Influence of the Functional Reserve of the Remnant Liver on Major Hepatectomy Combined With Pancreatoduodenectomy

Background/Purpose Major hepatopancreatoduodenectomy (HPD) is associated with a high risk of postoperative mortality, often due to pancreatic fistula formation and liver failure. We evaluated the impact of the functional reserve of the remnant liver on postoperative pancreatic fistula (POPF) formation and mortality. Methods Patients who underwent resection of ≥ 3 hepatic segments with pancreatoduodenectomy were retrospectively analyzed. The association of the future liver remnant‐to‐body weight ratio (FLR/BW) with POPF formation and mortality was assessed. With receiver operating characteristic (ROC) curve analysis, the optimal cutoff values were determined. Underlying pancreatic conditions were also examined. Results POPFs occurred in 64% of 177 patients. The predictors of POPFs included a high BMI, low pancreatic CT attenuation, and small pancreatic duct diameter. The FLR/BW was not associated with POPF formation. Postoperative mortality occurred in 6% of patients, mostly due to Grade C postpancreatectomy hemorrhage. An FLR/BW < 0.8% was an independent predictor of mortality (OR 15.79); patients with a ratio below 0.8% had a 14% mortality rate. Conclusions Poor remnant liver functional reserve is not associated with POPF formation but significantly increases mortality after major HPD. Ensuring sufficient liver reserve, perhaps through more proactive use of portal vein embolization or parenchyma‐sparing procedures, may improve outcomes.