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Preoperative optimization for major hepatic resection

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Abstract

Purpose

Major hepatic resections are performed for primary hepatobiliary malignancies, metastatic disease, and benign lesions. Patients with chronic liver disease, including cirrhosis and steatosis, are at an elevated risk of malnutrition and impaired strength and exercise capacity, deficits which cause increased risk of postoperative complications and mortality. The aims of this report are to discuss the pathophysiology of changes in nutrition, exercise capacity, and muscle strength in patient populations likely to require major hepatectomy, and review recommendations for preoperative evaluation and optimization.

Methods

Nutritional and functional impairment in preoperative hepatectomy patients, especially those with underlying liver disease, have a complex and multifactorial physiologic basis that is not completely understood.

Results

Recognition of malnutrition and compromised strength and exercise tolerance preoperatively can be difficult, but is critical in providing the opportunity to intervene prior to major hepatic resection and potentially improve postoperative outcomes. There is promising data on a variety of nutritional strategies to ensure adequate intake of calories, proteins, vitamins, and minerals in patients with cirrhosis and reduce liver size and degree of fatty infiltration in patients with hepatic steatosis. Emerging evidence supports structured exercise programs to improve exercise tolerance and counteract muscle wasting.

Conclusions

The importance of nutrition and functional status in patients indicated for major liver resection is apparent, and emerging evidence supports structured preoperative preparation programs involving nutritional intervention and exercise training. Further research is needed in this field to develop optimal protocols to evaluate and treat this heterogeneous cohort of patients.

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Authors and Affiliations

  1. Division of Surgical Oncology, Department of Surgery, Oregon Health and Science University, 3181 S.W. Sam Jackson Park Rd., Mail Code: L223, Portland, OR, 97239, USA

    Sarah Walcott-Sapp & Kevin G. Billingsley

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  1. Sarah Walcott-Sapp
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  2. Kevin G. Billingsley
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Study conception and design: Billingsley; acquisition of data: Walcott-Sapp; analysis and interpretation of data: Billingsley and Walcott-Sapp; drafting of manuscript: Billingsley and Walcott-Sapp; critical revision of manuscript: Billingsley and Walcott-Sapp.

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Correspondence to Sarah Walcott-Sapp.

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All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. This article does not contain any studies with animals performed by any of the authors.

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Informed consent was obtained from all individual participants included in the study.

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Walcott-Sapp, S., Billingsley, K.G. Preoperative optimization for major hepatic resection. Langenbecks Arch Surg 403, 23–35 (2018). https://doi.org/10.1007/s00423-017-1638-x

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