Postoperative liver failure after major hepatic resection for hepatocellular carcinoma in the modern era with special reference to remnant liver volume

Background: postoperative liver failure is a life-threatening complication after hepatic resection. Because of recent advances in liver surgery techni que and a more stringent patient selection, mortality after hepatic resecti on has steadily decreased, but its incidence still ranges from 10% to 20%. The factors linked to postoperative liver failure in major hepatic resectio n in the modern era should be reevaluated. Study Design: Of 80 patients with viral markers (hepatitis C viral antibody or hepatitis B surface antigen) who underwent major hepatic resections (no less than bisegmentectomies) for hepatocellular carcinoma between 1990 and 1996, 7 patients (8.8%) died of postoperative liver failure within 6 month s after hepatectomy. The cause of liver failure was analyzed based on both the preoperative data and the intraoperative findings. In addition, since a ll the patients who died of liver failure underwent a right hepatic lobecto my, a further data analysis was also done in 47 patients who underwent a ri ght lobectomy of the liver. A volumetric analysis by CT was then done to ev aluate the remnant liver volume. Results: Between the patients with liver failure and those without liver fa ilure who underwent a right lobectomy, there were no significant difference s in preoperative data or intraoperative findings. Volumetric analysis reve aled that the remnant liver volume of patients who died of liver failure wa s significantly smaller than that of patients who lived (p = 0.008). The in cidence of liver failure in patients with a remnant liver volume of less th an 250 mL/m(2) was 7 of 20 (38%), while it was 0 of 27 in patients with a l iver volume of no less than 250 mL/m(2) (p = 0.0012). The only significant risk factor for liver failure in patients with a remnant liver volume of le ss than 250 mL/m(2) was diabetes mellitus (p = 0.0072). Conclusions: The expected remnant liver volume appears to be a good predict or for liver failure in patients who undergo a right lobectomy of the liver . In patients with diabetes mellitus and an expected remnant liver volume o f less than 250 mL/m(2), a major hepatectomy should be avoided. Careful pat ient selection based on volumetric analysis in major hepatectomy cases coul d help prevent the occurrence of postoperative liver failure. (J Am Coil Su rg 1999;188:304-307. (C) 1999 by the American College of Surgeons).