Is there a life in MARS after hepatectomy? by Professor Lars Lundell

Hepatic resections are complex surgical procedures harboring a significant risk for complications. In line with the continued development of liver surgery, hepatic resections tend to be more complex and extensive, with to this associated enhanced risk for post-hepatectomy liver failure (PHLF). Despite these improvements in outcome after major liver resection, PHLF remains one of the most serious and fatal complication of major liver resection occurring in up to 8 % of the cases. Multiple factors increase the risk of PHLF but in clinical practice the risk of PHLF is closely associated with the assessment of the pre-operative Future Liver Remnant (FLR). Accordingly the prevention of PHLF is alleged to be affected by the induction of hypertrophy of the liver remnant via portal vein embolization or ligation if the expected functional left remnant in cases where the FLR is judged too small. An alternative therapeutic strategy is to perform a two-stage procedure allowing the FLR to grow after the first non-curative resection. Irrespective of these surgical-technical advancements, early recognition and initiation of supportive care is crucial to improve patient outcomes in PHLF. Despite its fatal consequences, the complexity behind the pathogenesis of PHLF remains poorly understood and treatment options (except for preventive measures) are limited. The advent of extra corporeal, albumin-based liver-dialysis system (Molecular Adsorbent Recirculating System, MARS) seemed to offer a treatment modality for patients with liver failure being either acute or acute on chronic (ACLF). The information on the use of MARS in PHLF is meager and basically no experiences have been reported with the use of well-defined criteria for liver failure. For instance Van de Kerkhove et al. reported on five patients treated with MARS due to unspecified PHLF, of whom 3 improved but only one survived. We have recently compiled our experience with MARS treatment for well-defined PHLF and found that four out of 13 patients survived (31%) three months postoperatively. However, this survival figure rose to 44% (4/9) if the analysis was confined to patients with primary PHLF fulfilling the Balzan criteria alone. These results formed the basis of a prospective clinical trial with the objective of evaluating early and consistent MARS treatment in patients with primary PHLF. Results from this study will be presented and discussed References Balzan S, Belghiti J, Farges O, Ogata S, Sauvanet A, Delefosse D, et al. The "50-50 criteria" on postoperative day 5: an accurate predictor of liver failure and death after hepatectomy. Annals of surgery. 2005;242(6):824-8 Stange J, Mitzner S, Ramlow W, Gliesche T, Hickstein H, Schmidt R. A new procedure for the removal of protein bound drugs and toxins. Asaio J. 1993;39(3):M621-5. Gilg S, Escorsell A, Fernandez J, Garcia-Valdecasas JC, Saraste L, Wahlin S Nowak G, Stromberg C, Lundell L, Isaksson B. Albumin dialysis with MARS in post-hepatectomy liver failure (PHLF): experiences from two HPB centers. Surgery Current Research, 2015, 6: 252.