Too Big to Fail

Objective: To assess the incidence of posthepatectomy liver failure (PHLF) and the role of the future liver remnant (FLR) in children undergoing major hepatectomy Summary Background Data: Incidence and risk factors of PHLF in children are unclear, with no validated definition for this age group. Consequently, the role of the FLR in pediatric hepatectomy and evidence-based preoperative guidelines remain undefined. Methods: All pediatric patients undergoing major hepatectomy at a tertiary care center over a 10-year study period were analyzed. Preoperative imaging was used for volumetry. The incidence of PHLF was assessed applying predefined definitions, and the prognostic impact of the FLR on PHLF and complications was evaluated. Results: 125 children underwent major hepatectomy, including 35 trisectionectomies. There was a strong correlation between imaging-based measured total liver volume and calculated standard liver volume (r=0.728, P <0.001). The median total liver volume-to-body weight (BW) ratio was 3.4%, the median FLR/BW ratio was 1.5%. The median FLR-to-total liver volume ratio was 44% (range 18%-97%). No clinically relevant PHLF occurred. FLR/total liver volume and FLR/BW ratios had low predictive value for postoperative liver dysfunction and morbidity. Conclusion: This is the largest reported single-center series of pediatric major hepatectomies. PHLF is exceedingly rare in children. The liver volume-to-body weight ratio is higher in children compared to adults, and the FLR is sufficient even in extreme resections with less than 20% of liver remnant. These findings strongly question the use of ALPPS, portal vein embolization, or transplantation based on suspected insufficient liver remnant in children.