Liver perfusion failure after pancreatoduodenectomy: clinical significance and perioperative risk factors

The definition of liver perfusion failure (LPF) following pancreatic surgery and its perioperative risk factors remain unclear. This study aimed to define clinically significant LPF among patients undergoing partial pancreatoduodenectomy (PD) or total pancreatoduodenectomy (TP) and to identify perioperative risk factors associated with its incidence.

Patients undergoing partial PD/TP between 2014 and 2017 were identified from a prospectively maintained database. Various criteria for identifying LPF over time (that is, on postoperative days 1-4) were evaluated for clinical significance based on their association with liver-specific complications. Univariable and multivariable analyses were performed to determine the association of LPF with relevant outcome parameters and perioperative risk factors.

In the analysis of 815 patients, the optimal LPF model was identified as an increase in liver enzymes (alanine aminotransferase (ALT) and aspartate aminotransferase (AST)) ≥ 200 U/l for two consecutive days (LPF_2d). LPF severity was categorized as no LPF (AST/ALT < 200 U/l), mild (AST/ALT ≥ 200-< 500 U/l), moderate (AST/ALT ≥ 500-< 1000 U/l), and severe (AST/ALT ≥ 1000 U/l). In all, 81 patients were identified with LPF: 29 (3.6%), 29, and 23 with mild, moderate, and severe LPF, respectively. The occurrence of LPF was significantly associated with postoperative outcomes, including liver-specific complications, liver failure, need for radiological interventions, length of intensive care unit stay, and 90-day mortality. Multivariable analysis identified coeliac axis stenosis, arterial resection, and duration of the operation as independent risk factors for LPF.

LPF is an underrated and serious postoperative complication in patients undergoing partial PD or TP. Based on the proposed definition (LPF_2d), LPF occurs in 9% of patients, is clinically relevant, and is associated with postoperative complications.