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Establishing the Minimum Future Liver Remnant Volume for Safe Hepatectomy
John A Steinharter1, Joanne Chou2, Crisanta H Ilagan1,3
1From the Hepatopancreatobiliary Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY (Steinharter, Ilagan, Saadat, Soares, Wei, Kingham, D'Angelica, Jarnagin).
Journal of the American College of Surgeons
|January 27, 2026
Summary
Adequate future liver remnant volume (FLRV%) is crucial for reducing post-hepatectomy liver failure (PHLF). Safe FLRV% thresholds vary by liver quality: ≥30% for normal livers and ≥50% for impaired livers, impacting PHLF-related morbidity.
Area of Science:
- Hepatobiliary surgery
- Surgical oncology
- Liver transplantation
Background:
- Post-hepatectomy liver failure (PHLF) is a significant risk following major liver resections.
- Adequate future liver remnant volume (FLRV%) is a key factor in preventing PHLF.
- Determining safe FLRV% thresholds is critical for patient outcomes.
Purpose of the Study:
- To evaluate the association between FLRV% and severe (grade 4/5) morbidity.
- To identify safe FLRV% thresholds for preventing both PHLF-related and non-PHLF-related major morbidity after hepatectomy.
Main Methods:
- Retrospective analysis of 1,748 patients undergoing major hepatectomy for malignancy (2000-2020).
- Assessment of FLRV%, morbidity grading, and cause of morbidity (PHLF-related vs. non-PHLF-related).
- Stratification of patients into normal liver (NL) and impaired liver (IL) groups; data split into training and testing cohorts for threshold validation.
Main Results:
- A significant inverse association was found between FLRV% and grade 4/5 PHLF-related morbidity (OR: 0.61 per 10% increase, p=0.002).
- No significant association was observed between FLRV% and non-PHLF-related grade 4/5 morbidity (OR: 0.95, p=0.65).
- Established safe minimum FLRV% thresholds: ≥30% for NL and ≥50% for IL.
Conclusions:
- FLRV% strongly correlates with PHLF-related morbidity, highlighting its importance in liver remnant quality.
- Safe resection limits are liver-quality dependent, with higher thresholds needed for impaired livers.
- Approximately 50% of severe morbidity was unrelated to PHLF and not influenced by FLRV%.
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