Morphometric Imaging Techniques and the Functional Liver Remnant

  • Mathew M. Augustine
  • Ihab R. Kamel
  • Timothy M. PawlikEmail author


Surgical resection is the treatment of choice for select patients with primary and ­secondary hepatic malignancies. The goal of hepatic surgery is complete resection with preservation of sufficient liver parenchyma. Inadequate hepatic reserve can result in the development of hepatic dysfunction and failure. One parameter used to assess the adequacy of liver reserve is to measure the future liver remnant (FLR) volume. Accurate measurement of FLR is important not only as a surrogate marker for liver function, but also assists in the selection of patients for preoperative portal vein ­embolization (PVE). The preferred modality to provide accurate and reproducible measurements of FLR is computer tomography (CT) volumetry. CT volumetry measurements can be performed utilizing either manual or automated techniques. The measured FLR is standardized to the patient’s total liver volume (TLV), which is derived from the body surface area (BSA). Various equations have been derived that relate TLV to BSA. CT volumetry provides hepatic surgeons and radiologists an informed approach toward the surgical management of patients with complex liver disease.


Computer tomography (CT) volumetry Functional liver remnant Future liver remnant volume Morphometric imaging techniques and the functional liver ­remnant MRI of the liver 



Body Height


Body Surface Area


Body Weight


Colorectal Metastasis


Computed Tomography


CT Angioportograms


Future Liver Remnant


Functional Liver Volume


Hepatocellular Carcinoma


Indocyanine Green Clearance


International Normalized Ratio


Liver Volume


Magnetic Resonance Imaging


Portal Vein Embolization


Remnant Liver Volume


Standardized Future Liver Remnant


Total Liver Volume


Technetium-99 m Galactosyl Serum Albumin


  1. 1.
    Pawlik TM, Schulick RD, Choti MA. Expanding criteria for resectability of colorectal liver metastases. Oncologist. 2008;13(1):51-64.PubMedCrossRefGoogle Scholar
  2. 2.
    Adam R, Lucidi V, Bismuth H. Hepatic colorectal metastases: methods of improving resectability. Surg Clin North Am. 2004;84(2):659-671.PubMedCrossRefGoogle Scholar
  3. 3.
    Elias D, Baton O, Sideris L, et al. Hepatectomy plus intraoperative radiofrequency ablation and chemotherapy to treat technically unresectable multiple colorectal liver metastases. J Surg Oncol. 2005;90(1):36-42.PubMedCrossRefGoogle Scholar
  4. 4.
    Elias D, Manganas D, Benizri E, et al. Trans-metastasis hepatectomy: results of a 21-case study. Eur J Surg Oncol. 2006;32(2):213-217.PubMedCrossRefGoogle Scholar
  5. 5.
    Hemming AW, Reed AI, Howard RJ, et al. Preoperative portal vein embolization for extended hepatectomy. Ann Surg. 2003;237(5):686-691. discussion 691-693.PubMedGoogle Scholar
  6. 6.
    Pawlik TM, Choti MA. Surgical therapy for colorectal metastases to the liver. J Gastrointest Surg. 2007;11(8):1057-1077.PubMedCrossRefGoogle Scholar
  7. 7.
    Ng KK, Vauthey JN, Pawlik TM, et al. Is hepatic resection for large or multinodular hepatocellular carcinoma justified? Results from a multi-institutional database. Ann Surg Oncol. 2005;12(5):364-373.PubMedCrossRefGoogle Scholar
  8. 8.
    Takizawa D, Kakizaki S, Sohara N, et al. Hepatocellular carcinoma with portal vein tumor thrombosis: clinical characteristics, prognosis, and patient survival analysis. Dig Dis Sci. 2007;52(11):3290-3295.PubMedCrossRefGoogle Scholar
  9. 9.
    Vauthey JN, Pawlik TM, Abdalla EK, et al. Is extended hepatectomy for hepatobiliary malignancy justified? Ann Surg. 2004;239(5):722-730. discussion 730-732.PubMedCrossRefGoogle Scholar
  10. 10.
    Virani S, Michaelson JS, Hutter MM, et al. Morbidity and mortality after liver resection: results of the patient safety in surgery study. J Am Coll Surg. 2007;204(6):1284-1292.PubMedCrossRefGoogle Scholar
  11. 11.
    Zhou L, Rui JA, Wang SB, et al. Outcomes and prognostic factors of cirrhotic patients with hepatocellular carcinoma after radical major hepatectomy. World J Surg. 2007;31(9):1782-1787.PubMedCrossRefGoogle Scholar
  12. 12.
    Fan ST, Lai EC, Lo CM, et al. Hospital mortality of major hepatectomy for hepatocellular carcinoma associated with cirrhosis. Arch Surg. 1995;130(2):198-203.PubMedCrossRefGoogle Scholar
  13. 13.
    Nagasue N, Yukaya H. Liver resection for hepatocellular carcinoma: results from 150 consecutive patients. Cancer Chemother Pharmacol. 1989;23(suppl):S78-S82.PubMedCrossRefGoogle Scholar
  14. 14.
    Thompson HH, Tompkins RK, Longmire WP Jr. Major hepatic resection. A 25-year experience. Ann Surg. 1983;197(4):375-388.PubMedCrossRefGoogle Scholar
  15. 15.
    Jarnagin WR, Gonen M, Fong Y, et al. Improvement in perioperative outcome after hepatic resection: analysis of 1,803 consecutive cases over the past decade. Ann Surg. 2002;236(4):397-406. discussion 406-407.PubMedCrossRefGoogle Scholar
  16. 16.
    Abdalla EK, Barnett CC, Doherty D, et al. Extended hepatectomy in patients with hepatobiliary malignancies with and without preoperative portal vein embolization. Arch Surg. 2002;137(6):675-680. discussion 680-681.PubMedCrossRefGoogle Scholar
  17. 17.
    Stone HH, Long WD, Smith RB III, Haynes CD. Physiologic considerations in major hepatic resections. Am J Surg. 1969;117(1):78-84.PubMedCrossRefGoogle Scholar
  18. 18.
    Fan ST, Lo CM, Liu CL, et al. Safety of donors in live donor liver transplantation using right lobe grafts. Arch Surg. 2000;135(3):336-340.PubMedCrossRefGoogle Scholar
  19. 19.
    Farges O, Belghiti J, Kianmanesh R, et al. Portal vein embolization before right hepatectomy: prospective clinical trial. Ann Surg. 2003;237(2):208-217.PubMedGoogle Scholar
  20. 20.
    Abdalla EK, Denys A, Chevalier P, et al. Total and segmental liver volume variations: implications for liver surgery. Surgery. 2004;135(4):404-410.PubMedCrossRefGoogle Scholar
  21. 21.
    Delesse MA. Procede mechanique pour determiner la composition des roches. C R Acad Sci. 1847;25:544-545.Google Scholar
  22. 22.
    Weibel ER. Principles and methods for the morphometric study of the lung and other organs. Lab Invest. 1963;12:131-155.PubMedGoogle Scholar
  23. 23.
    Hennig A. Kritische btrachtungen zur volumenund Oberflachen-messung in der mikroskopie. Zeiss Werkz. 1958;30:76-86.Google Scholar
  24. 24.
    Fritschy P, Robotti G, Schneekloth G, Vock P. Measurement of liver volume by ultrasound and computed tomography. J Clin Ultrasound. 1983;11(6):299-303.PubMedCrossRefGoogle Scholar
  25. 25.
    Henderson JM, Heymsfield SB, Horowitz J, Kutner MH. Measurement of liver and spleen volume by computed tomography. Assessment of reproducibility and changes found following a selective distal splenorenal shunt. Radio­logy. 1981;141(2):525-527.PubMedGoogle Scholar
  26. 26.
    Kamel IR, Kruskal JB, Pomfret EA, et al. Impact of multidetector CT on donor selection and surgical planning before living adult right lobe liver transplantation. AJR Am J Roentgenol. 2001;176(1):193-200.PubMedGoogle Scholar
  27. 27.
    Leelaudomlipi S, Sugawara Y, Kaneko J, et al. Volumetric analysis of liver segments in 155 living donors. Liver Transpl. 2002;8(7):612-614.PubMedCrossRefGoogle Scholar
  28. 28.
    Farraher SW, Jara H, Chang KJ, et al. Liver and spleen volumetry with quantitative MR imaging and dual-space clustering segmentation. Radiology. 2005;237(1):322-328.PubMedCrossRefGoogle Scholar
  29. 29.
    Caldwell SH, de Lange EE, Gaffey MJ, et al. Accuracy and significance of pretransplant liver volume measured by magnetic resonance imaging. Liver Transpl Surg. 1996;2(6):438-442.PubMedCrossRefGoogle Scholar
  30. 30.
    Luft AR, Skalej M, Welte D, et al. Reliability and exactness of MRI-based volumetry: a phantom study. J Magn Reson Imaging. 1996;6(4):700-704.PubMedCrossRefGoogle Scholar
  31. 31.
    Zacharia TT. Assessment of future remnant liver regeneration after portal vein embolization using three-dimensional CT and MR volumetric analyses. Australas Radiol. 2006;50(6):543-548.PubMedCrossRefGoogle Scholar
  32. 32.
    Heymsfield SB, Fulenwider T, Nordlinger B, et al. Accurate measurement of liver, kidney, and spleen volume and mass by computerized axial tomography. Ann Intern Med. 1979;90(2):185-187.PubMedGoogle Scholar
  33. 33.
    Soyer P, Roche A, Elias D, Levesque M. Hepatic metastases from colorectal cancer: influence of hepatic volumetric analysis on surgical decision making. Radiology. 1992;184(3):695-697.PubMedGoogle Scholar
  34. 34.
    Wigmore SJ, Redhead DN, Yan XJ, et al. Virtual hepatic resection using three-dimensional reconstruction of helical computed tomography angioportograms. Ann Surg. 2001;233(2):221-226.PubMedCrossRefGoogle Scholar
  35. 35.
    Kamel IR, Kruskal JB, Warmbrand G, et al. Accuracy of volumetric measurements after virtual right hepatectomy in potential donors undergoing living adult liver transplantation. AJR Am J Roentgenol. 2001;176(2):483-487.PubMedGoogle Scholar
  36. 36.
    Shirabe K, Shimada M, Gion T, et al. Postoperative liver failure after major hepatic resection for hepatocellular carcinoma in the modern era with special reference to remnant liver volume. J Am Coll Surg. 1999;188(3):304-309.PubMedCrossRefGoogle Scholar
  37. 37.
    Shoup M, Gonen M, D’Angelica M, et al. Volumetric analysis predicts hepatic dysfunction in patients undergoing major liver resection. J Gastrointest Surg. 2003;7(3):325-330.PubMedCrossRefGoogle Scholar
  38. 38.
    Schindl MJ, Redhead DN, Fearon KC, et al. The value of residual liver volume as a predictor of hepatic dysfunction and infection after major liver resection. Gut. 2005;54(2):289-296.PubMedCrossRefGoogle Scholar
  39. 39.
    Nakayama Y, Li Q, Katsuragawa S, et al. Automated hepatic volumetry for living related liver transplantation at multisection CT. Radiology. 2006;240(3):743-748.PubMedCrossRefGoogle Scholar
  40. 40.
    Dello SA, van Dam RM, Slangen JJ, et al. Liver volumetry plug and play: do it yourself with ImageJ. World J Surg. 2007;31(11):2215-2221.PubMedCrossRefGoogle Scholar
  41. 41.
    Lu Y, Wu Z, Liu C, Wang HH. Hepatic volumetry with PhotoShop in personal computer. Hepatobiliary Pancreat Dis Int. 2004;3(1):82-85.PubMedGoogle Scholar
  42. 42.
    Rasband W. ImageJ. U.S. National Institutes of Health, Bethesda, 1997–2005.Google Scholar
  43. 43.
    Johnson TN, Tucker GT, Tanner MS, Rostami-Hodjegan A. Changes in liver volume from birth to adulthood: a meta-analysis. Liver Transpl. 2005;11(12):1481-1493.PubMedCrossRefGoogle Scholar
  44. 44.
    Urata K, Kawasaki S, Matsunami H, et al. Calculation of child and adult standard liver volume for liver transplantation. Hepatology. 1995;21(5):1317-1321.PubMedCrossRefGoogle Scholar
  45. 45.
    Vauthey JN, Abdalla EK, Doherty DA, et al. Body surface area and body weight predict total liver volume in Western adults. Liver Transpl. 2002;8(3):233-240.PubMedCrossRefGoogle Scholar
  46. 46.
    DeLand FH, North WA. Relationship between liver size and body size. Radiology. 1968;91(6):1195-1198.PubMedGoogle Scholar
  47. 47.
    Zoli M, Magalotti D, Grimaldi M, et al. Physical examination of the liver: is it still worth it? Am J Gastroenterol. 1995;90(9):1428-1432.PubMedGoogle Scholar
  48. 48.
    Chandramohan A, Eapen A, Govil S, et al. Determining standard liver volume: assessment of existing formulae in Indian population. Indian J Gastroenterol. 2007;26(1):22-25.PubMedGoogle Scholar
  49. 49.
    Heinemann A, Wischhusen F, Puschel K, Rogiers X. Standard liver volume in the Caucasian population. Liver Transpl Surg. 1999;5(5):366-368.PubMedCrossRefGoogle Scholar
  50. 50.
    Urata K, Hashikura Y, Ikegami T, et al. Standard liver ­volume in adults. Transplant Proc. 2000;32(7):2093-2094.PubMedCrossRefGoogle Scholar
  51. 51.
    Chun YS, Ribero D, Abdalla EK, et al. Comparison of two methods of future liver remnant volume measurement. J Gastrointest Surg. 2008;12(1):123-128.PubMedCrossRefGoogle Scholar
  52. 52.
    Kiuchi T, Kasahara M, Uryuhara K, et al. Impact of graft size mismatching on graft prognosis in liver trans­plantation from living donors. Transplantation. 1999;67(2):321-327.PubMedCrossRefGoogle Scholar
  53. 53.
    Lo CM, Fan ST, Liu CL, et al. Minimum graft size for successful living donor liver transplantation. Transplantation. 1999;68(8):1112-1116.PubMedCrossRefGoogle Scholar
  54. 54.
    Ogiu N, Nakamura Y, Ijiri I, et al. A statistical analysis of the internal organ weights of normal Japanese people. Health Phys. 1997;72(3):368-383.PubMedCrossRefGoogle Scholar
  55. 55.
    Yoshizumi T, Gondolesi GE, Bodian CA, et al. A simple new formula to assess liver weight. Transplant Proc. 2003;35(4):1415-1420.PubMedCrossRefGoogle Scholar
  56. 56.
    Yu HC, You H, Lee H, et al. Estimation of standard liver volume for liver transplantation in the Korean population. Liver Transpl. 2004;10(6):779-783.PubMedCrossRefGoogle Scholar
  57. 57.
    Vauthey JN, Chaoui A, Do KA, et al. Standardized measurement of the future liver remnant prior to extended liver resection: methodology and clinical associations. Surgery. 2000;127(5):512-519.PubMedCrossRefGoogle Scholar
  58. 58.
    Ribero D, Abdalla EK, Madoff DC, et al. Portal vein embolization before major hepatectomy and its effects on regeneration, resectability and outcome. Br J Surg. 2007;94(11):1386-1394.PubMedCrossRefGoogle Scholar
  59. 59.
    Yigitler C, Farges O, Kianmanesh R, et al. The small remnant liver after major liver resection: how common and how relevant? Liver Transpl. 2003;9(9):S18-S25.PubMedCrossRefGoogle Scholar
  60. 60.
    Lin XZ, Sun YN, Liu YH, et al. Liver volume in patients with or without chronic liver diseases. Hepatogastroenterology. 1998;45(22):1069-1074.PubMedGoogle Scholar
  61. 61.
    Ribero D, Curley SA, Imamura H, et al. Selection for resection of hepatocellular carcinoma and surgical strategy: indications for resection, evaluation of liver function, portal vein embolization, and resection. Ann Surg Oncol. 2008;15(4):986-992.PubMedCrossRefGoogle Scholar
  62. 62.
    Nanashima A, Yamaguchi H, Shibasaki S, et al. Relationship between CT volumetry and functional liver volume using technetium-99 m galactosyl serum albumin scintigraphy in patients undergoing preoperative portal vein embolization before major hepatectomy: a preliminary study. Dig Dis Sci. 2006;51(7):1190-1195.PubMedCrossRefGoogle Scholar
  63. 63.
    Ashwell G, Harford J. Carbohydrate-specific receptors of the liver. Annu Rev Biochem. 1982;51:531-554.PubMedCrossRefGoogle Scholar
  64. 64.
    Kubota K, Makuuchi M, Kusaka K, et al. Measurement of liver volume and hepatic functional reserve as a guide to decision-making in resectional surgery for hepatic tumors. Hepatology. 1997;26(5):1176-1181.PubMedGoogle Scholar

Copyright information

© Springer-Verlag London Limited 2011

Authors and Affiliations

  • Mathew M. Augustine
    • 1
  • Ihab R. Kamel
    • 2
  • Timothy M. Pawlik
    • 3
    Email author
  1. 1.Department of SurgeryJohns Hopkins HospitalBaltimoreUSA
  2. 2.Department of RadiologyThe Johns Hopkins HospitalBaltimoreUSA
  3. 3.Division of Surgical Oncology, Department of SurgeryJohns Hopkins HospitalBaltimoreUSA

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