Scientific letter
Treatment of Hepatic Failure After Hepatectomy by the MARS Hepatic Dialysis System
Tratamiento del fallo hepático después de hepatectomía mediante sistema de diálisis hepática MARS
Antonio Martin Malagon
, Liliana Pezzetta, Iván Arteaga Gonzalez, Hermógenes Diaz Luis, Ángel Carrillo Pallares
Corresponding author
Servicio de Cirugía General y Digestiva, Hospital Universitario de Canarias, San Cristóbal de la Laguna, S/C de Tenerife, Spain
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In the case of livers with colorectal metastasis treated with preoperative chemotherapy, this volume has not been well defined, which, together with oncologic-surgical treatments that are becoming more and more aggressive, has led to PHLF currently being the main cause of death after liver resection due to colorectal cancer metastasis.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">There is little information about the best treatment for this complication once it has been established as it is considered a very serious situation with few therapeutic alternatives. The molecular absorbent recirculating system (MARS) is an extracorporeal liver dialysis system that uses a liquid solution rich in albumin to partially substitute the filtering function of the liver. It has been proposed by some authors as a treatment option, although it has not been shown to increase the survival of these patients in the few articles that have been published.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2–5</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">We present the case of a 48-year-old female patient with 7 bilobar liver metastases. The lesions were colorectal in origin and resected with right hepatectomy, with limited resection of 2 tumors in the left liver. Given the small size of the masses, we decided to use a direct surgical approach to avoid the disappearance of the lesions from the left side with chemotherapy. The volume of the left liver lobe calculated by CT was 32%; this was considered adequate, so preoperative portal embolization was not done. Surgery was completed without clamping the pedicle and blood loss amounted to 300<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleSup">3</span>.</p><p id="par0020" class="elsevierStylePara elsevierViewall">During the immediate postoperative period, the patient presented a good general state with no signs of encephalopathy, bleeding or infection. We did observe, however, a progressive decline in the hepatic profile with total bilirubin levels that progressively reached 11<span class="elsevierStyleHsp" style=""></span>mg/dl on the 9th day post-op, together with prothrombin time (PT) of 47%; the indocyanine green plasma disappearance rate (ICG-PDR) at that time was 10%/min. After a CT scan and exploratory laparotomy that ruled out a bile leak, bleeding or intraabdominal abscess, the only condition that justified PHLF was a culture of the drained liquid positive for pseudomonas, which was treated according to the antibiogram. Given the progressive liver function deterioration, it was decided to administer 4 MARS sessions after the 10th day post-op, which progressively reduced bilirubin levels and increased PT (<a class="elsevierStyleCrossRefs" href="#fig0005">Figs. 1 and 2</a>). The patient was discharged 30 days after the procedure with bilirubin 2.3<span class="elsevierStyleHsp" style=""></span>mg/dl and PT 82%.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">This complication was unexpected since the patient had not received preoperative chemotherapy, the procedure was done without clamping and with very limited bleeding, and the volume of the liver remnant was larger than 30%. Nonetheless, this calculation was made by measuring the total volume of the liver on CT and not by using the standardized formula based on surface area, which could have underestimated risk for PHLF.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Furthermore, infection of the surgical site may have perpetuated the symptoms, although we do not believe that this was the cause. It probably occurred after the second procedure, because until that time the leukocyte count and the appearance of the drained fluid were completely normal. It is difficult to know if the patient would have spontaneously recovered liver function with treatment of the surgical site infection alone. But, as bilirubin levels above 7<span class="elsevierStyleHsp" style=""></span>mg/dl in cases of PHLF are a strong predictor for mortality,<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> we decided to apply the MARS treatment straight away.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Experience with the use of MARS for the treatment of PHLF is very limited, with only 15 published cases and a mortality of 80%.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2–5</span></a> Nonetheless, in most of these cases, treatment was initiated later on or in patients with multi-organ failure. According to Inderbitzin et al.,<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> the main prognostic factor for response to treatment is minimal liver functionality, defined by a ICG-PDR >5%/min. In our case, the treatment was applied early on, there were no serious surgical complications that perpetuated the PHLF and the liver function at the time of maximum hyperbilirubinemia was relatively good (ICG-PDR 10%/min), which could explain the satisfactory evolution of our patient.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflict of Interests</span><p id="par0035" class="elsevierStylePara elsevierViewall">No funding was received for this article, and the authors have no conflict of interests to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflict of Interests" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:2 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Martin Malagon A, Pezzetta L, Arteaga Gonzalez I, Diaz Luis H, Carrillo Pallares Á. Tratamiento del fallo hepático después de hepatectomía mediante sistema de diálisis hepática MARS. Cir Esp. 2014;92:688–690.</p>" ] 1 => array:2 [ "etiqueta" => "☆☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">This paper was presented as a poster communication at the 29th National Meeting of Surgeons held in Burgos, Spain on October 23–25, 2013.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1336 "Ancho" => 2175 "Tamanyo" => 124786 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Evolution of total bilirubin levels in the immediate postoperative period.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1401 "Ancho" => 2173 "Tamanyo" => 117824 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Evolution of the PT levels in the immediate postoperative period.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:7 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Posthepatectomy liver failure: a definition and grading by the International Study Group of Liver Surgery (ISGLS)" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "N.N. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 October | 13 | 6 | 19 |
| 2024 September | 27 | 1 | 28 |
| 2024 August | 33 | 7 | 40 |
| 2024 July | 17 | 3 | 20 |
| 2024 June | 17 | 2 | 19 |
| 2024 May | 21 | 7 | 28 |
| 2024 April | 30 | 4 | 34 |
| 2024 March | 18 | 4 | 22 |
| 2024 February | 23 | 4 | 27 |
| 2024 January | 17 | 2 | 19 |
| 2023 December | 23 | 4 | 27 |
| 2023 November | 28 | 5 | 33 |
| 2023 October | 24 | 5 | 29 |
| 2023 September | 12 | 3 | 15 |
| 2023 August | 17 | 3 | 20 |
| 2023 July | 21 | 2 | 23 |
| 2023 June | 9 | 2 | 11 |
| 2023 May | 25 | 2 | 27 |
| 2023 April | 46 | 2 | 48 |
| 2023 March | 23 | 0 | 23 |
| 2023 February | 22 | 4 | 26 |
| 2023 January | 15 | 6 | 21 |
| 2022 December | 21 | 14 | 35 |
| 2022 November | 32 | 14 | 46 |
| 2022 October | 28 | 5 | 33 |
| 2022 September | 32 | 28 | 60 |
| 2022 August | 35 | 7 | 42 |
| 2022 July | 23 | 7 | 30 |
| 2022 June | 24 | 12 | 36 |
| 2022 May | 27 | 17 | 44 |
| 2022 April | 26 | 3 | 29 |
| 2022 March | 22 | 8 | 30 |
| 2022 February | 27 | 6 | 33 |
| 2022 January | 26 | 10 | 36 |
| 2021 December | 30 | 9 | 39 |
| 2021 November | 15 | 9 | 24 |
| 2021 October | 33 | 8 | 41 |
| 2021 September | 17 | 14 | 31 |
| 2021 August | 43 | 8 | 51 |
| 2021 July | 13 | 8 | 21 |
| 2021 June | 25 | 7 | 32 |
| 2021 May | 20 | 8 | 28 |
| 2021 April | 25 | 9 | 34 |
| 2021 March | 20 | 7 | 27 |
| 2021 February | 17 | 5 | 22 |
| 2021 January | 13 | 12 | 25 |
| 2020 December | 13 | 11 | 24 |
| 2020 November | 22 | 17 | 39 |
| 2020 October | 15 | 5 | 20 |
| 2020 September | 16 | 12 | 28 |
| 2020 August | 15 | 4 | 19 |
| 2020 July | 15 | 11 | 26 |
| 2020 June | 12 | 7 | 19 |
| 2020 May | 14 | 9 | 23 |
| 2020 April | 13 | 7 | 20 |
| 2020 March | 15 | 3 | 18 |
| 2020 February | 14 | 5 | 19 |
| 2020 January | 20 | 6 | 26 |
| 2019 December | 21 | 10 | 31 |
| 2019 November | 17 | 7 | 24 |
| 2019 October | 10 | 4 | 14 |
| 2019 September | 15 | 3 | 18 |
| 2019 August | 10 | 9 | 19 |
| 2019 July | 19 | 25 | 44 |
| 2019 June | 52 | 22 | 74 |
| 2019 May | 94 | 30 | 124 |
| 2019 April | 52 | 22 | 74 |
| 2019 March | 10 | 4 | 14 |
| 2019 February | 15 | 12 | 27 |
| 2019 January | 10 | 6 | 16 |
| 2018 December | 7 | 8 | 15 |
| 2018 November | 16 | 3 | 19 |
| 2018 October | 9 | 9 | 18 |
| 2018 September | 21 | 1 | 22 |
| 2018 August | 1 | 2 | 3 |
| 2018 July | 6 | 7 | 13 |
| 2018 June | 9 | 3 | 12 |
| 2018 May | 14 | 2 | 16 |
| 2018 April | 6 | 2 | 8 |
| 2018 March | 8 | 1 | 9 |
| 2018 February | 5 | 0 | 5 |
| 2018 January | 13 | 0 | 13 |
| 2017 December | 6 | 1 | 7 |
| 2017 November | 10 | 0 | 10 |
| 2017 October | 13 | 2 | 15 |
| 2017 September | 18 | 3 | 21 |
| 2017 August | 12 | 2 | 14 |
| 2017 July | 18 | 2 | 20 |
| 2017 June | 23 | 2 | 25 |
| 2017 May | 20 | 7 | 27 |
| 2017 April | 25 | 9 | 34 |
| 2017 March | 21 | 24 | 45 |
| 2017 February | 20 | 2 | 22 |
| 2017 January | 27 | 5 | 32 |
| 2016 December | 19 | 6 | 25 |
| 2016 November | 22 | 9 | 31 |
| 2016 October | 34 | 8 | 42 |
| 2016 September | 49 | 2 | 51 |
| 2016 August | 30 | 4 | 34 |
| 2016 July | 34 | 2 | 36 |
| 2016 June | 19 | 8 | 27 |
| 2016 May | 34 | 10 | 44 |
| 2016 April | 35 | 10 | 45 |
| 2016 March | 25 | 10 | 35 |
| 2016 February | 32 | 10 | 42 |
| 2016 January | 35 | 13 | 48 |
| 2015 December | 22 | 16 | 38 |
| 2015 November | 28 | 9 | 37 |
| 2015 October | 31 | 10 | 41 |
| 2015 September | 37 | 6 | 43 |
| 2015 August | 56 | 11 | 67 |
| 2015 July | 38 | 4 | 42 |
| 2015 June | 14 | 9 | 23 |
| 2015 May | 29 | 6 | 35 |
| 2015 April | 37 | 18 | 55 |
| 2015 March | 11 | 8 | 19 |
| 2015 January | 0 | 1 | 1 |
| 2014 December | 2 | 1 | 3 |
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