Remnant Liver Volume Research Articles

Liver Venous Deprivation Versus Portal Vein Embolization Before Major Hepatectomy for Colorectal Liver Metastases: A Retrospective Comparison of Short- and Medium-Term Outcomes

BackgroundLiver venous deprivation (LVD) is a recent radiological technique performed to induce hypertrophy of the future liver remnant. Medium-term results of major hepatectomy after LVD have never been compared with the actual standard of care, portal vein embolization (PVE). MethodsWe retrospectively compared data from 33 consecutive patients who had undergone LVD (n = 17) or PVE (n = 16) prior to a right hemi-hepatectomy or right extended hepatectomy indicated for colorectal liver metastases (CRLM) between May 2015 and December 2019. ResultsThe 1-year and 3-year overall survival (OS) rates in the LVD group were 81.3% (95% confidence interval [CI]: 72–90) and 54.7% (95% CI: 46–63), respectively, against 85% (95% CI: 69–101) and 77.4% (95% CI: 54–100) in the PVE group; the differences were not statistically significant (p = 0.64). The median disease-free survival (DFS) rate was also comparable: 6 months (95% CI: 4–7) in the LVD group and 12 months (95% CI: 1.5–13) in the PVE group (p = 0.29). The overall intra-operative and post-operative complication rates were similar between the two groups. The mean daily kinetic growth rate (KGR) was found to be higher after LVD than after PVE (0.2% vs. 0.1%, p = 0.05; 10 cc/day vs. 4.8 cc/day, p = 0.03), as was the mean increase in future liver remnant volume (FLR-V) (49% vs. 27%, p = 0.01). ConclusionsThe LVD technique is well tolerated in patients undergoing right hemi-hepatectomy or right extended hepatectomy for CRLM. When compared with the PVE technique, the LVD technique has similar peri-operative and medium-term outcomes, but higher KGR and FLR-V increase.

HPB P21 Surgery for peri-hilar cholangiocarcinoma: The Liverpool hepatobiliary unit experience

Abstract Background Surgery for perihilar cholangiocarcinoma (pCCA) offers the only possibility of long-term survival but remains a formidable undertaking associated with significant post-operative morbidity and mortality. We aim to share our experience of managing these complex patients within a high-volume UK centre. Methods A retrospective review of a prospectively maintained database was performed on all patients who underwent resection for pCCA at our unit between 2009–2021. Kaplan–Meier analysis was used to estimate overall and disease-free survival (OS/DFS). Post-op complications were graded using the Clavien-dindo classification and reported as minor (Grade1/2) or major complications (Grade3/4). Results 102 patients underwent surgery for pCCA at our unit between 2009–2021. The majority of patients required pre-operative biliary drainage via ERCP and metal stent insertion. Following MDT and CPEX assessment eligible patients underwent an initial staging laparoscopy followed by curative resection. 30% of patients required a PVE to increase the proposed functional liver remnant volume prior to surgery. The majority of patients (76%) had Bismuth-Corlette IIIA/B or IV disease necessitating a major liver resection along with radical bile-duct resection. Post-op morbidity rates were high with 42% experiencing a major (grade3/4) complication. Of these patients 14 individuals subsequently died culminating in a 90-day mortality rate of 13.7%. Median LOS was 11 days (IQR 5–59). Median OS for the entire cohort was 36.3 months (CI:26.7–45.8) with a nominal 5-year survival rate of 34.6%. 40% of patients received adjuvant chemotherapy post-op. During follow up 59% of patients suffered disease recurrence with a median DFS of 20.1 months (CI: 11.5–33.5). The administration of palliative chemotherapy upon recurrence was associated with an improvement in survival of 11 vs 5.3 months (HR 3.5 p 0.01). Conclusions Surgery for pCCA remains a significant undertaking for both patient and clinician with high rates of morbidity and mortality. Long term survival is achievable but recurrence rates remain a challenge. Overall our mortality, morbidity and survival rates are comparable to that reported in other Western centres.

Application of hepatic lobe hyperplasia techniques in the treatment of advanced hepatic alveolar echinococcosis: a single-centre experience

BackgroundThis study was designed to investigate clinical efficiency and application indications of hepatic lobe hyperplasia techniques for advanced hepatic alveolar echinococcosis (AE) patients.MethodsA retrospective case series covering 19 advanced hepatic AE patients admitted to the First Affiliated Hospital of Xinjiang Medical University from September 2014 to December 2021 and undergoing hepatic lobe hyperplasia techniques due to insufficient remnant liver volume were analyzed. Changes of liver function, lesions volume, remnant liver volume, total liver volume before and after operation have been observed.ResultsAmong the patients, 15 underwent portal vein embolization (PVE). There was no statistical difference in total liver volume and lesions volume before and after PVE (P > 0.05). However, the remnant liver volume was significantly increased after PVE (P < 0.05). The median monthly increase rate in future liver remnant volume (FLRV) after PVE stood at 4.49% (IQR 3.55–7.06). Among the four patients undergoing two-stage hepatectomy (TSH), FLRV was larger than that before the first stage surgery, and the median monthly increase rate in FLRV after it stood at 3.34% (IQR 2.17–4.61). Despite no statistical difference in total bilirubin (TBil), albumin (Alb), alanine aminotransferase (ALT), aspartate aminotransferase (AST) and gamma-glutamyl transpeptidase (GGT) in all patients with PVE, four patients who underwent TSH showed a decrease in ALT, AST and GGT. During the waiting process before the second stage operation, no serious complications occurred in all patients.ConclusionsFor patients suffering from advanced hepatic AE with insufficient FLRV, PVE and TSH are safe and feasible in promoting hepatic lobe hyperplasia.

Preoperative evaluation of liver regeneration following hepatectomy in hepatocellular carcinoma using magnetic resonance elastography.

For patients with hepatocellular carcinoma (HCC) undergoing hepatectomy, insufficient remnant liver regenerative capacity can lead to liver failure. The aim of this study was to evaluate the potential role of magnetic resonance elastography (MRE) for the preoperative prediction of liver regeneration in patients with HCC after partial hepatectomy (PH). A total of 54 patients with HCC undergoing MRE prior to PH were retrospectively included. The total functional liver, volume of preoperative future liver remnant (LVpre), and volume of postoperative liver remnant (LVpost), respectively, were measured, and the regeneration index (RI) and parenchymal hepatic resection rate (PHRR) were manually calculated. Univariate and multivariate logistic regression analyses were conducted to identify factors associated with a high RI, and receiver operating characteristic (ROC) curves were employed to evaluate the diagnostic performance of the liver stiffness (LS) values. Patients were classified into three subgroups based on the value of PHRR: low PHRR (<30%), intermediate PHRR (30-50%), and high PHRR (>50%). Subsequently, Spearman correlation analysis was used to investigate the relationship between LS values and RI in the subgroups. Multivariable analysis revealed a low LS value was associated with greater odds of a high RI [odds ratio (OR), 0.049; 95% confidence interval (CI): 0.002 to 0.980]. An optimal cutoff value of 3.30 kPa was used to divide all patients into a low RI group and a high RI group with an area under the curve (AUC) value of 0.882 (95% CI: 0.767 to 0.996). A significant negative relationship between RI and LS values (r=-0.799; P<0.001) was observed in the intermediate PHRR subgroup. The LS values based on MRE may serve as a potential preoperative predictor of liver regeneration for patients with HCC undergoing PH.

Radiological and pathological assessment with EOB-MRI after Y90 radiation lobectomy prior to liver resection for hepatocellular carcinoma.

Radiation lobectomy (RL) utilizes Yttrium-90 (Y90) radioembolization for achieving tumor control and inducing contralateral lobe hypertrophy. Our objective was to evaluate the chronological changes occurring radiologically and histopathologically after Y90 RL. We retrospectively reviewed 22 patients with chronic liver disease who underwent Y90 RL prior to planned liver resection for hepatocellular carcinoma. Gadolinium ethoxybenzyl diethylenetriamine penta-acetic acid (Gd-EOB-DTPA) enhanced magnetic resonance imaging (EOB-MRI) was performed every 3 months. Future liver remnant volume (FLRV) significantly increased up to 9 months after Y90 RL. Gd-EOB-DTPA uptake in the treated lobe experienced a 40% reduction in enhancement ratio (ER) during ensuing first 3 months, and never recovered. The reduced ER in the non-tumoral parenchyma was significantly correlated with increased FLRV and FLR (r=0.41 and r=0.35, respectively; both p < 0.01). Histopathological evaluation of non-tumor liver tissue found features of sinusoidal obstruction syndrome as an early change after Y90 RL (median 5.7 months) and parenchymal collapse as a late change (mean 11 months). The reduced uptake of Gd-EOB-DTPA at 3 months post Y90 RL correlates with a significant increase in FLRV prior to liver resection. EOB-MRI evaluation at 3 months can guide future plan of action after Y90 RL.

Application of liver venous deprivation in secondary hepatic resection of primary liver cancer

Objective: To investigate the efficacy and safety of liver venous deprivation (LVD) before secondary resection of primary liver cancer. Methods: 56 patients with advanced primary liver cancer who were not suitable for primary resection in Liver Surgery Department of Xinxiang Central Hospital from January 2018 to January 2019 were analyzed retrospectively. They were divided into liver vein deprivation group (LVD group: LVD+ PVE, n=26) and portal vein embolization group (PVE group, n=30). The dynamic changes of liver reserve function and future liver remnant volume (FLR-V), R0 resection rate, surgical complications, postoperative recurrence rate and overall survival rate of two groups before and after LVD/PVE were compared. Results: The success rate of puncture and embolization in LVD group and PVE group was 100%. There were no grade Ⅳ complications, and there was no significant difference of grades Ⅰ, Ⅱ and Ⅲ complications between the groups (P=0.808). The FLR-V of LVD group before embolization, 7, 14 and 21 days after embolization was (493.1±25.8), (673.2±56.1), (779.5±81.6) and (853.3±85.2) cm(3), respectively. The FLR-V of PVE group before embolization, 7, 14 and 21 days after embolization were (502.4±20.1), (688.6±43.9), (656.8±73.7) and (563.5±69.1) cm(3), respectively. There was no significant difference in FLR-V between the two groups before and 7 days after embolization (P>0.05). The FLR-V of LVD group was higher than that of PVE group at 14 and 21 days after embolization (P<0.01). The preparation time of LVD group was (20.4±6.3) days, which was shorter than that of PVE group [(31.5±8.8) days, P=0.045]. The rate of secondary hepatectomy was 92.3% (24/26), which was higher than that of PVE group [70.0% (21/30), P=0.036]. The R0 resection rate was 87.5% (21/24), which was higher than that of the PVE group [57.1% (12/21), P=0.022]. However, there were no significant differences in surgical methods, operation time, intraoperative blood loss, Clavien-Dindo complication grade and length of hospital stay between the two groups (P>0.05). After hepatectomy, the median recurrence time and median survival time of LVD group were 12.6 months and 21.3 months, respectively, which were longer than those of PVE group (9.4 months and 13.5 months, respectively, P<0.01). Conclusions: For patients with advanced liver cancer who are not suitable for primary hepatectomy, preoperative LVD can significantly increase FLR-V, improve the resection rate of secondary surgery, shorten the preparation time of two operations, and do not increase surgical complications. Moreover, patients with LVD can improve the R0 resection rate of secondary surgery. The postoperative recurrence time and overall survival rate of patients with LVD are better than those of patients with PVE, and LVD has a good long-term effect.

Volume and flow modulation strategies to mitigate post-hepatectomy liver failure.

Post hepatectomy liver failure is the most common cause of death following major hepatic resections with a perioperative mortality rate between 40% to 60%. Various strategies have been devised to increase the volume and function of future liver remnant (FLR). This study aims to review the strategies used for volume and flow modulation to reduce the incidence of post hepatectomy liver failure. An electronic search was performed of the MEDLINE, EMBASE and PubMed databases from 2000 to 2022 using the following search strategy "Post hepatectomy liver failure", "flow modulation", "small for size flow syndrome", "portal vein embolization", "dual vein embolization", "ALPPS" and "staged hepatectomy" to identify all articles published relating to this topic. Volume and flow modulation strategies have evolved over time to maximize the volume and function of FLR to mitigate the risk of PHLF. Portal vein with or without hepatic vein embolization/ligation, ALPPS, and staged hepatectomy have resulted in significant hypertrophy and kinetic growth of FLR. Similarly, techniques including portal flow diversion, splenic artery ligation, splenectomy and pharmacological agents like somatostatin and terlipressin are employed to reduce the risk of small for size flow syndrome SFSF syndrome by decreasing portal venous flow and increasing hepatic artery flow at the same time. The current review outlines the various strategies of volume and flow modulation that can be used in isolation or combination in the management of patients at risk of PHLF.

Remnant liver volume ratio less than 30% is not contraindication to living donor right hepatectomy

Remnant liver volume ratio less than 30% is not contraindication to living donor right hepatectomy

Elevated intramuscular adipose tissue content with a high Ishak fibrosis stage (>3) had a negative effect on liver regeneration in cirrhotic patients undergoing portal vein embolization.

This study investigated the relationship between body composition parameters and changes in future liver remnant volume (FLRV) in hepatocellular carcinoma (HCC) patients undergoing portal vein embolization (PVE) in preparation for right hepatectomy. This retrospective study enrolled 21 patients between May 2013 and October 2020. Body composition parameters, including skeletal muscle attenuation (SMA), skeletal muscle mass index (SMI), intramuscular adipose tissue content (IMAC), and visceral-to-subcutaneous adipose tissue area ratio (VSR), were measured by computed tomography (CT) prior to PVE. Liver volumetry was measured before and at least 5 weeks after PVE. The mean interval between two CT volumetries was 9.1 ± 4.9 weeks, the mean value of increase in FLRV (ΔFLRV) was 236.0 ± 118.3cm3 , the ratio of increased FLRV (ΔFLRV%) was 55.7 ± 29.4%, and the rate of increased FLRV was 31.0 ± 18.8 (cm3 /week). Subjects with high IMAC showed significantly lower (p=0.044) ΔFLRV% than those with normal IMAC. Furthermore, ΔFLRV% was linearly reduced (p for trend=0.043) among those with low Ishak fibrosis stage (<3) + normal IMAC (76.1 ± 36.8%), those with low Ishak fibrosis stage (<3) + high IMAC or high Ishak fibrosis stage (>3) + normal IMAC (54.0 ± 24.1%), and those with high Ishak fibrosis stage (>3) + low IMAC (28.7 ± 1.6%) (p for trend=0.043). Our data indicated that high IMAC with a high Ishak fibrosis stage (>3) had a significant negative effect on ΔFLRV%.

Portal vein embolization failure: Current strategies and future perspectives to improve liver hypertrophy before major oncological liver resection.

Portal vein embolization (PVE) is currently considered the standard of care to improve the volume of an inadequate future remnant liver (FRL) and decrease the risk of post-hepatectomy liver failure (PHLF). PHLF remains a significant limitation in performing major liver surgery and is the main cause of mortality after resection. The degree of hypertrophy obtained after PVE is variable and depends on multiple factors. Up to 20% of patients fail to undergo the planned surgery because of either an inadequate FRL growth or tumor progression after the PVE procedure (usually 6-8 wk are needed before surgery). The management of PVE failure is still debated, with a lack of consensus regarding the best clinical strategy. Different additional techniques have been proposed, such as sequential transarterial chemoembolization followed by PVE, segment 4 PVE, intra-portal administration of stem cells, dietary supplementation, and hepatic vein embolization. The aim of this review is to summarize the up-to-date strategies to overcome such difficult situations and discuss future perspectives on improving FRL hypertrophy.

Preoperative Predictive Nomogram Based on Alanine Aminotransferase, Prothrombin Time Activity, and Remnant Liver Proportion (APART Score) to Predict Post-Hepatectomy Liver Failure after Major Hepatectomy

Introduction: Post-hepatectomy liver failure (PHLF) is a serious complication associated with major hepatectomies. An accurate prediction of PHLF is necessary to determine the feasibility of major hepatectomy. This study aimed to assess the association between PHLF and preoperative laboratory and computed tomography (CT) findings. Methods: Medical records of 65 patients who underwent major hepatectomy and preoperative CT were retrospectively reviewed. We evaluated future remnant liver volume evaluation models and remnant liver hemodynamics, which were assessed by arterial enhancement fraction (AEF) by using preoperative CT. Variables, including CT findings, were compared between patients with and without PHLF after major hepatectomy, and the preoperative PHLF-predicting nomogram was constructed using multivariate logistic regression. Results: The PHLF group included 21 patients (32.3%). The AEF was not significantly different between the two groups. In the future remnant liver volume evaluation models, future remnant liver proportion (fRLP) had the highest concordance index (C-index) in the receiver operating characteristic curve analysis (C-index, 0.755). Multivariate analysis of preoperative evaluable factors revealed that alanine aminotransferase levels (p = 0.034), prothrombin time activity (p = 0.021), and fRLP (p = 0.012) were independent predictive factors of PHLF. A nomogram (APART score) was constructed using these three factors, with a receiver operating curve showing a C-index of 0.894. According to the APART score, scores of 51–60 indicated moderate risk (40.0%), and scores over 60 indicated a high risk of PHLF (83.3%) (p < 0.001). Discussion: The APART score may help predict PHLF in patients indicated for major hepatectomies.

Optimizing the selection of technically unresectable colorectal liver metastases

BackgroundThe prediction of conversion surgery in patients with technically unresectable colorectal liver metastases has not been generalized or well-established. We developed a predictive model for conversion surgery and assessed the long-term outcomes of patients with technically unresectable colorectal liver metastases. MethodsIn this single-center, retrospective study, we analyzed the perioperative parameters and outcomes of 892 consecutive patients (2014–2021). Conversion surgery was indicated when the chemotherapy response allowed the complete resection of colorectal liver metastases with negative margins and adequate remnant liver volume. ResultsOf the 892 patients, 122 had technically unresectable colorectal liver metastases; 61 underwent conversion surgery (conversion surgery group) and 61 did not (nonconversion surgery group). The median overall survival was significantly higher in the conversion surgery group than in the nonconversion surgery group (5.6 vs 1.8 years, P < .001). After univariate and multivariate analyses, the predictive model for conversion surgery was constructed using 4 predictive factors: Rat sarcoma viral oncogene homolog status (mutant, +2 points), tumor number (≥15, +1), hepatic vein contact (≥2 hepatic veins, +1), and the presence of preservable sections (absence of preservable sections, +2). The area under the curve for conversion surgery was 0.889. Patients were graded according to the scores (A [0–2], B [3–4], and C [5–6]), and the conversion rates were 91.5% (A), 32.6% (B), and 10.3% (C) (P < .001). Grade A patients (median survival time, 5.7 years) had significantly better overall survival than grade B and C patients (median survival time, 2.2 and 1.6 years, respectively; P < .001). ConclusionPatients who underwent conversion surgery for technically unresectable colorectal liver metastases had better prognoses, and our novel predictive model was useful in predicting conversion surgery and prognosis.

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.

Combination of Indocyanine green clearance test and remnant liver volume for safe major hepatectomy

Indocyanine green (ICG) clearance and remnant liver volume (RLV) are the two important factors in predicting post-hepatectomy liver failure (PHLF) after major hepatectomy; however, the combination of these is still controversial. This study is to find a way to combine these to select candidates for safe major hepatectomy. A prospective cohort study included 137 major hepatectomies. ICG clearance (through ICG remnant at 15 minutes: ICG-R15), liver function results and the ratio of remnant to standard liver volume (RLV/SLV) were analyzed to examine their relations to PHLF. These variables, gender and age were analyzed using multivariate logistic regression to establish a model to predict PHLF. PHLF rate after major hepatectomy was 16.8% with 5.8% for grade B-C. ICG-R15 and RLV/SLV were significantly associated with PHLF (p = 0.019 and 0.007 respectively). ICG-R15 was not significantly associated with the grade of PHLF while RLV/SLV was but the post-hoc analysis showed no significant difference. Group RLV/SLV &lt; 40% tended to have higher rate and grade of PHLF than group RLV/SLV &gt; 40% but the difference was not significant (p = 0.063 and 0.072 respectively). Based on gender, age, ICG-R15 and RLV/SLV, PHLF rate could be estimated with model performance of 77%. ICG clearance and RLV were associated with PHLF after major hepatectomy. It was safe and feasible to perform major hepatectomy with RLV/SLV under 40% and good ICG-R15. It was possible to estimate PHLF rate based on the patients’ gender, age, ICG-R15 and RLV/SLV.

Anatomical Resection Improved the Outcome of Intrahepatic Cholangiocarcinoma: A Propensity Score Matching Analysis of a Retrospective Cohort.

Intrahepatic cholangiocarcinoma (ICC) is the second most common liver malignancy after hepatocellular carcinoma (HCC), with a dismal prognosis and high heterogeneity. The oncological advantages of anatomical resection (AR) and nonanatomical resection (NAR) in HCC have been studied, but surgical strategies for ICC remain controversial with insufficient investigations. From Jan 2013 to Dec 2016, 3880 consecutive patients were retrospectively reviewed from a single center. Patients with ICC undergoing AR or NAR have been enrolled according to inclusion and exclusion criteria. Propensity score matching (PSM) analysis was performed between two groups with a 1 : 1 ratio. The primary endpoint was overall survival (OS), and the secondary endpoints included disease-free survival (DFS), intraoperative patterns, postoperative morbidity, mortality, complications and recurrence. A prognostic nomogram was developed by a multivariate Cox proportion hazard model. After PSM, 99 paired cases were selected from 276 patients enrolled in this study. Patients in the AR group achieved better 1-, 3-, and 5-year OS (70%, 46%, and 34%, respectively) and DFS (61%, 21%, and 10%, respectively) than patients in the NAR group with statistical significance after PSM analysis. The postoperative complications and recurrence patterns were comparable between the two groups. Multivariate analysis identified NAR, tumor size >5 cm, multiple tumors, and poor differentiation as independent risk factors for OS (p < 0.05). Selected patients can benefit most from AR, according to subgroup analysis. A prognostic nomogram based on six independent risk factors for OS and factors with clinical significance was constructed to predict OS in ICC patients. AR improved the long-term survival of ICC with comparable postoperative complications and similar recurrence patterns. AR is suggested in ICC patients with sufficient remnant liver volume. In addition to surgery strategy, malignant characteristics of tumors are risk factors for ICC prognosis.

Assessment of liver function-related mRNA expression and fluorescence imaging in outflow-obstructed regions in rats.

The liver function in outflow-obstructed regions is reportedly impaired; however, the functional decrease has not been quantitatively assessed. We therefore evaluated the uptake of indocyanine green (ICG) into hepatocytes and the mRNA expression associated with the liver function in outflow-obstructed regions using rat models. A total of 20 rats with the ligation of the right median hepatic vein to induce outflow obstruction were studied. Five rats each were grouped by the time of re-laparotomy, and the fluorescence intensity (FI) values of ICG. The mRNA expression, including that of Albumin, Cytochrome P450 (Cyp) 1a2, Cyp3a1, Cyp7a1, and Gamma-glutamylcysteine synthetase, in outflow-obstructed (mRNAOut-Ob) and non-outflow-obstructed (mRNANon) regions was assessed. Microscopic fluorescence imaging showed that the FI values were significantly lower in outflow-obstructed regions than in non-outflow-obstructed regions at 12h, 24h, and 3days after ligation of the hepatic vein. The mRNAOut-Ob/mRNANon ratios decreased to approximately 30% at 12h after the outflow obstruction and increased to approximately 70-80% at 7days. The liver function in outflow-obstructed regions was impaired in terms of the uptake of ICG and the mRNA expression. Our findings may help estimate the postoperative functional remnant liver volume by considering the decrease in the liver function in outflow-obstructed regions.

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.