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Measured versus Estimated Total Liver Volume to Preoperatively Assess the Adequacy of the Future Liver Remnant: Which Method Should We Use?

Ribero, Dario MD*; Amisano, Marco MD*; Bertuzzo, Francesca MD*; Langella, Serena MD*; Lo Tesoriere, Roberto MD*; Ferrero, Alessandro MD*; Regge, Daniele MD; Capussotti, Lorenzo MD*

doi: 10.1097/SLA.0000000000000213
Original Articles From the ESA Proceedings

Objectives: To determine which method of liver volumetry is more accurate in predicting a safe resection.

Background: Before major or extended hepatectomy, assessment of the future liver remnant (FLR) is crucial to reduce the risk of postoperative hepatic insufficiency. The FLR volume is usually expressed as the ratio of FLR to nontumorous total liver volume (TLV), which can be measured directly by computed tomography (mTLV) or estimated (eTLV) on the basis of correlation existing with the body surface area. To date, these 2 methods have never been compared.

Methods: All consecutive, noncirrhotic patients who underwent resection of 3 or more liver segments between April 2000 and April 2012 and for whom (i) preoperative computed tomographic scans and (ii) body surface area were available entered the study. The mTLV (calculated as TLV − tumor volume) was compared with the eTLV (calculated as −794.41 + 1267.28 × body surface area) using volumetric data (cm3) and clinical outcome measures (specifically, hepatic insufficiency and 90-day mortality). Definition of hepatic insufficiency was peak postoperative serum total bilirubin level of more than 7 mg/dL or, in jaundiced patients, an increasing bilirubin level on day 5 or thereafter.

Results: Two-hundred forty-three patients who had undergone major (n = 135) or extended (n = 108) hepatectomies met the inclusion criteria. Twenty-eight patients (11.5%) developed hepatic insufficiency, whereas 7 patients (2.9%) died postoperatively. Compared with the eTLV, the mTLV underestimated the liver volume in 60.1% of the patients (P < 0.01). Forty-seven and 73 patients had an inadequate FLR based on mTLV and eTLV, respectively. Portal vein occlusion (PVO) was used in 44 patients. In patients (n = 162) in whom both methods did not evidence the need for PVO, postoperative hepatic insufficiency and mortality were 4.9% and 0.6%, respectively. Conversely, in patients (n = 27) in whom the eTLV but not the mTLV evidenced the need for PVO, and thus PVO was not performed, hepatic insufficiency (22.2%; P = 0.001) and mortality (3.7%; P = ns) were higher.

Conclusions: The use of eTLV identifies a subset of patients (∼11%) in whom liver volumetry with the mTLV underestimates the risk of hepatic insufficiency.

Whether remnant liver volume should be evaluated as a ratio of future liver remnant to measured or estimated total liver volume is unknown. This study shows that the use of standardized volumetry is of clinical relevance because it identifies a subset of patients in whom the measured liver volumetry underestimates the risk of hepatic insufficiency.

*Department of General Surgery and Surgical Oncology, Ospedale Mauriziano “Umberto I”

Department of Radiology, Istituto per la Ricerca e la Cura del Cancro, Candiolo, Turin, Italy.

Reprints: Dario Ribero, MD, Department of General Surgery and Surgical Oncology, Ospedale Mauriziano “Umberto I,” Turin, Italy. E-mail:

Disclosure: The authors declare no conflicts of interest.

© 2013 by Lippincott Williams & Wilkins.