Preoperative Estimation of Operative Risk and Extension of Operative Indication in Hepatic Surgery

Ryuji Mizumoto

First Department of Surgery, Mie University School of Medicine

Approximately 20 years ago, using Child's criteria I pointed out that the indication for hepatic resection in cirrhotic patients was remarkably limited. In the present study, the preoperative estimation of operative risk and the possibility of extending operative indications for heaptic surgery were investigated, according to the clinical results for 469 patients with liver diseases who visited our clinic for about 13 years. 1) Limitation in hepatectomy: The patients with a total risk of 4 calculated by various liver function tests or ICG Rmax of the remnant liver of 0.2∼0.4 were at the limit of hepatectomy. Other factors influencing prognosis should be considered, such as histological findings of active hepatitis and HBV infection, disturbances in the coagulation-fibrinolysis system, poor nutritional status, hemodynamic changes in the liver during surgery and changes in cardiac, respiratory and renal functions. 2) Management of poor risk patients and surgical results: Recently, even the critically ill patients with severely impaired liver functions have been albe to undergo hepatic resection with the extension of surgical indications, achieving a good long-term outcome with intensive care before and after surgery, and introduction of the following management procedures: (1) partial splenic embolization for the patients with severe functional disturbances in the coagulation-fibrinolysis system, (2) aggressive nutritional support with BCAA administration, (3) maintenance of hepatic blood flow by infusion of PGE₁, etc. Our experimental trials for extending the operative indications and extended hepatectomy are also described.

Key words
hepatic resectability, operative risk in hepatic surgery, hepatic functional reserve, coagulation-fibrinolysis system, nutritional assessment in hepatic surgery

Reprint requests
Ryuji Mizumoto First Department of Surgery, Mie Uniersity School of Medicine
2-174 Edobashi, Tsu, 5l4 JAPAN

Accepted
June 13, 1990

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