Post-Hepatectomy Liver Failure: BJS | March 2026

• Modern liver surgery has become remarkably safe due to advances in surgical techniques, anesthesia, perioperative care, parenchyma-sparing strategies, and minimally invasive approaches.
• Despite these advances, post-hepatectomy liver failure (PHLF) remains the most feared complication after major liver resection.
• Although overall mortality after liver surgery is now generally below 1%–2%, PHLF continues to occur in approximately 8%–12% of major hepatectomies.
• PHLF is the single most important predictor of postoperative mortality following liver resection.
• Once clinically significant PHLF develops, treatment options are limited and are largely supportive, similar to management of acute liver failure from other causes.
• Mortality remains extremely high, often reaching 50%–80% in severe cases.
• The central principle in modern hepatobiliary surgery is therefore not treatment of PHLF, but prevention of PHLF.
• Adequate future liver remnant (FLR) volume and function remain the cornerstone of prevention.
• Preoperative assessment must evaluate:

Future liver remnant volume

Liver function

Presence of steatosis

Chemotherapy-associated liver injury

Cirrhosis or fibrosis

Portal hypertension

• Volumetric assessment alone is insufficient; functional liver reserve is increasingly recognized as equally important.
• Strategies to increase the future liver remnant include:

Portal vein embolization (PVE)

Liver venous deprivation

Staged hepatectomy approaches

ALPPS in selected patients

• Parenchyma-sparing liver surgery has become an important strategy to maximize oncological clearance while preserving functional liver tissue.
• Intraoperative factors such as blood loss, ischemia-reperfusion injury, prolonged operative time, and transfusion requirements also influence PHLF risk.
• Patients with underlying chronic liver disease, steatohepatitis, obesity, diabetes, and prior chemotherapy exposure represent particularly high-risk populations.
• Emerging technologies including functional imaging, dynamic liver function tests, and AI-based risk prediction models may improve future patient selection.
• The review emphasizes that PHLF is not a single disease entity but a complex syndrome involving impaired regeneration, insufficient liver reserve, systemic inflammation, and multi-organ dysfunction.

Bottom line: Post-hepatectomy liver failure remains the major life-threatening complication after liver resection. Because effective treatment is limited once PHLF develops, meticulous patient selection, accurate assessment of future liver remnant function, and parenchyma-preserving surgical strategies remain the most effective means of improving outcomes.