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Michael Kuncewitch*1, Mary Garland1, Rafel Tappouni2, Perry Shen1
1Surgical Oncology, Wake Forest School of Medicine, Winston Salem, NC; 2Radiology, Wake Forest University, Winston-Salem, NC

Introduction: Accurate pre-operative assessment of anticipated future liver volume (FLV) following major hepatectomy is essential in optimizing outcomes and preventing post-operative liver insufficiency. Conventional methods of estimating FLV include estimating liver volume by body surface area (BSA), use of cross-sectional volume measurements, or software-based 3-dimensional reconstructions. The purpose of this study was to apply all three methods to a select set of patients and compare anticipated and actual outcomes.
Methods: We identified 11 patients who underwent major hepatectomy by a single surgeon utilizing liver volume information provided by three-dimensional liver rendering software. We then retrospectively calculated the anticipated FLV for those patients according to both BSA and CT imaging volumetry. Operative outcomes as well as the utilization of pre-operative portal vein embolization (PVE) were analyzed in an attempt to identify how pre-operative decision making would be influenced by the results of one measurement vs another.
Results: Nine of the 11 patients underwent extended right hepatectomy. One patient underwent right hepatectomy and the other underwent a staged left hepatectomy following a prior right segmentectomy. There were no perioperative deaths. Six patients underwent pre-operative PVE based on software predicted FLV. Two patients developed post-operative liver insufficiency, both of whom underwent pre-operative right PVE. In both cases the three-dimensional volume rendering predicted an adequate post-embolization FLV whereas CT volumetry did not and would have led to non-operative management in these cases. Oppositely, we identified one case in which CT volumetry would have predicted an insufficient FLV and possibly treatment with PVE. The software predicted an adequate FLV and the patient had an uneventful post-operative course. On average, CT volumetry led to 10.2% reduction in the anticipated FLV compared to the three-dimensional rendering, whereas FLV estimation by BSA led to an 8.5% increase in anticipated FLV relative to the rendering. CT volumetry would have led to an 18% (2/11) change in management of patients - withholding surgery or additional procedure prior to surgery.
Conclusions: In our experience, relative to the three dimensional software prediction, BSA will overestimate and CT volumetry will underestimate anticipated FLV following major hepatectomy. On these grounds, utilization of CT volumetry may lead to unnecessary PVE or rejection of some patients as surgical candidates who might otherwise successfully undergo major hepatectomy.

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