Future Liver Remnant Volume Research Articles

Discrepancy between volume and functional recovery in early phase liver regeneration following extended hepatectomy with extrahepatic bile duct resection

To elucidate the clinical factors having an impact on liver regeneration rate following preoperative portal vein embolization (PVE) and subsequent extended hepatectomy. The correlation between liver volume and functional recovery after extended hepatectomy was also investigated. Records of patients who underwent extended hepatectomy with extrahepatic bile duct resection following PVE for perihilar cholangiocarcinoma were reviewed retrospectively with attention to liver regeneration. All patients underwent computed tomography before PVE, after PVE (immediately before surgery), and on postoperative day (POD) 7. The kinetic growth rate (KGR) was calculated as the percent increase in liver volume relative to the future liver remnant volume per day after PVE (KGRPVE ) and after POD 7 (KGRPOD7 ) using the computed tomography images before PVE, after PVE, and on POD 7. In the 289 study patients, the median of KGRPVE was 1.35%/day whereas that of KGRPOD7 was 5.56%/day. The extent of liver resection had the greatest impact on both KGRPVE and KGRPOD7 and the impacts of other factors were less. There was a significant negative correlation between KGRPVE and KGRPOD7 (P = 0.002). No correlations were observed between KGRPVE or KGRPOD7 and serum total bilirubin and prothrombin time - international normalized ratio on POD 7, nor in the incidence of liver failure after surgery. Early phase liver regeneration after extended hepatectomy was largely influenced by the extent of liver resection and showed no correlation with the indices of liver failure. There was a discrepancy between volume and functional recovery in early phase liver regeneration.

Quantitative assessment of liver function using hepatobiliary scintigraphy: the effect of microcirculatory alterations after portal vein embolization.

Hepatobiliary scintigraphy using technetium-99m mebrofenin has been validated as a quantitative liver function test. Preoperative portal vein embolization (PVE) is performed in patients to increase future remnant liver function and volume. Changes in hepatic microcirculation after PVE remain largely unknown and may influence the uptake of mebrofenin. The aim was to evaluate microcirculatory changes after PVE to examine differences in perfusion that might influence the uptake of mebrofenin, and consequently, assessment of function. Patients undergoing liver resection with or without preoperative PVE were included. Future remnant liver volume and function were measured before and after PVE. Hepatic microcirculation was measured in the embolized and the nonembolized lobes during resection. Microcirculatory flow index, perfused vessel density, sinusoidal diameter and red blood cell velocity were assessed. A total of 16 patients, eight with preoperative PVE and eight control patients without PVE, were included. After PVE, both function and volume of the nonembolized lobe were significantly increased, and the functional increase exceeded the increase in volume. Perfused vessel density and sinusoidal diameter were significantly higher in the nonembolized liver lobe (P<0.002 and <0.04). No significant differences between both lobes were found concerning microcirculatory flow index or red blood cell velocity. After PVE, the nonembolized lobe had a significantly higher (functional) microvascular density compared with the embolized lobe, without differences in microvascular flow. These findings indicate that the measured functional increase using hepatobiliary scintigraphy, which exceeded the volumetric increase, was not the consequence of an increase in hepatic perfusion, therefore, providing adequate representation of the liver function.

Differentiated approach to the minimally invasive management of malignant obstructive jaundice

Attitude towards preoperative biliary drainage for malignant obstructive jaundice have recently changed twice. This is due certain factors including complications of minimally invasive biliary drainage, level of bile duct block, cholangitis, need for neoadjuvant chemotherapy, time to scheduled surgery, severe general condition of patient, future liver remnant volume. We comprehensively searched PUBMED, MD Consult and National Library of Medicine using the following keywords: “obstructive jaundice (OJ)”, “cellular immunity”, “preoperative biliary drainage”, “selective biliary drainage”, “distal and proximal bile duct block”, “complications”. Randomized clinical trials and meta-analyzes, opinions of reputable specialists in hepatopancreatobiliary surgery and our own experimental and clinical studies were foreground. The analysis showed that preoperative biliary drainage is not a safe procedure and results an increased number of complications. Absolute indications for preoperative biliary drainage are cholangitis, need for neoadjuvant chemotherapy, increased risk of radical surgery and unresectable tumor. Future liver remnant volume should be considered in patients with portal cholangiocarcinoma followed by proximal block to determine indications for preoperative biliary drainage.

Accuracy of estimated total liver volume formulas before liver resection

BackgroundFuture remnant liver volume is used to predict the risk for liver failure in patients who will undergo major liver resection. Formulas to estimate total liver volume based on biometric data are widely used to calculate future remnant liver volume; however, it remains unclear which formula is most accurate. This study evaluated published estimate total liver volume formulas to determine which formula best predicts the actual future remnant liver volume based on measurements in a large number of patients who underwent associating liver partition and portal vein ligation for staged hepatectomy surgery. MethodsAll patients with complete liver volume data in the associating liver partition and portal vein ligation for staged hepatectomy registry were included in this study. Estimate total liver volume and estimated future remnant liver volume were calculated for 16 published formulas. The median over- or underestimation compared with actual measured volumes were determined for estimate total liver volume and future remnant liver volume. The proportion of patients with an under- or overestimated future remnant liver volume for each formula were compared with each other using a 25% cut-off for each formula. ResultsAmong 529 studied patients, the formulas ranged from a 19% underestimation to a 63% overestimation of estimate total liver volume. Estimation of future remnant liver volume lead to a 10% underestimation to a 5% overestimation among the formulas. Of all studied formulas, the Vauthey1 formula was the most accurate, generating underestimation of future remnant liver volume in 20% and overestimation of future remnant liver volume in 6% of patients. ConclusionValidation of 16 published total liver volume formulas in a multicenter international cohort of 529 patients that underwent staged hepatectomy revealed that the Vauthey formula (estimate total liver volume = 18.51 × body weight + 191.8) provides the most accurate prediction of the actual future remnant liver volume.

Dilatation of left portal vein after right portal vein embolization: a simple estimation for growth of future liver remnant.

To evaluate correlation between growth rate of left portal vein (LPV) and future liver remnant (FLR) after right portal vein embolization (PVE), and to design models predicting FLR growth rate and volume using LPV area measurements on computed tomography (CT). A total of 134 patients (59.6±10.2years; 103 men) who underwent right PVE with contrast-enhanced CT before and 3-5weeks after PVE were retrospectively identified. Kinetic hypertrophy ratio (KHR) and kinetic degree of hypertrophy (KDH) served as growth rate parameters. Correlations between LPV growth rate and FLR growth rate and volume change were evaluated by linear regression analysis. The agreements between actual volumetrically determined growth rates and volume of FLR and those estimated from regression equation using LPV measurements were assessed by Bland-Altman plots. Growth rates of LPV and FLR correlated significantly (P<0.001). The mean difference between actual and estimated value was 0.1% for KHR-FLR (actual, 9.5±6.0%; estimated, 9.4±3.8%), 0.0% for KDH-FLR (actual, 3.3±1.4%; estimated, 3.3±0.7%), -3.8cm3 for FLR volume (actual, 642.5±167.8cm3 ; estimated, 646.4±156.5cm3 ), and -0.1% for proportion of FLR volume (actual, 48.7±7.8%; estimated, 48.9±7.8%). After right PVE, FLR growth rate and volume can be simply estimated from the change in LPV area.

Preoperative biliary drainage of the hepatic lobe to be resected does not affect liver hypertrophy after percutaneous transhepatic portal vein embolization.

In patients with malignant perihilar biliary strictures, preoperative biliary drainage (PBD) of the hepatic lobe to be resected may decrease the liver volume of the future liver remnant (FLR) after percutaneous transhepatic portal vein embolization (PVE). However, evidence of its application is insufficient. This study aimed to clarify the effects of PBD on liver hypertrophy after PVE. Between January 2008 and December 2017, 169 patients with malignant perihilar biliary strictures underwent major hepatectomy or palliative surgery at our hospital. Of these, 76 patients who underwent PVE were categorized into two groups: group A (n = 29) who received unilateral PBD of the FLR and group B (n = 47) who received bilateral PBD, including that of the hepatic lobe to be resected. FLR ratios after PVE and liver hypertrophy ratios were retrospectively compared in both groups. Group B exhibited significantly severe biliary stenosis (p = 0.0038) and high serum bilirubin before biliary drainage (p = 0.0037). After PVE, the total liver volumes were 1287 ± 260ml and 1340 ± 257ml (p = 0.39), respectively. FLR volumes were 555 ± 135 and 577 ± 113ml (p = 0.45), respectively. FLR ratios were 43.4 ± 8.2% and 43.4 ± 6.4%, respectively (p = 0.98). Liver hypertrophy ratios were 124.2 ± 17.7% and 129.2 ± 20.9%, respectively (p = 0.28). In addition, an examination which excluded patients with Bismuth type I obtained similar result. PBD of the hepatic lobe to be resected did not decrease the FLR ratios and hypertrophy ratios. Thus, in patients with poor biliary drainage, additional PBD of the target lobe is acceptable.

Loco-regional intervention for hepatocellular carcinoma

Anatomic location/size and number of lesions, inadequate volume of future liver remnant, or poor coexisting premorbid conditions preclude surgery in the majority of patients with hepatocellular carcinoma (HCC). Liver transplantation can cure some patients with poor liver function, but few patients are eligible because of scarcity of donors. Without specific anti-cancer treatment, the prognosis of HCC is poor. Various locoregional therapies are used to treat patients who are not candidates for surgery, and have emerged as tools for palliation, tumor down-staging, and bridging therapy prior to liver transplantation. Currently, local ablative therapy even competes with partial hepatectomy and liver transplantation as a primary treatment for small HCC. HCC is well suited to treatment with loco-regional therapy because it has a tendency to stay within the liver, with distant metastasis generally occurring late in the course of disease. This suggests that an effective local-regional therapy can have a great impact on HCC patients who are not candidates for surgical treatment. Loco-regional therapy can further be justified because patients with HCC usually die of liver failure consequent to intrahepatic growth resulting in liver tissue destruction, rather than extrahepatic metastases.

Simultaneous super-selective hepatic arterial and portal vein embolization for staged hepatectomy in patients with hepatocellular carcinoma and cirrhosis

Objective To study the feasibility and safety of simultaneous super-selective hepatic arterial and portal vein embolization for staged hepatectomy (ASAPS) in the treatment of patients with hepatocellular carcinoma (HCC) and cirrhosis. Methods The clinical data of 8 patients with HCC who underwent ASAPS at the First Affiliated Hospital of the Army Medical University from December 2016 to January 2018 were retrospectively analyzed. All the patients, including 7 males and 1 female with an average age of 44.3±9.2, were diagnosed to have cirrhosis with insufficient volume of future liver remnant (FLR). Portal vein embolization (PVE) and super-selective hepatic arterial embolization (SHAE) were performed simultaneously. The patients were then closely monitored for the volumes of FLR. Once the FLR achieved the target volume, a second staged resectional surgery would be performed. The postoperative major complications, laboratory tests and patient long-term survival were studied. Results The ratio of FLR to the average standard liver volume (SLV) increased from (28.5±5) % to (49.6±7.3) % following the first-stage procedure. All the patients underwent liver resection successfully. The average second-stage operation time was 342.6±92.8 min, and the intraoperative blood loss was 743.8±432.1 ml. Both the postoperative serum alanine aminotransferase (ALT) and aspartate aminotransferase (AST) levels were elevated remarkably and then dropped to the near normal levels. All the patients were discharged home without any severe complications. Among them, 3 patients relapsed early in the postoperative period, 5 survived without recurrence, and 3 survived for over 1 year. Conclusions The first-stage surgery of associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) using ASAPS was minimally invasive. The volume growth rate of the FLR after ASAPS was comparable to that of the conventional first stage of ALPPS. In conclusion, ASAPS is a promising alternative to the traditional ALPPS as the first-line treatment of patients with insufficient FLR. Key words: Carcinoma, hepatocellular; Embolization, therapeutic; Hepatectomy; Liver cirrhosis; Future liver remnant

Growth of colorectal liver metastases is not accelerated by intraportal administration of stem cells after portal vein embolization

Future liver remnant volume (FLRV) is acrucial factor impacting resectability of colorectal liver metastases (CLM). In case of low FLRV, augmentation can be done by performing portal vein embolization (PVE). However, there is arisk of progression of CLM between PVE and resection. Intraportal application of autologous hematopoietic stem cells (HSC) is apossibility to accelerate the growth of FLRV. The effect of thus applied SC on CLM progression still remains unclear, though. 63 patients underwent PVE between 2003 and 2015. In 20 patients aproduct with HSC was applied intraportally on the first day after PVE (PVE HSC group). HSC were gained from peripheral blood (10 patients) or bone marrow (10 patients). FLRV and volume of liver metastases (VLM) were evaluated by CT volumetry. The gained data were statistically evaluated in relation to the disease free interval (DFI), overall survival (OS), achievement of CLM resectability and progression of extrahepatic metastases. We compared the PVE HSC group with the group of patient undergoing simple PVE. No significant difference in FLRV and VLM growth was observed between the study groups. The percentage of exploratory laparotomies was smaller in the group with PVE and HSC application. Patients with simple PVE had asignificantly higher incidence of extrahepatic metastases during follow up. We did not observe any significant differences in DFI and OS between the groups. HSC application did not accelerate CLM growth in comparison with PVE alone. PVE and HSC application had ahigher percentage of patients undergoing liver resection and alower incidence of extrahepatic metastases.

Treatment Strategies for Hepatocellular Carcinoma ⁻ a Multidisciplinary Approach.

Hepatocellular carcinoma (HCC) is the most common primary tumor of the liver and its mortality is third among all solid tumors, behind carcinomas of the lung and the colon. Despite continuous advancements in the management of this disease, the prognosis for HCC remains inferior compared to other tumor entities. While orthotopic liver transplantation (OLT) and surgical resection are the only two curative treatment options, OLT remains the best treatment strategy as it not only removes the tumor but cures the underlying liver disease. As the applicability of OLT is nowadays limited by organ shortage, major liver resections—even in patients with underlying chronic liver disease—are adopted increasingly into clinical practice. Against the background of the oftentimes present chronical liver disease, locoregional therapies have also gained increasing significance. These strategies range from radiofrequency ablation and trans-arterial chemoembolization to selective internal radiation therapy and are employed in both curative and palliative intent, individually, as a bridging to transplant or in combination with liver resection. The choice of the appropriate treatment, or combination of treatments, should consider the tumor stage, the function of the remaining liver parenchyma, the future liver remnant volume and the patient’s general condition. This review aims to address the topic of multimodal treatment strategies in HCC, highlighting a multidisciplinary treatment approach to further improve outcome in these patients.

Predicting liver failure after extended right hepatectomy following right portal vein embolization with gadoxetic acid-enhanced MRI.

Predicting post-hepatectomy liver failure (PHLF) after extended right hepatectomy following portal vein embolization (PVE) from serial gadoxetic acid-enhanced magnetic resonance imaging (MRI). Thirty-six patients who underwent hepatectomy following PVE were evaluated prospectively with gadoxetic acid-enhanced MRI examinations at predefined intervals during the course of their treatment, i.e., before and 14days and 28days after PVE as well as 10days after hepatectomy. Relative enhancement (RE) and volume of the left and right liver lobes were determined. The study population was divided into two groups with respect to signs of PHLF. Differences between the two groups were assessed using the Mann-Whitney U test, and predictive parameters for group membership were investigated using ROC and logistic regression analysis. RE of the left lobe prior to PVE versus 14days after PVE was significantly lower in patients with PHLF than in those without PHLF (Mann-Whitney U test p < 0.001) and proved to be the best predictor of PHLF in ROC analysis with an AUC of 0.854 (p < 0.001) and a cutoff value of - 0.044 with 75.0% sensitivity and 92.6% specificity. Consistent with this result, logistic linear regression analysis adjusted for age identified the same parameter to be a significant predictor of PHLF (p = 0.040). Gadoxetic acid-enhanced MRI performed as an imaging-based liver function test before and after PVE can help to predict PHLF. The risk of PHLF can be predicted as early as 14days after PVE. • To predict the likelihood of post-hepatectomy liver failure, it is important to estimate not only future liver remnant volume prior to extended liver resection but also future liver remnant function. • Future liver remnant function can be predicted by performing gadoxetic acid-enhanced MRI as an imaging-based liver function test before and after portal vein embolization. • A reduction of relative enhancement of the liver in gadoxetic acid-enhanced MRI after portal vein embolization of 0.044 predicts post-hepatectomy liver failure with 75.0% sensitivity and 92.6% specificity.

Rapid Induction of Liver Regeneration for Major Hepatectomy (REBIRTH): A Randomized Controlled Trial of Portal Vein Embolisation versus ALPPS Assisted with Radiofrequency.

To avoid liver insufficiency following major hepatic resection, portal vein embolisation (PVE) is used to induce liver hypertrophy pre-operatively. Associating liver partition with portal vein ligation for staged hepatectomy assisted with radiofrequency (RALPPS) was introduced as an alternative method. A randomized controlled trial comparing PVE with RALPPS for the pre-operative manipulation of liver volume in patients with a future liver remnant volume (FLRV) ≤25% (or ≤35% if receiving preoperative chemotherapy) was conducted. The primary endpoint was increase in size of the FLRV. The secondary endpoints were length of time taken for the volume gain, morbidity, operation length and post-operative liver function. Between July 2015 and October 2017, 57 patients were randomised to RALPPS (n = 29) and PVE (n = 28). The mean percentage of increase in the FLRV was 80.7 ± 13.7% after a median 20 days following RALPPS compared to 18.4 ± 9.8% after 35 days (p < 0.001) following PVE. Twenty-four patients after RALPPS and 21 after PVE underwent stage-2 operation. Final resection was achieved in 92.3% and 66.6% patients in RALPPS and PVE, respectively (p = 0.007). There was no difference in morbidity, and one 30-day mortality after RALPPS (p = 0.991) was reported. RALPPS is more effective than PVE in increasing FLRV and the number of patients for surgical resection.

Laparoscopic partial-ALPPS, stage 1. Initial experience

Background: Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS), continues to evolve into different variations and provoking debate about indications, associated morbidity and oncologic outcomes. Throughout this progression, the benefits of a laparoscopic approach and a partial parenchymal transection on the initial stage are becoming more evident (as opposed to a complete transection) in achieving the desired hypertrophy of the future liver remnant (FLR), while decreasing the overall severity of associated complications and simplifying their management between stages . We present our initial experience with Laparoscopic Partial-ALPPS, focused on the stage 1. Methods: 4 cases reviewed at multidisciplinary HPB tumor board, decided to proceed with extended right hepatectomy via ALPPS. Laparoscopic Partial ALPPS was performed during stage 1. Technical steps: 1-Cholecystectomy; 2-Traction cystic-duct stump exposing Right Hepatic Artery (RHA) and Main Portal Vein (MPV) extending into Right Portal Vein (RPV); 3-Circumferential dissection RHA and RPV; 4-Ligation RPV (tie and/or clips); 5- Partial parenchymal transection 50% preserving Middle Hepatic Vein (MHV) outflow. Postoperative imaging confirmed desired hypertrophy of the remnant liver volume within 9-11 days and the stage 2 ALPPS was carried out 14–16 days after stage 1. Three out of the four stage 2 cases were initiated with laparoscopy and intentionally converted to open extended right hepatectomy following a planned learning curve. Results: Case 1: 74F HCV s/p Harvoni, 6 cm HCC in segment 8, abutting the right hepatic and middle hepatic veins. Advanced liver fibrosis. Total liver volume 950 ml, volume of FLR 253 ml. Stage 1-Lap Partial ALPPS. Discharged POD#4. Repeat imaging POD#11, hypertrophied FLR 501ml. Stage 2-POD#16 Lap converted-to-open right extended hepatectomy. Discharged POD#6. Case 2: 58F PMHx of colon cancer, synchronous metastasis to the liver. FOLFOX+ Avastin. Total liver volume 910 ml. Right lobe 622 ml, 2 lesions occupy 58 ml. Left lobe 288 ml, 1 lesion occupies 23ml. Stage 1-Lap wedge LLS lesion+Lap Partial ALPPS. POD#2 Re-laparoscopy, bleeding-control hemostasis. Stage 2: preop imaging hypertrophied FLR 369 ml. POD#15- Open right hepatectomy + extended right colectomy. Discharged on POD#6. Case 3: 66M HCV s/p Harvoni, 3.5 cm HCC segment 8, abutting right hepatic vein, close to middle hepatic vein. Advanced liver fibrosis. Volume FLR 557 ml. Stage 1-Lap Partial ALPPS. Discharged POD#4. Repeated imaging POD#11, hypertrophied FLR 720 ml. Stage 2- POD#15, Lap converted-to-open right extended hepatectomy. Discharged POD#5. Case 4: 67M HCV s/p Harvoni) with 5 cm HCC segment 7, abutting right hepatic vein, close to middle hepatic vein. Advanced liver fibrosis. Volume FLR 583 ml. TACE followed 3 weeks later by Stage 1-Lap Partial ALPPS. Discharged POD#4. Repeated imaging POD#9. Hypertrophied FLR 976 ml. Stage 2-POD#14 Lap converted-to-open right extended hepatectomy. Complicated postop course, bleeding and infection. Reoperation/washout. Discharged POD#23. Conclusion: Each case is presented with a short video clip highlighting the technical steps of the Laparoscopic Partial-ALPPS during Stage 1, which were overall carried out without intraoperative difficulties and with satisfactory recovery and prompt discharge in all cases, while achieving the FLR hypertrophy within the expected timeframe. An additional video clip presents the laparoscopic findings during stage 2 prior to converting to open procedure, illustrating the amount of inflammation that challenged the laparoscopic completion of Stage 2 during this initial experience.

Semi-automated computed tomography Volumetry can predict hemihepatectomy specimens\u2019 volumes in patients with hepatic malignancy

BackgroundOne of the major causes of perioperative mortality of patients undergoing major hepatic resections is post-hepatectomy liver failure (PHLF). For preoperative appraisal of the risk of PHLF it is important to accurately predict resectate volume and future liver remnant volume (FLRV). The objective of our study is to prospectively evaluate the accuracy of hemihepatectomy resectate volumes that are determined by computed tomography volumetry (CTV) when compared with intraoperatively measured volumes and weights as gold standard in patients undergoing hemihepatectomy.MethodsTwenty four patients (13 women, 11 men) scheduled for hemihepatectomy due to histologically proven primary or secondary hepatic malignancies were included in our study. CTV was performed using a semi-automated module (S, hereinafter) (syngo.CT Liver Analysis VA30, Siemens Healthcare, Germany). Conversion factors between CT volumes on the one side and intraoperative volumes and weights on the other side were calculated using the method of least squares. Absolute and relative disagreements between CT volumes and intraoperative volumes were determined.ResultsA conversion factor of c = 0.906 most precisely predicted intraoperative volumes of exsanguinated hemihepatectomy specimens from CT volumes in all patients with mean absolute and relative disagreements between CT volumes and intraoperative volumes of 57 ml and 6.3%. The use of operation-specific conversion factors yielded even better results.ConclusionsCTV performed with S accurately predicts intraoperative volumes of hemihepatectomy specimens when applying conversion factors which compensate for exsanguination. This allows to precisely estimate the FLRV and thus minimize the risk of PHLF in patients undergoing major hepatic resections.

Percutaneous Portal Vein Embolization Using a Simplified Sheathless 18-Gauge Trocar Needle Approach: Review of Efficacy and Safety

PurposePortal vein (PV) embolization (PVE) is traditionally performed via a PV sheath with selective embolization of PV branches. Here, the efficacy and safety of PVE with the use of only an 18-gauge needle is reported. Materials and MethodsConsecutive patients who underwent PVE from 2009 through 2017 were retrospectively reviewed. Forty-five patients (mean age, 60 y ± 7.6; 38 men) underwent 45 PVE procedures. Hepatocellular carcinoma, cholangiocarcinoma, and metastases accounted for 26 (58%), 13 (29%), and 6 (13%) patients, respectively. PVE was performed by puncturing a branch of right PV with an 18-gauge needle under US guidance. Via the same needle, direct portography was performed, followed by PVE with an N-butyl cyanoacrylate/Lipiodol mixture. Percentage increase of future liver remnant (FLR) volume and increase in ratio of FLR to total liver volume were estimated as measures of efficacy. Complications were reported according to Society of Interventional Radiology classification. Fluoroscopy time, procedure time, and dose–area product (DAP) were recorded. ResultsTechnical success rate was 100%. The median DAP, fluoroscopy time, and procedure time were 74,387 mGy·cm2 (IQR, 90,349 mGy·cm2), 3.5 min (IQR, 2.10 min), and 24 min (IQR, 10.5 min). Among the 23 patients with complete CT volumetry data, mean increase in the ratio of FLR to total liver volume and percentage increase of FLR volume were 12.5% ± 7.7 and 50% ± 33, respectively. There were 3 minor complications (asymptomatic nonocclusive emboli in FLR) and 3 major complications (1 hepatic vein emboli, 1 subphrenic collection, and 1 hepatic infarct). ConclusionsPVE via a sheathless 18-gauge needle approach is feasible, with satisfactory FLR hypertrophy.

Future Liver Remnant Hypertrophy after Portal Vein Embolization Is Inversely Correlated with Intrahepatic Tumor Burden

PurposeTo determine if there is a correlation between intrahepatic tumor volume and future liver remnant (FLR) hypertrophy after portal vein embolization (PVE). Materials and MethodsForty-four consecutive patients with hepatocellular carcinoma or metastatic colorectal cancer who underwent PVE from 2009 to 2017 and who had complete imaging follow-up were retrospectively reviewed. To maximize the accuracy of tumor volume measurements, 11 patients were excluded for having more than 5 intrahepatic tumors. Volumetric analyses of the patient livers before and after PVE, as well as pre-embolization intrahepatic tumor burden, were performed. ResultsA significant inverse correlation was observed between tumor volume and FLR hypertrophy after PVE (Spearman ρ = -0.53, P = .002). Initial FLR volume was also inversely correlated with subsequent hypertrophy (P = .01). Fourteen patients received neoadjuvant chemotherapy 1 month prior to intervention. The number of chemotherapy cycles did not affect hypertrophy (P = .57). Patients with cirrhosis experienced less FLR hypertrophy than patients without cirrhosis (P = .02). ConclusionsPatients with large intrahepatic tumor burden may experience limited FLR hypertrophy.

Effect of portal vein embolization on treatment plan prior to major hepatectomy for hepatocellular carcinoma

BackgroundPortal vein embolization (PVE) is used before major hepatectomy for hepatocellular carcinoma (HCC) to increase future liver remnant (FLR) volume. However, this may increase tumour growth rate, leading to more extensive resections. This study aimed to determine the effect of tumour growth, following PVE, on treatment plan. MethodRetrospective cohort study conducted on patients treated from 2008 to 2015 with PVE before major hepatectomy for HCC. Liver and tumour volumetry was performed on pre- and post-PVE CT scans. Image-based and actioned plans were compared before and after PVE. ResultsThirty-one patients received PVE. Non-tumour total liver volume decreased (median 1440 to 1394 cm3; p = 0.031), while tumour (median 161–240 cm3; p < 0.001) and FLR volumes (median 430–574 cm3; p < 0.001) increased. The treatment plan changed in 15/31 patients: more extensive resection (n = 6), less extensive resection (n = 1), no resection as scheduled (n = 8). Tumour progression accounted for a clinically relevant change in treatment plan in 8/31 patients. ConclusionFollowing PVE in the setting of HCC, tumour progression accounts for a change in treatment plan in approximately a quarter of patients. Further research is warranted to determine whether additional liver directed therapy should routinely be used to slow the growth of HCC post-PVE.

The predictive value of future liver remnant function after liver resection for HCC in noncirrhotic and cirrhotic patients

BackgroundSurgical procedures in patients with underlying liver disease are still burdened by a high rate of postoperative morbidity, especially posthepatectomy liver failure (PHLF), ranging from 1.2 to 33.8%. The aim of this study was to investigate the prognostic value of volume/function analysis for the prediction of hepatectomy-related morbidity in patients with hepatocellular carcinoma. MethodsClinicopathological data were analysed in 261 patients who underwent liver resection for HCC between 2001 and 2014. Future liver remnant volume (FLRV) and future liver remnant function (FLRF) based on LiMAx test were obtained retrospectively. A subgroup analysis for high-risk patients with impaired liver function was conducted. Univariate and multivariate regression analysis was performed to identify risk factors for major complications, defined by Dindo ≥ IIIb and PHLF grade ≥ B. ResultsIn the total cohort, FLRF was independently associated with major complications. FLRV, resected liver volume, and FLRF were independent risk factors for PHLF. In a subgroup analysis of high-risk patients, FLRF was identified as the only independent risk factor for major complications and PHLF development. DiscussionThese results suggest the superior value of FLRF to FLRV in predicting postoperative complications as well as PHLF in patients with chronic liver disease.

Risk factors of hepatic failure after liver resection for perihilar cholangiocarcinoma: Importance of future liver remnant volume, body weight ratio, and impact on long-term survival.

348 Background: Hepatic resection for perihilar cholangiocarcinoma (PHCC) is associated with high postoperative mortality. Future liver remnant volume to total liver volume ratio has been used to anticipate the risks associated with liver resection for PHCC. We sought to investigate the independent factors associated with postoperative hepatic failure (PHLF) and assess predictive value of future liver remnant volume – body weight (FLRV/Wt) ratio after resection for PHCC. Methods: This study included 287 patients who underwent major hepatectomy including caudate lobectomy with bile duct resection for PHCC between 2008 and 2015 in single center. FLRV were calculated with CT volumetry and perioperative clinical and operative data were analyzed to identify independent determinants of PHLF (grade B/C according to the International Study Group of Liver Surgery criteria) and major postoperative complications (Dindo III to IV). Results: Combined Portal vein resection was performed in 18.8%. PHLF incidence was 13.6% and 90-day mortality was 3.5%. On multivariate analysis, predictors of PHLF (p &lt; 0.05) were FLRV/Wt ratio &lt; 0.5 (odds ratio [OR] 9.45), ICG R15 &gt; 15 (OR 3.72), BMI &lt; 25.0 (OR 6.41) and R1 resection (OR 3.97). There was no significant difference of survival between two groups divided by FLRV/Wt ratio (0.5) in Kaplan-Meier analysis. There was significant difference of survival according to PHLF. In without PHLF group, 1yr, 3yr, 5yr survival were 83.1%, 45.2%, 28.1%. In PHLF B group, 1yr, 3yr, 5yr survival were 66.7%, 40.7%, 20.7% respectively. Conclusions: Insufficient FLR volume (FLRV/Wt &lt; 0.5), ICG R15 (&lt; 15), BMI (&lt; 25) and R1 resection is associated with PHLF for patients with PHCC. We confirmed that PHLF is also associated with long term outcome. Preoperative assessment to patients with PHCC should be optimized to minimize the risk of PHLF. [Table: see text]

ALPPS in overcoming small remnant liver volume in alveolar echinococcosis

Aim.To evaluate the possibilities and indications for ALPPS, immediate and long-term results of surgical treatment of alveolar echinococcosis including great vessels invasion in case of small remnant liver volume.Material and methods. There were 30 ALPPS procedures. Seven patients had small future liver remnant (FLR) — 24.5% (22.4—26.7%). Bile ducts repair with Roux-en-Y procedure for biliodigestive anastomosis during the first surgical stage was performed in 5 patients (71.4%). ALPPS combined with great vessels resection (portal vein or portal vein and left hepatic vein) was required in 4 patients (57.1%). RO-resections were carried out in all patients.Results.Mean duration of ALPPS stage I was 365 (330—415) min, intraoperative blood loss — 800 (700—1000) ml. Time of stage II was 85 (70—110) min, intraoperative blood loss — 200 (100—300) ml. The second stage of ALPPS was performed in 6—7 days (max 8 days) after preliminary assessment of FLR volume according to CT-volumetry, which was 570 (430—630) ml (37.9% (31.9—52.4%) in relation to FLR volume before the first stage of ALPPS. Augmentation of FLR volume was 200 (150—290) ml (60.9% (48.3—80.6%)). The daily increase of FLR volume was 29 (23—46) ml. Overall postoperative morbidity was 42.9% (complications grade I were noted in 2 patients (28.6%), grade IV — in 1 patient (14.3%). Incidence of post-hepatectomy liver failure grade A (ISGLS, 2011) after ALPPS stage II was 42.9% (n = 3). Bile leakage grade A (ISGLS, 2011) occurred in 28.6% of cases (n = 2). Mortality was absent. Postoperative hospital-stay after stage II was 22 (18—35) days. Maximum follow-up was 50 months. Long-term disease-free survival was 100%, median survival — 29 months.Conclusion.ALPPS technique is feasible, followed by desired increase of FLR volume and safe hepatectomy. The procedure leads to good immediate and long-term postoperative results in patients with alveolar echinococcosis and small FLR volume regard less invasion of afferent and/or efferent liver vessels.