The role of hepatobiliary scintigraphy combined with spect/ct in predicting severity of liver failure before major hepatectomy: a single-center pilot study

Abstract

Hepatobiliary scintigraphy (HBS) has been demonstrated to predict post-hepatectomy liver failure (PHLF). However, existing cutoff values for future liver remnant function (FLR-F) were previously set according to the "50-50 criteria" PHLF definition. Methods of calculation and fields of application in liver surgery have changed in the meantime. The aim of this study was to demonstrate the role of HBS combined with single photon emission computed tomography (SPECT/CT) in predicting severity of PHLF, according to the International Study Group of Liver Surgery (ISGLS). All patients submitted to major hepatectomy with preoperative HBS-SPECT/CT between November 2016 and December 2019, were analyzed. Patients were resected according to hepatic volumetry. Receiver operating characteristic (ROC) curve analysis was performed to identify cutoffs of FLR function for predicting PHLF according to ISGLS definition and grading. Of the 38 patients enrolled, 26 were submitted to one-stage hepatectomy (living liver donors = 4) and 12 to two-stage procedures (portal vein embolization = 4, ALPPS = 8). Overall, 18 patients developed PHLF according to ISGLS criteria: 12 of grade A (no change in the patient's clinical management) and 6 of grade B (change in clinical management). ROC analysis established increasingly higher cutoffs of FLR-F for predicting PHLF according to the "50-50 criteria", ISGLS grade B and ISGLS grade A/B, respectively. HBS with SPECT/CT may help to assess severity of PHLF following major hepatectomy. Prospective multicenter trials are needed to confirm the effective role of HBS-SPECT/CT in liver surgery.

Keywords: Hepatectomy; Hepatobiliary scintigraphy; Liver failure; Mebrofenin; SPECT.

Fig. 1

Algorithm of the study protocol. HBS-SPECT/CT hepatobiliary scintigraphy combined with single photon emission computed tomography, FLR future liver remnant, sTLV standardized total liver volume, BW body weight, PVE portal vein embolization, ALPPS associating liver partition and portal vein ligation for staged hepatectomy; * HBS-SPECT/CT was not taken into consideration in the decision process

Fig. 2

SPECT showing the distribution of function within the liver (a). The tumor, occupying entirely the right lobe, transferred the liver function almost to the left side (i.e. the future liver remnant). Abdominal computed tomography of the same patient (b)

Fig. 3

Time-activity curves calculated from three different regions of interest (ROI). Global liver function is measured using values obtained between 150 and 350 s post-injection according to Ekman’s formula [18]

Fig. 4

Correlation plot of distribution of liver volume versus function (FLR-C) within the future liver remnant (FLR) in one-stage (r = 0.912, p < 0.001) and two-stage hepatectomy (r = 0.662, p = 0.019). mTLV = measured total liver volume

Fig. 5

Box and whiskers plot showing the distribution of HIBA index (HIBA-i), FLR function (FLR-F), standardized future liver remnant (FLR/sTLV) and FLR/body weight (BW) between patients without post-hepatectomy liver failure (PHLF) and those with grade A or grade B PHLF. a Median HIBA-i was 31.6% (IQR 21.8–42.6) in patients without PHLF, 17.86% (IQR 13.8–20.4) in patients with grade A PHLF and 11.36% (IQR 8–15.9) with grade B PHLF. b Median FLR-F was 4.09%/min/m2 (IQR 2.36–6.01) in patients without PHLF, 1.96%/min/m² (IQR 1.55–2.34) in patients with grade A PHLF and 1.40%/min/m2 (IQR 1.11–1.84) with grade B PHLF. c Median FLR/sTLV was 56% (IQR 34.3–70.2) in patients without PHLF, 30.9% (IQR 25.2–34.7) in patients with grade A PHLF and 26.4% (IQR 23.4–44.7) in patients with grade B PHLF. d Median FLR/BW was 1.19 (IQR 0.76–1.52) in patients without PHLF, 0.65% (IQR = 0.54–0.73) in patients with grade A PHLF and 0.54% (IQR 0.47–0.96) in grade B PHLF

Fig. 6

Receiver operator characteristics curve for future liver remnant function (FLR-F), HIBA index (HIBA-i), standardized FLR (FLR/sTLV) and FLR/body weight (BW) ratio in the diagnosis of post-hepatectomy liver failure grade A/B (a) and grade B (b), according to ISGLS criteria. AUC area under the curve, CI confidence interval