Hypertrophy responses after portal vein embolization, complete and partial ALPPS in patients undergoing major liver resection

Abstract

Background: Portal vein embolization (PVE) is the standard technique to induce hypertrophy of a small future remnant liver (FRL). ALPPS offers a more rapid hypertrophy response. The first stage (ALPPS1) can be performed with complete or partial (laparoscopic) transection of the liver parenchyma. The aim of this study was to investigate the increases in volume, function and postoperative outcomes among these procedures. Material & Methods: 72 patients with insufficient FRL were included in this retrospective analysis and were divided into three groups: 51 underwent PVE, 12 complete-ALPPS1 (open) and 9 partial-ALLPS1. All patients underwent CT-volumetry and functional assessment using 99mTc-mebrofenin hepatobiliary scintigraphy before and after VPE or ALPPS1. The increase in FRL function and volume were compared between the groups. Severe complications (Clavien-Dindo=3A) and 90-day mortality were evaluated after final liver resection. Results: The median increase in FRL function in the PVE, complete-ALPPS1 and partial-ALPPS1 group was 1.5, 1.7 and 1.3 fold higher, respectively, than the increase in volume; this was however not significant in the partial-ALPPS1 group (P<0.01, P<0.01 and P=0.44). The volumetric hypertrophy response did not differ between the three groups, but was reached earlier in both ALPPS1 groups (8 and 10 days, respectively) compared to the PVE group (23 days). Of all groups, 37 (73%), 10 (83%) and 6 (67%), respectively, proceeded with liver resection. All resected patients after partial-ALPPS1 had laparoscopic stage 1 in combination with percutaneous PVE. Of the resected patients, 18%, 30% and 17% had severe postoperative complications and the 90-day mortality was 2%, 25% and 0%, respectively. Conclusion: Increase of FRL function exceeded increase of volume after both PVE and ALPPS1. The target hypertrophy response was reached earlier in ALPPS. Complete and partial-ALPPS1 showed comparable functional and volumetric hypertrophy responses. Laparoscopic partial-ALPPS1 is preferred considering lower morbidity and mortality rates after resection.