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Les outils d'évaluation ( Volumetries, Pressions) - Dr Andrea Laurenzi - Pr Daniel Cherqui

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Journées de Chirurgie 2016
Les outils d'évaluation (Volumétries, Pressions)

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Les outils d'évaluation ( Volumetries, Pressions) - Dr Andrea Laurenzi - Pr Daniel Cherqui

  1. 1. Les outils d’evaluation Daniel Cherqui – Andrea Laurenzi
  2. 2. Stone, Am J Surg 1969
  3. 3. Truant, JACS 2007 • RLV-BWR was more relevant than RLV-TLV in predicting postoperative course after right trisectionectomy • Patients with an anticipated RLV < 0,5% of the body weight were at risk of hepatic dysfunction • No deaths in the group of patients with RLV/BWR >0,5%
  4. 4. Remnant liver volume assessment Truant, World J Surg 2015
  5. 5. Shin, JGIS 2007
  6. 6. 29 patients pour CHC uninodulaire Child A Only hepatic venous pressure gradient > 10 mmHg was significant in multivariate analysis for decompensated cirrhosis after hepat. Risk factor in univariate analysis Bilirubin rate Urea rate Rate of platelet ICG Clearence Hepatic venous pressure gradiant, 1996 Décompensation de la cirrhose : Persistance d’une ascite à 3 mois
  7. 7. Cucchetti, J Hep 2016
  8. 8. Makuuchi, Semin Surg Oncol 1993 Ascites None or controlled Not controlled ICGR15 Limited resection Enucleation Not indicated for hepatectomy Trisectorectomy bisectorectomy Left-sided hepatectomy Right-sided sectoriectomy Segmentectomy Limited resection Enucleation Normal 1.1 – 1.5 mg/dL 1.6 – 1.9 mg/dL > 2.0 mg/dL Total bilirubin level Normal 10% - 19% 30% - 39% > 40%20% - 29% Adapter la chirurgie hépatique à la fonction…
  9. 9. Survivors (n = 113) Non-survivors (n = 14) P * All ICG retention at 15 min (%) 11 (3 - 50) 18 (4 - 29) 0.008 Aminopyrine breath test (%) 4-4 (1.3 - 9.6) 4.3 (2.8 – 8.3) 0.69 Amino acid clearance test (1 m-2 min-1) 0.21(1.7 to 4.3) 0.15 (-0.2 to 0.9) 0.35 Albumin (g l-1) 42 (31 - 53) 41 (29 - 46) 0.40 Total bilirubin (µmol l-1) 9 (3 - 70) 14 (7 - 32) 0.05 Aspartate aminotransferase (units l-1) 59 (17 - 365) 97 (39 - 340) 0.02 Alanine aminotransferase (units l-1) 53 (9 - 480) 53 (21 - 322) 0.90 0 15 35 [IGC]mg% Survivors Distribution of indocyanine green (ICG) retention at ? in for survivors and patients who died in hospital Non-survivors 5 25 40 10 20 45 30  127 hepatectomies dont 91 Majeures  Child A (n=121) / Child B (n=6)  Mortalité Hospitalière : 14/127 (11%)  Valeur seuil d’ICG à 15 minutes 15% pour les Hep. Maj 23% pour les Hep. Min. Lau, BJS 1997
  10. 10. 90 pts including including 17 major hep. : 30% of liver decompensation (20% ascite) Cescon, Ann Surg 2012
  11. 11. > 16 kpA: Ascite and/or POLF Cescon, Ann Surg 2012
  12. 12. Correlation is linear… YesNo PosthepatectomyPVP(mmHg) 22.5 mmHg 15 mmHg P < 0.001 Liver failure « 50-50 » criteria Portal pressure after major liver resection An independent predictor of liver failure and mortality after major resection (N = 277) in humans1 Allard, Ann Surg 2013
  13. 13. Comment évaluer la réserve fonctionnelle: les autres paramètres Scintigraphie hépatique De Graaf, J Nucl Med 2010

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