Adequate Future Liver Remnant Research Articles

Comprehensive Review of Future Liver Remnant (FLR) Assessment and Hypertrophy Techniques Before Major Hepatectomy: How to Assess and Manage the FLR.

The regenerative capacities of the liver and improvements in surgical techniques have expanded the possibilities of resectability. Liver resection is often the only curative treatment for primary and secondary malignancies, despite the risk of post-hepatectomy liver failure (PHLF). This serious complication (with a 50% mortality rate) can be avoided by better assessment of liver volume and function of the future liver remnant (FLR). The aim of this review was to understand and assess clinical, biological, and imaging predictors of PHLF risk, as well as the various hypertrophy techniques, to achieve an adequate FLR before hepatectomy. We reviewed the state of the art in liver regeneration and FLR hypertrophy techniques. The use of new biological scores (such as the aspartate aminotransferase/platelet ratio index + albumin-bilirubin [APRI+ALBI] score), concurrent utilization of 99mTc-mebrofenin scintigraphy (HBS), or dynamic hepatocyte contrast-enhanced MRI (DHCE-MRI) for liver volumetry helps predict the risk of PHLF. Besides portal vein embolization, there are other FLR optimization techniques that have their indications in case of risk of failure (e.g., associating liver partition and portal vein ligation for staged hepatectomy, liver venous deprivation) or in specific situations (transarterial radioembolization). There is a need to standardize volumetry and function measurement techniques, as well as FLR hypertrophy techniques, to limit the risk of PHLF.

Laparoscopic liver ALPPS - How I do it

In complex oncological liver resections, insufficient future liver remnant (FLR) volume may become the most challenging problem to deal with in the postoperative setting. The Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy (ALPPS) is one of the techniques described for inducing hepatic hypertrophy and achieving an adequate FLR. The technique initially described is performed by a complete bipartition of the liver in the first operation and a portal vein ligation to achieve occlusion of the intrahepatic circulation followed by a major hepatectomy in the second operation once an adequate FLR has been reached. With the introduction of minimally invasive liver surgery, these procedures can be performed by laparoscopic or robotic approach. We aim to provide a comprehensive overview of ALPPS, highlighting key technical aspects. Furthermore, the main aspects of this technique based on current evidence, such as indications, outcomes, strengths, limitations and potential complications, will be analyzed.

Liver volumetric and anatomic assessment in living donor liver transplantation: The role of modern imaging and artificial intelligence.

The shortage of deceased donor organs has prompted the development of alternative liver grafts for transplantation. Living-donor liver transplantation (LDLT) has emerged as a viable option, expanding the donor pool and enabling timely transplantation with favorable graft function and improved long-term outcomes. An accurate evaluation of the donor liver's volumetry (LV) and anatomical study is crucial to ensure adequate future liver remnant, graft volume and precise liver resection. Thus, ensuring donor safety and an appropriate graft-to-recipient weight ratio. Manual LV (MLV) using computed tomography has traditionally been considered the gold standard for assessing liver volume. However, the method has been limited by cost, subjectivity, and variability. Automated LV techniques employing advanced segmentation algorithms offer improved reproducibility, reduced variability, and enhanced efficiency compared to manual measurements. However, the accuracy of automated LV requires further investigation. The study provides a comprehensive review of traditional and emerging LV methods, including semi-automated image processing, automated LV techniques, and machine learning-based approaches. Additionally, the study discusses the respective strengths and weaknesses of each of the aforementioned techniques. The use of artificial intelligence (AI) technologies, including machine learning and deep learning, is expected to become a routine part of surgical planning in the near future. The implementation of AI is expected to enable faster and more accurate image study interpretations, improve workflow efficiency, and enhance the safety, speed, and cost-effectiveness of the procedures. Accurate preoperative assessment of the liver plays a crucial role in ensuring safe donor selection and improved outcomes in LDLT. MLV has inherent limitations that have led to the adoption of semi-automated and automated software solutions. Moreover, AI has tremendous potential for LV and segmentation; however, its widespread use is hindered by cost and availability. Therefore, the integration of multiple specialties is necessary to embrace technology and explore its possibilities, ranging from patient counseling to intraoperative decision-making through automation and AI.

HPB P20 Radical Single Stage Liver Resection of Bilobar Colorectal Liver Metastases

Abstract Background Surgical resection of Colorectal Liver Metastases (CRLM) offers the best long-term patient survival with current 5-year survival rates of 50%. However, bilobar CRLM often require an individualised patient approach with the primary goals being oncological resection of metastases and adequate future liver remnant. A number of surgical approaches can be used for bilobar CRLM including resection ± ablation, two stage hepatectomy ± portal vein embolization, associating liver partition and portal vein ligation for staged hepatectomy (ALPSS), or extended hepatectomy. We describe our approach of single stage parenchymal preserving (SSPP) liver resection for bilobar CRLM. Methods All patients with bilobar CRLM that underwent liver resection in a single, tertiary, specialist cancer centre in the UK between April 2018 to December 2021 were included. All liver resections were carried out using an open approach and 6-8 weeks after the cessation of chemotherapy. Pringle was used in all patients. We assessed peri-operative and oncological outcomes as well as disease-free (DFS) and overall (OS) patient survival. Results A total of n=42 patients underwent SSPP surgery during the study period. Median age was 54 years (range 36-71) and 93% were performance status=0. Pre-operative chemotherapy was administered in n=39 patients. A median of 4 lesions were resected (range 3-12). Median blood loss was 450mls (range 115-2500mls). R0 resection rate was 95%, with no post-operative liver failure and no peri-operative mortality. Bile leak rate was 10% and n=1 required massive blood transfusion. Median DFS was 13 months, and n=26 patients recurred by the end of the study period. Of these, n=14 were suitable for further treatment. Five-year OS was 77%. Conclusions SSPP liver resection for bilobar CRLM is associated with low peri-operative complications and good oncological outcomes. Early recurrence is noted but patients remain eligible for further liver- directed therapies or systemic treatment allowing for good overall patient survival.

Portal vein embolization with N-butyl-cyanoacrylate improves liver hypertrophy compared to microparticles – A Swedish multicenter cohort study

BackgroundAn adequate future liver remnant (FLR) is fundamental for major liver resections. To achieve sufficient FLR, portal vein embolization (PVE) may be used. The most effective material for PVE has yet to be determined. The aim of this study was to investigate the differences in FLR growth between n-butyl-cyanoacrylate glue (NBCA) and microparticles. Material/methodsaretrospective study was performed at three Swedish hepatobiliary centers and included patients who underwent PVE 2013–2021. Electronic medical records were reviewed, and procedure-related data were collected. Data were analyzed with respect to embolizing material. ResultsA total of 265 patients were included: 160 in the NBCA group and 105 in the microparticle group. The NBCA group had a higher degree of hypertrophy (12.1 vs. 9.4 % points, p = 0.003) and a higher resection rate (68 vs. 59 %, p = 0.01) than the microparticle group. Procedure-related data all indicated the superiority of NBCA. No difference in inducing hypertrophy was observed when comparing patients who received chemotherapy before PVE with those who received chemotherapy before and after PVE within the NBCA group. Discussion/conclusionThis retrospective multicenter study supports the superiority of NBCA compared to microparticles in the setting of PVE. Chemotherapy after PVE does not seem to negatively affect hypertrophy.

Vessel-Guided Mesohepatectomy for Liver Partition and Staged Major Parenchyma-Sparing Hepatectomies with Super-Selective Portal Vein Embolization or Enhanced ALPPS to Achieve R0 Resection for Colorectal Liver Metastases at the Hepatocaval Confluence.

Background. R0 minor parenchyma-sparing hepatectomy (PSH) is feasible for colorectal liver metastases (CRLM) in contact with hepatic veins (HV) at hepatocaval confluence since HV can be reconstructed, but in the case of contact with the first-order glissonean pedicle (GP), major hepatectomy is mandatory. To pursue an R0 parenchyma-sparing policy, we proposed vessel-guided mesohepatectomy for liver partition (MLP) and eventually combination with liver augmentation techniques for staged major PSH. Methods. We analyzed 15 consecutive vessel-guided MLPs for CRLM at the hepatocaval confluence. Patients had a median of 11 (range: 0-67) lesions with a median diameter of 3.5 cm (range: 0.0-8.0), bilateral in 73% of cases. Results. Grade IIIb or more complications occurred in 13%, median hospital stay was 14 (range: 6-62) days, 90-day mortality was 0%. After a median follow-up of 17.5 months, 1-year OS and RFS were 92% and 62%. In nine (64%) patients, MLP was combined with portal vein embolization (PVE) or ALPPS to perform staged R0 major PSH. Future liver remnant (FLR) volume increased from a median of 15% (range: 7-20%) up to 41% (range: 37-69%). Super-selective PVE was performed in three (33%) patients and enhanced ALPPS (e-ALPPS) in six (66%). In two e-ALPPS an intermediate stage of deportalized liver PSH was necessary to achieve adequate FLR volume. Conclusions. Vessel-guided MLP may transform the liver in a paired organ. In selected cases of multiple bilobar CRLM, to guarantee oncological radicality (R0), major PSH is feasible combining advanced surgical parenchyma sparing with liver augmentation techniques when FLR volume is insufficient.

Simultaneous 3-way Paired Exchange Liver Transplantation Without Nondirected Donation: Novel Strategy to Expand the Donor Pool.

Simultaneous 3-way Paired Exchange Liver Transplantation Without Nondirected Donation: Novel Strategy to Expand the Donor Pool.

Optimizing the future liver remnant: Portal vein embolization, hepatic venous deprivation, and associating liver partition and portal vein ligation for staged hepatectomy

Preservation of an adequate future liver remnant is paramount when planning any major liver resection and is of particular concern in the setting of bilateral colorectal liver metastases. Procedures including portal vein embolization and hepatic venous deprivation for one- or two-stage hepatectomy, and associating liver partition and portal vein ligation for staged hepatectomy have been developed to enable curative-intent hepatectomy for colorectal liver metastases in patients with an initially insufficient future liver remnant.

Outcomes of Patients With Colorectal Liver Metastasis in the Developing World: Is Liver Transplantation for Unresectable Liver Metastasis, the Next Logical Step?

While half of the patients with colorectal cancer develop metastasis, some 20% develop liver-only disease, and 10% of patients with unresectable liver disease live for 5 years. This study audits the outcomes of patients with colorectal liver metastasis to identify patients with unresectable liver metastasis eligible for a liver transplant. All patients with colorectal liver metastasis, irrespective of the presence of metastasis at other sites, registered between January 1, 2018, and December 31, 2019, were included in this retrospective audit. Patients in whom R0 Resection with adequate future liver remnant was not possible even after downstaging with chemotherapy were deemed unresectable. Overall survival was calculated using the Kaplan-Meier analysis. Patients eligible for a liver transplant were identified using the International Hepato-Pancreatico-Biliary Association (IHBPA) consensus guidelines and Oslo and Fong clinical risk scores. Out of 284 patients, 80 were treated with curative intent and 185 with palliative intent. At a median follow-up of 36 months, the median and 3-year OS were 37 months and 55% for the curative intent group and 9 months and 4% for the palliative intent group, respectively. Among 173 patients with liver-only metastasis, 13 patients (7%) satisfied the IHBPA consensus guidelines and had both Oslo and Fong scores of 2 or less. Transplant-eligible patients with unresectable liver metastasis had median and 3-year OS of 24 months and 25% against 9 months and 5% for ineligible patients, respectively. Liver transplant has the potential to benefit a small but significant portion of patients with unresectable liver metastasis.

R1vasc surgery for colorectal liver metastases.

Surgical resection remains the gold standard for the treatment of colorectal liver metastases (CLM). The goal for successful surgery is to pursue the optimal balance between oncological radicality and adequate future liver remnant (FLR). The impact of surgical margin is under active debate since many years, and it remains controversial when the disease burden is high or when the tumor is deeply located. The strategy of a large parenchymal sacrifice, limiting the possibility of a future re-resection and risking leaving an inadequate FLR, rather than challenging tumor exposure with potentially increased local recurrence rates, is becoming a relevant issue. Parenchymal-sparing surgery (PSS) strategy, taking profit of the ultrasound guidance, allows to remove the tumors minimizing the sacrifice of functioning parenchyma. This policy has been pushed beyond the classic oncological criteria, introducing the tumor-vessel detachment (R1vasc surgery) in order to further maximize the parenchyma sparing. This finding makes feasible conservative surgery for patients generally candidate to major hepatectomies or staged procedures with comparable oncological results and better perioperative outcome, redefining the role of surgical margins.

Folinic Acid Potentiates the Liver Regeneration Process after Selective Portal Vein Ligation in Rats.

Simple SummaryFewer than 30% of patients with liver metastases are eligible for major liver resection, because liver remaining after such a surgery would be insufficient to cover the patient’s needs; this is called a low percentage of future liver remnant (FLR). Folinic acid (FA) has been shown to play a crucial role in cellular synthesis, regeneration, and nucleotide and amino acid biosynthesis. The aim of this piece of research was to evaluate the effect of FA as a potential hypertrophic hepatic enhancer agent after selective portal vein ligation (PVL) to ensure adequate FLR. We have confirmed in our rodent model that FA accelerates liver regeneration after PVL and enhances recovery of liver function. These findings may allow more patients to be eligible for liver resection without jeopardizing postoperative liver function.Liver resection remains the gold standard for hepatic metastases. The future liver remnant (FLR) and its functional status are two key points to consider before performing major liver resections, since patients with less than 25% FLR or a Child–Pugh B or C grade are not eligible for this procedure. Folinic acid (FA) is an essential agent in cell replication processes. Herein, we analyze the effect of FA as an enhancer of liver regeneration after selective portal vein ligation (PVL). Sixty-four male WAG/RijHsd rats were randomly distributed into eight groups: a control group and seven subjected to 50% PVL, by ligation of left portal branch. The treated animals received FA (2.5 m/kg), while the rest were given saline. After 36 h, 3 days or 7 days, liver tissue and blood samples were obtained. FA slightly but significantly increased FLR percentage (FLR%) on the 7th day (91.88 ± 0.61%) compared to control or saline-treated groups (86.72 ± 2.5 vs. 87 ± 3.33%; p < 0.01). The hepatocyte nuclear area was also increased both at 36 h and 7days with FA (61.55 ± 16.09 µm2, and 49.91 ± 15.38 µm2; p < 0.001). Finally, FA also improved liver function. In conclusion, FA has boosted liver regeneration assessed by FLR%, nuclear area size and restoration of liver function after PVL.

Current strategies to induce liver remnant hypertrophy before major liver resection.

Hepatic resection is the gold standard for patients affected by primary or metastatic liver tumors but is hampered by the risk of post-hepatectomy liver failure. Despite recent improvements, liver surgery still requires excellent clinical judgement in selecting patients for surgery and, above all, efficient pre-operative strategies to provide adequate future liver remnant. The aim of this article is to review the literature on the rational, the preliminary assessment, the advantages as well as the limits of each existing technique for preparing the liver for major hepatectomy.

The clinical value of terminal branches portal vein embolization for hepatocellular carcinoma with insufficient future liver remnant

Objectives: To examine the efficacy of terminal branches portal vein embolization(TBPVE) for the increment of FLR in hepatocellular carcinoma (HCC) patients and to introduce its clinical value with transcatheter chemoembolization(TACE) in the treatment of HCC patients without surgery. Methods: One hundred and fifty HCC patients from three clinical centers of china underwent TBPVE technique from December 2016 to May 2021,including 89 males and 61 females. The average age was 51.9 years(range:18 to 79 years).One hundred and one patients were diagnosed with a background of HBV infection,including 27 patients with portal venous hypertension.TACE was performed simultaneously with TBPVE in 102 patients.Fifty-three patients underwent hepatectomy,who were subdivided into HBV positive and HBV negative groups,with TACE and without TACE groups to analyze the increment of future liver remnant (FLR), complications and survival data.These data were also analyzed in other 97 patients without hepatectomy. Results: All the patients reached adequate FLR successfully in 14 days after TBPVE including patients with portal venous hypertension.The average increment rates of FLR was 56.2% in 7 days and 57.8% in 14 days after TBPVE. There was no significant difference neither between HBV positive and HBV negative groups(7 days:(55.0±27.3)% vs.(57.8±20.9)%,t=0.885,P=0.373; 14 days:(57.3±24.6)% vs.(58.3±23.7)%;t=0.801,P=0.447),or between with TACE and without TACE groups(7 days:(62.3±26.3)% vs. (48.8±20.6)%;t=1.788,P=0.077;14 days:(64.4±25.0)% vs.(55.2±23.1)%;t=1.097,P=0.257).The morbidity and mortality rates were 20.8% and 1.9% in patients with hepatectomy.The 1-,3-year overall survival(OS) and disease-free(DFS) rates were 87.5%,64.5% and 64.7%,40.6% for patients underwent surgery.There was no significant difference of 1-,3-year OS and DFS between HBV positive and negative groups,but there were different between TACE and without TACE groups.The 1-,3-year OS for patients underwent TBPVE and TACE but without surgery were 80.1%, 53.7%. Conclusion: TBPVE is a good alternative technique for modulation of FLR for staged hepatectomy even in HBV positive HCC patients and can be applied with TACE procedure simultaneously as an option treatment for patients with no intend to surgery.

The Role of Surgical Resection and Liver Transplantation for the Treatment of Intrahepatic Cholangiocarcinoma.

Intrahepatic cholangiocarcinoma (iCCA) is a rare and complex malignancy of the biliary epithelium. Due to its silent presentation, patients are frequently diagnosed late in their disease course, resulting in poor overall survival. Advances in molecular profiling and targeted therapies have improved medical management, but long-term survival is rarely seen with medical therapy alone. Surgical resection offers a survival advantage, but negative oncologic margins are difficult to achieve, recurrence rates are high, and the need for adequate future liver remnant limits the extent of resection. Advances in neoadjuvant and adjuvant treatments have broadened patient treatment options, and these agents are undergoing active investigation, especially in the setting of advanced, initially unresectable disease. For those who are not able to undergo resection, liver transplantation is emerging as a potential curative therapy in certain cases. Patient selection, favorable tumor biology, and a protocolized, multidisciplinary approach are ultimately necessary for best patient outcomes. This review will discuss the current surgical management of locally advanced, liver-limited intrahepatic cholangiocarcinoma as well as the role of liver transplantation for select patients with background liver disease.

3D voxel-based dosimetry to predict contralateral hypertrophy and an adequate future liver remnant after lobar radioembolization

Volume changes induced by selective internal radiation therapy (SIRT) may increase the possibility of tumor resection in patients with insufficient future liver remnant (FLR). The aim was to identify dosimetric and clinical parameters associated with contralateral hepatic hypertrophy after lobar/extended lobar SIRT with 90Y-resin microspheres. Patients underwent 90Y PET/CT after lobar or extended lobar (right + segment IV) SIRT. 90Y voxel dosimetry was retrospectively performed (PLANET Dose; DOSIsoft SA). Mean absorbed doses to tumoral/non-tumoral-treated volumes (NTL) and dose-volume histograms were extracted. Clinical variables were collected. Patients were stratified by FLR at baseline (T0-FLR): < 30% (would require hypertrophy) and ≥ 30%. Changes in volume of the treated, non-treated liver, and FLR were calculated at < 2 (T1), 2-5 (T2), and 6-12months (T3) post-SIRT. Univariable and multivariable regression analyses were performed to identify predictors of atrophy, hypertrophy, and increase in FLR. The best cut-off value to predict an increase of FLR to ≥ 40% was defined using ROC analysis. Fifty-six patients were studied; most had primary liver tumors (71.4%), 40.4% had cirrhosis, and 39.3% had been previously treated with chemotherapy. FLR in patients with T0-FLR < 30% increased progressively (T0: 25.2%; T1: 32.7%; T2: 38.1%; T3: 44.7%). No dosimetric parameter predicted atrophy. Both NTL-Dmean and NTL-V30 (fraction of NTL exposed to ≥ 30Gy) were predictive of increase in FLR in patients with T0 FLR < 30%, the latter also in the total cohort of patients. Hypertrophy was not significantly associated with tumor dose or tumor size. When ≥ 49% of NTL received ≥ 30Gy, FLR increased to ≥ 40% (accuracy: 76.4% in all patients and 80.95% in T0-FLR < 30% patients). NTL-Dmean and NTL exposed to ≥ 30Gy (NTL-V30) were most significantly associated with increase in FLR (particularly among patients with T0-FLR < 30%). When half of NTL received ≥ 30Gy, FLR increased to ≥ 40%, with higher accuracy among patients with T0-FLR < 30%.

Portal vein embolization with ethylene-vinyl alcohol copolymer for contralateral lobe hypertrophy before liver resection: safety, feasibility and initial experience.

To report our preliminary experience with preoperative portal vein embolization (PVE) using liquid ethylene vinyl alcohol (EVOH) copolymer. Retrospectively review of patients with primary or secondary liver malignancies scheduled for extensive hepatectomy after the induction of future liver remnant (FLR) hypertrophy by right or left PVE with EVOH as the only embolic agent between 2014 and 2018 at two academic centers. Cross-sectional imaging liver volumetry data obtained before and 3-6 weeks after PVE were used to assess the FLR volume (FLRV) increase, degree of FLR hypertrophy and the FLR kinetic growth rate (KGR). Twenty-six patients (17 males; mean age, 58.7±11 years; range, 32-79 years) were included. The technical and clinical success rate was 100%. PVE produced adequate FLR hypertrophy in all patients. Embolization occurred in all targeted portal branches and in no non-target vessels. The %FLRV increased by 52.9%±32.5% and the degree of FLR hypertrophy was 16.7%±6.8%. The KGR was 4.4%±2.0% per week. Four patients experience minor complications after PVE which resolved with symptomatic treatment. The resection rate was 84.5%. One patient died during surgery for reasons unrelated to PVE. Preoperative PVE with EVOH copolymer is feasible, safe, and effective in inducing FLR hypertrophy.

Robotic left hemihepatectomy with lymph node dissection for a large intrahepatic cholangiocarcinoma

Purpose: Intrahepatic cholangiocarcinoma (ICC) is the second most common primary liver tumor following HCC. The incidence of ICC is low in most parts of the world. However, incidence has been rising. The only curative treatment option involves surgical resection as part of a multidisciplinary treatment. The goal of surgery is to obtain negative section margins while leaving an adequate future liver remnant. The role of regional lymphadenectomy is still debated, as it might add to a higher postoperative morbidity. An expert consensus statement states that regional lymphadenectomy should be considered a standard part of surgical therapy for patients undergoing resection of ICC. Another question remains about the role of minimal invasive surgery for ICC. A laparoscopic approach may lead to lower morbidity without compromising oncological adequacy. However, some doubts remain about the extent of lymph node dissection in laparoscopic approach. This video aims to demonstrate the advantages of a robotic approach using the Da Vinci© XI for left hemihepatectomy with lymph node dissection for a large intrahepatic cholangiocarcinoma. Methods: After screening for hepatic of peritoneal metastases, an extensive lymph node dissection of lymph node groups one and two is performed. Hilar structures are divided selectively. Next, a left hemihepatectomy is performed using the robotic vessel sealer. Finally, the left hepatic vein is divided using a vascular stapler and resection is finished. Results: Operative time was 270 min and blood loss was 20ml. The postoperative course was uneventful and the patient was discharged on postoperative day 3. Pathologic investigation showed an intrahepatic cholangiocarcinoma of 5cm, with tumorfree margins of 17mm. 0/10 lymph nodes were positive. Conclusions: The robotic approach to major hepatectomy with lymph node dissection for intrahepatic cholangiocarcinoma is safe and feasible with an acceptable number of lymph nodes prelevated.

Faster Return to Intended Oncologic Treatment (RIOT) After Trisectionectomy Does Not Translate to Better Outcomes.

Resection with trisectionectomy may necessitate liver molding for adequate future liver remnant (FLR), and subsequent complications can impact return to intended oncologic therapy (RIOT). This study evaluated whether a difference in RIOT exists with the use of molding and between liver molding techniques (associating liver partition and portal vein ligation for staged hepatectomy [ALPPS] and portal vein embolization [PVE]) with trisectionectomy. A retrospective review evaluated trisectionectomies for malignancy. Outcomes were compared with and without molding, and RIOT was determined. Fifty-one patients underwent trisectionectomy: 11 ALPPS, 14 PVE, 26 without molding. 73% of ALPPS, 64% of PVE, and 58% without molding achieved RIOT (P = .971). There were no differences found in baseline characteristics, R0 rate, length of stay, readmission, complications, or mortality. Time to RIOT was significantly different (ALPPS: 3.3 months; PVE: 5.2 months; none: 2.4 months, P = .0203). There were no differences in recurrence or survival. Liver molding should not cause apprehension as there are no differences in achieving RIOT. Although technique alters time to RIOT, this does not translate into improved outcomes, implicating disease biology, and regeneration stimulus.

Large hepatocellular carcinoma conquered by ALPPS: a case report

BackgroundThe only means of achieving long-term survival in hepatocellular carcinoma (HCC) beyond transplant criteria is complete tumour resection. The limiting factor for curative resection in large HCC is an inadequate future liver remnant (FLR) that might culminate into post hepatectomy liver failure (PHLF). The most common method that has been employed thus far to increase the FLR is portal vein embolization (PVE), which has its own set of drawbacks mainly inadequate hypertrophy, longer duration to achieve adequate FLR and tumour progression in the waiting period. Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) is a novel upcoming technique that aids in achieving rapid hypertrophy of FLR, thereby facilitating resection of an otherwise unresectable tumour.Case presentationThe authors present a case of a 46-year-old female with non-metastatic large HCC with inadequate FLR unsuitable for upfront hepatectomy. A two-stage surgical resection with ALPPS technique was preferred over PVE in this patient. This facilitated early hypertrophy of FLR and complete surgical resection of the tumour was performed successfully with an uneventful perioperative period. The patient was disease free at 16 months of follow-up.ConclusionALPPS is a feasible option for otherwise unresectable large HCCs in carefully selected patients with acceptable morbidity.

In situ split plus portal vein ligation (ISLT) \u2013 a salvage procedure following inefficient portal vein embolization to gain adequate future liver remnant volume prior to extended liver resection

BackgroundRight extended liver resection is frequently required to achieve tumor-free margins. Portal venous embolization (PVE) of the prospective resected hepatic segments for conditioning segments II/III does not always induce adequate hypertrophy in segments II and III (future liver remnant volume (FLRV)) for extended right-resection. Here, we present the technique of in situ split dissection along segments II/III plus portal disruption to segments IV-VIII (ISLT) as a salvage procedure to overcome inadequate gain of FLRV after PVE.MethodsIn eight patients, FLRV was further pre-conditioned following failed PVE prior to hepatectomy (ISLT-group). We compared FLRV changes in the ISLT group with patients receiving extended right hepatectomy following sufficient PVE (PVEres-group). Survival of the ISLT-group was compared to PVEres patients and PVE patients with insufficient FLRV gain or tumor progress who did not receive further surgery (PVEnores-group).ResultsPatient characteristics and surgical outcome were comparable in both groups. The mean FLRV-to-body-weight ratio in the ISLT group was smaller than in the PVEres-group pre- and post-PVE. One intraoperative mortality due to a coronary infarction was observed for an ISLT patient. ISLT was successfully completed in the remaining seven ISLT patients. Liver function and 2-year survival of ~ 50% was comparable to patients with extended right hepatectomy after efficient PVE. Patients who received a PVE but who were not subsequently resected (PVEnores) demonstrated no survival beyond 4 months.ConclusionDespite extended embolization of segments I and IV-VIII, ISLT should be considered if hypertrophy was not adequate. Liver function and overall survival after ISLT was comparable to patients with trisectionectomy after efficient PVE.