Adequate Future Liver Remnant Research Articles

Preoperative Portal Vein Embolization in Hepatic Surgery: A Review about the Embolic Materials and Their Effects on Liver Regeneration and Outcome.

Liver volume and function after hepatectomies are directly correlated to postoperative complications and mortality. Consequently contemporary liver surgery has focused on reaching an adequate future liver remnant so as to diminish postoperative morbidity and mortality. Portal vein embolization has evolved and is the standard of care as a liver regenerative strategy in many surgery departments worldwide before major liver resections. Different embolic materials have been used for portal vein embolization including gelfoam, ethanol, polyvinyl-alcohol particles, calibrated microspheres, central vascular plugs, coils, n-butyl-cyanoacrylate glue, fibrin glue, polidocanol-foam, alcoholic prolamin solution, and ethylene vinyl alcohol copolymer, as sole occluders or in varied combinations. While to date there has been no prospective controlled trial comparing the efficacy of different embolic materials in portal vein embolization, retrospective data insinuates that the use of n-butyl-cyanoacrylate and absolute ethanol produces higher contralateral liver hypertrophies. In this review, we evaluated publications up to August 2019 to assess the technical and regenerative results of portal vein embolization accomplished with different embolic materials. Special attention was given to specific aspects, advantages, and drawbacks of each embolic agent used for portal vein embolization, its liver regenerative performance, and its influence on patient outcome.

3:09 PM Abstract No. 138 Comparative outcome study of surgically resectable hepatocellular carcinoma patients versus those requiring neoadjuvant radioembolization prior to surgical resection

Surgical Resection is considered curative for those with solitary hepatocellular carcinoma (HCC) and preserved liver function, but it is limited to those with adequate future liver remnant (FLR). Radioembolization (Y90) is used to improve margins and increase FLR, converting patients to surgical candidates. We aimed to study outcome differences between HCC patients who underwent resection vs. those requiring neoadjuvant Y90 prior to resection. With IRB approval, we studied patients with HCC resected between 2011-2014. Patients were categorized as resectable per multidiscipline tumor board vs. those deemed initially unresectable but converted to surgical resection with neoadjuvant Y90 (radiation lobectomy). Recurrence and survival outcomes were compared between these cohorts. Time to recurrence (TTR), recurrence free survival (RFS), and overall survival (OS) and were estimated using Kaplan-Meier method. 17 treatment naïve patients underwent surgical resection vs. 13 HCC patients that required neoadjuvant Y90. Mean age was 60 for resection cohort vs. 63 for neoadjuvant Y90 cohort (P = 0.5). Median tumor size was 4.1 cm in resection cohort vs. 5.6 cm for neoadjuvant Y90 cohort (P = 0.28). All patients had Child-Pugh A liver function. There was 1 (6%) 90-day mortality rate in resection cohort and 0% in neoadjuvant Y90 cohort. Resection cohort explants showed 100% viable tumors without necrosis. At explant, 5 (38%) had complete tumor necrosis and 8 (62%) had partial (>50%) necrosis in the neoadjuvant Y90 cohort. Time to recurrence analysis was similar between cohorts; median was not reached at 80 months follow-up. RFS was similar between cohorts, where 5-year RFS was 51% for resection cohort vs. 56% for neoadjuvant Y90 cohort (P = 0.67). Overall survival outcomes were also similar between cohorts, with 5-year OS of 74% for resection patients vs. 83% for neoadjuvant Y90 patients (P = 0.59). Neoadjuvant Y90 can convert patients with HCC initially declared unresectable and denied surgery into resection candidates. This approach imparts the same recurrence and survival advantages as those deemed optimal resection candidates at presentation.

ALPPS for hepatocarcinoma under cirrhosis: a feasible alternative to portal vein embolization.

Hepatocellular carcinoma (HCC) is one of the most common and malignant tumors. Preoperative portal vein embolization (PVE) is currently the most accepted treatment before major hepatic resection for HCC in patients with liver fibrosis or cirrhosis and associated insufficient future liver remnant (FLR). In the last decade, associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) technique has been described to obtain an increase of volume regarding PVE and a decrease of drop out. The initial excessive morbidity and mortality of this technique have decreased drastically due to a better selection of patients, the learning curve and the use of less aggressive variations of the original technique in the first stage. For both techniques a complete preoperative assessment of the FLR is the most important issue and only patients with and adequate FLR should be resected. ALPPS could be a feasible technique in very selected patients with HCC and cirrhosis. As long as it is performed in an experienced center could be used as a first choice technique versus PVE or could be used as a rescue technique in case of PVE failure.

Abstract CT207: Feasibility of neoadjuvant cabozantinib plus nivolumab followed by definitive resection for patients with locally advanced hepatocellular carcinoma: A Phase Ib trial (NCT03299946)

Abstract Long-term outcomes for patients with locally advanced hepatocellular carcinoma (HCC) are poor. Even if clear margins are obtained at the time of surgical resection, most patients with large tumors (>5 cm) relapse due to micrometastatic disease. No therapy has demonstrated clinical benefit in the perioperative setting, underscoring the need for novel therapeutic strategies for resectable HCC. We hypothesize that neoadjuvant therapy resulting in downstaging and elimination of micrometastasis may increase the probability of successful surgical resection. This ongoing open label, single arm Phase Ib trial (NCT03299946) aims to assess the feasibility of neoadjuvant cabozantinib plus nivolumab (CaboNivo) in patients with locally advanced HCC. Targets of cabozantinib include MET and VEGFR. Nivolumab is an immune checkpoint inhibitor targeting PD-1. This study will also allow us to test the hypothesis that cabozantinib primes the tumor microenvironment for anti-PD1 therapy and to study mechanisms of response and resistance to combination therapy. To our knowledge, this is the first neoadjuvant clinical trial of an immune checkpoint inhibitor and the first study of neoadjuvant combination therapy in HCC. 15 patients aged ≥ 18 with potentially resectable HCC that is at high risk of recurrence, ECOG ≤ 1, normal organ and marrow function, and adequate future liver remnant will be enrolled in the study. After 2 weeks of 40 mg daily cabozantinib monotherapy lead-in, patients will receive concurrent 240 mg nivolumab infusions once every 2 weeks for 4 doses. After 8 weeks of neoadjuvant therapy and restaging, patients eligible for resection will proceed to definitive surgical resection ≥ 28 days after the last dose of cabozantinib. Primary outcomes are feasibility and safety of neoadjuvant cabozantinib plus nivolumab. Secondary outcomes are percentage of patients obtaining an R0 resection, pathologic complete response and major pathologic response rates, objective response rate, median overall survival, and median disease free survival. Tumor biopsies from patients at baseline and after 2 weeks of cabozantinib lead-in as well as tumor tissue collected from surgical resection samples will be used to determine the effect of cabozantinib monotherapy and combination therapy with nivolumab on tumor-infiltrating lymphocytes, immune activation and suppression pathways, and cytokine/chemokine signaling. Citation Format: Aleksandra Popovic, Elizabeth Sugar, Anna Ferguson, Bradley Wilt, Jennifer N. Durham, Ihab R. Kamel, Amy Kim, Benjamin Philosophe, Robert A. Anders, Elizabeth M. Jaffee, Daniel Laheru, Matthew J. Weiss, Mark Yarchoan. Feasibility of neoadjuvant cabozantinib plus nivolumab followed by definitive resection for patients with locally advanced hepatocellular carcinoma: A Phase Ib trial (NCT03299946) [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr CT207.

Return to intended oncologic treatment (RIOT) after trisectionectomy with associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) versus portal vein embolization

Background: Return to intended oncologic treatment (RIOT) has been suggested as an important outcome for hepatic tumors. Resection of multifocal, bilobar liver tumors through extended hepatectomy often necessitates liver molding for an adequate future liver remnant (FLR), however a delay to surgery and the morbidity of liver molding could impact RIOT. Associating liver partition with portal vein ligation for staged hepatectomy (ALPPS) has been shown to stimulate faster FLR regeneration compared to portal vein embolization (PVE) which could reduce the chemotherapy-free interval and improve RIOT. This study aims to evaluate RIOT after liver molding with ALPPS compared to PVE with trisectionectomy. Methods: A retrospective review was conducted on all patients undergoing trisectionectomies (right or left) for liver tumors from 2008–2018 in a single tertiary institution. Tumor biology, chemotherapy treatment, operative and oncologic outcomes were compared between trisectionectomies with and without liver molding (ALPPS or PVE). FLR regeneration time was defined as the duration between portal vein occlusion (first ALPPS stage or PVE) and hepatic resection (second ALPPS stage or trisectionectomy). The chemotherapy-free interval (CFI) for RIOT was calculated for patients planned for neoadjuvant and adjuvant chemotherapy, including patients who died prior to receiving intended adjuvant treatment. Results: Of the 51 patients who underwent trisectionectomy, 25 (49%) required liver molding (11 ALPPS, 14 PVE). Median FLR regeneration time was 11 days for ALPPS and 44 days for PVE (p < 0.001). Patients who did not have adjuvant chemotherapy indicated (n = 15) or were lost to follow up shortly after surgery (n = 3) were not considered for RIOT. Successful RIOT was achieved in 89% (16/18) with liver molding and 87% (13/15) with trisectionectomy alone (p = 0.85). Patients receiving neoadjuvant and adjuvant chemotherapy had a shorter CFI when trisectionectomy did not require liver molding (110 vs 228 days, p = 0.014). For patients requiring liver molding, RIOT was similar between ALPPS (7/8) and PVE with trisectionectomy (9/10) (p = 0.87). Specifically for colorectal metastases requiring liver molding prior to resection, there was a 90-day difference in mean resumption of chemotherapy (CFI) between ALPPS and PVE (183 vs 273 days, p = 0.28). Conclusion: Liver molding for patients undergoing extended liver resections does not reduce the ability to achieve RIOT. While liver molding in general expectedly increases the CFI, the shorter FLR regeneration time in ALPPS may help to reduce the CFI compared to traditional PVE with trisegmentectomy.

Future liver remnant hypertrophy with Yttrium90Radioembolization in a patient with gastric neuroendocrine tumour liver metastasis

Background: Here we report a case of extensive gastric neuroendocrine tumour liver metastasis where an adequate future liver remnant (FLR) could be achieved with multiple Yttrium 90 (Y 90) radioembolizations before definitive surgery. Methods: A 56 year-old male was admitted to our centre with a right lobe liver metastasis of gastric neuroendocrine tumor. A resection area of 1564 cm3 (85% total liver volume) with multiple lesions and only 276 cm3 (15%TLV) FLR were determined by computed-tomograpy (CT) before Y 90 radioembolization. Results: After 3 embolizations in a years span, control CT scans showed adequate FLR (42%TLV). Total gastrectomy and right trisectionectomy were performed at the same session. Patient did not have postoperative liver failure however he had a prolonged recovery period requiring respiratory failure. At postoperative 7th month, he is without tumor and has normal liver function tests. Conclusion: Preoperative Y 90 radioembolization may be an optional procedure to provide an adequate FLR in patients with extensive liver malignancies.

MINI-ALPPS Achieves Adequate Future Liver Remnant (FLR) Hypertrophy To Allow Safe Two Stage Liver Resection

MINI-ALPPS Achieves Adequate Future Liver Remnant (FLR) Hypertrophy To Allow Safe Two Stage Liver Resection

Partial ALPPS with a longer wait between procedures is safe and yields adequate future liver remnant hypertrophy.

Backgrounds/AimsAssociating Liver Partition and Portal Vein Ligation for Staged Hepatectomy (ALPPS) has generated controversy due to high morbidity and mortality. We present our series of patients with 30–40% parenchymal transection and minimal hilar dissection.MethodsPatients who had partial ALPPS between April 2015 and April 2016 were included. Patients with colorectal liver metastases (CRLM) had their future liver remnants (FLR) cleared with metastasectomies. The liver was divided along the future line of transection to 30–40%, right portal vein was stapled and divided without extensive hilar dissection, with minimal handling of right liver, which was not mobilised. We preserved the middle hepatic vein. Data were collected prospectively for hypertrophy of the FLR, morbidity and mortality.ResultsAmong the 8 patients (age 25–68) investigated, one patient with cholangiocarcinoma had portal vein embolization prior to partial ALPPS. All patients completed two stages with adequate FLR hypertrophy at a median of 28 days. No mortality was found. The median length of stay after stages 1 and 2 was 9 and 9.6 days, respectively. The median increase in FLR was 38%.ConclusionsA limited transection of 30–40%, minimal hilar dissection and longer wait between stages yielded adequate FLR hypertrophy with low morbidity and no mortality.

MINI-ALPPS achieves adequate future liver remnant (FLR) hypertrophy to allow safe two stage liver resection

MINI-ALPPS achieves adequate future liver remnant (FLR) hypertrophy to allow safe two stage liver resection

Cholecystic Venous Anatomy: A Cadaveric Study with Implications for Portal Venous Interruption Procedure

The techniques of portal vein embolization (PVE) or ligation (PVL) have the goals of combining an induced atrophy of metastatic segments with the rapid relative compensatory hypertrophy of the postresection future liver remnant (FLR). Our study examines the anatomy of right-left hepatic lobar venous connections in the adult cadaver using corrosion cast analysis in an effort to define some of the inherent anatomical reasons why both PVL and PVE may be technically unsuccessful. Corrosion cast models of 215 cadaveric liver specimens were evaluated for hepatopetal venous blood flow, with a particular emphasis on cholecystic venous drainage patterns, including 57 cases prepared after lobar portal venous ligation. In 88.8 per cent of corrosion casts, there was a segmental venous communication between the gallbladder and all segments of the liver, except segment II. There was cystic vein drainage directly into a main lobar branch or directly into the portal vein itself in 11.2 per cent of cases. In all 57 cases, after portal lobar venous division, in situ cystic veins allowed persistent venous communication between lobes. Our cadaveric corrosion cast study has suggested that there is extensive intrahepatic cholecystic venous drainage to many segments of the liver. Perfusion from the gallbladder may potentially contribute to a limited response to procedures which interrupt the portal venous flow and could affect their capacity to induce an adequate FLR which would permit a wider hepatectomy.

Hepatectomía en 2 tiempos con técnica de ALPPS (Asociación de bipartición hepática con ligadura portal para hepatectomía en 2 tiempos). Experiencia y resultados iniciales del Hospital Regional de Talca

Introduction: Postoperative liver failure (POLF) is a relevant cause of morbimortality after liver surgery. An insufficient future liver remnant (FLR) is one of the main causes of POLF. The association of hepatic bipartition with portal ligation for 2-stage hepatectomy (ALPPS) is a relatively new technique that induces rapid parenchymal hypertrophy reducing the waiting time to achieve adequate FLR. Our aim is to communicate the experience and the initial results of the hepatectomy in 2-stages using the ALLPS technique. Material and Method: All patients in whom a 2-stage hepatectomy using ALPPS technique between June 1, 2014 and July 31, 2016 in the Digestive Surgery Unit of the Hospital Regional of Talca were included. Results: There were 47 hepatectomies performed at the Hospital Regional of Talca. In 3 cases (6.3%), a 2-stage hepatectomy was performed using the ALPPS technique, in all of which a hypertrophy of the future hepatic remnant (RHF) was achieved, which allowed completing the second stage without POLF clinically significant. Conclusion: In our initial experience, the ALPPS technique successfully allowed increase FLR in patients who initially had insufficient FLR to be submitted a major liver resection.

Future Liver Remnant (FLR) Increase in Patients with Colorectal Liver Metastases Is Highest the First Week After Portal Vein Occlusion

BackgroundPortal vein occlusion (PVO) is an established method to increase the volume of the future liver remnant (FLR). The main reasons for not proceeding to radical hepatectomy are lack of volume increase and tumor progression due to a wait-time interval of up to 8 weeks. The hypothesis was that the increase in FLR volume is not linear and is largest during the first weeks. MethodsPatients with colorectal liver metastases (CRLM) and standardized future liver remnant (sFLR) < 30% treated with PVO were prospectively included. All patients had at least one CT evaluation before radical hepatectomy. ResultsForty-eight patients were included. During the first week after PVO, the kinetic growth rate (KGR) was 5.4 (± 4), compared to 1.5 (± 2) between the first and second CT (p < 0.05). For patients reaching adequate FLR and therefore treated with radical hepatectomy, the KGR was 7 (± 4) the first week, compared to 4.3 (± 2) for patients who failed to reach a sufficient volume (p = 0.4). During the interval between the first and second CT, the KGR was 2.2 (± 2), respectively (± 0.1) (p = 0.017). DiscussionThe increase in liver volume after PVO is largest during the first week. As KGR decreases over time, it is important to shorten the interval between PVO and the first volume evaluation; this may aid in decision-making and reduce unnecessary waiting time.

Impact of the learning-curve with parenchyma sparing hepatectomy for deep tumors: time vs complexity?

Introduction: Parenchyma sparing hepatectomy (PSH) assures adequate future liver remnant (FLR) for deep located tumors, however, PSH requires complex surgical procedures with a learning curve that has never been analysed. Methods: Data from 127 consecutive patients treated with a PSH during the first 9 years of practice were registered in a prospective database. Two patients with preoperative total bilirubin >5 mg/dl were excluded. The initial period (4y) of low (< 14/y) and the later period (5y) of high (>14/y) case volume were compared. Results: Low (n=24) and high (n=101) case volume groups were comparable (P>0.05) for patient's baseline characteristics, PSH requiring HV exposure/resection (92% vs 78%), PSH with vascular reconstruction (25% vs 25%), extrahepatic surgical procedures (25% vs 28%), median blood loss (150 vs 150 ml), blood transfusion (37% vs 27%), overall (50% vs 38%) and severe (8% vs 8%) postoperative complications, and median length of stay (8.5 vs 9 days). Overall 90-day mortality was 1.6%. In high volume case period there was an increasing attitude in first/second order glissonian pedicles exposure (33% vs 68%; P=0.001) and the mean largest lesion size was greater (41±24 cm vs 55±37 cm, P=0.034). Furthermore the operative time was shorter (714±316 min vs 595±242 min, P=0.048) and the resected liver surface per minute was larger (0.93±0.35 cm2/min vs 1.44±0.69 cm2/min, P=0.001). Conclusions: The learning curve had significant impact on operative time and on liver-cut surface area per minute, in spite of an increased attitude in first/second order glissonian pedicles exposure and increased lesion size.

Future liver remnant (FLR) increase in patients with colorectal liver metastases is highest the first week after portal vein occlusion

Introduction: Portal vein occlusion (PVO) is an established method to increase the volume of the future liver remnant (FLR). The main reasons for not proceeding to radical hepatectomy is lack of volume increase or tumour progression due to a wait-time interval of up to 8 weeks. The hypothesis was that the increase in FLR volume is not linear and is largest during the first weeks. Method: Patients with colorectal liver metastases (CRLM) and standardized future liver remnant (sFLR) < 30 % treated with PVO were prospectively included. All patients had at least one CT-evaluation before radical hepatectomy. Results: Forty-eight patients were included. During the first week after PVO, the kinetic growth rate (KGR) was 5.4 (± 4), compared to 1.5 (± 2) between the first and second CT, p< 0.05. For patients reaching adequate FLR and therefore treated with radical hepatectomy, KGR was 7 (± 4) the first week, compared to 4.3 (± 2) for patients who failed to reach a sufficient volume, (p=0.4). During the interval between the first and second CT, KGR was 2.2 (± 2) respectively (± 0.1), p=0.017. Conclusions: The increase in liver volume after PVO is largest during the first week. As KGR decreases over time, it is important to shorten the interval between PVO and the first volume evaluation; this may aid in decision-making and reduce unnecessary waiting time.

Techniques of parenchyma-sparing hepatectomy for the treatment of tumors involving the hepatocaval confluence: A reliable way to assure an adequate future liver remnant volume

Parenchyma-sparing hepatectomy techniques allow a lesser volume resection (<3 adjacent segments) for tumors involving the hepatic veins at the hepatocaval confluence, assuring adequate volume of the future liver remnant. We report the ability to perform parenchyma-sparing hepatectomy as planned from the preoperative imaging and the type of vascular intervention used to preserve hepatic outflow. We analyzed 60 consecutive parenchyma-sparing hepatectomies in 54 patients for 7 primary and 53 metastatic tumors (48 colorectal), located in segments I, VII, VIII, or IVa and involving the hepatocaval confluence. Patients had a median of 2 (range: 1-18) lesions with median diameter of 4cm (range: 1.2-16.5), which were bilateral in 43%. A parenchyma-sparing hepatectomy was performed in all of the 60 cases, only one case required the resection of 3 adjacent segments. In 16 (27%) hepatic veins-resections, the outflow was assured by preservation of the inferior-right-hepatic veins in 3 (5%), of the communicating-veins in 4 (7%), of the middle-hepatic veins in 3 (4%; middle-hepatic veins patch-reconstruction in 2 cases), by polytetrafluoroethylene-grafts in 4 (7%), and by hepatic veins-anastomosis in 2 (3%). In 15 (25%) cases, the hepatic veins were resected tangentially and reconstructed by direct suture venorraphy. In 29 (48%) cases, the hepatic veins were skeletonized from the tumor. Grade IIIb to IV complications occurred in 7%, median hospital-stay was 9days, and 90-day mortality occurred in one cirrhotic patient. Median overall and disease-free survivals were 72 and 16months (median follow-up: 34months). A lesser volume parenchyma-sparing hepatectomy rather than a formal major hepatectomy for tumors involving the hepatocaval confluence can be performed with a low rate of major complications (7%). Parenchyma-sparing hepatectomy should be considered in highly selected patients when evaluating liver resection for tumors involving the hepatocaval confluence based on appropriate and accurate preoperative imaging.

An updated systematic review of the evolution of ALPPS and evaluation of its advantages and disadvantages in accordance with current evidence.

The main obstacle to achieving an R0 resection after a major hepatectomy is inability to preserve an adequate future liver remnant (FLR) to avoid postoperative liver failure (PLF). Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) is a novel technique for resecting tumors that were previously considered unresectable, and this technique results in a vast increase in the volume of the FLR in a short period of time. However, this technique continues to provoke heated debate because of its high mortality and morbidity.The evolution of ALPPS and its advantages and disadvantages have been systematically reviewed and evaluated in accordance with current evidence. Electronic databases (PubMed and Medline) were searched for potentially relevant articles from January 2007 to January 2016.ALPPS has evolved into various modified forms. Some of these modified techniques have reduced the difficulty of the procedure and enhanced its safety. Current evidence indicates that the advantages of ALPPS are rapid hypertrophy of the FLR, the feasibility of the procedure, and a higher rate of R0 resection in comparison to other techniques. However, ALPPS is associated with worse major complications, more deaths, and early tumor recurrence.Hepatobiliary surgeons should carefully consider whether to perform ALPPS. Some modified forms of ALPPS have reduced the mortality and morbidity of the procedure, but they cannot be recommended over the original procedure currently. Portal vein embolization (PVE) is still the procedure of choice for patients with a tumor-free FLR, and ALPPS could be used as a salvage procedure when PVE fails. More persuasive evidence needs to be assembled to determine whether ALPPS or two-stage hepatectomy (TSH) is better for patients with a tumor involving the FLR. Evidence with regard to long-term oncological outcomes is still limited. More meticulous comparative studies and studies of the 5-year survival rate of ALPPS could ultimately help to determine the usefulness of ALPPS. Indications and patient selection for the procedure need to be determined.

Colorectal liver metastases growth in the embolized and non-embolized liver after portal vein embolization: influence of initial response to induction chemotherapy.

To compare tumor progression in both embolized and non-embolized liver lobes after portal vein embolization (PVE) in patients with bilobar colorectal liver metastases (CLM), according to the initial response to induction chemotherapy. From 2002 to 2012, a total of 42 consecutive patients with bilobar CLM initially treated using induction chemotherapy underwent right PVE to achieve adequate future liver remnant volume. Tumoral and liver parenchyma volumes, as well as their volume variations, were measured on computed tomography before and after PVE in both embolized and non-embolized. Patients were classified as fast (≤6 cycles of induction chemotherapy) and slow (>6 cycles) responders. Overall, 432 metastases were analyzed in 42 patients. Patients were slow responders in 29 (69 %) cases. Tumoral volume increased in 29 (69 %) cases in the embolized liver (+48 %; p < 0.0001), and in 28 (66 %) cases in the non-embolized liver (+31 %; p < 0.0001). Fast responders had a tumoral volume decrease in both embolized (-4 %) and non-embolized (-9 %) lobes. On the opposite side, slow responders had tumoral volume increase in both embolized (+79 %) and non-embolized (+32 %) lobes. On multivariate analysis, a 'slow' response to induction chemotherapy was the only factor associated with tumoral progression in both embolized (p = 0.0012) and non-embolized (p = 0.001) lobes. Tumor growth after PVE is observed in both embolized and non-embolized liver lobes in most patients but is significantly associated with slow response to induction chemotherapy.

Portal Vein Embolization before Right Hepatectomy or Extended Right Hepatectomy Using Sodium Tetradecyl Sulfate Foam: Technique and Initial Results

PurposeTo evaluate the safety and efficacy of portal vein embolization (PVE) with sodium tetradecyl sulfate (STS) foam. Materials and MethodsA single-center retrospective review of 35 patients (27 men and 8 women; mean age, 61 y) who underwent PVE with STS foam was performed. The technical success rate, rate of PVE at producing adequate future liver remnant (FLR) hypertrophy, and rate of disease progression precluding resection after PVE were analyzed. Complications of PVE and liver resection after PVE were recorded. ResultsPVE was performed on 35 patients before right hepatic resection for both primary and secondary hepatic malignancies (22 hepatocellular carcinoma, 10 metastasis, 2 cholangiocarcinoma, 1 invasive gallbladder carcinoma). Technical success was achieved in 97.1% (34 of 35) of patients. Mean FLR of the total estimated liver volume increased from 24.5% (SD, 7.7%) to 36.5% (SD, 14.5%), a mean percentage increase of 48.8% (SD, 34.3%). PVE produced adequate FLR hypertrophy in 31 of 35 patients (88.6%). Proposed right hepatectomy was subsequently performed in 27 patients (77.1%). One patient remains scheduled for surgery, two had peritoneal spread at surgery and resection was aborted, two had disease progression on imaging after PVE, and three had inadequate FLR hypertrophy with no surgery. One major complication was observed related to PVE that involved nontarget embolization to segment III, which was managed conservatively. ConclusionsPreoperative PVE with STS foam is a safe and effective method to induce hypertrophy of the FLR.

ALPPS Procedure with the Use of Pneumoperitoneum

A new method for liver hypertrophy was recently introduced, the so-called associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) procedure. We present a video of an ALPPS procedure with the use of pneumoperitoneum. A 29-year-old woman with colon cancer and synchronous liver metastasis underwent a two-stage liver resection by the ALPPS technique because of an extremely small future liver remnant. The first operation began with 30 min pneumoperitoneum. Anatomical resection of segment 2 was performed, followed by multiple enucleations on the left liver. The right portal vein was ligated and the liver partitioned. The abdominal cavity was partially closed, and a 10 mm trocar was left to create a pneumoperitoneum for additional 30 min. The patient had an adequate future liver remnant volume after 7 days, but she was not clinically fit for the second stage of therapy, so it was postponed. She was discharged on day 7 after surgery. The second stage took place 3 weeks later and consisted of an en-bloc right trisectionectomy extended to segment 1. The patient recovered and was discharged 9 days after second-stage surgery. Postoperative CT scan revealed an enlarged remnant liver. The ALPPS procedure is a new revolutionary technique that permits R0 resection even in patients with massive liver metastasis. The use of pneumoperitoneum during the first stage is an easy tool that may prevent hard adhesions, allowing an easier second stage. This video may help oncological surgeons to perform and standardize this challenging procedure.

Optimal Future Liver Remnant in Patients Treated with Extensive Preoperative Chemotherapy for Colorectal Liver Metastases

Patients with colorectal liver metastases (CLM) are increasingly treated with preoperative chemotherapy. Chemotherapy associated liver injury is associated with postoperative hepatic insufficiency (PHI) and mortality. The adequate minimum future liver remnant (FLR) volume in patients treated with extensive chemotherapy remains unknown. All patients with standardized FLR>20%, who underwent extended right hepatectomy for CLM from 1993-2011, were divided into three cohorts by chemotherapy duration: no chemotherapy (NC, n=30), short duration (SD, ≤12weeks, n=78), long duration (LD, >12weeks, n=86). PHI and mortality were compared by using uni-/multivariate analyses. Optimal FLR for LD chemotherapy was determined using a minimum p-value approach. A total of 194 patients met inclusion criteria. LD chemotherapy was significantly associated with PHI (NC+SD 3.7 vs. LD 16.3%, p=0.006). Ninety-day mortality rates were 0% in NC, 1.3% in SD, and 2.3% in LD patients, respectively (p=0.95). In patients with FLR>30%, PHI occurred in only two patients (both LD, 2/20, 10%), but all patients with FLR>30% survived. The best cutoff of FLR for preventing PHI after chemotherapy >12weeks was estimated as >30%. Both LD chemotherapy (odds ratio [OR] 5.4, p=0.004) and FLR≤30% (OR 6.3, p=0.019) were independent predictors of PHI. Preoperative chemotherapy >12weeks increases the risk of PHI after extended right hepatectomy. In patients treated with long-duration chemotherapy, FLR>30% reduces the rate of PHI and may provide enough functional reserve for clinical rescue if PHI develops.