Outcome after liver resection : epidemiological and clinical studies with special focus on the role of post-hepatectomy liver failure

Abstract

Background: Liver surgery has undergone significant developments over the last three decades. However, population-based data are scarce, and there is limited knowledge of the impact on mortality and possible treatment modalities of a feared complication following hepatectomy, post-hepatectomy liver failure (PHLF). In theory, extracorporeal liver support with the Molecular Adsorbent Recirculating System (MARS) might have several positive effects in patients with PHLF. Until today, only very few single-center experiences have been reported with overall poor patient outcome. However, controlled, prospective data for the use of MARS in patients with PHLF are missing.

Aims: To investigate long-term results after hepatectomy in Sweden in a population-based setting. To evaluate the impact of PHLF on short-term mortality. To retrospectively analyze the outcome of patients with PHLF being treated with MARS. To prospectively evaluate safety and feasibility of an intensified MARS treatment protocol in patients with PHLF.

Methods: In paper I and II, data between 2002 and 2011 from different patient registries were used to assess outcome related to different types of liver resections and differential diagnosis. In paper II, a part of the data from paper I (between 2005 – 2009) were used to identify patients who died within 90 days from surgery. Data were then completed with additional information from local patient journals at the respective hospital. For paper III, all patients who were treated with MARS for PHLF at Karolinska University Hospital Huddinge and Hospital Clinic, Barcelona, were retrospectively analyzed. For paper IV, a prospective pilot study was performed, including all patients with PHLF between 1st of December 2012 and 30th of May 2015. Safety, feasibility, and outcome were assessed.

Results: Liver resections are performed with a very low short-term mortality and favorable long-term outcomes. 5-year survival in patients resected for colorectal liver metastasis (CRLM) was around 60%, and re-resection for CRLM significantly improved long-term survival. In a population-based setting, PHLF is whether the leading cause or significantly contributes to 90-day mortality, in more than 40% of all cases. Our data confirmed known risk factors for PHLF like extended hepatectomy or hepatectomy due to cholangiocarcinoma. In a retrospective series, 13 patients were identified who have been treated with MARS due to PHLF. A trend towards improved long-term survival was seen in patients being treated early and more frequent after hepatectomy. In a prospectively, controlled cohort study we found it to be safe and feasible to initiate MARS treatment in patients with PHLF early after hepatectomy according to a standardized treatment protocol. Short and long-term survival was improved compared to a historical control group.

Conclusion: In Sweden, liver resections are performed with favorable outcome both in regards to short-term and long-term results. PHLF is even in a population-based setting the single most important factor causing short-term mortality after hepatectomy. It is safe and feasible to use MARS in patients with PHLF early after hepatectomy and both short- and long-term survival might be improved.