. 2023 Sep 6;110(10):1331-1347.

doi: 10.1093/bjs/znad233.

E-AHPBA-ESSO-ESSR Innsbruck consensus guidelines for preoperative liver function assessment before hepatectomy

Florian Primavesi^{1

2}, Manuel Maglione¹, Federica Cipriani³, Timm Denecke⁴, Christian E Oberkofler^{5

6}, Patrick Starlinger^{7

8}, Bobby V M Dasari⁹, Jan Heil¹⁰, Olivia Sgarbura^{11

12}, Kjetil Søreide^{13

14}, Rafael Diaz-Nieto¹⁵, Constantino Fondevila¹⁶, Adam E Frampton^{17

18}, Dominik Geisel¹⁹, Benjamin Henninger²⁰, Amelia J Hessheimer¹⁶, Mickaël Lesurtel²¹, Damian Mole²², Robert Öllinger²³, Pim Olthof^{24

25}, Thomas Reiberger²⁶, Andreas A Schnitzbauer¹⁰, Christoph Schwarz²⁷, Ernesto Sparrelid²⁸, Martin Stockmann^{23

29}, Stéphanie Truant^{30

31}, Luca Aldrighetti³, Eva Braunwarth¹, Mathieu D'Hondt³², Michelle L DeOliveira⁵, Joris Erdmann³³, David Fuks³⁴, Thomas Gruenberger³⁵, Klaus Kaczirek²⁷, Hassan Malik¹⁵, Dietmar Öfner¹, Nuh N Rahbari³⁶, Georg Göbel³⁷, Ajith K Siriwardena³⁸, Stefan Stättner^{1

2}

Affiliations

¹ Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria.
² Department of General, Visceral and Vascular Surgery, Centre for Hepatobiliary Surgery, Vöcklabruck, Austria.
³ Hepatobiliary Surgery Division, San Raffaele Scientific Institute, Milan, Italy.
⁴ Department of Diagnostic and Interventional Radiology, University Medical Centre Leipzig, Leipzig, Germany.
⁵ Swiss Hepatopancreatobiliary Transplant Centre, Department of Surgery, University Hospital Zürich, Zürich, Switzerland.
⁶ Vivévis AG-Visceral, Tumour and Robotic Surgery, Clinic Hirslanden Zürich, Zürich, Switzerland.
⁷ Department of Surgery, Division of Hepatobiliary and Pancreatic Surgery, Mayo Clinic, Rochester, Minnesota, USA.
⁸ Centre of Physiology and Pharmacology, Medical University of Vienna, Vienna, Austria.
⁹ Department of Hepatobiliary-pancreatic and Liver Transplantation Surgery, University of Birmingham, Birmingham, UK.
¹⁰ Department of General, Visceral, Transplant and Thoracic Surgery, Goethe University Frankfurt, University Hospital, Frankfurt, Germany.
¹¹ Department of Surgical Oncology, Cancer Institute of Montpellier, University of Montpellier, Montpellier, France.
¹² IRCM, Institut de Recherche en Cancérologie de Montpellier, INSERM U1194, Université de Montpellier, Institut Régional du Cancer de Montpellier, Montpellier, France.
¹³ Department of Gastrointestinal Surgery, Hepatopancreatobiliary Unit, Stavanger University Hospital, Stavanger, Norway.
¹⁴ Department of Clinical Medicine, University of Bergen, Bergen, Norway.
¹⁵ Liver Surgery Unit, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK.
¹⁶ General and Digestive Surgery Service, Hospital Universitario La Paz, IdiPAZ, CIBERehd, Madrid, Spain.
¹⁷ Hepatopancreatobiliary Surgical Unit, Royal Surrey NHS Foundation Trust, Guildford, UK.
¹⁸ Section of Oncology, Department of Clinical and Experimental Medicine, University of Surrey, Guildford, UK.
¹⁹ Department of Radiology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.
²⁰ Department of Radiology, Medical University of Innsbruck, Innsbruck, Austria.
²¹ Department of Hepatopancreatobiliary Surgery and Liver Transplantation, Beaujon Hospital, Assistance Publique-Hôpitaux de Paris, University of Paris Cité, Clichy, France.
²² Hepatopancreatobiliary Surgery Unit, Department of Clinical Surgery, University of Edinburgh, Edinburgh, UK.
²³ Department of Surgery, Charité-Universitätsmedizin Berlin, Berlin, Germany.
²⁴ Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands.
²⁵ Department of Surgery, Amsterdam University Medical Centres, University of Amsterdam, Amsterdam, the Netherlands.
²⁶ Division of Gastroenterology and Hepatology, Department of Medicine III and CD-Lab for Portal Hypertension and Liver Fibrosis, Medical University of Vienna, Vienna, Austria.
²⁷ Department of General Surgery, Division of Visceral Surgery, Medical University Vienna, Vienna, Austria.
²⁸ Department of Clinical Science, Intervention and Technology, Division of Surgery and Oncology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden.
²⁹ Department of General, Visceral and Vascular Surgery, Evangelisches Krankenhaus Paul Gerhardt Stift, Lutherstadt Wittenberg, Germany.
³⁰ Department of Digestive Surgery and Transplantation, CHU Lille, Lille University, Lille, France.
³¹ CANTHER Laboratory 'Cancer Heterogeneity, Plasticity and Resistance to Therapies' UMR-S1277, Team 'Mucins, Cancer and Drug Resistance', Lille, France.
³² Department of Digestive and Hepatobiliary/Pancreatic Surgery, Groeninge Hospital Kortrijk, Kortrijk, Belgium.
³³ Department of Surgery, Amsterdam UMC, Cancer Centre Amsterdam, the Netherlands.
³⁴ Department of Digestive, Hepatobiliary and Endocrine Surgery, Assistance Publique-Hôpitaux de Paris Centre Hopital Cochin, Paris, France.
³⁵ Department of Surgery, Clinic Favoriten, Hepatopancreatobiliary Centre, Health Network Vienna and Sigmund Freud Private University, Vienna, Austria.
³⁶ Department of Surgery, University Hospital Mannheim, University of Heidelberg, Medical Faculty Mannheim, Mannheim, Germany.
³⁷ Department of Medical Statistics, Informatics, and Health Economics, Medical University of Innsbruck, Innsbruck, Austria.
³⁸ Regional Hepato-Pancreato-Biliary Unit, Manchester Royal Infirmary, Manchester, UK.

PMID: 37572099
PMCID: PMC10480040
DOI: 10.1093/bjs/znad233

E-AHPBA-ESSO-ESSR Innsbruck consensus guidelines for preoperative liver function assessment before hepatectomy

Florian Primavesi et al. Br J Surg. 2023.

. 2023 Sep 6;110(10):1331-1347.

doi: 10.1093/bjs/znad233.

Authors

Affiliations

¹ Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria.
² Department of General, Visceral and Vascular Surgery, Centre for Hepatobiliary Surgery, Vöcklabruck, Austria.
³ Hepatobiliary Surgery Division, San Raffaele Scientific Institute, Milan, Italy.
⁴ Department of Diagnostic and Interventional Radiology, University Medical Centre Leipzig, Leipzig, Germany.
⁵ Swiss Hepatopancreatobiliary Transplant Centre, Department of Surgery, University Hospital Zürich, Zürich, Switzerland.
⁶ Vivévis AG-Visceral, Tumour and Robotic Surgery, Clinic Hirslanden Zürich, Zürich, Switzerland.
⁷ Department of Surgery, Division of Hepatobiliary and Pancreatic Surgery, Mayo Clinic, Rochester, Minnesota, USA.
⁸ Centre of Physiology and Pharmacology, Medical University of Vienna, Vienna, Austria.
⁹ Department of Hepatobiliary-pancreatic and Liver Transplantation Surgery, University of Birmingham, Birmingham, UK.
¹⁰ Department of General, Visceral, Transplant and Thoracic Surgery, Goethe University Frankfurt, University Hospital, Frankfurt, Germany.
¹¹ Department of Surgical Oncology, Cancer Institute of Montpellier, University of Montpellier, Montpellier, France.
¹² IRCM, Institut de Recherche en Cancérologie de Montpellier, INSERM U1194, Université de Montpellier, Institut Régional du Cancer de Montpellier, Montpellier, France.
¹³ Department of Gastrointestinal Surgery, Hepatopancreatobiliary Unit, Stavanger University Hospital, Stavanger, Norway.
¹⁴ Department of Clinical Medicine, University of Bergen, Bergen, Norway.
¹⁵ Liver Surgery Unit, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK.
¹⁶ General and Digestive Surgery Service, Hospital Universitario La Paz, IdiPAZ, CIBERehd, Madrid, Spain.
¹⁷ Hepatopancreatobiliary Surgical Unit, Royal Surrey NHS Foundation Trust, Guildford, UK.
¹⁸ Section of Oncology, Department of Clinical and Experimental Medicine, University of Surrey, Guildford, UK.
¹⁹ Department of Radiology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.
²⁰ Department of Radiology, Medical University of Innsbruck, Innsbruck, Austria.
²¹ Department of Hepatopancreatobiliary Surgery and Liver Transplantation, Beaujon Hospital, Assistance Publique-Hôpitaux de Paris, University of Paris Cité, Clichy, France.
²² Hepatopancreatobiliary Surgery Unit, Department of Clinical Surgery, University of Edinburgh, Edinburgh, UK.
²³ Department of Surgery, Charité-Universitätsmedizin Berlin, Berlin, Germany.
²⁴ Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands.
²⁵ Department of Surgery, Amsterdam University Medical Centres, University of Amsterdam, Amsterdam, the Netherlands.
²⁶ Division of Gastroenterology and Hepatology, Department of Medicine III and CD-Lab for Portal Hypertension and Liver Fibrosis, Medical University of Vienna, Vienna, Austria.
²⁷ Department of General Surgery, Division of Visceral Surgery, Medical University Vienna, Vienna, Austria.
²⁸ Department of Clinical Science, Intervention and Technology, Division of Surgery and Oncology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden.
²⁹ Department of General, Visceral and Vascular Surgery, Evangelisches Krankenhaus Paul Gerhardt Stift, Lutherstadt Wittenberg, Germany.
³⁰ Department of Digestive Surgery and Transplantation, CHU Lille, Lille University, Lille, France.
³¹ CANTHER Laboratory 'Cancer Heterogeneity, Plasticity and Resistance to Therapies' UMR-S1277, Team 'Mucins, Cancer and Drug Resistance', Lille, France.
³² Department of Digestive and Hepatobiliary/Pancreatic Surgery, Groeninge Hospital Kortrijk, Kortrijk, Belgium.
³³ Department of Surgery, Amsterdam UMC, Cancer Centre Amsterdam, the Netherlands.
³⁴ Department of Digestive, Hepatobiliary and Endocrine Surgery, Assistance Publique-Hôpitaux de Paris Centre Hopital Cochin, Paris, France.
³⁵ Department of Surgery, Clinic Favoriten, Hepatopancreatobiliary Centre, Health Network Vienna and Sigmund Freud Private University, Vienna, Austria.
³⁶ Department of Surgery, University Hospital Mannheim, University of Heidelberg, Medical Faculty Mannheim, Mannheim, Germany.
³⁷ Department of Medical Statistics, Informatics, and Health Economics, Medical University of Innsbruck, Innsbruck, Austria.
³⁸ Regional Hepato-Pancreato-Biliary Unit, Manchester Royal Infirmary, Manchester, UK.

PMID: 37572099
PMCID: PMC10480040
DOI: 10.1093/bjs/znad233

Abstract

Background: Posthepatectomy liver failure (PHLF) contributes significantly to morbidity and mortality after liver surgery. Standardized assessment of preoperative liver function is crucial to identify patients at risk. These European consensus guidelines provide guidance for preoperative patient assessment.

Methods: A modified Delphi approach was used to achieve consensus. The expert panel consisted of hepatobiliary surgeons, radiologists, nuclear medicine specialists, and hepatologists. The guideline process was supervised by a methodologist and reviewed by a patient representative. A systematic literature search was performed in PubMed/MEDLINE, the Cochrane library, and the WHO International Clinical Trials Registry. Evidence assessment and statement development followed Scottish Intercollegiate Guidelines Network methodology.

Results: Based on 271 publications covering 4 key areas, 21 statements (at least 85 per cent agreement) were produced (median level of evidence 2- to 2+). Only a few systematic reviews (2++) and one RCT (1+) were identified. Preoperative liver function assessment should be considered before complex resections, and in patients with suspected or known underlying liver disease, or chemotherapy-associated or drug-induced liver injury. Clinical assessment and blood-based scores reflecting liver function or portal hypertension (for example albumin/bilirubin, platelet count) aid in identifying risk of PHLF. Volumetry of the future liver remnant represents the foundation for assessment, and can be combined with indocyanine green clearance or LiMAx® according to local expertise and availability. Functional MRI and liver scintigraphy are alternatives, combining FLR volume and function in one examination.

Conclusion: These guidelines reflect established methods to assess preoperative liver function and PHLF risk, and have uncovered evidence gaps of interest for future research.

Plain language summary

Liver surgery is an effective treatment for liver tumours. Liver failure is a major problem in patients with a poor liver quality or having large operations. The treatment options for liver failure are limited, with high death rates. To estimate patient risk, assessing liver function before surgery is important. Many methods exist for this purpose, including functional, blood, and imaging tests. This guideline summarizes the available literature and expert opinions, and aids clinicians in planning safe liver surgery.

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Figures

**Fig. 1**
**Clinical algorithm for preoperative liver function assessment in patients in whom hepatectomy is planned** ^,,,,

See this image and copyright information in PMC

Comment in

Preoperative assessment of liver function and perioperative management of posthepatectomy liver failure.
Shiihara M, Shimoda M, Suzuki S. Shiihara M, et al. Hepatobiliary Surg Nutr. 2024 Jun 1;13(3):527-529. doi: 10.21037/hbsn-24-83. Epub 2024 May 22. Hepatobiliary Surg Nutr. 2024. PMID: 38911212 Free PMC article. No abstract available.

References

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E-AHPBA-ESSO-ESSR Innsbruck consensus guidelines for preoperative liver function assessment before hepatectomy

Affiliations

E-AHPBA-ESSO-ESSR Innsbruck consensus guidelines for preoperative liver function assessment before hepatectomy

Authors

Affiliations

Abstract

Plain language summary

Figures

Comment in

References

MeSH terms

Substances

Grants and funding

LinkOut - more resources

Full Text Sources

Medical