Future Liver Remnant Volume Research Articles

Impact of the preoperative skeletal muscle index on early remnant liver regeneration in living donors after liver transplantation.

We investigated the correlation between the preoperative skeletal muscle index (SMI) and remnant liver regeneration after right hemihepatectomy for living-donor liver transplantation and aimed to identify preoperative predictors of greater early remnant liver regeneration in living donors. This retrospective study included 525 right hemiliver donors (mean age, 28.9±8.3 years; 345 male patients) between 2017 and 2018, who underwent computed tomography before surgery and on postoperative day (POD) 7. Preoperative anthropometry, laboratory parameters, skeletal muscle area at the third lumbar vertebral level, and liver volume before and after surgery were evaluated. Correlations were analyzed using Pearson correlation coefficients, and stepwise multiple regression analysis was performed to identify independent predictors of greater remnant liver regeneration. Remnant liver regeneration volume on POD 7 was positively correlated with body mass index (BMI; r=0.280, P<0.001) and SMI (r=0.322, P<0.001), and negatively correlated with age (r=-0.154, P<0.001) and the ratio of future remnant liver volume (FRLV) to total liver volume (TLV; r=-0.261, P<0.001). Stepwise multiple regression analysis showed that high BMI (β=0.146; P=0.001) and SMI (β=0.228, P<0.001), young age (β=-0.091, P=0.025), and a low FRLV/TLV ratio (β=-0.225, P<0.001) were predictors of greater remnant liver regeneration. High SMI and BMI, young age, and a low FRLV/TLV ratio may predict greater early remnant liver regeneration in living donors after LDLT.

Multimodal perioperative assessment of liver function and volume in patients undergoing hepatectomy for colorectal liver metastasis: a comparison of the indocyanine green retention test, 99mTc mebrofenin hepatobiliary scintigraphy and gadoxetic acid enhanced MRI.

To compare the dynamic changes in future liver remnant (FLR) function and volume after hepatectomy and to evaluate the associations between three modalities in assessment of liver function. Liver function and volume were quantified pre-operatively, at post-operative day (POD) 7 and POD 28 in 10 patients with colorectal liver metastases undergoing hemihepatectomy using the indocyanine green retention (ICG) test, hepatobiliary scintigraphy (HBS) and gadoxetic acid-enhanced MRI. The 99mTc mebrofenin uptake rate in the FLR was applied as a reference of liver function. MRI-derived parameters including liver-to-muscle ratio (LMR), liver-to-spleen ratio (LSR) and hepatocellular uptake index (HUI) were used for liver function assessment. Spearman's correlation analysis was used to evaluate the associations. Increase in liver function ranged from 13 to 152% (median 92%) and in volume from 37 to 134% (median 79%). There was no significant discrepancy in increase between FLR function and volume during the first month following hepatectomy. LMR showed a significant correlation to ICG test (r = -0.66, p < 0.05) while LSR had an association with standardized FLR function obtained by HBS (r = -0.71, p < 0.05). During the first week after hepatectomy, pre-operative HUI and LMR showed the strongest correlation to the FLR growth in function and volume respectively (p < 0.05). The observed growth in FLR volume is closely related to the functional increase within 1 month after hepatectomy. Gadoxetic acid-enhanced MRI might substitute HBS for regional liver function assessment and provide an imaging tool for liver growth prediction. Liver function growth was parallel with liver volume increase during the perioperative period. Liver function assessment with gadoxetic acid-enhanced MRI was comparable with that of HBS indicating that gadoxetic acid-enhanced MRI could substitute HBS for regional liver function evaluation.

Future liver remnant volume is associated with postoperative fentanyl consumption following open donor hepatectomy: a retrospective multivariate analysis.

Liver resection has a risk of postoperative hepatic dysfunction, including drug metabolism. Since fentanyl is primarily metabolized in the liver, liver resection requires exercising caution against fentanyl overdose in postoperative analgesia. The rationale for dose adjustment of fentanyl in the preoperative prescription for patients undergoing liver resection remains unclear. We examined whether postoperative fentanyl consumption is associated with the future liver remnant after liver resection and investigated factors influencing fentanyl consumption. In this retrospective study, 89 living liver donors undergoing open liver resection received intravenous patient-controlled analgesia with fentanyl 2mg with thoracic epidural analgesia. The primary outcome was postoperative hourly consumption of intravenous patient-controlled analgesia with fentanyl. Future liver remnant volume (ml) and the ratio of future liver remnant volume to whole liver volume (%) were estimated by computed tomography volumetry and compared to determine which correlated more strongly with fentanyl hourly consumption. Multivariable analysis identified independent factors affecting fentanyl consumption, with adjustments for patient characteristics and intravenous patient-controlled analgesia setting. Future liver remnant volume (ml) was significantly correlated more strongly than the ratio of future liver remnant (%) with postoperative fentanyl consumption (r = 0.53 vs. 0.36, p < 0.001). Larger future liver remnant volume (β = 0.25, p = 0.006) and age < 45years (β = 0.24, p = 0.009) were independently associated with higher fentanyl consumption, while sex and weight were not. Future liver remnant volume was significantly associated with postoperative fentanyl consumption. Smaller remnant liver volume and older age (≥ 45years) were independent factors reducing postoperative fentanyl consumption in patients undergoing open donor hepatectomy.

Increased future liver function after modified associating liver partition and portal vein ligation/embolization for staged hepatectomy.

BackgroundThe increasing ratio of functional future liver remnant (functional %FLR) after modified associating liver partition and portal vein ligation/embolization for staged hepatectomy (modified-ALPPS) compared with portal vein embolization (PVE) has not been comprehensively evaluated.PurposeTo compare the increasing ratio of functional %FLR between modified-ALPPS and PVE via technetium-99 m-galactosyl human serum albumin single-photon emission computed tomography (99mTc-GSA SPECT/CT) fusion imaging.Material and MethodsSeven and six patients underwent modified-ALPPS (modified-ALPPS group) and PVE (PVE group) from 2015 to 2019. The functional %FLR on 99 mTc-GSA SPECT/CT fusion imaging was assessed before and 1 week (modified-ALPPS group) and 3 weeks (PVE group) after each procedure. The increasing ratio of functional %FLR (functional %FLR ratio) was calculated and compared between the two groups. Moreover, the hypertrophy ratio of future liver remnant volume (FLRV ratio) and atrophy ratio of embolized liver volume (.ELV ratio) were evaluated.ResultsThe mean functional %FLR ratios of the modified-ALPPS group (1.47 ± 0.15) and the PVE group (1.49 ± 0.20) were comparable (p > .05). The median FLRV ratio of modified-ALPPS group (1.48) was higher than that of the PVE group (1.16), the median ELV ratio of the PVE group (0.81) was lower than that of the modified-ALPPS group (0.94), and the results significantly differed between the two groups (p < .05).ConclusionThe increasing ratio of functional %FLR was comparable between modified-ALPPS and PVE. Compared with PVE, ALPPS was associated with a higher hypertrophy rate of the remnant liver but a lower atrophy rate of the embolized liver.

Identification of crucial lncRNAs and mRNAs in liver regeneration after portal vein ligation through weighted gene correlation network analysis

BackgroundPortal vein ligation (PVL)-induced liver hypertrophy increases future liver remnant (FLR) volume and improves resectability of large hepatic carcinoma. However, the molecular mechanism by which PVL facilitates liver hypertrophy remains poorly understood.MethodsTo gain mechanistic insight, we established a rat PVL model and carried out a comprehensive transcriptome analyses of hepatic lobes preserving portal blood supply at 0, 1, 7, and 14-day after PVL. The differentially expressed (DE) long-non coding RNAs (lncRNAs) and mRNAs were applied to conduct weighted gene co-expression network analysis (WGCNA). LncRNA-mRNA co-expression network was constructed in the most significant module. The modules and genes associated with PVL-induced liver hypertrophy were assessed through quantitative real-time PCR.ResultsA total of 4213 DElncRNAs and 6809 DEmRNAs probesets, identified by transcriptome analyses, were used to carry out WGCNA, by which 10 modules were generated. The largest and most significant module (marked in black_M6) was selected for further analysis. Gene Ontology (GO) analysis of the module exhibited several key biological processes associated with liver regeneration such as complement activation, IL-6 production, Wnt signaling pathway, autophagy, etc. Sixteen mRNAs (Notch1, Grb2, IL-4, Cops4, Stxbp1, Khdrbs2, Hdac2, Gnb3, Gng10, Tlr2, Sod1, Gosr2, Rbbp5, Map3k3, Golga2, and Rev3l) and ten lncRNAs (BC092620, AB190508, EF076772, BC088302, BC158675, BC100646, BC089934, L20987, BC091187, and M23890) were identified as hub genes in accordance with gene significance value, module membership value, protein–protein interaction (PPI) and lncRNA-mRNA co-expression network. Furthermore, the overexpression of 3 mRNAs (Notch1, Grb2 and IL-4) and 4 lncRNAs (BC089934, EF076772, BC092620, and BC088302) was validated in hypertrophic liver lobe tissues from PVL rats and patients undergoing hepatectomy after portal vein embolization (PVE).ConclusionsMicroarray and WGCNA analysis revealed that the 3 mRNAs (Notch1, Grb2 and IL-4) and the 4 lncRNAs (BC089934, EF076772, BC092620 and BC088302) may be promising targets for accelerating liver regeneration before extensive hepatectomy.

P9.21: Future Liver Remnant Volume Ratio Less Than 30% Is Not A Contraindication to Living Donor Right Hepatectomy

Background: The evidence for defining a safe remnant/total volume ratio(RTVR) for in living donors undergoing right hepatectomy for living donor liver transplantation (LDLT) is still not clear yet. The current practice of arbitrarily requiring an RTVR of at least 30% is based on the experience of early studies to keep donor safety. Recently, some centers reported that extended resection with RTVR less than 30% for living donor right hepatectomy but there is no consensus has been established for future remnant liver volume (FRLV) ratio limit. Herein, we describe out center’s experience for living donor right hepatectomy with RTVR < 30% and evaluate the outcomes of living donors with RTVR < 30%. Methods: We retrospectively reviewed the outcomes of 473 living donor right hepatectomy (LDRH) which performed at our institution from January 2010 to December 2020. We performed right hepatectomy for living donors with RTVR <30% under the following criteria; 1) Age ≤40 2) Preservation of MHV 3) No or Minimal fatty changes (<15%) 4) Flat fish shaped left hemiliver 5) RTVR > 25% and FRLV/ BW ≥ 0.45. The outcomes in these extended living donors were compared with those in living donors under conventional criteria. Results: The mean RTVR in extended group was 27.1 ± 1.2 % (range, 25.1-28.9). Posthepatectomy liver failure (PHLF) occurred in 50 donors (10.6%) and most cases were grade A except one case in conventional group and no clinically significant PHLF was not evident for these extended donor group. PHLF and major complications were not more frequent in living donor group with RTVR <30%. In multivariate only the event for major complications was associated with PHLF but RTVR less than 30% was related to PHLF. To adjust for between-group differences, donors with FLR ≤30% and >30% were matched based on baseline characteristics and overall complication rates and the incidence of PHLF were not different between the two groups. Conclusion: DRH under our extended criteria could be performed safely in donors with RTVR ratio <30% under our strict criteria when no other donors are available and our extended criteria might be helpful to expand donor pools without adverse effects on donor safety.

Hyper accuracy three-dimensional (HA3D™) technology for planning complex liver resections: a preliminary single center experience

Three-dimensional visualization technology (3DVT) has been recently introduced to achieve a precise preoperative planning of liver surgery. The aim of this observational study was to assess the accuracy of 3DVT for complex liver resections. 3DVT with hyper accuracy three-dimensional (HA3D™) technology was introduced at our institution on February 2020. Anatomical characteristics were collected from two-dimensional imaging (2DI) and 3DVT, while intraoperative and postoperative outcomes were recorded prospectively. A total of 62 patients were enrolled into the study. 3DVT was able to study tumor extension and liver anatomy, identifying at least one vascular variation in 37 patients (59.7%). Future remnant liver volume (FRLV) was measured using 2DI and 3DVT. The paired samples t test assessed positive correlation between the two methods (p < 0.001). At least one vessel was suspected to be invaded by the tumor in 8 (15.7%) 2DI cases vs 16 (31.4%) 3DVT cases, respectively. During surgery, vascular invasion was detected in 17 patients (33.3%). A total of 73 surgical procedures were proposed basing on 2DI, including 2 alternatives for 16 patients. After 3DVT, the previously planned procedure was changed in 15 cases (29.4%), due to the clearer information provided. A total of 51 patients (82%) underwent surgery. The most frequent procedure was right hepatectomy (33.3%), followed by left hepatectomy (23.5%) and left trisectionectomy (13.7%). Vascular resection and reconstruction were performed in 10 patients (19.6%) and portal vein was resected in more than half of these cases (66.7%). 3DVT leads to a more detailed and tailored approach to complex liver surgery, improving surgeons’ knowledge of liver anatomy and accuracy of liver resection.Graphical abstract

Portal vein embolization with absolute ethanol to induce hypertrophy of the future liver remnant

BackgroundPreoperative portal vein embolization (PVE) is widely used prior to major liver resection to reduce the risk of post-hepatectomy liver failure (PHLF). We evaluated the efficacy and safety of PVE using absolute ethanol.MethodsConsecutive patients undergoing preoperative PVE between February 2003 and February 2020 at a high-volume tertiary institution were retrospectively reviewed. Hypertrophy of the future liver remnant (FLR) was determined by comparing volumetric data using semi-automated software on computed tomography or magnetic resonance imaging before and after PVE. Efficacy of absolute ethanol was evaluated by the percentage increase in the FLR volume and the ratio of the FLR to the total liver volume (TLV). Technical success and complications following PVE were evaluated. Feasibility of hepatectomy following PVE and the incidence of PHLF were determined.ResultsSixty-two patients underwent preoperative PVE using absolute ethanol. The technical success rate was 95.2%. Median time interval between PVE and follow-up imaging was 34 days (range 6–144 days). The mean increase in FLR volume and ratio of the FLR to TLV were 43.6 ± 34.4% and 12.3 ± 7.7% respectively. Major adverse events occurred in 3 cases (4.8%) and did not preclude consideration of surgery. Forty-two patients (67.8%) proceeded to surgery for intended hepatectomy of which 36 patients (58.1%) underwent liver resection. Major post-operative complications occurred in 4 patients (11.1%) and there were no cases of PHLF.ConclusionPreoperative PVE with absolute ethanol is effective and safe in inducing hypertrophy of the FLR before partial hepatectomy to prevent PHLF.

Rescue percutaneous transhepatic portal vein embolization after failed associated liver partition and portal vein ligation for staged hepatectomy in a patient with multiple liver metastases of rectal cancer: a case report

BackgroundLiver metastasis is the most common form of distant spread of colorectal cancer. Despite oncological and surgical advances, only about 25% of patients are eligible to undergo resection. As the liver has a limited resectable volume, tumor reduction and remnant liver hypertrophy are of critical importance in treating initially unresectable colorectal cancer liver metastasis. Associated liver partition and portal vein ligation for staged hepatectomy (ALPPS) allows rapid liver hypertrophy within a short period and has been reported to be useful in recent years.Case presentationA 29-year-old woman complaining of bloody stool was referred to our hospital. She was diagnosed with rectal cancer (Rb) with simultaneous multiple liver and lung metastases. The patient was then initially commenced on chemotherapy and completed it with a satisfactory response. Right trisectionectomy was necessary to achieve hepatic clearance; however, the future liver remnant (FLR) volume was insufficient. Therefore, we decided to perform totally laparoscopic ALPPS to obtain enough FLR volume. However, the FLR increase was slow, and FLR did not attain the required volume for right trisectionectomy. Computed tomography showed that right portal venous blood flow was increased via developed collateral vessels around the portal vein. We attempted to induce further liver growth by blocking portal blood flow using additional percutaneous transhepatic portal vein embolization (PTPE), and a rapid increase in FLR was obtained. The patient underwent right trisectionectomy and partial resection of S2 with negative margins, and the patient was discharged without postoperative liver failure.ConclusionsResumption of the portal venous blood flow through collateral vessels after ALPPS may have interfered with the planned residual liver hypertrophy. Performing PTPE in addition to ALPPS increased the FLR volume, and radical hepatectomy was completed safely. Remnant portal venous blood flow following ALPPS is an important issue to be considered in surgical planning, and early additional portal vein embolization could be effective.

A prospective study of sequential hepatic vein embolization after portal vein embolization in patients scheduled for right-sided major hepatectomy: Results of feasibility and surgical strategy using functional liver assessment.

Hepatic vein embolization (HVE) added to portal vein embolization (PVE) can further increase future remnant liver volume (FRLV) compared with PVE alone. This study was aimed to evaluate feasibility of sequential HVE in a prospective trial and to verify surgical strategy using functional FRLV (fFRLV). Hepatic vein embolization was prospectively indicated for post-PVE patients scheduled for right-sided major hepatectomy if the resection limit of fFRLV using EOB-magnetic resonance imaging was not satisfied. The resection limit was fFRLV: 615 mL/m2 for predicting post-hepatectomy liver failure. Patients who underwent sequential PVE-HVE (n=12) were compared with those who underwent PVE alone (n=31). All patients underwent HVE with no severe complications. Median fFRLV increased from 396 (range: 251-581) to 634 (range: 422-740) mL/m2 by sequential PVE-HVE. From PVE to HVE, both of FRLV (P < .001) and fFRLV (P=.005) significantly increased. The increased width of fFRLV was larger than that of FRLV after performing HVE. Median growth rate was 71.3 (range: 33.3-80.3) %, which was higher than that of PVE alone (27.0%, range: 6.0-78.0). All-cohort resection rate was 88.3%. Strategy of using fFRLV for the resection limit and performing HVE in patients with insufficient functional volume resulted in no liver failure in all patients who underwent hepatectomy. Sequential HVE after PVE is feasible and safe, and HVE induced possibility of further liver growth and its functional improvement. Our surgical strategy using fFRLV may be justified.

Increasing Living Liver Donor Pools: Liver Paired Exchange Versus ABO-incompatible Living Donor Liver Transplantation.

Increasing Living Liver Donor Pools: Liver Paired Exchange Versus ABO-incompatible Living Donor Liver Transplantation.

Developmental artificial neural network model to evaluate the preoperative safe limit of future liver remnant volume for HCC combined with clinically significant portal hypertension.

Background & aims: Finding a way to comprehensively integrate the presence and grade of clinically significant portal hypertension, amount of preserved liver function and extent of hepatectomy into the guidelines for choosing appropriate candidates tohepatectomy remained challenging. This study sheds light on these issues to facilitate precise surgical decisions for clinicians. Methods: Independent risk factors associated with grade B/C post-hepatectomy liver failure were identified by stochastic forest algorithm and logistic regression in hepatitis B virus-related hepatocellular carcinoma patients. Results: The artificial neural network model was generated by integrating preoperative pre-ALB, prothrombin time, total bilirubin, AST, indocyanine green retention rate at 15 min, standard future liver remnant volume and clinically significant portal hypertension grade. In addition, stratification of patients into three risk groups emphasized significant distinctions in the risk of grade B/C post-hepatectomy liver failure. Conclusion: The authors' artificial neural network model could provide a reasonable therapeutic option for clinicians to select optimal candidates with clinically significant portal hypertension for hepatectomy and supplement the hepatocellular carcinoma surgical treatment algorithm.

Treatment of choice for advanced HCC with small future remnant liver volume for a hepatologist?

Treatment of choice for advanced HCC with small future remnant liver volume for a hepatologist?

Combining Laparoscopic Liver Partitioning and Simultaneous Portohepatic Venous Deprivation for Rapid Liver Hypertrophy

Future liver remnant (FLR) volume is an important indicator of the risk of posthepatectomy liver failure (PHLF) and limits the feasibility of major hepatectomies. A case series of 5 patients treated with a novel approach is presented. Laparoscopic liver partitioning was combined with subsequent liver venous deprivation (embolization of both the portal and the hepatic veins). Baseline average FLR was 28.8%. All procedures were successfully performed without major complications. Mean 1-, 2- and 4-week hypertrophy of the FLR were 35%, 40.3%, and 46.4%, respectively. Four patients underwent planned surgery after a mean interval of 28 days. Of these, 2 patients achieved sufficient FLR volume and function after 2 weeks and underwent surgery before the 4-week volumetric analysis. One patient did not undergo surgery because of intraoperative diagnosis of peritoneal metastases. No cases of PHLF were observed at 5-day follow-up.

A single center comparative retrospective study of in situ split plus portal vein ligation versus conventional two-stage hepatectomy for cholangiocellular carcinoma

Introduction Cholangiocellular carcinoma (CCA) has a poor prognosis and the goldstandard even in locally advanced cases remains radical surgical resection. This approach however is limited by the future liver remnant volume (FLRV) after extensive parenchymal dissection leading to post-operative liver failure and high mortality rates. The aim of this study was to compare the outcome of in situ liver transection with portal vein ligation (ISLT) procedure and conventional two-stage hepatectomy with portal vein embolization (PVE/TSH) in patients with CCA. Methods All patients with CCA and insufficient FLR considered for either ISLT or PVE/TSH were analyzed for outcomes including post-operative morbidity, mortality, and overall survival rates (OS). Results Sixteen patients received ISLT and eight patients underwent PVE/TSH. The completion rate of the second stage in the PVE/TSH group was 62% and 100% in the ISLT group (p = 0.027). The overall 90-day morbidity rates including severe complications (Clavien-Dindo ≥3b) were comparable (PVE/TSH 40% vs. ISLT 69%, p = 0.262). The median OS (PVE/TSH 7 months vs. ISLT 3 months) and the 90-day mortality rates (PVE/TSH 0% vs. ISLT 50%) did not significantly differ between the two groups (p > 0.05). In multivariate analysis, biliary resection and reconstruction was the only risk factor independently associated with 90-day post-operative morbidity [HR = 20.0; 95%CI (1.68–238.63); p = 0.018]. Conclusion Our results demonstrate comparable outcomes in both groups in a rather prognostically unfavorable disease. The completion rate in the ISLT group was significantly higher than in the PVE/TSH cohort. This work encourages specialized hepato-biliary-pancreatic centers in applying the ISLT procedure in selected cases with CCA.

Portal vein embolization via the ipsilateral percutaneous transhepatic approach versus laparotomic transileocecal approach: complications, profile and changes in future liver remnant volume.

Major liver resection is an effective treatment option for patients with liver malignancy. The future liver remnant (FLR) volume and complications after portal vein embolization (PVE) were compared between the ipsilateral right portal vein (PTPE) and transileocolic (TIPE) approaches. A total of 42 patients (TIPE, n = 22; PTPE, n = 20) underwent right lobectomy after PVE. CT and hepatobiliary scintigraphy were repeated before and after PVE. The blood examination findings and the FLR values (FLRCT: calculated from CT, %FLRCT: FLRCT ratio, %FLRSPECT: FLR ratio using single photon emission CT, FLRCT/BS: FLRCT to body surface ratio) were compared between two approach sites. The complications and mortality were also analyzed after PVE and major right hepatectomy. There were no significant differences in the patient characteristics, blood examination findings or FLR values between two groups. Adequate liver regeneration was observed without significant differences between PTPE and TIPE (increased ratio of FLRCT: 8.7% vs 19.2%, p = 0.15 [25-75 percentile: 17.1-60.4], %FLRCT: 11.2% vs 8.3%, p = 0.25 [6.3-13.3], %FLRSPECT: 15.4% vs 19.2%, p = 0.09 [16.0-22.4], FLRCT/BS: 33.6% vs 47.1%, p = 0.19 [17.2-60.4], respectively), but TIPE required a significantly longer procedure time than PTPE [181.4 min vs 108.7 min, p < 0.01 (103.3-193.5)]. However, one patient was converted to TIPE due to bleeding during PTPE. After right lobectomy, portal vein stenosis or thrombosis was noted in three patients [two with TIPE (9.1%) and one with PTPE (5%)] and three TIPE patients died within 90 days (13.6%) after right hepatectomy. FLR volume significantly increased after PVE, regardless of the approach sites; however, PTPE is a useful technique with a shorter procedure time.

Impact of laparoscopic liver resection on liver regeneration.

Liver regeneration after liver resection plays an important role in preventing posthepatectomy liver failure. In this study, we aimed to evaluate and compare the impact of laparoscopic liver resection (LLR) and open liver resection (OLR) on liver regeneration. Patients who underwent curative anatomical liver resection for hepatocellular carcinoma, cholangiocellular carcinoma, and colorectal liver metastases at our institution between January 2010 and December 2018 were included in this study. The patients were divided into the OLR and LLR groups. Preoperative liver volume (PLV), future remnant liver volume, resected liver volume (RLV), liver volume at 1month after the surgery, and liver volume at 6months after the surgery were calculated. The liver regeneration rate was defined as the increase in the rate of RLV, and the liver recovery rate was defined as the rate of return to the PLV. The study included 72 patients. Among them, 43 were included in the OLR group and 29 were included in the LLR group. No differences were observed in the baseline characteristics and surgical procedures between the two groups. Moreover, no significant difference was observed in the liver regeneration rate at 1month after the surgery (OLR vs. LLR: 68.9% vs. 69.0%, p = 0.875) and at 6months after the surgery (91.8% vs. 93.2%, p = 0.995). Furthermore, the liver recovery rates were not significantly different between the two groups at 1month after the surgery (90.3% vs. 90.6%, p = 0.893) and at 6months after the surgery (96.9% vs. 98.8%, p = 0.986). Liver regeneration after liver resection is not affected by the type of surgical procedure and both laparoscopic and open procedures yield similar regeneration and recovery rates.

Future liver volume combined with platelet count predicts liver failure after major hepatectomy

BackgroundMajor hepatectomy is associated with high incidence of post-hepatectomy liver failure (PHLF). This study aimed to evaluate the effect of future remnant liver volume combined with liver function tests on predicting PHLF. MethodsPatients who underwent major hepatectomy from April 2009 to May 2017 were enrolled in the training cohort. Univariate and multivariate logistic regression analyses were performed to identify independent risk factors of PHLF and generate a logistic regression model for the prediction of PHLF. A conditional inference tree was generated based on the optimal cutoff value of independent predictive factors of PHLF. The precedent results were validated in an independent cohort from June 2017 to March 2018. ResultsOne hundred and eighteen patients were included in the training cohort, while another 34 in the validation cohort. Future remnant liver volume/estimated standard total liver volume (FLV/eTV) and preoperative platelet count were independent predictive factors of PHLF (P = 0.0021 and P = 0.012, respectively). The conditional inference tree showed that patients with FLV/eTV ≤0.56 and PLT count ≤145 × 109/L were at high risk of developing PHLF. ConclusionFLV/eTV combined with preoperative PLT count is effective in predicting PHLF after major hepatectomy.

Comment on Liver Venous Deprivation or Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy?: A Retrospective Multicentric Study.

To the Editor: We read with great interest the results of comparing liver venous deprivation (LVD) with associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) for compensatory increase rates of future liver remnant (FLR). We wish to congratulate Chebaro et al1 for completing such a pivotal study. As indicated, this first retrospective study demonstrated a faster hypertrophy rate and higher resection rates for ALPPS than for LVD (P < 0.001), whereas 90-day major complication and mortality rates were comparable. However, some issues merit further discussion. First, the authors did not explore the differences in the mechanisms of ALPPS and LVD. While comparing LVD with ALPPS in terms of the efficiency of remnant liver volume (RLV) gain, relative RLV increase was similar between LVD and ALPPS (63% vs 56%, P = 0.727) but with slower kinetic growth rates (KGR) in LVD than in ALPPS (2%/day vs 7%/day, P < 0.001). ALPPS increases FLR volume by an average of 48.6% to 90.0% in 7 to 14 days of ALPPS.2 Guiu et al3 have reported that the percentage of FLR volume increased from 28.2% to 40.9% after 21 days of LVD. ALPPS can increase active proliferation by increasing the hepatic parenchymal partition between the portal and nonportal vein embolic lobes, leading to transection of extensive communicating branches between them.4 Moreover, the increased levels of systemic inflammatory factors and cytokines, such as interleukin 6 and tumor necrosis factors, may have an important effect on the rapid increase in residual liver volume.5 LVD combines embolization of the portal inflow and venous outflow. The main mechanism explaining the effect of LVD involved the reaction of continuous miniportal inflow and a decrease in the portal collateral branches.6 LVD is an interventional procedure that is superior to invasive ALPPS. However, an increase in the KGR of LVD is a critical issue that needs to be solved urgently. Second, although this study reported that the successful resection rate was significantly lower for LVD than for ALPPS (72.6% vs 90.6%, P < 0.001), it did not really reflect the success rate due to different indications. Therefore, it is better to explore successful resection rates aimed at primary liver tumors for LVD and ALPPS. Although ALPPS is mainly indicated for colorectal liver metastases (CRLM), it is also used for primary liver tumors. A single-center study in 2018 selected 45 patients with hepatocellular carcinoma who underwent standard ALPPS. After the first stage of ALPPS, the median increase rate of FLR reached 56.8%. A two-stage hepatectomy was completed in 41 patients (91.1%) in approximately 2 weeks. The 90-day mortality rate was 11.1%, and the 1-year and 3-year overall survival rates were 64.2% and 60.2%, respectively.7 Third, the authors did not report if, and for how long, they followed up these patients to evaluate the prognosis after surgery. Further follow-up (5-year survival) studies are needed to determine the effects of LVD and ALPPS, which will help determine better options in the future. Schnitzbauer et al8 reported that the 3-year overall survival rate of CRLM patients after ALPPS was 50%. Another study showed that the 1-, 3-, and 5-year survival rates of CRLM patients after ALPPS were 76.2%, 57.1%, and 22.9%, respectively.9 Finally, ALPPS did cause direct or indirect squeezing and repeated touching of the liver tumor, which may have resulted in the proliferation or metastasis of tumor cells.10 Postoperative liver tumor markers should be evaluated and compared between the embolized and nonembolized hepatic lobes. Moreover, the number and size of tumors should be compared before and after surgery to assess the degree of progress. In summary, we appreciate the excellent work of Chebaro et al1; however, whether LVD will have a better performance is worthy of more in-depth research.

Associating liver partition and portal vein ligation for staged hepatectomy ​for colorectal liver metastasis: a single-center experience

Associated liver partition and portal vein ligation for staged hepatectomy (ALPPS) is increasingly used for the treatment of primarily unresectable colorectal liver metastases (CRLM) because of the insufficient future liver remnant (FLR). The aim of this study was to share our experience with ALPPS for advanced CRLM and review the role of ALPPS in the management of patients with CRLM. Consecutive patients (n = 10) with CRLM who underwent ALPPS at our center between December 2014 and October 2021 were retrospectively studied. The median age of patients was 58 years (range 49–70 years). Five patients had metachronous CRLM and the other 5 patients had synchronous CRLM. Five patients had unilateral CRLM and the other 5 patients had bilateral CRLM. All patients previously underwent neoadjuvant chemotherapy. The FLR volume increased by 45.3% (35.8%–61.6%) over 14 days (range 7–21 days). The absolute and relative kinetic growth rates were 17.9 mL/day (range 7.5–32.1 mL/day) and 4.6%/day (range 2.3%–8.8%/day), respectively. Overall morbidity rates were 20% (2/10) and 40% (4/10) after ALPPS stage 1 and stage 2, respectively. The 30-day and 90-day mortality rates were 0% and 10%, respectively. R0 resection was achieved for all patients, and the median disease-free survival was 18.7 months. ALPPS is an effective treatment option for advanced CRLM. It enables rapid hypertrophy of the FLR and achieves a high R0 resection rate with an acceptable oncological outcome. However, ALPPS should be reserved for selected patients because of its relatively high morbidity and mortality.