### Pre-operative planning 1. low threshold to calculate [[Future Liver Remnant|sFLR]] (especially for any major resection) 2. Review imaging for anomalous anatomy - right posterior sectoral duct draining to left system - right hepatic artery traveling anterior to bile duct 3. Assess for occult portal HTN → low threshold to calculate [[portal HTN |portal pressures]] - splenomegaly - varices, porto-systemic (caval) collaterals - thrombocytopenia - prolonged oxaliplatin exposure 4. Consider the use of PHLF risk calculators - [TELLAPRIALBI calculator](https://tellaprialbi.howto.health/home) for prediction of PHLF 5. Optimize liver quality preoperatively - nutrition, weight loss (steatosis reduction)→ consider recommending a preoperative [liver weight loss diet](https://www.royalberkshire.nhs.uk/media/annpjkhp/liver-reduction-diet-prior-to-bariatric-surgery_apr25.pdf) - biliary drainage → based on dilation on imaging ± labs (alk phos, bilirubin) --- ### Intra-operative risk modifiers Factors associated with postoperative liver dysfunction: > Goal: preserve functional remnant quality, inflow, outflow, and biliary drainage. - prolonged inflow occlusion / ischemia - excessive blood loss or transfusion - venous congestion - inadequate future liver remnant - biliary injury or devascularization - prolonged operative time - major hepatectomy in chemotherapy-injured liver --- ### Post-operative considerations - avoid infection and sepsis - maintain adequate nutrition/caloric intake - recognize expected postoperative lab trajectories - identify evolving PHLF early >[!info] Key Principle >The postop period is an essential time for hepatocyte regeneration → preserve hepatic perfusion and oxygen delivery ##### Expected postoperative lab trends - AST/ALT rise immediately then decline - INR peaks around 36–48 hr - bilirubin often peaks later (POD 4–6) ![[Pasted image 20260514134931.png|350]] *Graph @ [Dr. Steve Wigmore](https://profstevewigmore.wordpress.com/2012/12/19/why-do-people-develop-jaundice-after-liver-resection/)* | Concerning Feature | Potential Etiologies | | ----------------------------------- | ------------------------------------------------------------------------------------ | | Persistent INR elevation | PHLF, inadequate liver remnant, ongoing ischemic injury, sepsis | | Rising bilirubin after POD5 | PHLF, biliary obstruction, bile leak/collection, sepsis | | Worsening transaminases | Ongoing ischemia-reperfusion injury, vascular compromise, congestion, sepsis | | Encephalopathy or lactate elevation | Significant hepatic dysfunction/PHLF, sepsis, inadequate hepatic clearance/perfusion | *Findings are nonspecific and often overlapping; interpretation depends on operative context, remnant quality, and associated clinical findings.* --- ### References >[!quote]- Selected References >- [Dr. Steve Wigmore: Why do people develop jaundice after liver resection? 2012.](https://profstevewigmore.wordpress.com/2012/12/19/why-do-people-develop-jaundice-after-liver-resection/) >- [Schindl MJ, et al. The value of residual liver volume as a predictor of hepatic dysfunction and infection after major liver resection. Gut. 2005](https://pubmed.ncbi.nlm.nih.gov/15647196/) --- ### Related pages - [[Post-Hepatectomy Liver Failure (PHLF)]] - [[Future Liver Remnant]] - [[Liver Regeneration]]