Measurement of Liver Volume and Hepatic Functional Reserve
as a Guide to Decision-Making in Resectional Surgery
for Hepatic Tumors
KEIICHI KUBOTA, MASATOSHI MAKUUCHI, KOJI KUSAKA, TAKASHI KOBAYASHI, KENJI MIKI, KIYOSHI HASEGAWA,
YASUSHI HARIHARA, AND TADATOSHI TAKAYAMA
The respective volumes of hepatic tumors and nontumor-
ous parenchyma of 50 patients requiring hepatectomy of more
than one segment of Healey for tumor removal were measured
using computed tomography (Vol-CT). The volume estimated
by Vol-CT was found to correlate with the real weight resected
(P õ .0001) with a mean absolute error of 64.9 mL. The ratio
of the nontumorous parenchymal volume of the resected liver
to that of the whole liver (R2) in 15 patients who underwent
right or extended right hepatic lobectomy was 43% { 15%.
Eight of 15 patients with R2s õ 60% underwent the proce-
dures without right portal vein embolization (PE). The other
seven with R2s exceeding 60% or an indocyanine green reten-
tion rate after 15 minutes (ICG15) of 10% to 20% underwent
PE: in six of seven, the nontumorous parenchyma of the right
hepatic lobe became atrophic and in all seven, the volume of
the remaining left hepatic lobe increased with a decrease in
the mean R2 from 62% { 14% to 55% { 8% (P Å .0006). In
the remaining 35 who underwent other hepatectomy proce-
dures, R2s also remained õ60%. Overall, at surgery, in 27
with normal liver function (ICG15 õ 10%), R2s exceeded
60% in one, remained at 50% to 60% in five, and õ50% in
21, whereas 23 patients except for one with an ICG15 ex-
ceeding 10%, had R2s of õ50%. The postoperative serum
total bilirubin levels in 84% of the patients remained within
the normal range and there was no surgery-related mortality.
In conclusion, 1) Vol-CT can accurately assess the extent of
liver resection, 2) individuals with normal liver function can
undergo resection of up to 60% of the nontumorous paren-
chyma without the need for PE, and 3) PE can be used to
Abbreviations: RHL, right hepatic lobectomy; ERHL, extended right hepatic lobec-
tomy; PE, right portal vein embolization; CT, computed tomography; Vol-CT, volumet-
ric measurement of the liver using CT; ICG15, indocyanine green (0.5 mg/kg) retention
rate after 15 minutes; AE, absolute error; LHL, left hepatic lobectomy; VR, liver volume
including the tumor to be resected; WR, weight of the resected liver specimen; ELHL,
extended left hepatic lobectomy; HCC, hepatocellular carcinoma; VW, whole liver
volume including the tumor; VT, tumor volume; R1, VR/VW 1100; R2, (VR-VT)/
(VW-VT) 1100.
From the Second Department of Surgery, Faculty of Medicine, University of Tokyo,
Tokyo, Japan.
Received March 28, 1997; accepted July 7, 1997.
Supported in part by grants-in-aid for cancer research from the Japanese Ministry
of Health and Welfare and by a grant-in-aid for scientific research from the Ministries
of Health and Welfare and Education, Science and Culture of Japan, Tokyo, Japan
(grant 08407036).
Address reprint requests to: Keiichi Kubota, M.D., Ph.D., Assistant Professor, Sec-
ond Department of Surgery, Faculty of Medicine, University of Tokyo, 7-3-1 Hongo,
Bunkyo-ku, Tokyo 113, Japan. Fax: 81-3-5684-3989.
Copyright q 1997 by the American Association for the Study of Liver Diseases.
0270-9139/97/2605-0015$3.00/0
1176
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reduce the size of the resected tissue and increase the volume
of the remnant liver to approximate the target limits in indi-
viduals with large tumors or minimally abnormal liver func-
tion. (HEPATOLOGY 1997;26:1176-1181.)
With advances in perioperative care, including surgical
techniques, liver resection for patients with chronic liver
diseases can now be performed with low morbidity and mor-
tality.1-6 The operative procedures are usually selected on the
basis of liver function and the location and extent of the
tumor.6 In particular, as surgical procedures that involve
resection of a large proportion of the liver, such as right
(RHL) and extended (ERHL) right hepatic lobectomy, are
occasionally associated with postoperative liver failure,7 the
decision to perform them should be taken with care for each
individual. Recently, to improve the safety of RHL, right
portal vein embolization (PE) has been employed, according
to the remnant liver volume, to reduce the size of the liver
region to be resected and induce hypertrophy of the contra-
lateral liver.8 Thus, to select the most appropriate surgical
procedure, including PE, the extent of liver resection, in
terms of the resection volume to whole liver volume ratio,
should be estimated precisely.
Clinically, the liver volume has been measured to evaluate
liver regeneration after hepatectomy using several diagnostic
imaging techniques, such as scintigraphy,9,10 ultrasound,11,12
single-photon emission computed tomography,13,14 com-
puted tomography (CT),15-17 and magnetic resonance im-
aging.17 Because it was first reported by Heymsfield et al.,18
liver volume determination by CT has been used in the fields
of liver resection17,19,20 and transplantation21-24 and for evalu-
ating the progression of various diseases.25 Furthermore, vol-
umetric measurement of the liver using CT (Vol-CT) has
been shown to represent the volume precisely upon compari-
son with the actual resected liver weight, and recently it
has been used to assess graft sizes for living-related liver
transplantation.21-24 However, it has not yet been fully dis-
cussed how Vol-CT should be employed for selecting the
most suitable hepatectomy procedure.
In this study, the role of Vol-CT in helping to determine
appropriate surgical procedures, including PE, for patients
with hepatic tumors was investigated.
PATIENTS AND METHODS
Patients. This study was performed at the Second Department of
Surgery, Faculty of Medicine, University of Tokyo. Fifty patients
who underwent hepatic resection of more than one segment of
hepa WBS: Hepatology
HEPATOLOGY Vol. 26, No. 5, 1997
Healey and Schloy26 for hepatic tumor removal between November
1994 and February 1997 were included (male/female: 36/14, mean
age: 61 years). Their liver function was evaluated by determining
the indocyanine green (0.5 mg/kg) retention rate after 15 minutes
(ICG15), and an ICG15 of õ10% was considered normal.
Measurement of Liver Volume. Preoperative measurements of liver
volume were obtained using contrasted CT. Serial abdominal trans-
verse CT scans taken at 0.5- or 1.0-cm intervals, including the
segments between the dome of the diaphragm and the most caudal
part of the liver, were used to calculate the liver volume (mL) by
the method of Heymsfield18 with minor modifications. Each liver
slice was traced with a cursor, and the areas of the anterior, poste-
rior, medial and lateral segments and caudate lobe were calculated.
The right and middle hepatic veins, falciform ligament, umbilical
portion of the left portal vein, gallbladder, and inferior vena cava
were used to determine the respective borderlines of these segments.
Then, two ratios, R1 and R2, and the absolute error (AE) were
calculated using the following formula:
R1 Å [VR] / [VW] 1 100 (%);
R2 Å ([VR] 0 [VT]) / ([VW] 0 [VT]) 1 100 (%); and
AE Å ÉVR] 0 [WRÉ (mL).
Abbreviations are the following: VR Å liver volume including the
tumor to be resected (mL); VT Å tumor volume (mL); VW Å whole
liver volume including the tumor (mL); and WR Å weight of the
resected liver specimen (g).
R1 is the ratio of VR to VW, whereas R2 is the ratio of the
nontumorous parenchymal volume of the resected liver to that of
the whole liver.
Selection of Surgical Procedures. The surgical procedures were se-
lected mainly according to the serum total bilirubin level and liver
function.27 When a patient had an increased serum bilirubin level
because of cirrhosis itself, the area of nontumorous parenchyma to
be resected was limited. If the bilirubin level was more than twice
the upper limit of the normal range (normal range: ° 1.3 mg/dL),
hepatectomy was abandoned. In patients with a normal bilirubin
level, the extent of liver resection was determined according to the
ICG15: patients with a normal ICG15 and those with ICG15 values
of 10% to 20%, 20% to 30%, and exceeding 30% were subjected to
hepatectomy extended to trisegmentectomy or bisegmentectomy,
left hepatic lobectomy (LHL), anterior or posterior segmentectomy,
systematic subsegmentectomy, and limited resection, respectively,
and the results of volumetric measurement were referred to before
making a final decision about the surgical procedure. PE8 was indi-
cated for patients scheduled for RHL or ERHL whose R2s exceeded
60% of the normal liver or whose ICG15 values were between 10%
and 20%, and Vol-CT was repeated to evaluate the effect of PE 2
weeks later.
Serum Total Bilirubin Levels. The serum total bilirubin levels were
measured preoperatively and on the first, second, third, fourth,
fifth, seventh, tenth, and fourteenth postoperative days. Levels ex-
ceeding 1.4 mg/dL were considered high.
Statistical Analysis. To evaluate the correlation between liver vol-
ume including the tumor to be resected (VR) and weight of the
resected liver specimen (WR) in the 50 patients, the correlation
coefficient was estimated and its statistical significance (P õ .05)
was evaluated using Fisher’s Z-transformation. The R1s and R2s
before and after PE were compared using Student’s t test for paired
samples, and differences at P õ .05 were considered significant.
The data are expressed as mean { standard deviations.
RESULTS
Surgical Procedures, Liver Function, and Histological Find-
ings. RHL or ERHL, left (LHL) or extended left (ELHL) he-
patic lobectomy, anterior, lateral and posterior segmentecto-
mies and central bisegmentectomy were performed in 15, 15,
10, 5, 3, and 2 patients, respectively, with mean ICG15 values
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KUBOTA ET AL. 1177
of 7.6% { 4.5%, 10% { 8.0%, 12% { 8.6%, 12% { 6.5%,
12 { 3.7%, and 12% { 8.6%, respectively. Seven patients
with normal liver, seven with chronic hepatitis, and one with
liver cirrhosis underwent RHL or ERHL: 12 had ICG15 values
of õ10% and the remaining three had values of 11%, 12%,
and 20%, respectively. The mean ICG15 values in seven and
eight patients who underwent or did not undergo PE were
8% { 2.4% and 8% { 6.0%, respectively. Six patients with
normal liver, seven with chronic hepatitis, and two with
liver cirrhosis underwent LHL or ELHL: 11 had normal liver
function, three had ICG15 values of 10% to 20%, and one
had a value of 34%. The last of these patients had icteric-
type hepatocellular carcinoma (HCC). Three patients with
normal liver, seven with chronic hepatitis, and 10 with liver
cirrhosis underwent the other types of segmentectomy: four
had normal liver function and 16 had ICG15 values of 10%
to 20%. HCCs were diagnosed histologically in 33 patients
with chronic hepatitis or liver cirrhosis, metastatic lesions
were diagnosed in nine with normal livers, cholangiocellular
carcinoma was diagnosed in five with normal livers or
chronic hepatitis, and cavernous hemangioma, leiomyoma,
and granuloma were diagnosed in one each with normal
livers.
Volumetric Data. The whole liver volume including the tu-
mor (VWs), VRs, tumor volume (VTs), and tumor sizes of
the patients who underwent the above surgical procedures
are summarized in Table 1. The VWs and VRs were estimated
easily using CT images and it was possible to measure the
VTs in all the patients except one, who had multiple small
metastatic lesions from a colon cancer and subsequently un-
derwent RHL after PE. There was a significant correlation
between VR and WR, as shown in Fig. 1 (correlation coeffi-
cient, 0.984; P õ .0001). The mean AEs of the operative
procedures are also summarized in Table 1. As the extent of
liver resection increased, the AE tended to become larger
and the mean AE for the 50 patients was 64.9 mL (14%).
The R1s and R2s for the various surgical procedures are
summarized in Table 1. The differences between R1s and
R2s were remarkable, particularly in patients who underwent
RHL, ERHL, LHL, or ELHL for removal of large tumors.
Although the R1s of 10 of the 15 patients who underwent
RHL or ERHL exceeded 60%, the R2s of only 4 of 10 exceeded
this level, and these patients also underwent PE. Three other
patients underwent PE; two with R2s of 55% and 40% and
ICG15 values of 9% and 12%, respectively, who had chronic
hepatitis, and one whose R2 was 57% and ICG15 5%, who
was scheduled for ERHL with combined resection of the
inferior vena cava. Although the R1s of four of 15 patients
who underwent LHL or ELHL exceeded 60%, their R2s were
õ60%, whereas the R1s and R2s of the other 11 were õ47%
and 35%, respectively. The R1s and R2s of the remaining
10, 5, 3, and 2 patients who underwent anterior, lateral or
posterior segmentectomy, or central bisegmentectomy were
below 58%, 30%, 54%, and 37% and 56%, 25%, 41%, and
35%, respectively. The respective R1s and R2s of the 50
patients are shown in Fig. 2. (In patients who underwent
PE, R1s, and R2s after PE were used.) Overall, in 27 patients
with normal liver function, R2s exceeded 60% in one, re-
mained at 50% to 60% in five, and õ50% in 21, whereas 1
and 22 patients with ICG15 values exceeding 10% had R2s
of 56% and õ50%, respectively.
Effects of Portal Vein Embolization. In six of seven patients
who underwent PE, the nontumorous parenchyma of the
hepa WBS: Hepatology
1178 KUBOTA ET AL. HEPATOLOGY November 1997

TABLE 1. Volumetric Liver Data

AE (mL) R1 R2
Hepatectomy Procedure Number VS (mL) VR (mL) VT (mL) Size (cm) WR (g) (%) (%) (%)

Right or extended right

hepatic lobectomy 15 1682 { 617 1018 { 465 532 { 552 9.0 { 5.4 1002 { 521 87.9 (8.8) 59 { 10 43 { 15
PE (0) 8 1899 { 726 1134 { 568 753 { 615 10.7 { 6.1 1147 { 649 57 { 13 33 { 12
PE (/)
Before PE 7 1466 { 436 1034 { 367 314 { 460 7.4 { 4.4 70 { 9 63 { 12
After PE 7 1433 { 371 867 { 260 237 { 280 6.7 { 3.7 836 { 288 60 { 6 54 { 9
Left or extended left
hepatic lobectomy 15 1618 { 582 673 { 486 314 { 460 6.8 { 4.8 615 { 466 66.9 (10.9) 40 { 19 29 { 15
Anterior segmentectomy 10 1182 { 226 326 { 163 83 { 124 4.5 { 2.3 306 { 167 30.4 (9.9) 28 { 14 23 { 13
Lateral segmentectomy 5 1111 { 202 268 { 94 82 { 127 3.8 { 2.5 246 { 48 42.2 (17.2) 22 { 7 17 { 9
Posterior segmentectomy 3 1046 { 264 433 { 34 70 { 79 5.2 { 2.5 480 { 101 23 (4.8) 43 { 10 38 { 4
Central bisegmentectomy 2 1258 { 134 357 { 112 42 { 11 5.7 { 3.3 368 { 166 38 (10.3) 29 { 12 27 { 12
Mean AE 64.9 (13.8)

Abbreviations: PE, right portal vein embolization; VR, liver volume including tumor which would be resected; VT, tumor volume; VW, whole liver
volume including tumor; WR, weight of resected liver specimen; N, normal liver; CH, chronic hepatitis; LC, liver cirrhosis; AE (absolute error) Å [VR]
0 [WR], R1 Å [VR]/[VW] 1 100 (%); R2 Å ([VR]0[VT])/([VW] 0 [VT]) 1 100 (%).

right hepatic lobe became atrophic and the volume of the and other operative procedures, respectively, remained
remaining left hepatic lobe increased, whereas in the other within the normal range on the first, second, third, fourth,
patient, the former volume hardly changed, but the latter fifth, seventh, tenth, and fourteenth postoperative days. The
increased (Table 1). The tumor volume of the last patient levels in 3 of 15 who underwent RHL or ERHL and in 5 of
decreased significantly after transcatheter arterial emboliza-
tion. Overall, the R1s and R2s of the seven decreased from
69% { 8% and 62% { 14% to 61% { 7% and 55% { 8%,
respectively (P Å .0009 and .0006, respectively).
Serum Total Bilirubin Levels. The data for three patients who
had jaundice preoperatively because of icteric-type HCCs or
cholangiocellular carcinoma were excluded from this analy-
sis. Preoperatively, all the patients except for these three had
normal serum total bilirubin levels. The serum total bilirubin
levels of 12 and 27 patients who underwent RHL or ERHL

FIG. 1. Correlation between the estimated volume (VR) and actual re-
sected weight (WR). There was a statistically significant correlation between
VR and WR (correlation coefficient, 0.984; P õ .0001). (j) Right or ex-
tended right hepatic lobectomy; (h) left or extended left hepatic lobectomy;
(m) anterior segmentectomy; (l) posterior segmentectomy; (s) lateral
segmentectomy; and (●) central bisegmentectomy.
FIG. 2. R1s and R2s of 50 patients. The differences between R1s and
R2s were remarkable in patients who underwent RHL, ERHL, LHL, or ELHL
for removal of large tumors. In patients who underwent PE, R1s and R2s
after PE were used. (j) Right or extended right hepatic lobectomy; (h)
left or extended left hepatic lobectomy; (m) anterior segmentectomy; (l)
posterior segmentectomy; (s) lateral segmentectomy; and (●) central biseg-
mentectomy.

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HEPATOLOGY Vol. 26, No. 5, 1997 KUBOTA ET AL. 1179

the remaining 32 exceeded 1.4 mg/dL (Table 2): the levels in

([VR] 0 [VT])/([VW] 0 [VT]) 1 100 (%); ICG15, indocyanine green (0.5 mg/kg) retention rate after 15 minutes; HCC, hepatocellular carcinoma; ERHL, extended right hepatic lobectomy; RHL, right
hepatic lobectomy; PE, right portal vein embolization; LHL, left hepatic lobectomy; ELHL, extended left hepatic lobectomy; Ant Seg, anterior segmentectomy; Lat Seg, lateral segmentectomy; LC, liver
VW, whole liver volume including tumor; VR, liver volume including tumor which would be resected; VT, tumor volume; WR, weight of resected liver specimen; R1 Å [VR]/[VW] 1 100 (%); R2 Å
0.7

1.4
1.3
0.6
0.7
2.2
14
three of these eight returned to normal within 4 postoperative
days, those in two became normal on the seventh postopera-

0.8
0.8
0.8
1.8
0.9

2.6
10
tive day, those in two more stayed high until the 10th and

1
26th postoperative days, respectively, and that in the re-

Serum Total Bilirubin Level (mg/dL)

maining patient reached 1.4 mg/dL for the first time on the

0.7

0.6
1.3
1.2
1.2

0.9
7
14th postoperative day, but returned to normal on the follow-

2
ing day. Overall, there was no mortality related to the surgical
procedures.

1.1
0.9
0.6
2.1

1.4
2.4
0.9
5

2
DISCUSSION

1.2

0.6
0.7
2.2
1.4
2.7
1.1
Most patients with HCCs have chronic liver diseases, and

4
are therefore at risk of developing liver failure after hepatec-
tomy. In fact, chronic hepatitis or liver cirrhosis was diag-

1.4
0.6
0.6
2.1

1.7
1.4
3
nosed histologically in 34 of our 50 patients. Although the

2
1
normal liver is reported to tolerate removal of up to 70% of
its volume,28 the extent to which the liver parenchyma can

1.8

0.6
2.9
2.5
0.8
0.9
1.2
2

1
be resected in patients with chronic liver diseases has yet
to be elucidated. Therefore, in such patients, the surgical

0.9
1.4
0.6

2.4
1.2
1.2
1.2
1
procedures should be selected carefully. In our department,

4
surgical procedures are determined on the basis of the serum
total bilirubin level and ICG15 value.6 Although the relation-

0.5
0.9
0.7
0.7
0.6
0.7
0.7
0.8
Pre
TABLE 2. Details of Patients With High Serum Bilirubin Levels
ship between total liver volume and body weight is reported
to be relatively constant,29,30 the hepatic segmental and lobar
volumes may vary markedly,24 and therefore volumetric liver

Histology

CH
CH
CH
CH
LC

LC
LC
LC
measurements using CT are necessary before making a final
decision about the extent of liver resection in each case,
predicting the remnant liver function19,20,31 and deciding
whether PE is indicated.8

ICG15

7.6
9.8
10.2
7.3
17.3
(%)
Vol-CT can reflect the volume of the resected liver accu-

20
5
12
rately, as the current generation of CT systems have fairly
high resolutions, and the artifacts caused by respiratory (%)

18
34
49
39
58
21
25
3
R2

movements have been reduced considerably in comparison

with the old systems.14 Close relationships between the CT
and actual liver volumes in the fields of liver resection and
(%)
R1

52
71
66
65
61
24
25
12
liver transplantation15,21 have been reported, and in our pa-
tients the resected liver volumes were also predicted with
acceptable accuracy, as shown in Fig. 1. This suggests that
660
315
280
250
1530
1720
1410
1280
WR
(g)

the volume of any hepatic segment can be estimated precisely

by Vol-CT. However, it should be borne in mind that there
is the problem of the AE of Vol-CT, which tends to increase
(cm)
Size

5.5

1.5
14
13
9
16

as the extent of liver resection increases (mean, 64.8 mL).

A particular advantage of Vol-CT is that the tumor and
nontumorous parenchymal volumes can be measured sepa-
719
810

2
1200
1243

80
33

94
(mL)
VT

rately.14,17 In all of our patients except for one, it was possible

to estimate the respective segmental and tumor volumes. The
exceptional patient had multiple small metastatic lesions in
671
283
301
129
1500
1567
1414
1253
(mL)
VR

the right hepatic lobe, and therefore the total volume of these
lesions could not be measured accurately by this method.
The ratio of the resected volume, including tumors, relative
2900
2200
2140
1942
1096
1203
1201
1114
(mL)
VW

to the whole liver volume (R1) cannot predict the postopera-

tive function of the remaining liver. Therefore, after exclud-
ing the tumor volume, it is necessary to estimate the percent-
Hepatectomy

PE / RHL

cirrhosis; CH, chronic hepatitis.

age of the nontumorous parenchymal volume resected (R2),

Procedure

Ant Seg
Lat Seg
Lat Seg

which is considered to represent the amount of normally

ERHL
ERHL

ELHL
LHL

functioning liver lost. In previous studies, R2 was also termed

the parenchymal or effective resection ratio.14,17 In our study,
12 of 15 patients, who underwent RHL or ERHL had normal
Disease

liver function and tolerated resection of approximately 60%

HCC
HCC
HCC
HCC
HCC
HCC
HCC
HCC

of the nontumorous parenchyma, whereas the remaining

three with ICG15 values of 10% to 20% tolerated resection
of õ50% of the nontumorous parenchyma. In patients who
Age

underwent LHL or ELHL, anterior, lateral, and posterior seg-

67
47
63
54
62
63
70
62

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1180 KUBOTA ET AL.
mentectomies and central bisegmentectomy, the mean R2
values were 29%, 23%, 17%, 38%, and 27%, respectively, and
those with ICG15 values õ20% tolerated the operations well.
These results suggest that hepatectomy procedures involving
resection of up to 60% and 50% of the nontumorous paren-
chyma can be justified in patients with normal liver function
and those with ICG15 values õ20%, respectively.
This type of volume measurement is particularly essential
when performing RHL or ERHL in patients with chronic liver
diseases, as these procedures are always associated with a
risk of postoperative liver failure.7 Recently, although PE has
been introduced in an attempt to prevent postoperative liver
failure,8 clear criteria for the use of PE have not been estab-
lished. In our department, PE is, in principle, indicated when
the Vol-CT–estimated R2 exceeds 60% in patients with the
normal liver or when the ICG15 value is 10% to 20%. Four
and one patients underwent PE according to the first and
the second criterion, respectively. In addition, one patient
who was shown to have chronic hepatitis with R2 of 55%
and an ICG15 value of 9%, and another with a normal liver
who was scheduled for ERHL, underwent PE. Thus, a total
of seven patients underwent PE, the effects of which could
be evaluated by Vol-CT. During the 2 weeks following PE,
repeated CT showed a decrease in the nontumorous paren-
chyma of the right hepatic lobe in six of seven patients, and
hypertrophy of the left hepatic lobe in all seven. Our results
indicate that PE is useful for reducing the volume of the
right hepatic lobe to be resected and increasing that of the
contralateral hepatic lobe.
Two of eight patients who underwent RHL or ERHL with-
out PE had ICG15 values of 11% and 20%. In principle, PE
is indicated for patients with R2s exceeding 60% or ICG15
values of 10% to 20%, but in these two patients, as their
tumors were large and their R2s were 18% and 37%, almost
equal to one segment, RHL was considered not to be exces-
sive, as discussed above, and it was performed successfully
without PE. Vol-CT is considered useful for evaluating the
adequacy of surgical procedures for patients with large tu-
mors. Thus, for a total of 15 patients, including three with
ICG15 values of 10% to 20%, who were not originally candi-
dates for RHL, the procedure, selected according to the sup-
portive CT volumetric data, was found to be justifiable and
carried out uneventfully. The postoperative serum total bili-
rubin levels in most of these patients remained within the
normal range, indicating that our criteria for PE are reason-
able.
The postoperative courses of all our patients were unevent-
ful. The postoperative serum total bilirubin levels in 39 re-
mained within the normal range, whereas those in three of
15 who underwent RHL and five of 32 who underwent other
surgical procedures were slightly elevated. All these eight
patients had chronic liver diseases. The levels in five returned
to normal within seven postoperative days, those in two re-
mained high until the 10th and 26th postoperative days,
respectively, and one patient had a level of 1.4 mg/dL on the
14th postoperative day, which might have been attributable
to a cause other than surgery. Although the surgical proce-
dures selected might be a considerable burden to these pa-
tients with high serum total bilirubin levels, they tolerated
surgery well and there was no associated mortality. This
good clinical outcome lends support to our criteria, including
volumetric measurement of the liver, for selection of the
appropriate surgical procedure.
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HEPATOLOGY November 1997
In conclusion: 1) Vol-CT can accurately assess the extent
of liver resection; 2) individuals with normal hepatic function
can undergo resection of up to 60% of the nontumorous
parenchyma without the need for PE; and 3) PE can be used
to reduce the size of the resected tissue and increase the
volume of the residual liver to approximate these limits in
individuals with large tumors or minimally abnormal liver
function.
REFERENCES
1. Makuuchi M, Hasegawa H, Yamazaki S. Ultrasonically guided subseg-
mentectomy. Surg Gynecol Obstet 1985;161:346-350.
2. Al-Hadeedi S, Choi TK, Wong J. Extended hepatectomy for hepatocellu-
lar carcinoma. Br J Surg 1990;77:1247-1250.
3. Scheele J, Stangl R, Altendorf-Hofmann A. Hepatic metastases from
colorectal carcinoma: impact of surgical resection on the natural history.
Br J Surg 1990;77:1241-1246.
4. Paquet KJ, Koussouris P, Mercado MA, Kalk JF, Muting D, Rambach
W. Limited hepatic resection for selected cirrhotic patients with
hepatocellular or cholangiocellular carcinoma: a prospective study.
Br J Surg 1991; 78:459-462.
5. Wu C-C, Yang M-D, Liu T-J. Improvements in hepatocellular carcinoma
resection by intraoperative ultrasonography and intermittent hepatic
inflow blood occlusion. Jpn J Clin Oncol 1992;22:107-112.
6. Miyagawa S, Makuuchi M, Kawasaki S, Kakazu T. Criteria for safe
hepatic resection. Am J Surg 1995;169:589-594.
7. Thompson HH, Tompkins RK, Longmire WP. Major hepatic resection:
A 25-year experience. Ann Surg 1983;197:375-388.
8. Makuuchi M, Thai BL, Takayasu K, Takayama T, Kosuge T, Gunven P,
Yamazaki S, et al. Preoperative portal embolization to increase safety of
major hepatectomy for hilar bile duct carcinoma: a preliminary report.
Surgery 1990;107:521-527.
9. Rollo FD, De Land FH. The determination of liver mass from radionu-
clide imaging. Radiology 1968;91:1191-1194.
10. Lin TY, Lee CS, Chen CC, Liaw KY, Lin WSJ. Regeneration of human
liver after hepatic lobectomy studied by repeated liver scanning and
repeated biopsy. Ann Surg 1979;190:48-53.
11. Carr D, Duncan JG. Liver volume determination by ultrasound: a feasi-
bility study. Br J Radiol 1976;49:776-778.
12. Van Thiel DH, Hagler NG, Schade RR, Skolnick ML, Heyl AP, Rosen-
blum E, Galaver JS, et al. In vivo hepatic volume determination using
sonography and computed tomography. Gastroenterology 1985;88:
1812-1817.
13. Kan MK, Hopkins GB. Measurement of liver volume by emission com-
puted tomography. J Nucl Med 1979;20:514-520.
14. Jansen PLM, Chamuleau RAFM, van Leeuwen DJ, Schipper HG, Buse-
mann-Sokole E, van der Heyde MN. Liver regeneration and restoration
of liver function after partial hepatectomy in patients with liver tumors.
Scand J Gastroenterol 1990;25:112-118.
15. Nagasue N, Yukaya H, Ogawa Y, Kahno H, Nakamura T. Human
liver regeneration after major hepatectomy. Ann Surg 1987; 206:30-
39.
16. Chen M-F, Hwang T-L, Hung C-F. Human liver regeneration after major
hepatectomy: A study of liver volume by computed tomography. Ann
Surg 1991;213:227-229.
17. Ogasawara K, Une Y, Nakajima Y, Uchino J. The significance of measur-
ing liver volume using computed tomographic images before and after
hepatectomy. Jpn J Surg 1995;25:43-48.
18. Heymsfield SB, Fulenwider T, Nordlinger B, Barlow R, Sones P, Kutner
M. Accurate measurement of liver, kidney and spleen volume and
mass by computerized axial tomography. Ann Intern Med 1979;90:185-
187.
19. Okamoto E, Kyo A, Yamanaka N, Tanaka N, Kuwata K. Prediction of
the safe limits of hepatectomy by combined volumetric and functional
measurements in patients with impaired hepatic function. Surgery 1984;
95:586-592.
20. Yamanaka N, Okamoto E, Kawamura E, Kato T, Oriyama T, Fujimoto
J, Furukawa K, et al. Dynamics of normal and injured human liver
regeneration after hepatectomy as assessed on the basis of computed
tomography and liver function. HEPATOLOGY 1993;18:79-85.
21. Broelsch CE, Emond JC, Whitington PF, Thistlethwaite JR, Baker AL,
Lichtor JL. Application of reduced-size liver transplants as split grafts,
auxiliary orthotopic grafts, and living related segmental transplants.
Ann Surg 1990;212:368-377.
hepa WBS: Hepatology
HEPATOLOGY Vol. 26, No. 5, 1997 KUBOTA ET AL. 1181

22. Broelsch CE, Whitington PF, Emond JC, Heffron TG, Thistlethwaite
JR, Stevens L, Piper J, et al. Liver transplantation in children from living
related donors. Ann Surg 1991;214:428-439.
23. Higashiyama H, Yamaguchi T, Mori K, Nakano Y, Yokoyama T, Take-
uchi T, Yamamoto N, et al. Graft size assessment by preoperative com-
puted tomography in living related partial liver transplantation. Br J
Surg 1993;80:489-492.
24. Kawasaki S, Makuuchi M, Matsunami H, Hashikura Y, Ikegami T, Chi-
suwa H, Ikeno T, et al. Preoperative measurement of segmental liver
volume of donors for living related liver transplantation. HEPATOLOGY
1993;18:1115-1120.
25. Henderson JM, Warren WD, Millikan WJ, Galloway JR, Kawasaki S,
Stahl RL, Hertzler G. Surgical options, hematologic evaluation, and
pathologic changes in Budd-Chiari syndrome. Am J Surg 1990;159:41-
50.
26. Healey JE Jr, Schroy PC. Anatomy of the biliary ducts within the human
liver; analysis of the prevailing pattern of branching and the major
variations of the biliary ducts. Arch Surg 1953;66:599-616.
27. Makuuchi M, Kosuge T, Takayama T, Yamazaki S, Kakazu T, Miyagawa
S, Kawasaki S. Surgery for small liver cancers. Semin Surg Oncol 1993;
9:298-304.
28. Stone HH, Long WD, Smith RB III, Haynes CD. Physiological considera-
tions in major hepatic resection. Am J Surg 1969;117:78-84.
29. DeLand FH, North WA. Relationship between liver size and body size.
Radiology 1968;91:1195-1198.
30. Henderson JM, Heymsfield SB, Horowitz J, Kutner MH. Measurement
of liver and spleen volume by computed tomography. Radiology 1981;
141:525-527.
31. Tanabe M, Tamai T, Mimura H, Orita K, Tsumura M, Mizukawa K, Satoh
K, et al. Clinical values for an index predicting postoperative residual liver
function by preoperative liver scintigraphy in patients with liver disease.
Ann Nucl Med 1989;3:25-29.

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