Predicting liver failure after extended right hepatectomy following right portal vein embolization with gadoxetic acid-enhanced MRI



Predicting post-hepatectomy liver failure (PHLF) after extended right hepatectomy following portal vein embolization (PVE) from serial gadoxetic acid-enhanced magnetic resonance imaging (MRI).


Thirty-six patients who underwent hepatectomy following PVE were evaluated prospectively with gadoxetic acid-enhanced MRI examinations at predefined intervals during the course of their treatment, i.e., before and 14 days and 28 days after PVE as well as 10 days after hepatectomy. Relative enhancement (RE) and volume of the left and right liver lobes were determined. The study population was divided into two groups with respect to signs of PHLF. Differences between the two groups were assessed using the Mann-Whitney U test, and predictive parameters for group membership were investigated using ROC and logistic regression analysis.


RE of the left lobe prior to PVE versus 14 days after PVE was significantly lower in patients with PHLF than in those without PHLF (Mann-Whitney U test p < 0.001) and proved to be the best predictor of PHLF in ROC analysis with an AUC of 0.854 (p < 0.001) and a cutoff value of − 0.044 with 75.0% sensitivity and 92.6% specificity. Consistent with this result, logistic linear regression analysis adjusted for age identified the same parameter to be a significant predictor of PHLF (p = 0.040).


Gadoxetic acid-enhanced MRI performed as an imaging-based liver function test before and after PVE can help to predict PHLF. The risk of PHLF can be predicted as early as 14 days after PVE.

Key Points

To predict the likelihood of post-hepatectomy liver failure, it is important to estimate not only future liver remnant volume prior to extended liver resection but also future liver remnant function.

Future liver remnant function can be predicted by performing gadoxetic acid-enhanced MRI as an imaging-based liver function test before and after portal vein embolization.

A reduction of relative enhancement of the liver in gadoxetic acid-enhanced MRI after portal vein embolization of 0.044 predicts post-hepatectomy liver failure with 75.0% sensitivity and 92.6% specificity.

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Fig. 1
Fig. 2
Fig. 3





Future liver remnant function


Future liver remnant volume


Kinetic growth rate


13C-Methacetin breath test


Left liver lobe


Post-hepatectomy liver failure


Portal vein embolization


Relative enhancement


Right liver lobe


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The authors thank Bettina Herwig for language editing.


The authors state that this work has not received any funding.

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Corresponding author

Correspondence to Dorothea Theilig.

Ethics declarations


The scientific guarantor of this publication is Dominik Geisel.

Conflict of interest

Drs Geisel, Hamm, and Denecke have received travel support and honoraria from Bayer AG.

Statistics and biometry

One of the authors has significant statistical expertise.

Informed consent

Written informed consent was obtained from all patients in this study.

Ethical approval

Institutional review board approval was obtained.

Study subjects or cohorts overlap

The 36 patients included in the current study have already been the subject of an earlier report [23]. The prior study investigated the increase in liver volume and the potential of gadoxetic acid-enhanced MRI to predict the volume increase and monitor the functional increase of the future liver remnant after portal vein embolization. With a longer observation period until the point well after extended hemihepatectomy following portal vein embolization and newly available information of the outcome of surgery and clinical status afterwards, the focus of the current study is on clinical outcome and means of predicting this outcome using several functional parameters including gadoxetic acid-enhanced MRI.


• prospective study

• diagnostic or prognostic study

• performed at one institution

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Theilig, D., Steffen, I., Malinowski, M. et al. Predicting liver failure after extended right hepatectomy following right portal vein embolization with gadoxetic acid-enhanced MRI. Eur Radiol 29, 5861–5872 (2019).

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  • Liver
  • Hepatectomy
  • Contrast agent
  • Magnetic resonance imaging