Reductions in post-hepatectomy liver failure and related mortality after implementation of the LiMAx algorithm in preoperative work-up: a single-centre analysis of 1170 hepatectomies of one or more segments

Abstract

Objectives: Post-hepatectomy liver failure has a major impact on patient outcome. This study aims to explore the impact of the integration of a novel patient-centred evaluation, the LiMAx algorithm, on perioperative patient outcome after hepatectomy.

Methods: Trends in perioperative variables and morbidity and mortality rates in 1170 consecutive patients undergoing elective hepatectomy between January 2006 and December 2011 were analysed retrospectively. Propensity score matching was used to compare the effects on morbidity and mortality of the integration of the LiMAx algorithm into clinical practice.

Results: Over the study period, the proportion of complex hepatectomies increased from 29.1% in 2006 to 37.7% in 2011 (P = 0.034). Similarly, the proportion of patients with liver cirrhosis selected for hepatic surgery rose from 6.9% in 2006 to 11.3% in 2011 (P = 0.039). Despite these increases, rates of post-hepatectomy liver failure fell from 24.7% in 2006 to 9.0% in 2011 (P < 0.001) and liver failure-related postoperative mortality decreased from 4.0% in 2006 to 0.9% in 2011 (P = 0.014). Propensity score matching was associated with reduced rates of post-hepatectomy liver failure [24.7% (n = 77) versus 11.2% (n = 35); P < 0.001] and related mortality [3.8% (n = 12) versus 1.0% (n = 3); P = 0.035].

Conclusions: Postoperative liver failure and postoperative liver failure-related mortality decreased in patients undergoing hepatectomy following the implementation of the LiMAx algorithm.

Figure 1

Clinical decision tree for preoperative evaluation of patients undergoing hepatectomy (modified according to Stockmann et al.23). If pre-existing hepatic injury is unlikely and a small segmental resection (up to two segments) is planned, surgery can be performed safely. However, in cases of suspected hepatic injury or planned larger resections, a preoperative LiMAx test to evaluate actual enzymatic hepatic function is performed. In patients with normal liver function (LiMAx <315 μg/kg/h), resections of up to four segments can be performed, but patients with considerably impaired liver function (LiMAx <140 μg/kg/h) should be refused and alternative management options considered. In patients with intermediate liver function (LiMAx 140–315 μg/kg/h) or in whom major hepatic resection (more than four segments) is planned, clinical decisions should be guided by preoperative volume/function analysis as follows: resections with future remnant liver function (FRLF) of <100 μg/kg/h are feasible and safe; resections with FRLF of 80–100 μg/kg/h represent critical interventions, and resections with an expected FRLF of <80 μg/kg/h should not be considered. In the last category, alternative preoperative options such as portal vein embolization to increase future remnant liver volume, stenting in patients with biliary obstruction and application of neoadjuvant chemotherapeutic regimes to reduce tumour volume and facilitate smaller resections (colorectal liver metastases) should be considered. Hereafter, close LiMAx monitoring and preoperative repeated volume/function analysis may help to ascertain the optimal timing for partial hepatic resection, even in patients with marginal LiMAx values