Abstract
Accurate assessment of hepatic functional reserve is essential in patients with primary or secondary liver malignancies undergoing liver resection, particularly in the presence of chronic liver disease, chemotherapy-associated liver injury, cholestasis, or portal hypertension. Conventional laboratory parameters and clinical scores, including Child-Pugh, MELD, ALBI, and the combined APRI/ALBI score, provide accessible measures of global hepatic status and risk stratification but do not directly quantify regional function or dynamic metabolic capacity. Complementary approaches include indocyanine green clearance, LiMAx testing, liver stiffness measurement, hepatobiliary scintigraphy, gadoxetic acid-enhanced magnetic resonance imaging, and CT/MRI-based future liver remnant volumetry. This narrative review critically examines the strengths, limitations, and clinical applicability of these modalities in the context of contemporary evidence and recommendations. Building on, but extending beyond, the 2023 E-AHPBA-ESSO-ESSR Innsbruck consensus, we incorporate subsequent comparative evidence on blood-based scores and functional imaging and discuss emerging approaches including longitudinal assessment, radiomics, and artificial intelligence. Current evidence supports an individualized, multimodal strategy in which volumetry remains central to surgical planning, while additional functional and portal-hypertension assessment is selected according to the extent of resection, underlying parenchymal disease, previous treatment, and local expertise. No single modality or fixed combination can currently be considered universally superior, highlighting the need for prospective validation of integrated and cost-effective assessment strategies.