Intraoperative simulation of remnant liver function during anatomic liver resection with indocyanine green clearance (LiMON) measurements

Abstract

Objective: Post-hepatectomy liver failure (PHLF) is the major cause of death following liver resection. The aim of this study was to evaluate the feasibility of an intraoperative simulation of post-resection liver function.

Methods: Intraoperative liver function was measured by indocyanine green (ICG) clearance using the LiMON technology. In 20 patients undergoing anatomic liver resection, ICG plasma disappearance rate (PDR (%/min) and ICG retention at 15 min (R15 ) (%) were measured immediately after the induction of anaesthesia (t0 ), after selective arterial and portovenous inflow trial clamping (TC) of the resected liver segments (t1 ), after the completion of resection (t2 ) and before the closure of the abdominal cavity (t3 ).

Results: The median baseline (t0 ) PDR was 16.5%/min. Trial clamping of the inflow (t1 ) resulted in a significant reduction in PDR to 10.5%/min. Results under TC were similar to those obtained after resection (t2 ) (median PDR: 10.5%/min). Linear regression modelling showed that post-resection liver volume could be accurately predicted by TC of liver inflow (P < 0.0001), but not by determining the resected liver volume. Simulated post-resection liver function under TC correlated well with PHLF and length of hospital stay.

Conclusions: Intraoperative ICG clearance measurements allow real-time monitoring of intraoperative liver function during surgery. Trial clamping of arterial and portovenous inflow accurately predicts immediate post-resection liver function. The intraoperative measurement of liver function and simulation of post-resection liver function may help to avoid PHLF.

© 2015 International Hepato-Pancreato-Biliary Association.

Figures

Figure 1

Trial clamping in a right hemi-hepatectomy. This schematic drawing shows the inflow clamping of the right portal vein (pv) and the right hepatic artery (ha) in preparation for an intended right hepatectomy with a resection line slightly right of the middle hepatic vein. Indocyanine green clearance was determined prior to resection (t0), under trial clamping (t1) and after resection (t2)

Figure 2

Intraoperative simulation of remnant liver function [mean ± standard error of the mean (SEM)] indocyanine green (ICG) plasma disappearance rate (PDR) and ICG clearance rate at 15 min (R15)

Figure 3

Correlations between (a) indocyanine green (ICG) plasma disappearance rate (PDR) measured preoperatively and post-resection (r = 0.3589, r2 = 0.1288, P = 0.1202), (b) ICG PDR at clamping and at post-resection (r = 0.8045, r2 = 0.6473, P < 0.0001), and (c) the percentage of ICG PDR at t2/t0 and the percentage of remnant/total liver volume (r = 0.4797, r2 = 0.2301, P = 0.0514)

Figure 4

Intraoperative indocyanine green clearance rate at 15 min (R15) (t1) in patients with and without post-hepatectomy liver failure (PHLF)

Figure 5

Postoperative hospital stay in patients with and without post-hepatectomy liver failure (PHLF)