Liver Perfusion Failure After Pancreatoduodenectomy: BJS Open | August 2026

Introduction:

Liver perfusion failure (LPF) after pancreatoduodenectomy is an underrecognized postoperative complication that may lead to liver failure and increased mortality. This study established a clinically meaningful definition of LPF and identified perioperative factors associated with its development.

Why was this study needed?

• Liver perfusion failure after pancreatoduodenectomy lacks a standardised definition.
• The incidence and clinical consequences of LPF are poorly understood.
• Early identification may help prevent severe liver-related complications.
• Perioperative risk factors for LPF have not been clearly defined.
• Standardised criteria are needed for clinical practice and future research.

Results:

• Clinically significant LPF was best defined as AST and ALT ≥200 U/L for two consecutive postoperative days, occurring in approximately 9% of patients undergoing pancreatoduodenectomy.
• LPF was strongly associated with worse postoperative outcomes, including liver-specific complications, postoperative liver failure, increased need for radiological interventions, prolonged ICU stay, and higher 90-day mortality.
• Coeliac axis stenosis, arterial resection, and longer operative duration were independent predictors of LPF, identifying patients who may benefit from closer perioperative monitoring.

Clinical Impact:

This study establishes a practical definition of LPF₂d that can be readily applied after pancreatoduodenectomy. Early recognition of persistent postoperative transaminase elevation may facilitate timely investigation of hepatic perfusion, optimize postoperative management, and improve outcomes in high-risk patients.

Bottom Line:

Liver perfusion failure is a clinically important but often overlooked complication after pancreatoduodenectomy. Persistent AST/ALT elevation ≥200 U/L for two consecutive days identifies patients at significantly higher risk of liver-related complications and mortality, emphasizing the importance of early diagnosis and vigilant postoperative care.