Yamamoto Yuzo
Department of Gastroenterological Surgery, Akita University Graduate School of Medicine, Akita, Japan.
Visc Med. 2021 Feb;37(1):10-17. doi: 10.1159/000512439. Epub 2020 Dec 11.
Prevention of posthepatectomy liver failure is a prerequisite for improving the postoperative outcome of perihilar cholangiocarcinoma. From this perspective, appropriate assessment of future liver remnant (FLR) function and the optimized preparation are mandatory.
FLR volume ratio using CT volumetry based on 3-dimensional vascular imaging is the current assessment yardstick and is sufficient for assessing a normal liver. However, in a liver with underling parenchymal disease such as fibrosis or prolonged jaundice, weighing up the degree of liver damage against the FLR volume ratio is necessary to know the real FLR function. For this purpose, the indocyanine green (ICG) clearance test, monoethylglycinexylidide (MEGX) test, liver maximum capacity (LiMAX) test, Tc-labeled galactosyl human serum albumin (Tc-GSA) scintigraphy, albumin-bilirubin (ALBI) grade, and ALPlat (albumin × platelets) criterion are used. After the optimization of FLR function by means of portal vein embolization or associating liver partition and PVL (portal vein ligation) for staged hepatectomy (ALPPS), SPECT scintigraphy with either Tc-GSA or Tc-mebrofenin compensates for misestimation due to the regional heterogeneity of liver function. The role of preoperative biliary drainage has long been debated, with the associated complications having led to a lack of approval. However, the recent establishment of safety and an improvement in success rates of endoscopic biliary drainage seem to be changing the awareness of the importance of biliary drainage.
Appropriate selection of an assessment method is of prime importance to predict the FLR function according to the preoperative condition of the liver. Preoperative biliary drainage in patients with perihilar cholangiocarcinoma is gaining support due to the increasing safety and success rate, especially in patients who need optimization of their liver function before hepatectomy.
预防肝切除术后肝衰竭是改善肝门部胆管癌术后结局的前提条件。从这个角度来看，对未来肝残余（FLR）功能进行恰当评估并进行优化准备是必不可少的。
基于三维血管成像的CT容积测量法得出的FLR体积比是目前的评估标准，足以评估正常肝脏。然而，对于存在潜在实质病变（如纤维化或长期黄疸）的肝脏，权衡肝脏损伤程度与FLR体积比对于了解真实的FLR功能是必要的。为此，可采用吲哚菁绿（ICG）清除试验、单乙基甘氨酰二甲苯胺（MEGX）试验、肝脏最大功能（LiMAX）试验、锝标记半乳糖基人血清白蛋白（Tc-GSA）闪烁扫描、白蛋白-胆红素（ALBI）分级以及ALPlat（白蛋白×血小板）标准。通过门静脉栓塞或联合肝脏分隔与门静脉结扎分期肝切除术（ALPPS）对FLR功能进行优化后，使用Tc-GSA或Tc-美罗芬宁的SPECT闪烁扫描可弥补因肝功能区域异质性导致的估计错误。术前胆道引流的作用长期以来一直存在争议，其相关并发症导致该方法未获认可。然而，近期内镜下胆道引流安全性的提高和成功率的改善似乎正在改变人们对胆道引流重要性的认识。
根据肝脏术前状况恰当选择评估方法对于预测FLR功能至关重要。肝门部胆管癌患者的术前胆道引流因安全性和成功率不断提高而越来越受到支持，尤其是对于那些在肝切除术前需要优化肝功能的患者。
