Insufficient Future Liver Remnant Research Articles

Advancements and controversies in conversion therapy for biliary tract malignant tumors with insufficient future liver remnant

Due to the unique location and aggressive tumor biology,hilar cholangiocarcinoma,intrahepatic cholangiocarcinoma,and gallbladder cancer often present with obstructive jaundice and require extensive liver resection,also exhibit high rates of recurrence and metastasis after radical excision. Therefore,surgeons should make treatment decisions based on the biliary anatomy of patients and the biological characteristics of tumors as it significantly affects patient's prognosis. Treatment strategy should be made to ensure the successful implementation of radical resection for biliary tract malignant tumors while maximizing the survival benefits of patients. Firstly,conversion of liver function by relieving jaundice technology and conversion of tumor biological characteristics through systematic therapy,followed by the conversion of future liver remnant. Currently,there are still controversies surrounding indications,methods,standards of relieving jaundice,and treatment plans,cycles,evaluation of therapeutic effects for systematic conversion therapy,and the standards and techniques of conversion therapy for future liver remnant.This article discusses these issues through literature analysis and the author's experience in the hope of resonating with colleagues.

Single center experience with ALPPS and timing with stage 2 in patients with fibrotic/cirrhotic liver.

Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) is a novel procedure for major resection in patients with insufficient future liver remnant (FLR). Effective FLR augmentation is pivotal in the completion of ALPPS. Liver fibrosis/cirrhosis associated with chronic viral hepatitis impairs liver regeneration. To investigate the augmentation of FLR in associating ALPPS between patients with fibrotic/cirrhotic livers (FL) and non-fibrotic livers (NFL) and compare their short-term clinical outcomes and long-term survival. Patients were divided into two groups based on the Ishak modified staging: non-fibrotic liver group (NFL, stage 0) and fibrotic/cirrhotic liver group (FL, stage 1-5/6). Weekly liver regeneration in FLR, perioperative data, and survival outcomes were investigated. Twenty-seven patients with liver tumors underwent ALPPS (NFL, n = 7; FL, n = 20). NFL and FL patients had viral hepatitis (28.6% [n = 2] and 95% [n = 19]), absolute FLR volume increments of 134.90ml and 161.85ml (p = 0.825), and rates of hypertrophy were 16.46ml/day and 13.66ml/day (p = 0.507), respectively. In the FL group, baseline FLR volume was 360.13ml, postoperatively it increased to a plateau (542.30ml) in week 2 and declined (378.45ml) in week 3. One patient (3.7%) with cirrhotic liver (stage 6) failed to proceed to ALPPS-II. The overall ALPPS-related major complication rate was 7.4%. ALPPS is feasible for fibrotic liver patients classified by Ishak modified stages ≤ 5. After ALPPS-I, 14days for FLR augmentation seems an appropriate waiting time to reach a maximum FLR volume in these patients.

Novel multiparametric MRI detects improved future liver remnant quality post-dual vein embolization

BackgroundOptimisation of the future liver remnant (FLR) is crucial to outcomes of extended liver resections. This study aimed to assess the quality of the FLR before and after dual vein embolization (DVE) by quantitative multiparametric MRI. MethodsOf 100 patients with liver metastases recruited in a clinical trial (Precision1:NCT04597710), ten consecutive patients with insufficient FLR underwent quantitative multiparametric MRI pre- and post-DVE (right portal and hepatic vein). FLR volume, liver fibro-inflammation (corrected T1) scores and fat percentage (proton density fat fraction, PDFF) were determined. Patient metrics were compared by Wilcoxon signed-rank test and statistical analysis done using R software. ResultsAll patients underwent uncomplicated DVE with improvement in liver remnant health, median 37 days after DVE: cT1 scores reduced from median (interquartile range) 790 ms (753–833 ms) to 741 ms (708–760 ms) p = 0.014 [healthy range <795 ms], as did PDFF from 11% (4–21%), to 3% (2–12%) p = 0.017 [healthy range <5.6%]. There was a significant increase in median (interquartile range) FLR volume from 33% (30–37%)% to 49% (44–52%), p = 0.002. ConclusionThis non-invasive and reproducible MRI technique showed improvement in volume and quality of the FLR after DVE. This is a significant advance in our understanding of how to prevent liver failure in patients undergoing major liver surgery.

Laparoscopic Portal Vein Ligation and Embolization During First-Stage Hepatectomy for Initially Unresectable Colorectal Liver Metastases.

Two-stage hepatectomy (TSH) is the only treatment for the patients with multiple bilobar colorectal liver metastases (CRMs) who are not candidates for one-step hepatectomy because of insufficient future remnant liver volume and/or impaired liver function.1-5 Although laparoscopic approaches have been introduced for TSH,6-8 the postoperative morbidity and mortality remains high because of the technical difficulties during second-stage hepatectomy.9,10 The authors present a video of laparoscopic TSH with portal vein (PV) ligation and embolization, which minimizes adhesions and PV thrombosis risk in the remnant liver, thereby facilitating second-stage hepatectomy. Three patients with initially unresectable bilateral CRMs received a median of chemotherapy 12 cycles, followed by conversion TSH. After right PV ligation, laproscopic PV embolization was performed by injection of 100% ethanol into the hepatic side of the right PV using a 23-gauge winged needle. After PV embolization, a spray adhesion barrier (AdSpray, Terumo, Tokyo, Japan)11 was applied. During the first stage of hepatectomy, two patients underwent simultaneous laparoscopic colorectal resection (left hemicolectomy and high anterior resection). In the initial hepatectomy, two patients underwent two limited hepatectomies each, and one patient underwent six hepatectomies in the left lobe. After hepatectomy, all the patients underwent right PV embolization. During the second stage, two patients underwent open extended right hepatectomy (right adrenalectomy was performed because of adrenal invasion in one patient), and one patient underwent laparoscopic extended right hepatectomy. No postoperative complications occurred in the six surgeries. Laparoscopic TSH with PV embolization is recommended for safe completion of the second hepatectomy.

90Y-/166Ho- ‘Radiation lobectomy’ for liver tumors induces abnormal morphology and impaired drainage of peritumor lymphatics

High-dose unilobar radioembolization, or 'radiation lobectomy' (RL), is an induction therapy that achieves contralateral future liver remnant hypertrophy while simultaneously irradiating the tumor. As such, it may prevent further growth, but it is unknown whether RL affects intrahepatic lymphatics, a major route via which liver tumors disseminate. This was a case-control study conducted at University Medical Center Utrecht. The study compared lymph vessels in livers that had undergone RL (cases) with those in livers that had not undergone RL (controls). Histological samples were acquired from patients diagnosed with hepatocellular carcinoma (HCC) or colorectal liver metastases (CRLM) between 2017 and 2022. Lymph vessel morphology was analyzed by two researchers using podoplanin, a protein that is expressed in lymphatic endothelium. Invivo liver lymph drainage of radioembolized livers was assessed using intraoperative liver lymphangiography (ILL): during liver surgery, patent blue dye was injected into the liver parenchyma, followed by inspection for staining of perihepatic lymph structures. ILL results were compared to a previously published cohort. Immunohistochemical analysis on post-RL tumor tissues from ten patients with CRLM and nine patients with HCC revealed aberrant morphology of irradiated liver lymphatics when compared to controls (n= 3 per group). Irradiated lymphatics were tortuous (p <0.05), thickened (p <0.05) and discontinuous (p <0.05). Moreover, post-RL lymphatics had larger lumens (1.5-1.7x, p <0.0001), indicating lymph stasis. ILL revealed diminished lymphatic drainage to perihepatic lymph nodes and vessels in irradiated livers when compared to non-radioembolized controls (p= 1.0x10-4). Radioembolization impairs peritumoral lymph vessel function. Further research is needed to evaluate if radioembolization impairs tumor dissemination via this route. Unilobar radioembolization can serve as an alternative to portal venous embolization for patients who are considered unresectable due to an insufficient future liver remnant. This research suggests that radioembolization impairs the function of peritumoral liver lymph vessels, potentially hindering dissemination via this route. These findings provide support for considering unilobar radioembolization over standard portal venous embolization.

ЭФФЕКТИВНОСТЬ МЕТОДОВ ОККЛЮЗИИ ВОРОТНОГО КРОВОТОКА ПРИ ПЛАНИРОВАНИИ ОБШИРНЫХ РЕЗЕКЦИЙ У ПАЦИЕНТОВ С ЭХИНОКОККОЗОМ ПЕЧЕНИ

Background. Surgery is the main and an effective treatment option for liver echinococcosis. The choice of surgical strategy for advanced liver echinococcosis given suspected poor liver functional reserve and post-operative hepatic failure remains challenging. Objective. To present and analyze the effectiveness of portal blood flow occlusion techniques in planning two-stage extensive resections in patients with advanced liver echinococcosis. Material and methods. The article presents the outcomes of surgical treatment of 22 patients (8/36,4% men, 14/63,6% women) operated on for advanced liver echinococcosis in the surgical department No.2 of State Autonomous Healthcare Institution ‘Kuzbass Clinical Emergency Hospital named after A.I. M. A. Podgorbunsky’ (Kemerovo). The application of a two-stage extensive resection protocol was used as an entry criterion. Stage I included right portal vein branch occlusion techniques aimed at achieving vicarious hypertrophy of the contralateral lobe. A two-stage extensive resection protocol was applied in case of both expected poor hepatic functional reserve and insufficient future remnant liver volume, accounting for inability of safe implementation of a one-stage extensive resection due to predicted postoperative hepatic failure and a fatal outcome. Results. The applied two-stage resection techniques for the prevention of post-operative hepatic failure are effective in relation to the following indicators: CT volumetry (p&lt;0,05), OK15 ICG (p&lt;0,05), statistical model value (p&lt;0.05). Though the laparotomic technique of the right portal vein branch ligation is of a comparable effectiveness with the laparoscopic one, the latter being less traumatic, which can significantly reduce postoperative hospital stay (p&lt;0,05). Moreover, the laparoscopic technique was not found to cause any specific and nonspecific complications. Conclusions. The applied methods of portal blood flow occlusion are considered to be effective and safe when planning two-stage extensive resections in specialized hepatology centers and can be recommended in case of initial poor hepatic functional reserve and insufficient future remnant liver volume.

Totally laparoscopic associating simultaneous bile duct and portal vein ligation for planned hepatectomy for primary liver cancer: a case report

BackgroundSome patients with liver cancer lose the chance to have surgical treatment due to insufficient future remnant liver. To address this problem, individual or occlusion of both the portal vein and the bile duct was used to achieve quick hypertrophy. This is the first study reported in which simultaneous ligation of the portal vein and the bile duct was applied as the first step of planned hepatectomy of primary liver cancer.Case presentationHere we report a case of a 38-year-old Asian male patient with hepatocellular carcinoma with tumor thrombus in the right anterior branch of the portal vein. Right hemihepatectomy can be curative, but patients face a high risk of liver failure because of the small volume of the remaining left liver lobe. Hence we developed a two-step liver resection strategy in which the patient underwent laparoscopic simultaneous bile duct and portal vein ligation of the right hepatic lobe prior to right hemihepatectomy under laparoscopy. Using this procedure, we achieved fast hypertrophy of the left liver lobe and successfully reversed the primary unresectability.ConclusionThis case report demonstrates that simultaneous bile duct and portal vein ligation may be a feasible option for those patients with liver cancer who cannot get surgical treatment due to insufficient future remnant liver.

Safety and Efficacy of Liver Venous Deprivation Following Transarterial Chemoembolization Before Major Hepatectomy for Hepatocellular Carcinoma.

This study aimed to evaluate the safety and efficacy of liver venous deprivation (LVD) following transarterial chemoembolization (TACE) in patients with hepatocellular carcinoma (HCC). Between January 2021 and December 2022, HCC patients indicated for hepatectomy with initial insufficient future liver remnant (FLR) underwent LVD after TACE to induce preoperative liver hypertrophy. Twenty-seven HCC patients with a median age of 55 years underwent LVD. No TACE or LVD procedure-associated complications occurred, except for 1 case presenting with grade A liver failure after LVD (then recovered after 7 days). The FLR volume was 29.3% (interquartile range [IQR] = 7.5) and 48.9% (IQR = 8.6) of the total liver volume before and after LVD, respectively (p < 0.001). The degree of hypertrophy and FLR hypertrophy rate were 14.8% (IQR = 8.4) and 55.2% (IQR = 36.7), respectively. All 27 patients demonstrated sufficient FLR after LVD (24 patients at three weeks post-LVD, one at six weeks, and two at ten weeks), but only 21 patients accepted surgery. Postoperative histopathology showed 16 patients with cirrhosis and five with mild fibrosis (F1, F2). One patient presented with severe intraoperative bleeding due to damage of left hepatic vein and developed grade C liver failure, then died on day 32 postoperation. LVD following TACE seems to be a safe, effective, and feasible method of inducing significant FLR regeneration in HCC, even in well-selected cirrhotic livers. Comparative studies with a large patient population and multicenter data are needed for further evaluation.

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

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

Study of ultrasound-guided percutaneous microwave ablation combined with portal vein embolization for rapid future liver remnant increase of planned hepatectomy.

To evaluate the efficacy of ultrasound-guided percutaneous microwave ablation (PMA) combined with portal vein embolization (PVE) for planned hepatectomy. We retrospectively reviewed data of 18 patients with multiple right liver tumors or hilar tumor of liver invades the surrounding tissue and insufficient future liver remnant (FLR) for hepatectomy from July 2015 to March 2017. Ultrasound-guided PMA was performed by using PMCT cold circulation microwave treatment apparatus. PVE was performed after PMA. The increase of FLR was evaluated by computed tomography (CT) 6-22 days after PVE. The proportion of FLR, increase in the amplitude of FLR, procedure-related complications, perioperative morbidity and mortality, and overall survival (OS) rates, the median survival time were analyzed. The median volume of FLR before PMA and PVE was 369.7ml (range: 239.4-493.1ml). After a median waiting period of 11.5 days (range: 6-22 days), the median volume of FLR was increased to 523.4ml (range: 355.4-833.3ml). The changes in FLR before and after PMA and PVE were statistically significant (p<0.001). No serious perioperative complications or mortality were found. After a median follow-up time of 51.0 months (range: 2-54 months), the 6-month, 1-year, 2-year, 3-year and 4-year survival rates were 88.9%, 72.2%, 44.4%, 33.3%, 22.2%, respectively, and the median survival time was 15.0 ± 7.1 months. PMA combined with PVE increases FLR rapidly, avoids touching malignant tumors, and produces fewer procedure-related complications. It appears safe and efficacious for planned hepatectomy.

Sequential therapy of portal vein embolization and systemic chemotherapy for locally advanced perihilar biliary tract cancer.

Curative resection is the only potential treatment for cure in patients with perihilar biliary tract cancer (PBTC). However, post hepatectomy liver failure (PHLF) due to insufficient future liver remnant volume (FRLV) remains a lingering risk even after portal vein embolization (PVE). This study aimed to investigate the feasibility and efficacy of a sequential treatment strategy consisting of PVE followed by preoperative chemotherapy before surgery. Between April 2019 and December 2021, 15 patients with locally advanced PBTC (LA-PBTC) underwent sequential treatment consisting of PVE followed by preoperative chemotherapy. The feasibility and efficacy, including resection rate, changes of FRLV, and chemotherapeutic effect, were investigated retrospectively. Thirteen of 15 patients (86.6%) underwent curative resection. The median duration time between PVE and surgery was 144 days. FRLV/TLV ratio was 31.3% at prePVE, 38.4%, at two weeks after PVE, and 45.7% before surgery, respectively. There was significant increase in FRLV/TLV ratio two weeks after PVE. Additional increase in FRLV/TLV ratio was significantly achieved before surgery. PHLF occurred in 5 patients (38.4%). Pathological complete response was found in 2 of 13 patients (15.3%). Sequential PVE and systemic chemotherapy contribute to the sufficient hypertrophy of FRLV without compromising resectability in patients with LA-PBTC.

HPB P68 Multimetric MRI detects improved quality of the future liver remnant post-dual vein embolization – a novel finding

Abstract Background Optimisation of the future liver remnant (FLR) is crucial to the safety of extended liver resections. This study aimed to assess volume and quality of the FLR pre- and post-dual vein embolisation (DVE) by MRI, in patients with insufficient FLR, needing major hepatectomy. Methods Of 81 patients recruited in a clinical trial (Precision1:NCT04597710), seven consecutive patients with colorectal liver metastases underwent multiparametric MRI (Hepatica®) pre- and post-DVE (right hepatic and portal vein). One patient had DVE after a first-stage hepatectomy. FLR volume, fibro-inflammation map (corrected T1) and fat (proton density fat fraction, PDFF) was determined. Results All 7 patients underwent uncomplicated DVE, with significant increase in median(range) %FLR volume at liver surgery [45.7(27.0–57.8)% versus 32.4 (19.5–37.7)%, p=0.016], 46 days (range 28–77) post-DVE. Median(range) FLR cT1 scores reduced post-DVE [747.33 (684–884)ms, versus 771.25(726–945)ms, p=0.047; healthy range&amp;lt;794ms], as did median(range) PDFF scores [3.4 (2–13.25)% versus 6 (1.5–22.5)%, p=0.078; healthy range &amp;lt;5.6%]. No patient developed post-hepatectomy liver failure (PHLF). Conclusions This novel, non-invasive and readily accessible MRI technique shows that volume and quality of the FLR improves after DVE. This is a significant step in improving surgical decision making in patients with borderline FLR, preventing PHLF and improving outcomes.

Long-term survival of a patient with liver metastases from clear cell gastric adenocarcinoma after multimodality treatment including interventional oncology techniques: case report

BackgroundGastric cancer (GC) is the fourth most common cancer and the third leading cancer-related cause of death worldwide since most patients are diagnosed at an advanced stage. The majority of GCs are adenocarcinomas (ACs), and the poorly characterized clear cell AC represents a unique subgroup of GCs and is an independent marker of poor prognosis. Even though the prognosis for patients with advanced GC is poor we present a report of a patient with long-term survival despite having liver metastases from clear cell gastric AC.Case presentationA 45-year-old male with clear cell gastric AC underwent subtotal gastrectomy and postoperative chemoradiation. Only a year and a half after his initial treatment the disease spread to his liver. He received two lines of chemotherapy treatment within the next two years before a right hepatectomy was suggested. Due to an initially insufficient future liver remnant (FLR), transarterial chemoembolization (TACE) and portal vein embolization (PVE) were performed, which made the surgical procedure possible. Shortly after a disease progression in the remaining liver was detected. In the following three years the patient was treated with a carefully planned combination of systemic therapy and different interventional oncology techniques including selective internal radiation therapy (SIRT) and TACE. And as illustrated, an attentive, patient-tailored, multimodality treatment approach can sometimes greatly benefit our patients as he had an overall survival of 88 months despite the poor prognosis of his disease.ConclusionTo the best of our knowledge, this report is the first to describe a patient with liver metastases from clear cell gastric AC treated with interventional oncology techniques (PVE, TACE, and SIRT) in combination with other locoregional and systemic therapies thereby presenting that these interventional oncology techniques can be successfully integrated into long-term management of non-conventional liver tumors.

Percutaneous liver venous deprivation: outcomes in heavily pretreated metastatic colorectal cancer patients.

To evaluate liver venous deprivation (LVD) outcomes in patients with colorectal liver metastasis (CRLM) heavily pretreated with systemic and hepatic arterial infusion pump (HAIP) chemotherapies that had an anticipated insufficient future liver remnant (FLR) hypertrophy after portal vein embolization (PVE). PVE was performed with liquid embolics using a transsplenic or ipsilateral transhepatic approach. Simultaneously and via a trans-jugular approach, the right hepatic vein was embolized with vascular plugs. Liver volumetry was assessed on computed tomography before and 3-6 weeks after LVD. Twelve consecutive CRLM patients that underwent LVD before right hepatectomy or trisectionectomy were included, all previously treated with systemic chemotherapy for a mean of 11.9 months. Six patients had additional HAIP. After embolization, FLR ratio increased from 28.7%±5.9 to 42.2%±9.0 (P<0.01). Mean kinetic growth rate (KGR) was 3.56%/week±2.3, with a degree of hypertrophy (DH) of 13.8%±7.1. In the HAIP subgroup, mean KGR and DH were respectively 3.58%/week±2.8 and 14.3%±8.7. No severe complications occurred. Ten patients reached surgery after 39 days±7.5. In heavily pretreated patients, LVD safely stimulated a rapid and effective FLR hypertrophy, with a resultant high rate of resection.

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.

Ten-year retrospect of ALPPS in the treatment of hepatocellular carcinoma:an eternal concept with cautious technologic choice

Clinical practice using associating liver partition and portal vein ligation for staged hepatectomy(ALPPS) or its modified procedures in treatment of primary hepatocellular carcinoma(HCC) with insufficient future liver remnant(FLR) in the past 10 years has failed to meet our expectations both in achieving decreased perioperative complications and mortality.The efficacy of ALPPS in improving long-term survival outcome of HCC still remains poor.Due to the trauma of two surgery within a short period,and patients with inadequate FLR are all diagnosed at advanced disease stages,ALPPS can only achieve surgical rather than biological tumor-curability.Previous studies have demonstrated comparable 5-year survival rates between early and advanced stages of HCC who underwent regional treatments.Therefore,tumor biological conversion is the key strategy prior to liver remnant volume conversion in improving treatment outcomes for HCC patients with insufficient FLR.Target therapy,immunotherapy together with locally treatment were expected to improve the conversion efficacy.Looking back at the development of ALPPS for the last decade,the rapid proliferation of FLR should be passed on,while the technology costs high risks and result in poor long-term outcome must be cautiously selected.

A Comparative Retrospective Study of in Situ Split Plus Portal Vein Ligation (ISLT) Versus Conventional Two-Stage Hepatectomy for Cholangiocellular Carcinoma - Does the ISLT Procedure Have an Oncological Advantage?

Introduction: Cholangiocellular carcinoma (CCA) has a poor prognosis and the mainstay of therapy even in locally advanced cases remains radical surgical resection. This approach however is limited by the future liver remnant (FLR) volume after extensive parenchymal dissection leading to postoperative 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 postoperative morbidity and mortality as well as overall survival rates (OS). Results: Of the total 24 patients included, 16 patients received ISLT. The remaining 8 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-days-morbidity was comparable (PVE/TSH 40% vs. ISLT 69%, p=0.262). OS at follow-up (median: 7 months) 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 significantly higher morbidity and mortality rates (HR=23.33; 95%CI (1.99-273.29); p=0.012). Conclusion: Our results demonstrate comparable outcomes in both groups in a rather prognostically unfavourable disease. The completion rate in the ISLT group was significantly higher than in the PVE/TSH cohort. This work encourages specialized HPB centers in applying the ISLT procedure in selected cases with cholangiocellular carcinoma.

Two Cases of Splenectomy Combined with Hepatectomy for Patients with Insufficient Future Liver Remnant Volume

The usefulness of splenectomy combined with hepatectomy for patients without liver cirrhosis (LC) have been equivocal, even though splenectomy for hepatocellular carcinoma (HCC) patients with portal hypertension could improve the surgical safety. We performed splenectomy with hepatectomy in one case of HCC patient with LC and one case of intrahepatic cholangiocarcinoma (ICC) patient without LC. Therefore, we will report the cases. Case 1: A 77-year-old woman with LC underwent hepatectomy for HCC in liver segment 5 with portal vein (PV) tumor thrombosis. Her blood test showed platelets count of 148,000 /μl, ICG 15-minute value of 18.3%, ICG-K value of 0.110. Right lobectomy was planned, and the future liver remnant volume (FLRV) was 336 ml (36.1%) / remnant liver ICG-K value was 0.039. Intraoperative PV pressure slightly increased from 10 to 11 mmHg after hepatectomy, and decreased to 9 mmHg after splenectomy. She was discharged 18 days after the operation without any major complications. Case 2: A 46-year-old man without LC underwent hepatectomy for ICC. His blood test showed platelets count of 248,000 /μl, ICG 15-minute value of 12.9%, ICG-K value of 0.152. Extended right lobectomy was planned and the FLRV was 736 ml (39.3%) / remnant liver ICG-K value was 0.059. Intraoperative PV pressure increased from 20 to 25 mmHg after hepatectomy, and decreased to 20 mmHg after splenectomy. He was discharged 31 days after the operation without any major complications, but intractable ascites. Conclusion: Splenectomy combined with hepatectomy for patients without LC may improve the surgical safety.

Parenchyma Sparing ALPPS - Ultrasound Guided Partition Through Segment 4 to Maximize Resectability (with video)

Background: Associating liver partition and portal vein ligation (ALPPS) has evolved as a treatment strategy for patients with liver tumors who are not amenable for upfront hepatectomy because of an insufficient future liver remnant (FLR). Aim of this study was to test the applicability of ultrasound guided parenchyma sparing surgery to ALPPS concept, by non-anatomically shifting the plane of transection in favor of FLR, resulting in a new technical variant of ALPPS, entitled parenchyma sparing ALPPS (psALPPS). Materials and Methods: Patients who could not safely undergo right trisectionectomy ALPPS because of insufficient FLR were considered eligible for psALPPS, consisting in liver partition through segment 4 using ultrasound guidance. Results: Between April 2017 and April 2021, five patients with median age of 68 years (range: 66-78), four male and one female, underwent psALPPS for colorectal liver metastases (N=2), intrahepatic cholangiocarcinoma (N=2), and hepatocellular carcinoma (N=1). Standardized FLR (sFLR) for segments 2-3 before stage 1 surgery would have been a median of 11.6%. PsALPPS could double the sFLR at stage 1 resulting in an increase of ps-sFLR from a median of 22.7% (at stage 1) to 34.0% (at stage 2) after a median interstage interval of 15 days. All patients tolerated surgery well and no major complications were recorded. Conclusions: Applying the principles of parenchyma sparing surgery to ALPPS offers the advantage to maximize FLR and simultaneously reduce ischemic injury of segment 4 compared to conventional ALPPS. In this way, psALPPS may markedly increase resectability while reducing morbidity.

Induction of Robust Future Liver Remnant Hypertrophy Before Hepatectomy With a Modified Liver Venous Deprivation Technique Using a Trans-venous Access for Hepatic Vein Embolization.

Purpose: Hepatic and/or portal vein embolization are performed before hepatectomy for patients with insufficient future liver remnant and usually achieved with a trans-hepatic approach. The aim of the present study is to describe a modified trans-venous liver venous deprivation technique (mLVD), avoiding the potential risks and limitations of a percutaneous approach to hepatic vein embolization, and to assess the safety, efficacy, and surgical outcome after mLVD. Materials and Methods: Retrospective single-center institutional review board-approved study. From March 2016 to June 2019, consecutive oncologic patients with combined portal and hepatic vein embolization were included. CT volumetric analysis was performed before and after mLVD to assess liver hypertrophy. Complications related to mLVD and surgical outcome were obtained from medical records. Results: Thirty patients (62.7 ± 14.5 years old, 20 men) with liver metastasis (60%) or primary liver cancer (40%) underwent mLVD. Twenty-one patients (70%) had hepatic vein anatomic variants. Technical success of mLVD was 100%. Four patients had complications (three minor and one major). FLR hypertrophy was 64.2% ± 51.3% (mean ± SD). Twenty-four patients (80%) underwent the planned hepatectomy and no surgery was canceled as a consequence of mLVD complications or insufficient hypertrophy. Fifty percent of patients (12/24) had no or mild complications after surgery (Clavien-Dindo 0-II), and 45.8% (11/24) had more serious complications (Clavien-Dindo III-IV). Thirty-day mortality was 4.2% (1/24). Conclusion: mLVD is an effective method to induce FLR hypertrophy. This technique is applicable in a wide range of oncologic situations and in patients with complex right liver vein anatomy.