Breitenstein, Stefan

Clavien, Pierre-Alain

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‘‘State of the Art’’ in Liver Resection and Living Donor LiverTransplantation: A Worldwide Survey of 100 LiverCenters—Reply to LetterStefan Breitenstein • Pierre-Alain ClavienPublished online: 12 February 2010 Socie´te´ Internationale de Chirurgie 2010We thank the Amsterdam group for the interest and com-ments on our article. We highly appreciate their contribu-tion and investigation in the field of quantification of liverfunction. However, in our survey we did not correlate theimpact of remnant liver volume on liver function inpatients with different underlying liver diseases. We pro-vided an overview of current practices of liver surgery innormal and cirrhotic livers. The critical size of 25% ofremnant liver volume was related to patients with normalparenchyma [1].Impaired function of the remaining liver is of majorconcern for the hepatopancreatobiliary surgeon, particu-larly in patients with an underlying liver disease. Wecompletely agree that in addition to the volume of remnantliver the preoperative application of liver function testsmay have a relevant impact on the assessment of liverfunction after resection in patients with underlying liverdisease. However, none of the metabolic tests available thattarget hepatic physiology is currently widely accepted [2].Metabolic tests are most often used in Asia, where most ofthe patients undergoing liver surgery have hepatocellularcarcinoma related to hepatitis B or C cirrhosis. The mostcommonly used test is intravenous injection of indocyaninegreen (ICG). However, ICG results are not completelyreproducible because the rate of retention of indocyanine isinfluenced by several factors, especially portal flow [3, 4].According to our knowledge, there has been no con-vincing evaluation of the impact of the ICG test in patientsafter noncirrhotic liver resection. A recent publication bythe Amsterdam group on 99mTc-mebrofenin hepatobiliaryscintigraphy as an alternative metabolic liver function testhas produced promising results regarding the prediction ofpostoperative liver failure [5]. Even so, reproducibility ofthe accuracy of this examination needs to be confirmed byother centers. In addition, its use requires a Department ofNuclear Medicine to dispose of the radioisotope, and suchdepartments are not available everywhere in the world.Certainly, further investigations are required to assessthe mechanism and the degree of liver disease that nega-tively affect postoperative outcome. Functional liver testsmay play an increasing role in the future regarding pre-operative risk assessment in patients undergoing liversurgery.References1. Breitenstein S, Apestegui C, Petrowsky H et al (2009) ‘‘State of theart’’ in liver resection and living donor liver transplantation: aworldwide survey of 100 liver centers. World J Surg 33:797–8032. Clavien PA, Petrowsky H, DeOliveira ML et al (2007) Strategiesfor safer liver surgery and partial liver transplantation. N Engl JMed 356:1545–15593. Imamura H, Seyama Y, Kokudo N et al (2003) One thousand fifty-six hepatectomies without mortality in 8 years. Arch Surg138:1198–1206 (discussion 1206)4. Mullin EJ, Metcalfe MS, Maddern GJ (2005) How much liverresection is too much? Am J Surg 190:87–975. De Graaf W, van Lienden KP, Dinant S, et al (2009) Assessmentof future remnant liver function using hepatobiliary scintigraphy inpatients undergoing major liver resection. J Gastrointest Surg Nov24 [Epub ahead of print]S. Breitenstein  P.-A. Clavien (&)Department of Surgery, Swiss HPB (Hepato-Pancreato-Biliary)Center, University Hospital Zurich, Zurich, Switzerlande-mail: clavien@chir.uzh.ch123World J Surg (2010) 34:870DOI 10.1007/s00268-010-0423-6

"State of the Art” in Liver Resection and Living Donor Liver Transplantation: A Worldwide Survey of 100 Liver Centers—Reply to Letter

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"State of the Art” in Liver Resection and Living Donor Liver Transplantation: A Worldwide Survey of 100 Liver Centers—Reply to Letter

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