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The aim of a dexter liver trisectorectomy is the complete excision of a liver tumor with curative intention. Due to advancements in diagnostic development, surgical technics and postoperative management complications and death rates have been dramatically reduced in the last decade. But the postoperative liver insufficiency is still the main reason for complications and lethality after a larger partial liver resection. Studies about the minimal residual volume after dexter liver trisectorectomy are lacking. Therefore this study was conducted to evaluate the residual liver volume as reference for a postoperative liver insufficiency.
Material and Methods
All data were extracted from the clinical patient documents. In addition we inquired the current state of health from the patients’ attending physicians.
Between January 1988 and September 2006 a dexter liver trisectorectomy was conducted in 51 patients at the general, visceral and transplantation clinic at University Hospital Berlin Charité. There were 34 men and 17 women at a median age of 62 years old (33-79 years).The surgical indications were: central bile duct carcinoma (n = 33), metastases of colorectal carcinoma (n = 9), intrahepatic bile duct carcinoma (n = 5) as well as hepatocellular carcinoma and gallbladder carcinoma (n = 2 both). 31 patients (60.8%) were given a preoperative chemoembolization (right portal vein: n = 11, right hepatic artery: n = 20).
The liver volume was preoperatively determined by organ volumetry by means of “summation of area method” based on CT-data sets and postoperatively by expulsion volumetry.
The preoperative median total liver volume was 1840 ml (1180-2830 ml). Postoperatively the median relative residual liver volume was 19.0% (6.7 up to 48.8%), measured by means of expulsion volumetry.
9 from 51 patients (17.6%) died. 22 patients (43.1%) had postoperative complications: liver insufficiency (29.4%), wound infections (27.5%), renal failure (19.6%), gallbladder leakage (15.7%), multi organ failure (15.7%), cholangitis (11.8%), pneumonia (9.8%), thrombosis (9.8%), secondary bleeding (7.8%), anastomosis insufficiency (5.9%), pulmonary embolism (2.0%).
The absolute residual liver volume after dexter resection did not affect the development of postoperative liver insufficiency or lethality statistically significant. But none of the patients with a relative residual liver volume of ≥25% had a liver insufficiency and no patient with an absolute residual liver volume of more than 450 ml passed away. According to statistical analysis only the relative residual liver volume and the development of a postoperative liver insufficiency led to death. All deceased patients suffered from liver insufficiency (p = 0.001) and showed a relative residual liver volume of <25% (p = 0.057).
A low relative residual liver volume of <20% was not necessary associated with any complications. 13 out of 22 patients (59.1%) with postoperative complications had a relative residual liver volume of <20% and 9 patients (40.9%) ≥20%. A low relative liver volume <20% influenced the incidence of renal failure (p = 0.005) and was in principle correlated with the development of postoperative pneumonia (p = 0.059) and multi organ failure (p = 0.092).
Our examination on patients with a dexter trisectorectomy confirms previous experiences of other study groups on patients with extensive liver resections: a relative residual liver volume <20% increases the risk of death and of a prognostic unfavourable liver insuffiency. But the preoperative status of liver parenchyma makes a decisive contribution to prognosis. In stead of implementing limiting values for the residual liver volume, it would seem more appropriate to search and define prognostic more reliable criteria as the preoperative liver function measured by means of the LIMAx-test. As a matter of fact even in patients with an expected low residual liver volume a major resection must not necessary be contradicted if the remaining parenchyma is functioning.