Post-hepatectomy liver failure

Liver resection has evolved from being rather risky and rarely performed, to an overall safe and widely performed modern surgical operation with low overall morbidity and very low mortality rates. Progress in liver surgery was not only enabled by development of surgical techniques, instruments, and minimally invasive approaches, but also by an evolution in perioperative care including intraoperative anaesthetic techniques. The concepts of parenchyma-sparing surgery and adjunct interventions including ablations have also contributed. Major liver resections are however still associated with higher risk of complications. Post-hepatectomy liver failure (PHLF) is the most dreaded complication. Although mortality in modern liver surgery is reported at <1–2% for all procedures, and likely <1% for minor procedures, the risk of PHLF is still reported around 8–12% for major liver surgery in many centres1,2. PHLF is the single most important factor associated with postoperative death after hepatectomy. When PHLF first develops (Fig. 1), treatment is essentially the same as for other medical causes of acute liver failure3; largely supportive, directed at organ failure management and, unfortunately, not often successful, with a very high mortality rate at 50–80%. Hence, avoiding PHLF has become a much investigated yet still poorly understood Achilles heel to modern liver surgery (Fig. 1). Here we present an overview of some core principles important to understand PHLF.