Ex Vivo Liver Resection And Autotransplantation Research Articles

Single-center experience of Ex vivo liver resection and autotransplantation for complex hepatic alveolar echinoccosis.

To summarize the single-centre experience of Ex vivo Liver Resection and Autotransplantation (ELRA) to treat end-stage hepatic alveolar echinococcosis (HAE). Retrospective analysis of clinical data and follow-up data of 13 patients admitted to the Affiliated Hospital of Qinghai University from January 2015 to December 1, 2020, with the Ex vivo Liver Resection and Autotransplantation for hepatic alveolar echinococcosis. 13 patients underwent successful total/ semi-ex-vivo liver resection combined with Ex vivo Liver Resection and Autotransplantation with no intra-operative deaths. the median standard liver volume was 1,118 ml (1,085-1,206.5 ml); the median residual liver volume was 634 ml (526.5-1,338 ml); The median weight of the autograft was 845.8 g (619.5-1,020.5 g), the median operation time was 14.5 h (11.5-16.15 h); the median anhepatic period time was 290 min (257-312.5 min). The median intraoperative blood loss was 1,900 ml (1,300-3,500 ml); the median number of erythrocyte suspensions entered was 7.5 u (6-9u). The median length of hospital stay was 32 days (24-40 days). Postoperative complications occurred in 9 patients during hospitalization,with 7 patients graded at grade III or higher by Clavien-Dindo; 4 patients died postoperatively. 1 patient had recurrent abdominal distension with massive thoracoabdominal fluid and coagulation dysfunction 8 months after surgery and was considered to have small liver syndrome. 1 patient developed HAE recurrence during the follow-up, which was considered intraoperative incisional implantation. ELRA is one of the most valuable therapeutic measures for the treatment of end-stage complicated hepatic alveolar echinococcosis. Precise preoperative assessment of liver function, individualized intraoperative duct reconstruction, and precise management of the postoperative disease can achieve better treatment results.

Approaches to reconstruction of inferior vena cava by ex vivo liver resection and autotransplantation in 114 patients with hepatic alveolar echinococcosis

BACKGROUNDHepatic alveolar echinococcosis (AE) is most commonly found in retrohepatic inferior vena cava (RHIVC). Ex vivo liver resection and autotransplantation (ELRA) can better realize the radical resection of end-stage hepatic AE with severely compromised hepatocaval confluences, and reconstruction of the affected vessels. Currently, there is a scarcity of information regarding RHIVC reconstruction in ELRA.AIMTo propose reasonable RHICV reconstruction strategies for ex vivo liver resection and autotransplantation.METHODSWe retrospectively summarized the clinical data of 114 patients diagnosed with hepatic AE who treated by ELRA in our department. A total of 114 patients were divided into three groups according to the different reconstruction methods of RHIVC: Group A with original RHIVC being repaired and reconstructed (n = 64), group B with RHIVC being replaced (n = 43), and group C with RHIVC being resected without reconstruction (n = 7). The clinical data of patients, including the operation time, anhepatic phase, intraoperative blood loss, complications and postoperative hospital stay, were analyzed and the patients were routinely followed up. The normally distributed continuous variables were expressed as means ± SD, whereas the abnormally distributed ones were expressed as median and analyzed by analysis of variance. Survival curve was plotted by the Kaplan-Meier method.RESULTSAll patients were routinely followed up for a median duration of 52 (range, 12-125) mo. The 30 d mortality rate was 7.0% (8/114) and 7 patients died within 90 d. Among all subjects, the inferior vena cava (IVC)-related complication rates were 17.5% (11/63) in group A and 16.3% (7/43) in group B. IVC stenosis was found in 12 patients (10.5%), whereas thrombus was formed in 6 patients (5.3%). Twenty-two patients had grade III or higher complications, with the complication rates being 17.2%, 16.3%, and 57.1% in the three groups. The average postoperative hospital stay in the three groups was 32.3 ± 19.8, 26.7 ± 18.2, and 51.3 ± 29.4 d (P = 0.03), respectively.CONCLUSIONELRA can be considered a safe and feasible option for end-stage hepatic AE patients with RHIVC infiltration. The RHIVC reconstruction methods should be selected appropriately depending on the defect degree of AE lesions in IVC lumen. The RHIVC resection without any reconstruction method should be considered with caution.

Massive sympathetic nerve infiltration in advanced hepatic alveolar echinococcosis: a case report and review of the literature

BackgroundAlveolar echinococcosis is a zoonotic disease that mostly affects the liver, with vascular invasion and a protean clinical symptom. However, no reports of sympathetic nerve infiltration in hepatic alveolar echinococcosis have been reported. Here, we report a case of hepatic alveolar echinococcosis in a 33-year-old man. In this end-stage case, the lesion was heavily involved in the large vessels and biliary tract, and immunohistochemistry also incidentally revealed extensive nerve infiltration in the specimens after surgical treatment. Subsequently, neural classification was identified.Case presentationWe herein report a case of advanced hepatic alveolar echinococcosis with macrovascular invasion and sympathetic nerve infiltration. In this case, inferior vena cava (IVC), the portal vein and bile duct were infiltrated. Ultimately, according to our experience, ex vivo liver resection and autotransplantation (ELRA) was the optimal treatment way to perform for this unresectable patient. Samples were collected from normal liver tissue, junction tissue and the lesion. Hematoxylin–eosin (HE) staining was used to confirm the diagnosis. Neural infiltration was observed by immunohistochemical staining with protein gene product 9.5 (PGP9.5). Fluorescence colocalization was determined with PGP9.5 and tyrosine hydroxylase (TH). These results suggest that a large amount of sympathetic nerve infiltration occurred at the junction.ConclusionThis study suggests that advanced hepatic alveolar echinococcosis shows infiltrating growth, often invades the large vessels and biliary ducts, and may be accompanied by sympathetic nerve infiltration.

Evaluating the Benefits and Risks of Ex Vivo Liver Resection and Autotransplantation in Treating Hepatic End-stage Alveolar Echinococcosis.

Ex vivo liver resection and autotransplantation (ELRA) has shown promising outcomes in treating end-stage hepatic alveolar echinococcosis (AE). However, the actual benefits and risks remain unclear. This study aims to analyze the benefits and risks of ELRA. This retrospective cohort analysis included 228 patients with end-stage hepatic AE who underwent ELRA or nonsurgical treatment between 2014 and 2020. Propensity score matching was used. Long-term survival was compared in the matched cohorts using Kaplan-Meier curves generated with the log-rank test. Short-term mortality in entire cohort was predicted based on the nonsurgical group, and the interaction between the predicted mortality risk and observed mortality was tested. Risk factors for postoperative major morbidity in the ELRA group were evaluated using logistic regression analyses. The long-term overall survival of the ELRA group was superior to that of the nonsurgical group (82.1% vs 19.1%, 5-year survival). Regarding short-term outcomes, the basic risk of 12-month mortality exerted a significant effect on the benefit of ELRA in entire cohort (per 1%, odds ratio, 1.043; 95% confidence interval [CI]: 1.007-1.082; P = .021). Patients with a predicted 12-month mortality risk >75% would significantly benefit from ELRA. Combined resection (hazard ratio [HR], 3.32; 95% CI: 1.01-10.99; P = .049) and overall surgery time (per hour, HR, 1.41; 95% CI: 1.09-1.82; P = .009) were identified as independent risk factors for postoperative major morbidity. ELRA was significantly beneficial in selected patients with end-stage AE compared with nonsurgical treatment. The timing of conducting ELRA remarkably affected the short-term risk of mortality and should be carefully determined.

Reconstruction of hepatic venous outflow and management of its complications using ex vivo liver resection and autotransplantation: a single-center experience

Background This study was designed to investigate the techniques of hepatic venous outflow reconstruction and the management of its complications using ex vivo liver resection and autotransplantation (ELRA). Methods Being a retrospective case series covering 84 patients who underwent hepatic venous outflow reconstruction during ELRA from January 2016 to October 2020, 11 cases of postoperative hepatic venous outflow obstruction (HVOO), whose surgery details were described and survival rates analyzed. Results A total of the 84 alveolar Echinococcosis (AE) series was no intraoperative death. The 30-day mortality was 5.95% (5 /84). The most common postoperative complication was pleural effusion in 21 cases (25%). HVOO occurred in 11 cases, one of them died of liver failure, and the other 10 patients underwent interventional revascularization with good results. There was no significant difference in survival between patients with successful interventional revascularization due to HVOO and patients without HVOO (P > 0.05). Conclusions Individualized and well design reconstruction of hepatic vein can be considered as a key procedure to reduce the complications of HVOO in ELRA. Once HVOO occurs, emergent management must be performed immediately before liver dysfunction. Interventional revascularization showed an effective approach, though the more clinical cases need to be evaluated.

Learning Curve of Ex Vivo Liver Resection and Autotransplantation in Treating End-Stage Hepatic Alveolar Echinococcosis: A RA-CUSUM Analysis.

Background: This retrospective study aimed to evaluate the safety and learning curve of ex vivo liver resection and autotransplantation (ELRA).Methods: A total of 102 consecutive end-stage HAE patients who underwent ELRA between 2014 and 2020 in West China Hospital were enrolled. The primary endpoint was major postoperative complications (comprehensive complication index, CCI > 26). The ELRA learning curve was evaluated using risk-adjusted cumulative sum (RA-CUSUM) methods. The learning phases were determined based on RA-CUSUM analysis and tested for their association with intra- and post-operative endpoints.Results: The median surgery time was 738 (659–818) min, with a median blood loss of 2,250 (1,600–3,000) ml. The overall incidence of major morbidity was 38.24% (39/102). Risk-adjusted cumulative sum analysis demonstrated a learning curve of 53 ELRAs for major postoperative complications. The learning phase showed a significant association with the hemodynamic unstable time (HR −30.29, 95% CI −43.32, −17.25, P < 0.0001), reimplantation time (HR −13.92, 95% CI −23.17, −4.67, P = 0.004), total postoperative stay (HR −6.87, 95% CI −11.33, −2.41, P = 0.0033), and postoperative major morbidity (HR 0.25, 95% CI 0.09, 0.68, p = 0.007) when adjusted for age, disease course, liver function, and remote metastasis.Discussion: Ex vivo liver resection and autotransplantation is feasible and safe with a learning curve of 53 cases for major postoperative complications.

A Sarcopenia-Based Prediction Model for Postoperative Complications of ex vivo Liver Resection and Autotransplantation to Treat End-Stage Hepatic Alveolar Echinococcosis.

BackgroundSarcopenia and visceral adiposity have been shown to be associated with postoperative complications in numerous diseases. However, their effects on the postoperative complications of end-stage hepatic alveolar echinococcosis (HAE) patients undergoing ex vivo liver resection and autotransplantation (ELRA) remain unclear.MethodsThis retrospective study included 101 end-stage HAE patients who underwent ELRA from January 2014 to August 2020. We measured the skeletal muscle and adipose tissue of all patients at the level of the third lumbar vertebra on plain abdominal computed tomography (CT) images and subsequently derived an equation via least absolute shrinkage and selection operator (LASSO) regression analysis to calculate the sarcopenia score. Univariate and multivariate regression were performed to reveal the relationship between major postoperative complications and perioperative clinical data, and the obtained nomogram was validated with the bootstrapping method.ResultsThe sarcopenia score was constructed as a personalized indicator to evaluate sarcopenia and visceral adiposity in each patient. Logistic regression analysis finally selected duration from primary diagnosis to obvious symptoms (OR=1.024, 95% CI, 1.007–1.042), surgical time (OR=1.003, 95% CI, 0.999–1.007) and sarcopenia score (OR=4.283, 95% CI, 1.739–10.551) as independent risk factors for predicting major postoperative complications following ELRA for end-stage HAE patients. The area under the receiver operating characteristic curve (AUROC) of 0.807 (95% CI, 0.720–0.895) and the calibration curve for this prediction model were satisfactory.ConclusionThe sarcopenia score, which systematically evaluates the skeletal muscle and adipose tissue of end-stage HAE patients, was a significant predictive factor for major postoperative complications of ELRA. Relevant interventions should be conducted for those who have a high risk of postoperative complications according to the nomogram.

Application of ex vivo liver resection and autotransplantation in treating Budd-Chiari syndrome secondary to end-stage hepatic alveolar echinococcosis: A case series.

Background:Secondary Budd-Chiari syndrome (BCS) occurs due to a blockage in the liver caused by invasion or compression by a large lesion. Conventional treatments for BCS do not solve practical problems, wherease liver transplantation has been only applied as a last-resort therapy and as the only opportunity for a radical cure. We explored the feasibility of applying ex vivo liver resection and autotransplantation (ELRA) for the new indications of treating patients with end-stage hepatic alveolar echinococcosis (HAE). Our center has firstly proposed the idea and successfully treated the 49 patients with HAE. This article for the first time reports the application of ELRA in treating patients with BCS secondary to HAE.Methods:According to the degree of lesion invasion and surgical options, 11 patients were divided into 4 types. These 11 patients had large lesions that invaded the second and third hilum of the caudate lobe and involved the confluence of the hepatic vein and the inferior vena cava, suprahepatic vena cava, or at least 2 hepatic veins and led to secondary BCS. The aim of the present work was to report 11 patients with life-threatening diseases who underwent ELRA (ex vivo liver resection and autotransplantation) for secondary BCS, to propose a classification system for secondary BCS, and to suggest that secondary BCS is an indication for ELRA.Results:Eleven patients successfully underwent ELRA without intraoperative mortality. The median autograft weight was 690 g (440–950 g); operative time was 12.5 hours (9.4–16.5 hours); Postoperative hospital stay was 15 days (7–21 days). Clavien-Dindo grade IIIa or higher postoperative complications occurred in only 5 patients.Conclusions:This article for the first time reports the application of ELRA in treating patients with BCS secondary to HAE, not only provides new ideas for alternative treatments of secondary BCS, but also provides a classification system for secondary BCS. This article describes the technical process of outflow tract reconstruction and the experience for expanding the indications for ELRA. Our study demonstrated that ELRA is well feasible for treatment of BCS secondary to advanced HAE.

Ex Vivo Liver Resection and Autotransplantation as Surgical Option for Zone II-III Leiomyosarcoma of IVC: A Case Report and Literature Review.

We report the first documented case of leiomyosarcoma at zone II-III of inferior vena cava with thrombi in three hepatic veins undergoing ex vivo liver resection and autotransplantation (ELRA) and hepatic veins thrombectomy. A 33-year-old female patient presented with abdominal distention and lower extremities edema. Abdominal wall varicosis and shifting dullness were positive on physical examination. Her liver function was classified as Child-Pugh B and a solid tumor at retro-hepatic vena cava extending to right atrium with thrombi in three hepatic veins were confirmed. The diagnosis of leiomyosarcoma with Budd-Chiari syndrome was highly suspected with preoperative ultrasound, echocardiogram, CT scan, and three-dimensional reconstruction. A zone II-III leiomyosarcoma of IVC origin was confirmed at surgery and ex vivo liver resection and autotransplantation, and hepatic vein thrombectomy with atrial reconstruction were performed under cardiopulmonary bypass (CPB). Operative time, anhepatic time, and CPB time were 12 h, 128 min, and 84 min, respectively. The patients experienced post-operative liver dysfunction and was cured with conservative therapy. Hepatic recurrence two years after surgery was managed with radiofrequency. The patient was alive with liver metastasis three years after surgery. Despite being regarded as an extremely aggressive procedure, ELRA could be considered in the treatment of advanced leiomyosarcoma with Budd-Chiari syndrome and hepatic vein thrombi.

&lt;i&gt;Ex vivo&lt;/i&gt; Liver Resection and Autotransplantation as Radical Alternative to Sorafenib for Conventionally Unresectable Advanced-Stage Hepatocellular Carcinoma Without Portal Vein Invasion

Background and Aims: Although sorafenib can prolong survival by 2.8 months in patients with advanced-stage hepatocellular carcinoma (HCC), radical hepatectomy is still the best treatment. However, R0 resection is difficult to achieve by conventional hepatectomy for those patients. The aim of this study was to assess the clinical outcomes of ex vivo liver resection and autotransplantation (ELRA) for conventionally unresectable HCC and establish a possible patient selection strategy. Methods: In this prospective study, 33 consecutive patients with conventionally unresectable advanced-stage HCC given ELRA and 499 that of patients administrated sorafenib were analyzed. The feasibility, safety, short- and long-term clinical outcome of this technique were assessed. Results: After analysis, the median overall survival (OS) of those patients with portal vein invasion given ELRA was only 3.87 months, lower than that of patients administrated sorafenib (6.5/10.7 months). For all patients without portal vein invasion, the median OS was 16.2 months, higher than that of patients administrated sorafenib. The 90-day mortality was 4.55%, and the 1-, 3-, and 5-year OS rates were 81.82%, 45.45% and 36.36%, respectively. Patients are considered candidates for ELRA could be defined as follows: the hepatic lesion scope (1)simultaneously involves two or more areas of the first, second and third porta hepatis; (2)involves the second porta hepatis only, but ≥ 2 main branches of major vessels were invaded; (3)involves the second porta hepatis only, but major vessels are damaged, the adhesions being difficult to separate. Results were verified by previous case reports. Conclusion: ELRA could be an effective radical treatment for patients with conventionally unresectable advanced-stage HCC without portal vein invasion. Careful patient selection is crucial for ELRA. Funding Information: There is no financial support. Declaration of Interests: The authors declare no potential conflict of interest. Ethics Approval Statement: The retrospective study design and the management of patients who underwent ELRA were in accordance with the 1975 Declaration of Helsinki and approved by the Human Ethics Committee of Southwest Hospital. Written informed consent, in which the risks of this major procedure were detailed, including prolonged hospitalization, severe debility, decrease in patient quality of life and risk of death, was obtained from all subjects and/or legal custodians. All patients and/or legal custodians consented with full understanding of the risks and benefits of the procedure.

Feasibility of Retrohepatic Inferior Vena Cava Resection Without Reconstruction for Hepatic Alveolar Echinococcosis.

This study evaluates the feasibility of retrohepatic inferior vena cava (RHIVC) resection without reconstruction in patients with end-stage hepatic alveolar echinococcosis (AE). Four hundred and fifty-seven patients diagnosed with hepatic AE and who underwent surgical resections between January 2010 and October 2018 were retrospectively analyzed. Nine patients receiving RHIVC resection without reconstruction were included in this study. Among the patients, 5 were male and 4 female. Mean follow-up time was 64.4 months (18-95). In this series, adequate collateral circulation was formed before operation in all patients, and 7 cases underwent ex vivo liver resection and autotransplantation (ELRA) and 2 cases underwent extended right hemi-hepatectomy. Average standard liver volume, graft volume, surgical time, and anhepatic phase in ELRA group patients was 1144 ± 127 cm3, 740 ± 235 cm3, 16.8 ± 4.1 hours, and 337.4 ± 108.65 minutes respectively. Average hospital stay time for all patients was 45 ± 36.4 days. There were no intraoperative deaths. The 30-day mortality rate was 11.1%, and total mortality rate was 22.2%. Postoperative complications occurred in 4 patients. During follow-up, no relapsed AE lesions were found. RHIVC resection without reconstruction is a feasible way for hepatic AE patients with adequate collateral circulation. Careful protection of collateral venous is the key factor for successful operation.

Current status of ex-vivo liver resection and autologous liver transplantation for end-stage hepatic alveolar echinococcosis.

Hepatic alveolar echinococcosis (HAE) is a cosmopolitan zoonosis distribute widely in the northern hemisphere with high estimated 10-year mortality. Radical resection combined with oral albendazole administration are the major methods for HAE treatment, whereas most patients delayed diagnosis and treatment because which was considered as benign disease. For the cases with end-stage HAE could not be treated through conventional hepatectomy, allograft liver transplantation (LT) was regarded as a life-saving technique previously. However, graft shortage, high recurrence rate and long-term immunosuppressive therapy limited its utilization. Since the ex-vivo liver resection and autotransplantation (ERAT) procedure was first used in treating for end-stage HAE in 2011, there are more than 120 HAE cases patients were reported treating in this method up to now. Comparing with LT, ERAT needs neither an organ donor nor long term immunosuppressive therapy, and provide preferable overall survival rates. Based on the conventional ERAT procedure, some modification such as auxiliary partial autologous LT were introduced in the high selected end-stage HAE patients presently. However, the standard procedures for ERAT including surgical details and perioperative management have not been established because of limited reported cases. Also, the present ERAT experience for end-stage HAE treatment are all summarizes by the Chinese surgeon groups. For summarizing the knowledge and experience details, we reviewed present opinions about ERAT for end-stage HAE patients, and presented the future perspectives about this topic in this manuscript. We aimed at discussing the feasibility, indications, preparation, technical details, and postoperative outcomes of ERAT for HAE patients.

Resection of retrohepatic inferior vena cava without reconstruction in ex vivo liver resection and autotransplantation: a retrospective study

BackgroundRetrohepatic inferior vena cava (RIVC) resection without reconstruction in ex vivo liver resection and autotransplantation (ERAT) for advanced alveolar echinococcosis (HAE) is unclear.MethodsThis is a retrospective study of consecutive patients referred to our hospital from 2014 to 2018. Depending on the presence of a rich collateral circulation and stable blood volume in ERAT, patients did not rebuild the RIVC. Then, patients were selected some appropriate revascularization techniques for the hepatic and renal veins. Finally, all ERAT procedures were completed, and short- and long-term outcomes were observed.ResultsFive advanced HAE patients underwent ERAT without RIVC reconstruction. One patient died of circulatory failure 1 day after surgery. Another four patients, with a median follow-up duration of 18 months (range, 10–25 months), demonstrated normal liver and kidney function, no thrombosis and no HAE recurrence.ConclusionsThrough the long-term results of ERAT, the pros and cons of not reconstructing the RIVC need to be re-examined. In cases with a rich collateral circulation, the RIVC cannot be reconstructed. However, in cases requiring the resection of multiple organs, RIVC without reconstruction was prudential.

Outcomes of different surgical resection techniques for end-stage hepatic alveolar echinococcosis with inferior vena cava invasion

BackgroundHepatic alveolar echinococcosis (HAE) lesions with inferior vena cava (IVC) invasion require combined resection of the liver and IVC. The outcomes of different surgical treatments, including in situ, ante situm and ex vivo resection, remain unclear. MethodsA total of 71 consecutive HAE patients who underwent hepatectomy with retrohepatic IVC resection were included. The patients were divided into ex vivo liver resection and autotransplantation (ERAT) group (n = 45) and in vivo resection group (n = 26). These techniques were assessed for feasibility and short- and long-term outcomes. ResultsThere were no significant differences with respect to postoperative complications and mortality between the ERAT and in vivo resection groups. The causes of mortality were liver failure in 3 patients, hemorrhagic shock in 1 patient, intra-abdominal bleeding in 1 patient, and acute cerebral hemorrhage in 1 patient. During a median of 22 months followed-up time, 2 patients developed ascites because of venous outflow stenosis, and 1 patient developed biliary stenosis in the ERAT group. The distant metastasis, local recurrence, and mortality rates were 0%, 1.4%, and 8.5%, respectively. ConclusionCombined liver resection and reconstruction of the IVC can be safely performed in selected patients with in situ, ante situm, and ex vivo resection.

Ex vivo liver resection and autotransplantation versus allotransplantation for end-stage hepatic alveolar echinococcosis

ObjectiveThe aim of this study was to compare the clinical outcomes of ex vivo liver resection and autotransplantation (ERAT) with allotransplantation in patients with end-stage hepatic alveolar echinococcosis (HAE). MethodsFrom January 2008 to October 2017, 41 of 254 patients with end-stage HAE fulfilled the inclusion criteria (ERAT group, n=35; allotransplantation group, n=6). Each group was assessed for indications and short- and long-term outcomes. ResultsThe intraoperative mortality was zero in both groups. Two patients died after ERAT due to intra-abdominal bleeding and acute cerebral hemorrhage. The most frequent postoperative complications were biliary complications, which occurred in six patients (14.6%). Parasite recurrence was recorded in two patients, at 16 months and 52 months after allotransplantation. The survival curve showed a longer survival time in the ERAT group than in the allotransplantation group (P=0.028). In the ERAT group, the 1-, 3-, and 5-year overall survival rates were all 100%. In the allotransplantation group, the 1-, 3-, and 5-year overall survival rates were 100%, 83.3%, and 66.7%, respectively. ConclusionsThis appears to be the first series comparing ERAT with allotransplantation for end-stage HAE. ERAT may be a superior alternative to allotransplantation in some cases, as it requires neither an organ donor nor immunosuppressive therapy.

Remnant Liver-to-Standard Liver Volume Ratio Below 40% is Safe in Ex Vivo Liver Resection and Autotransplantation

BackgroundThe successful application of ex vivo liver resection and autotransplantation (ERAT) has gained widespread attention for the treatment of end-stage hepatic alveolar echinococcosis, which is considered to be unresectable by conventional methods due to extensive invasion of the extra- and intrahepatic vasculature. However, data on remnant liver volume (RLV) are limited, and the safe volume limit of remnant liver is still unclear. MethodsTo determine the effect of liver volume in the technically developed era, we investigated the impact of the remnant liver-to-standard liver volume ratio (RLV/SLV) on the outcomes of ERAT. ResultsFrom February 2014 to May 2018, 56 ERAT procedures were performed. Eleven patients with an RLV/SLV < 40% (group S) were compared with 45 patients with an RLV/SLV ≥ 40% (group L). Serial changes in postoperative serum total bilirubin, alanine aminotransferase, aspartate aminotransferase, and international normalized ratio were comparable in both groups. The incidences of postoperative complications did not significantly differ between the two groups. Three patients died of intra-abdominal bleeding, acute cerebral hemorrhage, and severe liver dysfunction. In RLV estimation analysis, the actual RLV and RLV/SLV were significantly smaller than the expected RLV and RLV/SLV as determined by preoperative three-dimensional reconstruction software in patients with hepatic venous outflow obstruction. ConclusionPatients with a smaller RLV/SLV did not have outcomes inferior to those with a larger RLV/SLV. Further studies are warranted to clarify the factors that contribute to preoperative volumetric estimation and the safe lower limits for ERAT.