What is the management approach for post-hepatectomy liver failure?

Management of Post-Hepatectomy Liver Failure

Post-hepatectomy liver failure (PHLF) management is fundamentally supportive care focused on preventing sepsis, maintaining hemodynamic stability, and providing metabolic support, with liver transplantation reserved for severe cases that fail to recover. 1

Diagnosis and Severity Grading

Use the 50-50 criteria to identify PHLF: prothrombin time index <50% AND serum bilirubin >50 μmol/L on postoperative day 5, which predicts 59% mortality risk versus 1.2% when criteria are not met. 1

Apply the International Study Group of Liver Surgery (ISGLS) grading system to stratify severity: 1

• Grade A: Laboratory abnormalities only, no clinical impact
• Grade B: Requires deviation from standard postoperative care
• Grade C: Requires intensive care support

Core Management Principles

Hemodynamic Support

Maintain mean arterial pressure ≥50-60 mmHg through aggressive fluid resuscitation followed by vasopressor support if needed. 2

• Fluid resuscitation: Use colloid (albumin) rather than crystalloid as first-line, with all solutions containing dextrose to maintain euglycemia 2
• Vasopressor choice: Use epinephrine, norepinephrine, or dopamine (NOT vasopressin) if fluid replacement fails to maintain adequate MAP 2
• Monitoring: Consider pulmonary artery catheterization in hemodynamically unstable patients to ensure appropriate volume replacement 2

Infection Prevention and Treatment

Administer empirical broad-spectrum antibiotics immediately if there are signs of worsening encephalopathy or systemic inflammatory response syndrome (SIRS). 2

• Bacterial infections occur in 60-80% of acute liver failure patients 3
• Fungal infections occur in one-third of patients and should be considered with persistent fever despite antibacterial therapy 3
• Do NOT use postoperative "prophylactic" antibiotics routinely 2

Metabolic and Nutritional Support

Monitor blood glucose at least every 2 hours and maintain normoglycemia with continuous glucose infusions and insulin therapy. 2, 3

• Hypoglycemia symptoms may be obscured by encephalopathy 2
• Implement early oral intake with normal diet immediately after hepatectomy 2, 1
• Reserve enteral or parenteral feeding for malnourished patients or those with prolonged fasting due to complications (ileus >5 days, delayed gastric emptying) 2, 1
• Provide 60 grams per day of protein; severe protein restrictions should be avoided 2
• Supplement phosphate, magnesium, and potassium as needed 2

Renal Support

If dialysis is needed for acute renal failure, use continuous renal replacement therapy rather than intermittent hemodialysis. 2

• Avoid nephrotoxic drugs including NSAIDs 2, 4

Coagulation Management

Do NOT routinely correct coagulation abnormalities. 2, 4, 3

• Restrict clotting factor administration to active bleeding or high-risk invasive procedures only 2, 4, 3
• Most patients have rebalanced hemostasis, and prophylactic administration obscures disease progression monitoring 3

Encephalopathy Management

Monitor encephalopathy frequently and maintain serum sodium between 140-145 mmol/L. 2

• Perform tracheal intubation and sedation if progressive hepatic encephalopathy with Glasgow Coma Scale <8 2
• Minimize depth of sedation 2
• Do NOT use lactulose or rifaximin to lower ammonia levels in this setting 2
• Avoid benzodiazepines and psychotropic drugs 2

Stress Ulcer Prophylaxis

Provide stress ulcer prophylaxis with H2 blocking agents or proton pump inhibitors. 2, 3

Advanced Therapies

Liver Support Systems

Current evidence is insufficient to recommend liver support systems (MARS, Prometheus, plasma exchange) for routine management of severe PHLF. 5

• Observational data suggest potential benefit as a "bridge to transplant" in select patients with acute-on-chronic liver failure and multiple organ failure 2
• Two multicenter randomized trials showed no survival benefit at 28 and 90 days, though post-hoc analysis suggested improvement in hepatic encephalopathy and hepatorenal syndrome 2
• The pooled 90-day mortality rate across studies using liver support systems was 38%, but with substantial heterogeneity 5

Liver Transplantation

Urgent hepatic transplantation is indicated when prognostic indicators suggest high likelihood of death. 2

• Post-transplant survival rates for acute liver failure are 80-90% 2
• Early referral to a transplant center is critical as the "transplantation window" is often narrow 2
• Rapid decision-making by a multidisciplinary specialized team is necessary 2

Critical Pitfalls to Avoid

• Do NOT delay empirical antibiotics while awaiting culture results—infection is the most common precipitant and must be treated immediately 2, 3
• Do NOT use growth factors for leukopenia—there is no evidence for this approach in liver failure 3
• Do NOT routinely correct coagulation unless active bleeding is present 2, 4, 3
• Do NOT use lactulose or rifaximin for ammonia reduction in post-hepatectomy liver failure 2
• Do NOT administer vasopressin for hemodynamic support 2

Postoperative Thromboprophylaxis

Start low molecular weight heparin or unfragmented heparin postoperatively unless exceptional circumstances make this unsafe. 1

• Add intermittent pneumatic compression devices to further decrease thrombotic risk 2