المتخصصون في المجالات الطبية

July 07, 2026

Determining resectability in patients with liver tumors and concomitant liver disease can be challenging. For surgeons at Mayo Clinic, this decision has moved beyond basic volumetric thresholds to more precise measures of various functional risk components.

"When we identify risk, we can often modify it preoperatively so that patients once deemed ineligible can undergo surgery," says Patrick P. Starlinger, M.D., Ph.D., a hepatobiliary and pancreatic surgeon at Mayo Clinic Comprehensive Cancer Center in Rochester, Minnesota. "Our efforts after surgery to rapidly recognize and treat complications have also enhanced our ability to offer complex surgical procedures."

This continuum of risk assessment, surgical optimization and postoperative rescue is central to the modern framework for expanding eligibility for liver resection.

Preoperative liver function testing

Successful hepatectomy requires anatomical considerations, such as preserving biliary drainage and blood flow into and out of the liver. Equally critical is leaving a sufficient future liver remnant (FLR) to prevent posthepatectomy liver failure, a leading cause of postoperative mortality.

Volumetry is a widely used tool for determining resectability. In general, healthy individuals require an FLR of approximately 20% to 25% of total liver volume, with higher thresholds for patients who have received chemotherapy or have cirrhosis.

"While these volumetric measurements are useful, they ignore baseline liver function as well as the heterogeneity of liver disease we see in practice," Dr. Starlinger says. "Indeed, the vast majority of our patients today experience some form of underlying liver disease."

To enhance preoperative assessment, Mayo Clinic researchers have pioneered a risk stratification model to estimate the probability of liver failure following hepatectomy. Described in a 2025 article in Liver Transplantation, the model incorporates two scores based on routine laboratory tests:

• APRI+ALBI score, a measure of liver function and health that combines aspartate aminotransferase (AST)-to-platelet ratio index (APRI) and albumin–bilirubin grade (ALBI).
• Von Willebrand factor antigen, a correlate of portal hypertension.

To support broader clinical adoption of this model, the research team developed a smartphone application that generates patient-specific risk estimates prior to liver resection.

Additional biomarkers also are under investigation. For example, a 2025 study published in the Annals of Surgical Oncology found that circulating microRNAs have even greater predictive accuracy.

"Our current focus is on combining these functional risk scores with volumetric data so we can be very specific about the volume of liver that needs to be preserved," Dr. Starlinger says. "As mortality remains a significant challenge, we are excited that we can now routinely offer a more holistic assessment to make liver surgery safer. It also enables us to consider complex surgical procedures in patients that otherwise would be deemed unresectable."

Preoperative patient optimization

For patients with marginal liver volume, impaired liver function or high-risk comorbidities, targeted strategies can improve candidacy for resection.

Liver volume modulation

Preoperative volume modulation aims to increase the size of the future liver remnant before surgery. Portal vein embolization (PVE) is a well-established technique that directs blood flow away from the diseased portion of the liver, stimulating growth in the nondiseased segments.

In patients requiring extensive resections, Mayo Clinic surgeons may perform portal vein embolization with occlusion of the hepatic vein(s) — typically using a vascular plug — in a technique known as liver venous deprivation (LVD). This technique induces greater and more rapid hypertrophy of the future liver remnant than portal vein embolization alone.

The timing of volume modulation and hepatectomy depends on the approach used:

• PVE is typically performed 4 to 6 weeks before resection.
• LVD typically allows surgery within 3 to 4 weeks.

Managing comorbidities and metabolic risk before liver surgery

Optimizing comorbid conditions is another key component of preoperative preparation. Patients with poorly controlled diabetes, cardiovascular disease and other chronic conditions benefit from multidisciplinary evaluation and optimization. "Mayo Clinic surgeons work with a wide range of specialists to manage patients before surgery," Dr. Starlinger says.

One notable example of this partnership is the management of carcinoid heart disease in patients with neuroendocrine tumors that have metastasized to the liver. Serotonin secreted by the tumor can lead to scarring and plaque formation, especially in the right-sided heart valves. Through advanced cardiac evaluation and optimization, including surgical intervention when necessary, patients can safely proceed to liver resection, according to a 2025 study in the Annals of Surgical Oncology.

Tailoring surgical risk assessment based on genetic predisposition

Chemotherapy has been very helpful in managing patients with different types of liver tumors. However, it also has the potential to harm the liver — a phenomenon that is called chemotherapy-associated liver injury (CALI). However, the extent of liver injury can strikingly vary between patients, for reasons that remain largely unknown. Research published in 2025 in eBioMedicine found that a genetic variation in the patatin-like phospholipase domain-containing protein 3 (PNPLA3) gene worsens CALI in patients with colorectal cancer liver metastasis and outcomes following hepatectomy.

"This genetic predisposition is helping guide our clinical decision-making in assessing surgical risk and determining whether to use neoadjuvant chemotherapy or the extent of its use in high-risk patients," Dr. Starlinger says.

Surgical planning for liver surgery

High-quality preoperative imaging is essential for successful liver resection. Advanced CT and MRI protocols use precise timing of contrast media administration to provide detailed visualization of the hepatic vasculature and biliary tree.

New patients often need repeat imaging to ensure optimal surgical planning. In complex cases, 3D-printed liver models created by Mayo Clinic's 3D anatomic modeling laboratories further support preoperative decision-making and allow surgeons to refine operative strategy.

Postoperative management of liver resection complications

Despite meticulous preparation, serious complications can occur in some patients after liver surgery. Outcomes are strongly influenced by a center's ability to rapidly recognize and manage these complications. The inability to do this is called failure to rescue.

A 2025 study published in JHEP Reports examined outcomes of patients undergoing hepatectomy for perihilar cholangiocarcinoma across three successive surgical eras. Although surgical complexity increased with largely stable complication rates, failure to rescue declined from 29.2% to 9.7%, and mortality fell drastically from 12.1% to 3.9%.

At Mayo Clinic, interventional radiologists and gastroenterologists manage postoperative complications using minimally invasive, endoscopic or image-guided techniques, reducing the need for reoperation. "Their exceptional skill helps save lives and assists in faster patient recovery," Dr. Starlinger says.

When to refer a patient for liver surgery

Mayo Clinic collaborates with referring physicians, offering both comprehensive multidisciplinary evaluations and surgery-only consultations. Patients traveling for care can often receive medical oncology treatments and follow-up care closer to home.

Early referral to a high-volume liver surgery center is critical, especially when resectability is uncertain. It also is important to refer before attempting resection or the use of liver-directed therapies, such as any form of radiation, embolization or ablation, which may compromise future surgical options. Even if resection is not feasible, patients may be eligible for advanced treatments, such as hepatic arterial infusion pump or liver transplantation at Mayo Clinic.

"As physician-scientists, we are constantly looking for better ways to optimize liver regeneration after resection and, if needed, optimize liver disease prior to resection," Dr. Starlinger says. "Our efforts to explore new therapies through clinical trials continue to expand options for patients and might improve long-term outcomes in the future."

For more information

Dong Y, et al. Preoperative von Willebrand factor is an independent predictive biomarker for post-hepatectomy liver failure — A multivariable model with APRI+ALBI. Liver Transplantation. 2025;31:1450.

Kern AE, et al. MicroRNA based prediction of posthepatectomy liver failure and mortality outperforms established markers of preoperative risk assessment. Annals of Surgical Oncology. 2025;32:6283.

Ammann M, et al. Carcinoid syndrome impacts long-term outcomes after hepatectomy for small bowel neuroendocrine tumor liver metastasis. Annals of Surgical Oncology. 2026;33:609.

Rumpf B, et al. PNPLA3 polymorphism worsens chemotherapy associated liver injury and affects overall survival in colorectal cancer patients with liver metastasis undergoing hepatic resection. eBioMedicine. 2025;120:105928.

Dong Y, et al. Failure-to-rescue as a determinant of overall survival following resection for perihilar cholangiocarcinoma. JHEP Reports. 2025;7:101615.

Refer a patient to Mayo Clinic.