Limitations of adult post-hepatectomy liver failure criteria in pediatric liver tumor surgery: A single-center retrospective study

Abstract

Background: Post-hepatectomy liver failure (PHLF) is a major concern after extensive liver resection. Adult volumetric rules (20/30/40 rules) and International Study Group of Liver Surgery (ISGLS) definitions are often applied to children, but their relevance is unclear. We evaluated PHLF incidence and course in a pediatric surgical series, with attention to salvage liver transplantation (SLTx).

Methods: Retrospective review of 57 consecutive pediatric patients (<18) undergoing initial curative hepatectomy for hepatoblastoma (HB) at our institution (2003-2025). PHLF was assessed using adult criteria (ISGLS, 50:50, and bilirubin >7 mg/dL). Clinical outcomes, volumetric parameters, and chemotherapy exposure were analyzed.

Results: Twenty-eight patients (49 %) underwent liver resection, leaving <3 Couinaud segments. All patients had FLR/TLV ≥30 %. Six patients (10.5 %) met adult PHLF criteria, but none required SLTx during the early postoperative period. One patient developed late-onset hepatic failure several months after liver resection, leaving <3 Couinaud segments despite adequate FLR/TLV and required SLTx. Histology revealed fibrosis progression likely attributable to cumulative chemotherapy, radiotherapy, and perioperative complications. Overall, liver resection leaving <3 Couinaud segments was associated with more frequent postoperative complications (P < 0.05), but not with higher early PHLF incidence.

Conclusion: Adult-based PHLF criteria may capture transient dysfunction in pediatric HB patients but fail to identify those at risk for late, clinically significant hepatic failure requiring SLTx. Beyond volumetry, cumulative therapy-related hepatic injury, perioperative complications, and baseline fragility appear central to PHLF pathogenesis in children. Careful preoperative assessment and centralized surgical management with access to transplantation backup are essential.

Keywords: Hepatoblastoma; Late-onset liver failure; Liver volumetry; Pediatric hepatectomy; Post-hepatectomy liver failure; Salvage liver transplantation.