Liver failure following partial hepatectomy

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Abstract
Among all organs, the liver is unique in its ability to repair itself after suffering loss of tissue mass from toxins, infectious agents or surgical resection. This regenerative capacity has made it possible for surgeons to remove large portions of liver without permanent impairment of function. From the first descriptions by Keen in 1899 [ 1 x [1] Keen, W.W. Report of a case of resection of the liver for the removal of a neoplasm, with a table of seventy-six cases of resection of the liver for hepatic tumors. Ann Surg. 1899; 30: 267–283 Crossref | PubMed | Google Scholar See all References ] [1] of major hepatic resections for tumors, the postoperative course of these patients was largely uneventful, provided that they survived the operation. Mortality was high (almost 15% in 74 patients), usually from bleeding, and few, if any, of the deaths seemed to be due to liver failure. With a clearer understanding of hepatic anatomy [ 2 x [2] Couinaud, C. Lobes et segments hepatiques: notes sur architecture anatomique et chirurgicale du foie. Presse Med. 1954; 62: 709–712 PubMed | Google Scholar See all References ] [2] , and refinements in operative technique [ 3 x [3] Lortat-Jacob, J.L., Robert, H.G., and Henry, C. Un cas d'hepatectomie droite reglee. Memoires del'Acadamie de Chirurgie. 1952; 78: 244–251 PubMed | Google Scholar See all References , 4 x [4] Quatttlebaum, J.K. and Quattlebaum, J.K. Jr. Technique of hepatic resection. Surgery. 1965; 58: 1075–1080 PubMed | Google Scholar See all References ], liver resection became more commonplace. Foster and Berman [ 5 x [5] Foster, J.H. and Berman, M.M. Solid liver tumors. Major Problems in Clinical Surgery. 1977; 22: 255–259 Google Scholar See all References ] [5] , in their 1974 liver tumor survey, examined 621 patients who had undergone liver resection in 98 different hospitals. The overall mortality rate was 13%. Upon reviewing the deaths, the authors found that 29 patients succumbed to “liver failure”, most within 30 days of operation. Fourteen of these deaths were thought to be due to technical causes, usually removal of “too much” liver or vascular compromise to remnant liver, and 12 deaths were in patients with cirrhosis. Three cases of liver failure could not be explained. More recent clinical series cast a similar light. In a series of over 400 partial hepatectomies, Iwatsuki and Starzl [ 6 x [6] Iwatsuki, S. and Starzl, T.E. Personal experience with 411 hepatic resections. Ann Surg. 1988; 208: 421–434 Crossref | PubMed | Google Scholar See all References ] [6] detailed 19 in-hospital deaths. Eleven of these deaths were due to liver failure, nine after the first postoperative week and six after 1 month. In this group of 11 patients, 8 had undergone extended right hepatectomy (trisegmentectomy) and 7 were over 60 years of age. Savage and Malt [ 7 x [7] Savage, A.P. and Malt, R.A. Elective and emergency hepatic resections: determinants of operative morbidity. Ann Surg. 1991; 214: 689–695 Crossref | PubMed | Google Scholar See all References ] [7] published a large series of hepatectomies, 75% of which were major, in which 12 patients died of liver failure (and five from septicemia) and 14 developed reversible liver insufficiency. Scheel and Stangl [ 8 x [8] Scheel, J. and Stangl, R. Segment oriented anatomic liver resection. in: Blumgart L.H. (Ed.) Surgery of the liver and biliary tract. Churchill Livingstone, New York; 1994 Google Scholar See all References ] [8] observed a greater chance of liver failure in non-cirrhotics (11.5%) if more than 50% of functioning liver was removed—resulting in 5 (of 18) deaths—than if less were resected (1.3%). The dangers of extended hepatic resections, during which well over half of the liver was removed, were illustrated by Melendez and co-authors [ 9 x [9] Melendez, J., Ferri, E., Zwillman, M., Fischer, M., DeMatteo, R., and Leung, D. Extended hepatic resection: a 6-year retrospective study of risk factors for perioperative mortality. J Am Coll Surg. 2001; 192: 47–53 Abstract | Full Text | Full Text PDF | PubMed | Scopus (117) | Google Scholar See all References ] [9] . They encountered 14 postoperative deaths in these patients, 6 from sepsis and 3 from liver failure. Others [ 10 x [10] Brancatisano, R., Isla, A., and Habib, N. Is radical hepatic surgery safe?. Am J Surg. 1998; 175: 161–163 Abstract | Full Text PDF | PubMed | Scopus (58) | Google Scholar See all References ] [10] noted similar findings, observing that sepsis and liver failure accounted for five of seven postoperative deaths.