Les outils d’evaluation

Daniel Cherqui – Andrea Laurenzi

Stone, Am J Surg 1969

Truant, JACS 2007

• RLV-BWR was more relevant than RLV-TLV in predicting postoperative course after right trisectionectomy

• Patients with an anticipated RLV < 0,5% of the body weight were at risk of hepatic dysfunction

• No deaths in the group of patients with RLV/BWR >0,5%

Remnant liver volume assessment

Truant, World J Surg 2015

Shin, JGIS 2007

29 patients pour CHC uninodulaire Child A

Only hepatic venous pressure gradient > 10 mmHg was significant in multivariate analysis for decompensated cirrhosis after hepat.

Risk factor in univariate analysis

Bilirubin rateUrea rateRate of plateletICG ClearenceHepatic venous pressure gradiant,

1996

Décompensation de la cirrhose : Persistance d’une ascite à 3 mois

Cucchetti, J Hep 2016

Makuuchi, Semin Surg Oncol 1993

Ascites

None or controlled Not controlled

ICGR15 Limited resection Enucleation Not indicated for hepatectomy

Trisectorectomy bisectorectomy

Left-sided hepatectomyRight-sided

sectoriectomy

Segmentectomy Limited resection Enucleation

Normal 1.1 – 1.5 mg/dL 1.6 – 1.9 mg/dL > 2.0 mg/dL

Total bilirubin level

Normal 10% - 19% 30% - 39% > 40%20% - 29%

Adapter la chirurgie hépatique à la fonction…

Survivors (n = 113) Non-survivors (n = 14) P *All ICG retention at 15 min (%) 11 (3 - 50) 18 (4 - 29) 0.008Aminopyrine breath test (%) 4-4 (1.3 - 9.6) 4.3 (2.8 – 8.3) 0.69Amino acid clearance test (1 m-2 min-1) 0.21(1.7 to 4.3) 0.15 (-0.2 to 0.9) 0.35Albumin (g l-1) 42 (31 - 53) 41 (29 - 46) 0.40Total bilirubin (µmol l-1) 9 (3 - 70) 14 (7 - 32) 0.05Aspartate aminotransferase (units l-1) 59 (17 - 365) 97 (39 - 340) 0.02Alanine aminotransferase (units l-1) 53 (9 - 480) 53 (21 - 322) 0.90

0

15

35

[IGC]

mg

%

Survivors

Distribution of indocyanine green (ICG) retention at

? in for survivors and patients who died in hospital

Non-survivors

5

25

40

10

20

45

30

127 hepatectomies dont 91 Majeures Child A (n=121) / Child B (n=6) Mortalité Hospitalière : 14/127 (11%)

Valeur seuil d’ICG à 15 minutes15% pour les Hep. Maj23% pour les Hep. Min.

Lau, BJS 1997

90 pts including including 17 major hep. : 30% of liver decompensation (20% ascite)

Cescon, Ann Surg 2012

> 16 kpA: Ascite and/or POLF

Cescon, Ann Surg 2012

Correlation is linear…YesNoPo

sthe

pate

ctom

y PV

P (m

mHg

)

22.5 mmHg

15 mmHg

P < 0.001

Liver failure « 50-50 » criteria

Portal pressure after major liver resectionAn independent predictor of liver failure and mortalityafter major resection (N = 277) in humans1

Allard, Ann Surg 2013

Comment évaluer la réserve fonctionnelle: les autres paramètres

Scintigraphie hépatique

De Graaf, J Nucl Med 2010