Umemura Kentaro, Shimizu Akira, Notake Tsuyoshi, Kubota Koji, Hosoda Kiyotaka, Yasukawa Koya, Kamachi Atsushi, Goto Takamune, Tomida Hidenori, Soejima Yuji
Division of Gastroenterological, Hepato-Biliary-Pancreatic, Transplantation and Pediatric Surgery, Department of Surgery Shinshu University School of Medicine Matsumoto Japan.
Ann Gastroenterol Surg. 2024 Aug 18;9(1):188-198. doi: 10.1002/ags3.12850. eCollection 2025 Jan.
Post-hepatectomy liver failure (PHLF) after major hepatopancreatoduodenectomy (HPD) is a challenge to overcome. However, the appropriate target proportion of the future liver remnant (pFLR) to prevent severe PHLF in major HPD remains uncertain. This study aimed to determine the minimum pFLR required for safe major HPD.
This retrospective study involved 48 major HPD patients. We assessed pFLR and remnant liver function scores (pFLR × albumin-bilirubin [ALBI] / albumin-indocyanine green evaluation [ALICE]/plasma clearance rate of indocyanine green [KICG]) as predictors for Grade B/C PHLF and established safety criteria.
Grade B/C PHLF occurred in 40% of the patients ( = 19), leading to severe morbidity and two in-hospital deaths. pFLR was a good predictor of Grade B/C PHLF [area under the curve (AUC) 0.80, < 0.01] with a 45% optimal cutoff. While all remnant liver function scores predicted PHLF, the remnant ALICE demonstrated the best predictability (AUC 0.85, < 0.01), with the sensitivity and specificity at 89% and 83%, respectively, using -0.86 as the cutoff. Independent risk factors for Grade B/C PHLF were remnant ALICE ≥-0.86 and blood loss ≥1500 mL. Grade B/C PHLF developed in 14% with pFLR ≥45% but reached 64% with pFLR <45%. However, the rate could be reduced to 33% with remnant ALICE <-0.86.
To prevent Grade B/C PHLF, a pFLR ≥45% is recommended. Nevertheless, major HPD may be considered in patients with good remnant liver function.
在进行胰十二指肠切除术（HPD）后发生的肝切除术后肝功能衰竭（PHLF）是一个亟待克服的挑战。然而，在主要的HPD手术中，用于预防严重PHLF的未来肝脏残余体积（pFLR）的合适目标比例仍不明确。本研究旨在确定安全进行主要HPD手术所需的最小pFLR。
这项回顾性研究纳入了48例接受主要HPD手术的患者。我们评估了pFLR和残余肝功能评分（pFLR×白蛋白-胆红素[ALBI]/白蛋白-吲哚菁绿评估[ALICE]/吲哚菁绿血浆清除率[KICG]），将其作为B/C级PHLF的预测指标，并确立了安全标准。
40%（n = 19）的患者发生了B/C级PHLF，导致严重并发症及2例院内死亡。pFLR是B/C级PHLF的良好预测指标[曲线下面积（AUC）为0.80，P < 0.01]，最佳截断值为45%。虽然所有残余肝功能评分均能预测PHLF，但残余ALICE的预测能力最佳（AUC为0.85，P < 0.01），以-0.86作为截断值时，其敏感性和特异性分别为89%和83%。B/C级PHLF的独立危险因素为残余ALICE≥ -0.86和失血≥1500 mL。当pFLR≥45%时，B/C级PHLF的发生率为14%，而当pFLR < 45%时，该发生率达到64%。然而，当残余ALICE < -0.86时，该发生率可降至33%。
为预防B/C级PHLF，建议pFLR≥45%。尽管如此，对于残余肝功能良好的患者，可考虑进行主要HPD手术。
