastatic neuroendocrine tumors 1.

Postoperative Care

Thromboprophylaxis

Low molecular weight heparin or unfragmented heparin should be started postoperatively (not preoperatively) unless exceptional circumstances make this unsafe. 2, 5

Intermittent pneumatic compression devices applied prior to anesthesia induction provide additional thromboembolic risk reduction 2, 5.

Nutritional Management

Early oral intake with normal diet should be implemented immediately after hepatectomy. 2

Individualized artificial nutrition assessment is needed only for malnourished patients, those with complications causing prolonged fasting, or cirrhotic patients 2.

Common Pitfalls to Avoid

• Proceeding with major hepatectomy in patients with clinically significant portal hypertension or Child-Pugh B cirrhosis without considering alternatives 1
• Relying solely on RLV without functional assessment - equal liver volumes have unequal function depending on underlying disease 3, 4
• Choosing ALPPS without careful consideration of its substantially higher morbidity and mortality compared to PVE 1
• Excessive or prolonged Pringle maneuver in cirrhotics with borderline FLR 1
• Inadequate preoperative nutritional optimization in malnourished patients 1, 2
• Starting anticoagulation preoperatively rather than postoperatively, which increases bleeding risk 2, 5