Endorsed by IHPBA
Total of 20 separate questions, hence 20 panels
WG1: DEFINITIONS, DIAGNOSIS & MONITORING
Q1. What definition and grading system for post-hepatectomy liver failure (PHLF) best reflects clinically meaningful liver dysfunction and is most appropriate for outcome reporting and clinical decision-making in contemporary hepatic surgery?
- ISGLS vs 50–50 and bilirubin/INR-based models
- Clinical relevance of Grade A
- Static vs dynamic definitions
- Reporting standards for Grade B/C and implications for long-term outcome assessment
Q2. In patients with established or evolving PHLF, which prognostic scores and biomarkers best predict short-term mortality and clinically relevant deterioration?
- Conventional laboratory parameters
- Emerging biomarkers (e.g. lactate, microRNAs)
- Early vs delayed prediction
Q3. What postoperative monitoring strategies most effectively enable early detection of evolving PHLF following hepatectomy?
- Frequency and timing of laboratory tests
- Role of imaging
- Functional liver tests in the postoperative period
WG2: IMPACT, RISK FACTORS & OUTCOMES
Q4. What are the short- and long-term outcomes attributable to PHLF?
- Mortality and morbidity
- Functional recovery and quality of life
- Organ-based outcomes
- Oncological outcomes, including disease-free and overall survival
Q5. Which patient-related clinical and biological characteristics are independently associated with the development of PHLF?
- Cirrhosis and fibrosis
- Metabolic liver disease (CASH)
- Obesity, diabetes, systemic inflammation
- Chemotherapy-associated liver injury
Q6. How does indication influence PHLF risk and perioperative decision-making?
- Colorectal liver metastases vs hepatocellular carcinoma vs cholangiocarcinoma
- Simultaneous multiorgan resection vs staged approaches
- Bowel resection combined with major hepatectomy
WG3: PREOPERATIVE ASSESSMENT & PREVENTION
Q7. Which preoperative liver volume and functional assessment modalities best predict PHLF risk, and what minimum acceptable thresholds should be applied according to baseline liver status and surgical indication?
- CT/MRI volumetry and elastography
- Dynamic functional tests (ICG clearance, LiMAx, hepatobiliary scintigraphy)
- Definition of safe limits in normal, steatotic, fibrotic, and cirrhotic livers
- Indication-specific FLR thresholds
- Discordance between volumetric and functional assessment
- Assessment of post-augmentation adequacy using volumetric and functional criteria
Q8. In jaundiced patients undergoing hepatectomy, what is the effectiveness of preoperative biliary decompression strategies in reducing PHLF risk, and how should bilirubin thresholds guide timing and sequencing of surgery?Bilirubin cut-offs for upfront surgery
- Indications, timing, and modality of biliary drainage
- Impact of biliary decompression on infection risk, treatment delay, and cancer outcomes
- how should these inform decisions to proceed with hepatectomy and the timing and sequencing of cancer surgery
Q9 In adults with an inadequate future liver remnant prior to hepatectomy, how do preoperative portal inflow and hepatic arterial modulation strategies compare in reducing clinically relevant post-hepatectomy liver failure and enabling safe resection?
- PVE plus hepatic vein embolisation
- ALPPS
- PVE
- HA etc
Q10. Does preoperative nutritional and functional prehabilitation reduce the risk or severity of PHLF following hepatectomy?
- Nutritional optimisation
- BCAA supplementation
- Sarcopenia reversal
Q11. Do pharmacological agents administered before hepatic injury (pre- or intra-operatively) condition or prime the liver and reduce the risk of post-hepatectomy liver failure (PHLF)?
- Bile acid mimetics
- Regenerative growth factors
- Statin etc
WG4: INTRAOPERATIVE RISK MODULATION & PREDICTION
Q12. Which intraoperative surgical techniques and perfusion-modulating strategies reduce the risk of PHLF during hepatectomy?
- Ischaemic preconditioning
- Pringle manoeuvre
- Liver perfusion monitoring (ICG fluorescence)
- Portal pressure measurement and modulation
- Liver transection techniques and thermal damage
Q13. How do anaesthetic and haemodynamic management strategies during hepatectomy influence the incidence of PHLF?
- Low-CVP anaesthesia
- Vasopressor use
- Fluid management strategies
Q14. Which intraoperative factors best predict the subsequent development of PHLF following hepatectomy?
- Ischaemia time
- Blood loss and transfusion
- Haemodynamic instability
- FLR performance
WG5: POSTOPERATIVE MANAGEMENT AND RESCUE THERAPIES
Q15. What antimicrobial strategies are effective in preventing infection-related deterioration or managing infection in patients with or at risk of PHLF?
- Prophylactic vs targeted antibiotics
- Antifungal therapy in high-risk patients
Q16. Which supportive intensive care interventions improve survival and recovery in patients with evolving or established PHLF?
- Renal replacement therapy
- Nutritional support
- Haemodynamic optimisation
Q17. Which pharmacological therapies administered after hepatic resection (or continued postoperatively) are effective in preventing progression, attenuating severity, or treating postoperative liver dysfunction or established PHLF?
- N-acetylcysteine
- Albumin
- Terlipressin
- Octreotide
- FXR agonists
Q18. Which non-pharmacological rescue strategies improve outcomes in patients with severe or refractory PHLF?
- Liver support systems (MARS, ELAD, Prometheus)
- Plasma exchange
- Postoperative portal modulation (e.g. splenic artery embolisation, shunts)
- ICU organ support strategies
Q19. Which patients with PHLF should be considered for liver transplantation, when should referral or listing occur, and what ethical principles should guide decision-making?
- Severity and reversibility of PHLF
- Oncological context and prognosis
- Super-urgent listing vs living donor liver transplantation
- Futility, equity, and resource allocation
WG6: FUTURE DIRECTIONS & RESEARCH PRIORITIES
Q20. What are the key evidence gaps and emerging strategies for improving the prevention, diagnosis, and management of PHLF?
- AI-driven risk prediction and decision-support models
- Novel regenerative therapies (e.g. stem cells, hepatocyte growth factors)
- Bile acid signalling and metabolic modulation
- Gut–liver axis modulation
- Trial design, endpoints, and implementation science gaps