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20
E. O. Pertusso et al.
3.5 Accessory Biliary Tract
3.5.1 Gallbladder andCystic Duct
The gallbladder is a piriform sac located in the fossa vesicae
in the inferior surface of the liver. When it is distended, its
size is 40mm wide and 70–100mm long. The gallbladder can
be divided into three sectors. The fundus is a blind extreme
located under the inferior hepatic margin and projected in the
intersection of the right costal margin with the midclavicular
line at the level of the ninth costal cartilage. The body is its
bigger portion, located between the visceral surface of the
liver and the rst knee of the duodenum. It decreases size
while it goes backwards, forming the infundibulum which is
continuous with the neck. On the right side of the gallbladder’s neck, the patients with chronic obstruction a recess may
be sometimes found, named Hartmann’s pouch (Photo 3.3).
The visceral peritoneum covers the inferior surface of the
gallbladder, but in some cases, it may cover its two surfaces
and form the mesentery that joins it with the hepatic peritoneum (oating gallbladder). The superior gallbladder surface
is separated from the hepatic parenchyma by the cystic plate,
a thickening of the conjunctive tissue which is continuous
with the hilar plate.
The anomalies of the gallbladder are rare; some cases are
described with gallbladders in the left side of the liver or
completely included in the hepatic parenchyma. Agenesia
and the septated gallbladder, bilobed or duplicated, are
extremely infrequent.
The cystic duct is continuous with the neck and its size is
4–65mm long and an average diameter of 4mm. The mucosa
that covers it has 5–12 oblique folds that create a spiral valve
known as the valve of Heister.
In most of the cases, the cystic-choledochal union is
approximately at 20 mm from the superior biliary conu-
ence, and it may be classied as angled, parallel, or spiral.
When it debouches in the choledochus, it admits multiple
variations, such as very caudal, next to the major duodenal
papilla, which is known as low implantation of the cystic
duct, and very close to the conuence of the right and left
hepatic ducts.
The cystic duct joins the right lateral surface of the common bile duct in most of the cases. In 10% of the cases, it
may join the posterior or anterior wall of the common bile
duct or less frequently to the left wall. There are reports
about aberrant cystic ducts that join in the right and left
hepatic ducts or directly into the duodenum.
3.5.2 Vascularization
The arterial vascularization of the gallbladder is given by the
cystic artery, which is a branch of the right hepatic artery;
less frequently, its origin is in the left hepatic artery, gastroduodenal, or superior mesenteric. It runs by the superior
margin of the cystic duct to the gallbladder neck, where it
divides into two branches, a supercial one that follows the
inferior surface of the gallbladder and a deep one located
between the superior surface and the liver. The relation of the
cystic artery with the triangle of Calot and the cystic duct is
usually variable, which exposes it to lesion during cholecystectomy. In 65–85% of the cases, it crosses the Calot’s triangle at some point, but 3% is parallel to the cystic and it
even covers it.
The venous drainage is tributary of the intrahepatic veins,
and there is not a satellite cystic vein of the artery.
3.5.3 Triangle oftheBiliary Tract
At the level of the hepatic hilum, two triangles of great surgical
importance are dened: The triangle of Calot is delimited by
the cystic artery, the cystic duct, and the biliary tract. Frequently,
the triangle of Calot is confused with another triangle dened
between the inferior surface of the liver, the cystic duct, and the
common bile duct, named hepatocystic triangle, of the biliary
tract or triangle of Buddé. Inside this triangle are found the
cystic artery and ganglion, the right hepatic artery and the lymphatic ducts. By this area also run right bile ducts or right
accessory hepatic arteries or aberrant ones.
Photo 3.3 Triangles of the biliary tract. MBD main bile duct. Arrows:
MBD path. CD cystic duct, CA cystic artery, GB gallbladder. White
triangle: Calot’s triangle. Blue triangle: hepatocystic triangle or Budde
triangle
References
1. Babu C, Ramesh S, Sharma M.Biliary tract anatomy and its rela-
tionship with venous drainage. J Clin Exp Hepatol. 2014;4:S18–26.
2. Castaing D. Surgical anatomy of the biliary tract. HPB.
2008;10:72–6.
3 Surgical Anatomy oftheBiliary Tract
21
3. Catalano O, etal. Vascular and biliary variants in the liver: implications for liver surgery. Radiographics. 2008;28:359–78.
4. Cedrón H, Gutiérrez C, Ocaña J.Arteria cística: variantes anatómicas. In: Anales de la Facultad de Medicina, vol. 57. Universidad
Nacional Mayor de San Marcos; 1996. p.109–12.
5. Ding Y, Wang B, Wang W, Wang P, Yan J.New classication of the
anatomic variations of cystic artery during laparoscopic cholecystectomy. World J Gastroenterol: WJG. 2007;2007(13):5629.
6. Belghiti J, Clavien P, Gadzijev E, Garden J, Lau W, Makuuchi M,
Strong W.The Brisbane 2000 Terminology of Liver Anatomy and
Resections Terminology Committee of the International HepatoPancreato- Biliary Association: Chairman, SM Strasberg (USA).
HPB (Oxford). 2000;2:333–9.
7. Horiguchi S, Kamisawa T.Major duodenal papilla and its normal
anatomy. Digest Surg. 2010;27:90–3.
8. Kawarada Y, Das B, Taoka H.Anatomy of the hepatic hilar area:
the plate system. J Hepato-Biliary-Pancreat Surg. 2000;7:580–6.
9. Keplinger K, Bloomston M.Anatomy and embryology of the biliary tract. Surg Clin. 2014;94(2):203–17.
10. Lamah M, Karanjia N, Dickson G. Anatomical variations of the
extrahepatic biliary tree: review of the world literature. Clin Anat.
2001;14:167–72.
11. Mirjalili S, Stringer M.The arterial supply of the major duodenal
papilla and its relevance to endoscopic sphincterotomy. Endoscopy.
2011;43:307–11.
12. Vakili K, Pomfret E.Biliary anatomy and embryology. Surg Clin N
Am. 2008;88:1159–74.
13. Couinaud C. Lobes et segments hépatiques. Presse Med.
1954;62:709.
Liver Function andPosthepatectomy
Liver Failure
TakanobuHara andSusumuEguchi
4
Abstract
The possibility of liver resection is usually determined by
the technical feasibility of radical surgery and the volumetric and functional capacity of the future liver remnant.
With the addition of recent advances in surgical techniques and perioperative management, liver resection has
become safer. Nevertheless, posthepatectomy liver failure
(PHLF) is one of the most serious complications after
liver resection, and PHLF remains the major cause of
perioperative morbidity and mortality. The present article
reviewed a denition of PHLF and the reported liver function assessment tools used for surgical decision-making.
According to the safety criteria in the indocyanine green
testing, morbidity and mortality after hepatic resection
can be reduced. Recent advances in imaging studies
enable precise preoperative surgical planning and calculating future liver remnant volume. Combining imaging
studies and liver function testing will achieve more accurate preoperative surgical planning to avoid PHLF.
4.1 Introduction
Liver resection is an established method that is considered
the only curative treatment option for patients with primary
and metastatic liver tumors. As a result of recent advances in
surgical techniques and perioperative management, liver
resection has become safer; morbidity and mortality rates
after surgery have decreased over the past 10 years [1–4].
The possibility of liver resection is usually determined by the
technical feasibility of radical surgery and the volumetric
and functional capacity of the future liver remnant (FLR).
Recent reports indicated that a future liver remnant of 25% is
sufcient in patients without parenchymal disease, and that
T. Hara (*) · S. Eguchi
Department of Surgery, Nagasaki University Graduate School of
Biomedical Sciences, Nagasaki, Japan
e-mail: harataka@nagasaki-u.ac.jp
an FLR of 40%–50% is necessary in patients with parenchymal liver disease [5–7]. In addition, three-dimensional volumetric analysis has contributed signicantly to precise
surgical planning [8–10]. Despite these developments, posthepatectomy liver failure (PHLF) is still one of the most
serious complications after liver resection, and PHLF
remains the major cause of perioperative morbidity and mortality. The incidence of PHLF varies between 1.2% and 32%;
in the most recent literature, the incidence is up to 8% [11,
12]. This wide range in the frequency of PHLF can be attrib-
uted to the lack of a universal denition of PHLF.Predicting
PHLF by evaluating preoperative liver function could help
hepatobiliary surgeons decide whether hepatectomy can be
performed safely or whether additional procedures are necessary prior to the planned hepatectomy.
This article provides a denition of PHLF and discusses
recent topics regarding accurate and realistic evaluation of
liver function testing to perform safe liver resection.
4.2 Posthepatectomy Liver Failure (PHLF)
A number of denitions of PHLF have been reported. PHLF
has been most commonly dened quantitatively by postoperative laboratory tests using various cut-off values for serum
bilirubin concentration and prothrombin time–international
normalized ratio (PT–INR). In 2005, Balzan etal. analyzed
the outcomes of 704 patients undergoing partial hepatectomy and proposed a denition of PHLF as the combination
of PT<50% and serum bilirubin >50μmol/L (2.9mg/dL) on
postoperative day 5 (“50–50 criteria”) [13]. This denition
predicted in-hospital mortality with a sensitivity of 69.6%
and specicity of 98.5%. Mullen et al. analyzed the outcomes of 1059 patients with normal preoperative liver function undergoing hepatectomy in 2007. The authors proposed
a different criterion of peak postoperative bilirubin
level>7.0mg/dL (120μmol/L). The criterion predicted liver
failure-related death with a sensitivity of 93.3% and specic-
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2022
M. Makuuchi et al. (eds.), The IASGO Textbook of Multi-Disciplinary Management of Hepato-Pancreato-Biliary Diseases,
https://doi.org/10.1007/978-981-19-0063-1_4
23
24
T. Hara and S. Eguchi
Table 4.1 IGLS Consensus denition and severity grading of pos-
thepatectomy liver failure (From Rahbari etal. [12])
A postoperatively acquired deterioration in the ability of
the liver (in patients with normal and abnormal liver
function) to maintain its synthetic, excretory, and
detoxifying functions, characterized by an increased
INR (or need of clotting factors to maintain normal
INR) and hyperbilirubinemia (according to the normal
cut-off levels dened by the local laboratory) on or after
postoperative day 5. If INR or serum bilirubin
concentration is increased preoperatively, PHLF is
dened by an increasing INR (decreasing prothrombin
time) and increasing serum bilirubin concentration on or
after postoperative day 5 (compared with the values of
the previous day). Other obvious causes for the
Denition
of PHLF
Grade
A PHLF resulting in abnormal laboratory parameters but
B PHLF resulting in a deviation from the regular clinical
C PHLF resulting in a deviation from the regular clinical
PHLF posthepatectomy liver failure, INR international normalized ratio
observed biochemical and clinical alterations such as
biliary obstruction should be ruled out
requiring no change in the clinical management of the
patient
management but manageable without invasive treatment
management and requiring invasive treatment
ity of 94.3% [14]. In 2011, the International Study Group of
Liver Surgery (ISGLS) dened PHLF as postoperative deterioration in the ability of the liver to maintain its synthetic,
excretory, and detoxifying functions, characterized by
increased PT–INR and concomitant hyperbilirubinemia on
or after postoperative day 5 (Table 4.1) [12]. A proposed
grading system was based on a review of 1928 studies,
including the above-mentioned references. Because the
ISGLS denition is easily comparable, it can be used widely.
The ISGLS also differentiated the severity of PHLF into
three grades from A to C; grade B and C are generally considered to indicate clinically relevant PHLF [15].
4.3 Preoperative Evaluation ofLiver
Function
4.3.1 Portal Hypertension
Portal hypertension is considered a contraindication to liver
resection according to the AASLD/BCLC guidelines [16].
Clinically relevant portal hypertension is dened as a
hepatic vein pressure gradient greater than 10mm Hg or the
presence of esophageal varices or splenomegaly associated
with a platelet count lower than 100× 109/L [17]. Major
hepatic resection increases portal venous pressure in both
cirrhotic and non-cirrhotic livers. Although an association
between portal hypertension and poor long-term outcomes
after liver resection for HCC has been reported [18, 19],
increased portal venous pressure does not appear to have a
direct effect on early postoperative morbidity and mortality
[20]. Recent reports indicated that limited resection in
patients with preserved liver function and moderate portal
hypertension yields competitive survival outcomes [21].
Therefore, the 2018 EASL Clinical Practice Guidelines do
not consider portal hypertension a contraindication for
minor liver resection [21].
4.3.2 Model forEnd-Stage Liver Disease
(MELD) Score
The MELD score was initially reported to predict survival in
patients with liver cirrhosis following a transjugular intrahepatic portosystemic shunt [22]. To improve the score’s accuracy, pretransplant dialysis and serum sodium concentration
have been added, and the MELD score is now widely used to
allocate liver transplant candidates [23]. Since then, several
studies have validated the score for predicting PHLF. Teh
etal. retrospectively analyzed 82 patients with cirrhosis who
underwent liver resection for HCC.The authors reported that
a preoperative MELD score≥9 was a signicant risk factor
for postoperative mortality [24]. In 2006, Cucchetti et al.
analyzed 200 HCC patients with cirrhosis undergoing liver
resection and demonstrated that preoperative MELD ≥11
and MELD score increases between postoperative day 3 and
5 were independent predictors of PHLF [25]. Citterio etal.
reviewed data for 543 patients with chronic liver disease who
underwent liver resection for HCC and reported that the
combination of portal hypertension and MELD score was a
useful predictor of PHLF [26]. In contrast, Schroeder etal.
reported that preoperative MELD score was not an accurate
predictor of morbidity or mortality [27]. MELD might not
accurately predict mortality in patients without cirrhosis
because the original formula was developed for patients with
extremely poor liver function in whom liver resection is not
indicated [28].
4.3.3 Blood Chemistry Tests
A number of studies have reported that a preoperative platelet count <10–15 × 104/μL was associated with PHLF or
mortality [29–31]. In 2003, Wai etal. proposed the aspartate
aminotransferase (AST) to platelet ratio index (APRI=AST
level/upper normal limit of AST/platelet count [109/L]×100)
as a simple predictor of signicant brosis and cirrhosis in
patients with chronic hepatitis C [32]. Ichikawa etal. retrospectively evaluated 366 patients and reported the usefulness
of APRI for predicting PHLF [33]. Likewise, Mai etal. evaluated 1044 patients with HCC who underwent liver resection
and reported a sensitivity and specicity of the APRI score
for predicting PHLF of 72.2% and 68.0%, respectively.
4 Liver Function andPosthepatectomy Liver Failure
25
PHLF incidence and grade in patients with APRI scores
>0.55 were signicantly higher than in patients with lower
scores [34].
In 2015, the albumin–bilirubin (ALBI) score was created
to predict overall survival after hepatectomy in patients with
HCC [35]. Zhang etal. analyzed 338 HCC patients undergoing liver resection and reported that ALBI predicted PHLF
according to the ISGLS criteria. The rate of PHLF was 7.7%
in the study, and higher ALBI grades correlated with higher
PHLF grades. Notably, ALBI was a superior predictor compared with MELD and Child–Pugh–Turcotte (CP) scores
using ROC analysis [35]. Zou et al. evaluated 229 HCC
patients and reported that ALBI showed superior predictive
value for PHLF over the CP score. In addition, the combination of standardized future liver remnant (sFLR) and ALBI
scores was a stronger predictor of PHLF than either sFLR or
ALBI score alone [36].
4.3.4 Indocyanine Green (ICG) Clearance Test
ICG is a highly plasma protein-bound, water-soluble anionic
organic tricarbocyanine dye. Measuring ICG clearance is a
dynamic method of studying liver functional reserve. After
intravenous injection, ICG is taken up by organic anion
+
transporting polypeptides (OATP) and Na
-taurocholate cotransporting polypeptide, which are abundantly located in
the basolateral membrane of hepatocytes [37]. ICG is almost
exclusively extracted by the liver and excreted into the bile
without intrahepatic biotransformation [38]. Its elimination
is thought to be dependent on hepatocyte function, liver
blood ow, and bile secretion [39].
The ICG retention ratio after 15 min (ICG R15) is the
ratio between the ICG concentration 15min after injection
and the initial concentration. A surgical decision-making
algorithm based on ICG R15 was reported by Makuuchi
etal. in 1993 that includes ICG R15, presence of ascites, and
serum total bilirubin concentration [40]. In cases of total bilirubin concentration < 1 mg/dl without ascites, major liver
resections should only be performed in patients with ICG
R15 lower than 20% [41] (Fig.4.1). This algorithm has certainly contributed to a reduction in operative mortality in
Japan [1].
Recently, Kokudo etal. proposed the albumin–indocyanine green evaluation (ALICE) grading system as a tool to
assess the preoperative liver functional reserve of patients
undergoing hepatectomy for HCC [42]. This score was superior for predicting postoperative long- and short-term out-
No or controllable Incontrollable
Total bilirubin No hepatectomy
Normal 1.1~1.5 mg/dL 1.6~1.9 mg/dL
ICG R15
Normal 10~19%
Trisectionectomy
Bisectionectomy
Limited resection
K=0.15 K=0.11 K=0.08 K=0.06
Left hemihepatectomy
Right sectionectomy
Enucleation
(segment of Couinaud)
Ascites
20~29%
Segmentectomy
≥2.0 mg/dL
No hepatectomy
30~39% ≥40%
Limited resection
Enucleation
Fig. 4.1 A decision tree for hepatectomy proposed by Makuuchi etal.
which involves the presence or absence of uncontrollable ascites, the
serum bilirubin level, and the ICG R15. Because the ICG R15 is not a
linear quantitative parameter, only the surgical procedure, and not the
exact numbers for the hepatic parenchymal resection rate, is presented
for each ICG category. The designations of the hepatectomy have
changed according to the Brisbane 2000 Terminology of Liver Anatomy
and Resections
26
T. Hara and S. Eguchi
comes compared with the risk class according to the
presence/absence of portal hypertension. In 2018, the same
group analyzed 1025 consecutive patients undergoing liver
resection for HCC to evaluate the role of liver function factors in predicting postoperative large-volume ascites and
PHLF. The incidence of large-volume ascites was 13.9%,
and PHLF was 3.7%. The authors reported that the ALICE
score was the strongest predictor of large-volume ascites and
PHLF [43]. Another study suggested the possibility of using
the ALICE score to predict portal hypertension in HIV/HCV
co-infected hemophilia patients [44].
The plasma disappearance rate of ICG (KICG) can be calculated using linear regression analysis and plasma ICG concentrations [45]. KICG has been thought to reect the
pharmacokinetics of ICG more accurately than ICG R15.
Lower preoperative KICG is a predictive factor for PHLF as
well as increased ICG R15 [46].
Although the ICG clearance test is a reliable dynamic
liver function test, results should be interpreted carefully in
patients with cholestasis because bilirubin and ICG competitively bind to the same OATP, such as 1B3 [37].
Decreased ICG clearance values are observed in patients
with intrahepatic shunts or sinusoidal capillarization
because the ICG clearance test depends on overall liver
blood ow [47].
4.4 M2BPGi
Recent studies have reported the usefulness of Mac-2 binding protein glycosylation isomer (M2BPGi) as a predictor
of hepatic decompensation and HCC development in
patients with chronic liver diseases [48, 49]. In 2017, Okuda
etal. evaluated PHLF in 138 HCC patients who underwent
liver resection. The authors reported that M2BPGi, platelet
count, and resection rate were associated with PHLF ≥
grade B.In patients with HCV infection, the predictive ability of M2BPGi for PHLF was higher than for the other
parameters [50].
4.5 Scintigraphy
The asialoglycoprotein receptor is located on the sinusoidal surface of hepatocytes and is involved in clearing glycoproteins containing terminal galactose residues from the
circulation [51]. Scintigraphy using
enetriaminepentaacetic acid galactosyl human serum albumin (GSA), an analog of asialoglycoproteins has been widely
performed to estimate function in damaged livers [52]. The
development of
99m
Tc-GSA single-photon emission computed
tomography (SPECT) allows the evaluation of regional GSA
accumulation in the liver. Because the uptake of
not affected by high bilirubin serum levels,
tigraphy is applicable in patients with cholestatic liver diseases [53]. A receptor index parameter obtained from the
liver and heart time-activity data as the ratio of radioactivity
of the liver to that of the liver plus heart 15min after intravenous injection of
99m
Tc-GSA (LHL15) is used to evaluate
liver function because the ratio correlates with serum albumin level, serum bilirubin level, prothrombin time, ICG R15,
or CT score [54, 55]. In our institute, surgical decisions
regarding safe hepatic resection were made using ICG R15
and LHL15, which reects the severity of portal hypertension and hepatocyte function in moderately damaged livers
[56] (Fig.4.2).
In Europe,
tigraphy is more popular than
99m
Tc-labeled mebrofenin hepatobiliary scin-
99m
hepatocytes and is excreted into the bile canaliculi unmetabolized; therefore,
99m
Tc-labeled mebrofenin hepatobiliary
scintigraphy measures the kinetic process of uptake and
excretion by hepatocytes [57].
99m
Tc-labeled diethyl-
99m
Tc-GSA is
99m
Tc-GSA scin-
Tc-GSA.Mebrofenin enters
Child-Pugh classification A or B
ICG R15
99m
Tc-GSA
LHL15
Trisectionectomy
Bisectionectomy
Fig. 4.2 A decision tree for hepatectomy currently used at Nagasaki University. This algorithm involves the ICG R15 and
LHL15. If the intraoperative portal venous pressure is higher than 20cmH
≥ 0.90
<15%
<0.90
Sectionectomy
Bisectionectomy
15~24% 25~30%
≥ 0.90
<0.90
Sectionectomy
Segmentectomy or
Lt lateral sectionectomy
O, the resection area should be reduced by one step
2
≥ 0.90
<0.90
Limited
resection
Lt lateral sectionectomy
≥ 0.90
Segmentectomy or
≥ 30%
<0.90
Limited resection
or No hepatectomy
99m
Tc-GSA scintigraphy
4 Liver Function andPosthepatectomy Liver Failure
27
These imaging studies have advantages in clarifying functional heterogeneity among the hepatic segments compared
with the ICG clearance test.
4.6 Measuring Future Liver Remnant
(FLR) Volume
Preoperative FLR volume calculation is the method of choice
to evaluate the risk of PHLF. Several reports indicated the
usefulness of FLR by calculating body surface area or body
weight [58, 59]. Truant etal. suggested a cut-off value of remnant liver volume to body weight ratio of ≥0.5% to estimate
PHLF [60]. Current consensus regarding the minimal safe
FLR volume in patients with a normal liver is approximately
25%–30% of the total functional liver volume, with liver volume not including the volume occupied by the tumor [7, 61,
62]. However, remnant liver function estimated with CT volu-
metry is only completely reliable when liver function is
assumed to be homogeneous throughout the whole liver [61].
4.7 Measuring FLR Function
To evaluate FLR function preoperatively, several methods
combining liver volumetry and liver function testing have
been reported. Nagino et al. evaluated the change in FLR
volume and KICG in patients who underwent extended hepatectomy following portal vein embolization (PVE) for biliary cancer. This group proposed a KICG of the FLR dened
by the formula KICG × FLR [ml]/total liver volume [ml] of
≥0.05 as a criterion for safe hepatectomy [63].
As functional heterogeneity among hepatic segments has
been reported in damaged livers using
the usefulness of this method for precisely predicting postoperative hepatic functional reserve in the damaged liver has
been suggested [64–66]. Kwon etal. evaluated the maximal
removal rate of
99m
Tc-GSA (GSA-Rmax) in the FLR measured from SPECT images. According to their analysis of
178 patients, 7 cases of postoperative hyperbilirubinemia
occurred in the patients with GSA-Rmax in FLR of <0.15,
and 2 patients died of postoperative failure with GSA-Rmax
values in the FLR of <0.1. The authors concluded that GSARmax in FLR should be maintained at >0.15 to avoid postoperative hyperbilirubinemia or hepatic failure and to consider
preoperative PVE for cases with GSA-Rmax in the FLR of
<0.15 [67].
Recent advances in 3D CT unable precise preoperative
surgical planning. Therefore, fusion images combining
99m
Tc-GSA SPECT and X-ray CT could be critically helpful
for preoperative surgical decision-making. Iimuro etal. evaluated fusion images combining
X-ray CT to overcome the relatively poor anatomical resolu-
99m
Tc-GSA SPECT,
99m
Tc-GSA SPECT and
tion of SPECT for surgical simulation. The authors calculated the liver uptake ratio (liver radioactivity/injected
radioactivity × 100%; LUR) and reported that estimated
remnant LUR, but not the estimated remnant FLR volume,
was signicantly correlated with postoperative liver function
parameters [68].
In European countries, hepatobiliary scintigraphy using
99m
Tc-mebrofenin is used to estimate functional distribution
in the liver. de Graaf et al. proposed using the value of
≤2.69%/min/m2 for the equation, 99mTc-labeled mebro-
fenin uptake rate in the FLR [%/min] divided by the body
surface area [m2], as a predictor of PHLF.The authors suggested that preoperative PVE be performed when FLR
mebrofenin uptake is <2.69%/min/m2 [69].
Another, simpler, method of evaluating FLR function is
magnetic resonance imaging with intravenous injection of
gadolinium ethoxybenzyl diethylenetriamine pentaacetic
acid (Gd-EOB-DTPA), which is transported into hepatocytes. The increase in the signal intensity in the FLR in the
hepatobiliary phase compared with the unenhanced phase
might be an indicator of FLR function that could predict the
risk of PHLF [70, 71]. Chuang et al. reported that the remnant contrast enhancement ratio measured using Gd-EOBDPTA MRI strongly predicted postoperative liver failure
[72]. Orimo etal. introduced the standardized remnant hepatocellular uptake index (SrHUI), which was calculated as
FLR volume × [(signal intensity of the remnant liver in hepatobiliary phase images/signal intensity of the spleen in hepatobiliary phase images)−1]/body surface area. The authors
reported that the SrHUI cut-off value for predicting PHLF
and PHLF grade ≥ B was 0.313 L/m
2
and 0.257 L/m2,
respectively [73].
4.8 Conclusions
The present article reviewed the reported liver function
assessment tools used for surgical decision-making.
According to the safety criteria in ICG R15 testing, morbidity
and mortality after hepatic resection can be reduced. Recent
advances in imaging studies enable precise preoperative surgical planning and calculating FLR volume. Combining
imaging studies and liver function testing will achieve more
accurate preoperative surgical planning to avoid PHLF.
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