Present status and future perspectives of preoperative portal vein embolization

Overcome intraoperative difficulties of ALPPS procedure: a single-center outcomes and technical experience

Backgrounds/aims

Recently, the ALPPS (Associating liver partition and portal vein ligation for staged hepatectomy) has become widely known to achieve hepatic resection by rapid future liver remnant hypertrophy, but it comes with intraoperative difficulties, followed by increased complications. This study aimed to report the outcomes of an oncology center in a low-income and middle-income country with ALPPS in patients with liver tumors and its technical variants, which were invented to overcome intraoperative difficulties of the ALPPS procedure.

Patients and methods

A retrospective analysis of patients undergoing ALPPS from September 2022 to December 2023 was performed.

Results

A total of 25 patients underwent the ALPPS procedure: 21 procedures for hepatocellular carcinoma (HCC), 3 combined hepatocellular-cholangiocarcinoma (cHCC-CCA), and 1 for small cell neuroendocrine carcinoma (SNEC). The mean postoperative stay was 29.6 ± 9.3 days (range 16-58 days). After stage 1, we counted 8 complications, all of grade II; after stage 2, the number of complications was decreased to 3:2 were of grade I and 1 were of grade IIIB. 3 (12%) patients failed to proceed to ALPPS stage 2. After a median follow-up of 9 months (range 2-25), disease recurrence has been recorded in 3 patients (12%), while 1 patient (4%) died, affected by HCC. The entire group's 2-year overall survival (OS) and disease-free survival (DFS) were 83.3% and 82.5%, respectively.

Conclusion

The ALPPS procedure is an approach for large liver tumors with small future liver remnant with acceptable OS and DFS in a low-income and middle-income country.

Optimizing Growth of the Future Liver Remnant and Making In-Situ Liver Transsection Safe—A Standardized Approach to ISLT or ALPPS

In-situ splitting of the liver before extended resection has gained broad attention. This two-step procedure requires several measures to make an effective and safe procedure. Although the procedure is performed in many institutions, there is no consensus on a uniform technique. The two steps can be divided into different parts and a standardized technique may render the procedure safer and the results will be easier to evaluate. In this paper, we describe a detailed approach to in-situ splitting that allows making both procedures safe, avoids liver necrosis, and is easily reproducible. In the first procedure the portal branches to segments I and IV to VIII are divided, the arterial branches and bile ducts to these segments are preserved and encircled and the parenchyma between segments II/III and IVa/b is divided. This avoids necrosis and bile leaks of segments I and IV and avoids urgent completion operations. In particular, the handling of vital structures close to the dissection line seems important to us. Complete splitting and securing the right and middle hepatic vein will make the second step of this procedure a minimal-risk procedure at a stage where the patient is still recovering from the more demanding first step.

Impact of endothelial nitric oxide synthase activation on accelerated liver regeneration in a rat ALPPS model

BACKGROUND

Although the associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) induces more rapid liver regeneration than portal vein embolization, the mechanism remains unclear.

AIM

To assess the influence of inflammatory cytokines and endothelial nitric oxide synthase (eNOS) activation on liver regeneration in ALPPS.

METHODS

The future liver remnant/body weight (FLR/BW) ratio, hepatocyte proliferation, inflammatory cytokine expression, and activation of the Akt-eNOS pathway were evaluated in rat ALPPS and portal vein ligation (PVL) models. Hepatocyte proliferation was assessed based on Ki-67 expression, which was confirmed using immunohistochemistry. The serum concentrations of inflammatory cytokines were measured using enzyme linked immune-solvent assays. The Akt-eNOS pathway was assessed using western blotting. To explore the role of inflammatory cytokines and NO, Kupffer cell inhibitor gadolinium chloride (GdCl₃), NOS inhibitor N-nitro-arginine methyl ester (L-NAME), and NO enhancer molsidomine were administered intraperitoneally.

RESULTS

The ALPPS group showed significant FLR regeneration (FLR/BW: 1.60% ± 0.08%, P < 0.05) compared with that observed in the PVL group (1.33% ± 0.11%) 48 h after surgery. In the ALPPS group, serum interleukin-6 expression was suppressed using GdCl₃ to the same extent as that in the PVL group. However, the FLR/BW ratio and Ki-67 labeling index were significantly higher in the ALPPS group administered GdCl₃ (1.72% ± 0.19%, P < 0.05; 22.25% ± 1.30%, P < 0.05) than in the PVL group (1.33% ± 0.11% and 12.78% ± 1.55%, respectively). Phospho-Akt Ser⁴⁷³ and phospho-eNOS Ser¹¹⁷⁷ levels were enhanced in the ALPPS group compared with those in the PVL group. There was no difference between the ALPPS group treated with L-NAME and the PVL group in the FLR/BW ratio and Ki-67 labeling index. In the PVL group treated with molsidomine, the FLR/BW ratio and Ki-67 labeling index increased to the same level as in the ALPPS group.

CONCLUSION

Early induction of inflammatory cytokines may not be pivotal for accelerated FLR regeneration after ALPPS, whereas Akt-eNOS pathway activation may contribute to accelerated regeneration of the FLR.

Influence of cholestasis on portal vein embolization-induced hypertrophy of the future liver remnant

PURPOSE

In the pre-clinical setting, hepatocellular bile salt accumulation impairs liver regeneration following partial hepatectomy. Here, we study the impact of cholestasis on portal vein embolization (PVE)-induced hypertrophy of the future liver remnant (FLR).

METHODS

Patients were enrolled with perihilar cholangiocarcinoma (pCCA) or colorectal liver metastases (CRLM) undergoing PVE before a (extended) right hemihepatectomy. Volume of segments II/III was considered FLR and assessed on pre-embolization and post-embolization CT scans. The degree of hypertrophy (DH, percentual increase) and kinetic growth rate (KGR, percentage/week) were used to assess PVE-induced hypertrophy.

RESULTS

A total of 50 patients (31 CRLM, 19 pCCA) were included. After PVE, the DH and KGR were similar in patients with CRLM and pCCA (5.2 [3.3-6.9] versus 5.7 [3.2-7.4] %, respectively, p = 0.960 for DH; 1.4 [0.9-2.5] versus 1.9 [1.0-2.4] %/week, respectively, p = 0.742 for KGR). Moreover, pCCA patients with or without hyperbilirubinemia had comparable DH (5.6 [3.0-7.5] versus 5.7 [2.4-7.0] %, respectively, p = 0.806) and KGR (1.7 [1.0-2.4] versus 1.9 [0.8-2.4] %/week, respectively, p = 1.000). For patients with pCCA, unilateral drainage in FLR induced a higher DH than bilateral drainage (6.7 [4.9-7.9] versus 2.7 [1.5-4.2] %, p = 0.012). C-reactive protein before PVE was negatively correlated with DH (ρ = - 0.539, p = 0.038) and KGR (ρ = - 0.532, p = 0.041) in patients with pCCA.

CONCLUSIONS

There was no influence of cholestasis on FLR hypertrophy in patients undergoing PVE. Bilateral drainage and inflammation appeared to be negatively associated with FLR hypertrophy. Further prospective studies with larger and more homogenous patient cohorts are desirable.

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

Background

Liver 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 presentation

A 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.

Conclusions

Resumption 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.

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

Background

The 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.

Purpose

To 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 Methods

Seven 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.

Results

The 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).

Conclusion

The 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.

Liver Venous Deprivation (LVD) Versus Portal Vein Embolization (PVE) Alone Prior to Extended Hepatectomy: A Matched Pair Analysis

BACKGROUND

To investigate whether liver venous deprivation (LVD) as simultaneous, portal vein (PVE) and right hepatic vein embolization offers advantages in terms of hypertrophy induction before extended hepatectomy in non-cirrhotic liver.

MATERIALS AND METHODS

Between June 2018 and August 2019, 20 patients were recruited for a prospective, non-randomized study to investigate the efficacy of LVD. After screening of 134 patients treated using PVE alone from January 2015 to August 2019, 14 directly matched pairs regarding tumor entity (cholangiocarcinoma, CC and colorectal carcinoma, CRC) and hypertrophy time (defined as time from embolization to follow-up imaging) were identified. In both treatment groups, the same experienced reader (> 5 years experience) performed imaging-based measurement of the volumes of liver segments of the future liver remnant (FLR) prior to embolization and after the standard clinical hypertrophy interval (~ 30 days), before surgery. Percentage growth of segments was calculated and compared.

RESULTS

After matched follow-up periods (mean of 30.5 days), there were no statistically significant differences in relative hypertrophy of FLRs. Mean ± standard deviation relative hypertrophy rates for LVD/PVE were 59 ± 29.6%/54.1 ± 27.6% (p = 0.637) for segments II + III and 48.2 ± 22.2%/44.9 ± 28.9% (p = 0.719) for segments II-IV, respectively.

CONCLUSIONS

LVD had no significant advantages over the standard method (PVE alone) in terms of hypertrophy induction of the FLR before extended hepatectomy in this study population.

The Role of Farnesoid X Receptor in Accelerated Liver Regeneration in Rats Subjected to ALPPS

Background: the role of bile acid (BA)-induced farnesoid X receptor (Fxr) signaling in liver regeneration following associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) was investigated in a rat model. Methods: Male Wistar rats underwent portal vein ligation (PVL) (n = 30) or ALPPS (n = 30). Animals were sacrificed pre-operatively and at 24, 48, 72, or 168 h after intervention. Regeneration rate, Ki67 index, hemodynamic changes in the hepatic circulation, and BA levels were assessed. Transcriptome analysis of molecular regulators involved in the Fxr signaling pathway, BA transport, and BA production was performed. Results: ALLPS induced more extensive liver regeneration (p < 0.001) and elevation of systemic and portal BA levels (p < 0.05) than PVL. The mRNA levels of proteins participating in hepatic Fxr signaling were comparable between the intervention groups. More profound activation of the intestinal Fxr pathway was observed 24 h after ALPPS compared to PVL. Conclusion: Our study elaborates on a possible linkage between BA-induced Fxr signaling and accelerated liver regeneration induced by ALPPS in rats. ALPPS could trigger liver regeneration via intestinal Fxr signaling cascades instead of hepatic Fxr signaling, thereby deviating from the mechanism of BA-mediated regeneration following one-stage hepatectomy.

Combination of transcatheter arterial chemoembolization and portal vein embolization for patients with hepatocellular carcinoma: a review

BACKGROUND

Transcatheter arterial chemoembolization has been widely used in patients with hepatocellular carcinoma. However, double blood supply and the existence of portal vein tumor thrombus influence the efficacy of transcatheter arterial chemoembolization.

MAIN BODY

Theoretically, portal vein embolization combined with transcatheter arterial chemoembolization may bring a breakthrough in the therapeutic effect of hepatocellular carcinoma. The feasibility, efficacy, long-term survival benefits, and side effects of the combined treatment have been explored in previous studies. Chemotherapeutic agents may also be added in the portal vein embolization procedure to further improve the treatment response.

CONCLUSION

In this study, we review the existing data and studies on the combined treatment in patients with hepatocellular carcinoma and provide an overall view of the strategy.

BestFLR Trial: Liver Regeneration at CT before Major Hepatectomies for Liver Cancer-A Randomized Controlled Trial Comparing Portal Vein Embolization with N-Butyl-Cyanoacrylate Plus Iodized Oil versus Polyvinyl Alcohol Particles Plus Coils

Background In patients with liver cancer, portal vein embolization (PVE) is recommended to promote liver growth before major hepatectomies. However, the optimal embolization strategy has not been established. Purpose To compare liver regeneration as seen at CT in participants with liver cancer, before major hepatectomies, with N-butyl-cyanoacrylate (NBCA) plus iodized oil versus standard polyvinyl alcohol (PVA) particles plus coils, for PVE. Materials and Methods In this single-center, prospective, randomized controlled trial (Best Future Liver Remnant, or BestFLR, trial; International Standard Randomized Controlled Trial Number 16062796), PVE with NBCA plus iodized oil was compared with standard PVE with PVA particles plus coils in participants with liver cancer. Participant recruitment started in November 2017 and ended in March 2020. Participants were randomly assigned to undergo PVE with PVA particles plus coils or PVE with NBCA plus iodized oil. The primary end point was liver growth assessed with CT 14 days and 28 days after PVE. Secondary outcomes included posthepatectomy liver failure, surgical complications, and length of intensive care treatment and hospital stay. The Mann-Whitney U test was used to compare continuous outcomes according to PVE material, whereas the Χ² test or Fisher exact test was used for categoric variables. Results Sixty participants (mean age, 61 years ± 11 [standard deviation]; 32 men) were assigned to the PVA particles plus coils group (n = 30) or to the NBCA plus iodized oil group (n = 30). Interim analysis revealed faster and superior liver hypertrophy for the NBCA plus iodized oil group versus the PVA particles plus coils group 14 days and 28 days after PVE (absolute hypertrophy of 46% vs 30% [P < .001] and 57% vs 37% [P < .001], respectively). Liver growth for the proposed hepatectomy was achieved in 87% of participants (26 of 30) in the NBCA plus iodized oil group versus 53% of participants (16 of 30) in the PVA particles plus coils group (P = .008) 14 days after PVE. Liver failure occurred in 13% of participants (three of 24) in the NBCA plus iodized oil group and in 27% of participants (six of 22) in the PVA particles plus coils group (P = .27). Conclusion Portal vein embolization with N-butyl-cyanoacrylate plus iodized oil produced greater and faster liver growth as seen at CT in participants with liver cancer, compared with portal vein embolization with polyvinyl alcohol particles plus coils, allowing for earlier surgical intervention. © RSNA, 2021 Online supplemental material is available for this article. See also the editorial by Arellano in this issue.

3D voxel-based dosimetry to predict contralateral hypertrophy and an adequate future liver remnant after lobar radioembolization

INTRODUCTION

Volume changes induced by selective internal radiation therapy (SIRT) may increase the possibility of tumor resection in patients with insufficient future liver remnant (FLR). The aim was to identify dosimetric and clinical parameters associated with contralateral hepatic hypertrophy after lobar/extended lobar SIRT with ⁹⁰Y-resin microspheres.

MATERIALS AND METHODS

Patients underwent ⁹⁰Y PET/CT after lobar or extended lobar (right + segment IV) SIRT. ⁹⁰Y voxel dosimetry was retrospectively performed (PLANET Dose; DOSIsoft SA). Mean absorbed doses to tumoral/non-tumoral-treated volumes (NTL) and dose-volume histograms were extracted. Clinical variables were collected. Patients were stratified by FLR at baseline (T0-FLR): < 30% (would require hypertrophy) and ≥ 30%. Changes in volume of the treated, non-treated liver, and FLR were calculated at < 2 (T1), 2-5 (T2), and 6-12 months (T3) post-SIRT. Univariable and multivariable regression analyses were performed to identify predictors of atrophy, hypertrophy, and increase in FLR. The best cut-off value to predict an increase of FLR to ≥ 40% was defined using ROC analysis.

RESULTS

Fifty-six patients were studied; most had primary liver tumors (71.4%), 40.4% had cirrhosis, and 39.3% had been previously treated with chemotherapy. FLR in patients with T0-FLR < 30% increased progressively (T0: 25.2%; T1: 32.7%; T2: 38.1%; T3: 44.7%). No dosimetric parameter predicted atrophy. Both NTL-Dmean and NTL-V30 (fraction of NTL exposed to ≥ 30 Gy) were predictive of increase in FLR in patients with T0 FLR < 30%, the latter also in the total cohort of patients. Hypertrophy was not significantly associated with tumor dose or tumor size. When ≥ 49% of NTL received ≥ 30 Gy, FLR increased to ≥ 40% (accuracy: 76.4% in all patients and 80.95% in T0-FLR < 30% patients).

CONCLUSION

NTL-Dmean and NTL exposed to ≥ 30 Gy (NTL-V30) were most significantly associated with increase in FLR (particularly among patients with T0-FLR < 30%). When half of NTL received ≥ 30 Gy, FLR increased to ≥ 40%, with higher accuracy among patients with T0-FLR < 30%.

A comparative study of portal vein embolization versus radiation lobectomy with Yttrium-90 micropheres in preparation for liver resection for initially unresectable hepatocellular carcinoma

BACKGROUND

Portal vein embolization before liver resection is considered the therapy of choice for patients with inadequate future liver remnants. The concept of radioembolization with Yttrium-90 to achieve the same goal has limited data.

METHODS

We retrospectively compared patients who underwent portal vein embolization and Yttrium-90 lobectomy before resection of hepatocellular carcinoma in patients with chronic liver disease.

RESULTS

Seventy-three patients underwent portal vein embolization and 22 patients underwent Yttrium-90. Forty-seven percent of patients before portal vein embolization required additional procedures for tumor control, and 27% of patients after Yttrium-90 required additional procedure to mainly induce further hypertrophy. Both therapies achieved the goal of future liver remnants >40%, but the degree of hypertrophy was significantly higher in Yttrium-90 patients (63% for Yttrium-90, 36% for portal vein embolization, P < .01). Tumor response was significantly better with Yttrium-90, achieving complete response in 50% of patients. Resectability rate was higher after portal vein embolization (85% for portal vein embolization, 64% for Yttrium-90, P = .03). Tumor progression was the most common reason precluding surgery. Complete tumor control was the reason not to pursue surgery in 18% of patients after Yttrium-90.

CONCLUSION

Both preoperative portal vein embolization and Yttrium-90, increases liver resectability rates by inducing hypertrophy of future liver remnants in patients with hepatocellular carcinoma and chronic liver disease. Yttrium-90 lobectomy achieved better tumor control and provided more time to assess therapy response, optimizing the indication for surgery.

Surgical Therapy for Perihilar Cholangiocarcinoma: State of the Art

BACKGROUND

Surgical therapy still offers the only chance of long-term survival for patients with perihilar cholangiocarcinoma (pCCA). The aim of this narrative review is to summarize the current standards and challenges in the surgical treatment of pCCA.

SUMMARY

After imaging and defining resectability, the first step towards optimal surgical treatment is optimizing biliary drainage and preventing cholangitis, followed by securing adequate future liver remnant volume and/or function. The main goal of resection for pCCA is achieving radical resection and ultimately long-term survival. In order to achieve radical resection, several points will be addressed (e.g., vascular resection and reconstruction, intraoperative frozen sections, right versus left hemihepatectomy, and the usefulness of preoperative [chemo]therapy).

KEY MESSAGES

In order to optimize long-term outcomes for patients with pCCA, collaboration between leading centers should be increased. In addition, this collaboration is necessary to design large prospective randomized controlled trials, as the incidence of pCCA is low and the number of resectable patients is even lower. Currently, most results are based on small retrospective cohort studies resulting in low evidence. In order to properly investigate how to improve long-term survival, we need to set up trials to confirm the results of small series suggesting the positive effect of preoperative chemotherapy and extended lymph node resection.

Liver Regeneration and Recanalization Time Course following Repeated Reversible Portal Vein Embolization in Swine

INTRODUCTION

Portal vein embolization (PVE) is an accepted technique to preoperatively increase the volume of the future remnant liver before major hepatectomy. A permanent material is usually preferred since its superiority to induce liver hypertrophy over absorbable material has been demonstrated. Nevertheless, the use of an absorbable material generates a reversible PVE (RPVE) capable of inducing significant liver hypertrophy. In small animal models, the possibility to proceed to a repeated RPVE (RRPVE) has shown to boost liver hypertrophy further. The aim of this preliminary study was to assess the feasibility and the tolerance of RRPVE in a large animal model, in comparison with permanent PVE (PPVE) and single RPVE.

METHODS

Six swine (2 per group) were assigned either to single RPVE group (using powdered gelatin sponge), RRPVE group (2 RPVEs separated by 14 days) or PPVE group (using N-butyl-cyanoacrylate). The feasibility and tolerance of the procedures were evaluated using portography, liver function tests and histological analysis. Evolution of liver volumes was assessed with volumetric imaging by computed tomography.

RESULTS

Embolization of portal branches corresponding to 75% of total liver volume was performed successfully in all animals. Procedures were well tolerated, inducing moderate changes in portal pressure and transient aminotransferase increase. None of the animals developed portal vein thrombosis. After RPVE, complete recanalization occurred at day 11. RRPVE showed a trend for higher hypertrophy, the non-embolized liver to total liver ratio reaching 5.2 ± 1.0% in the RPVE group, 6.8 ± 0.1% in the RRPVE group and 5.0 ± 0.3% in the PPVE group.

DISCUSSION/CONCLUSION

In this preliminary comparative study, RRPVE was as feasible and as well tolerated as the other procedures, and resulted in higher liver hypertrophy.

Resection of NAFLD-Associated HCC: Patient Selection and Reported Outcomes

Global prevalence of non-alcoholic fatty liver disease (NAFLD) has been growing in the last decades, especially in western countries, due to increased prevalence of diabetes, obesity or other components of metabolic syndrome. NAFLD recently became an important cause of hepatocellular carcinoma (HCC), even in non-cirrhotic patients. Patients with HCC-NAFLD are usually older, with more morbidities (especially cardiovascular diseases and metabolic disorders) and have advanced disease at the diagnosis due to the absence of surveillance, which is considered not cost-effective in patients without advanced fibrosis/cirrhosis, given the large prevalence of NAFLD in the general population. For these reasons, patients with HCC-NAFLD unlikely underwent curative treatments, and have been reported to have lower overall survival (OS) compared to individuals with HCC related to other aetiologies. However, this difference is not confirmed by data of patient subgroups who received curative treatment. In our review, we selected studies published over the past 8 years that analyse characteristics and outcomes of HCC-NAFLD patients who underwent surgery with the aim of identifying features that could predict outcomes and potential selection criteria. All the studies confirm that patients with HCC-NAFLD are older, with many comorbidities and that HCC occurs frequently even in non-cirrhotic livers. There is no agreement about intraoperative and perioperative complications. Regarding outcomes, all papers agree that patients with HCC in NAFLD who undergo surgery have a better OS compared to other aetiologies. Summarizing, surgery is a good curative option for patients with HCC-NAFLD, perhaps even better than transplantation in terms of OS. In this group of patients, it seems to be essential to evaluate cardio-pulmonary and general operative risk, in addition to the normal risk assessment related to liver function to avoid an underestimation, especially for patients without severe underlying fibrosis.

Reg3α and Reg3β Expressions Followed by JAK2/STAT3 Activation Play a Pivotal Role in the Acceleration of Liver Hypertrophy in a Rat ALPPS Model

To explore the underlying mechanism of rapid liver hypertrophy by liver partition in associating liver partition and portal vein ligation for staged hepatectomy (ALPPS), liver partition at different sites was investigated. Increased inflammatory cytokines owing to the liver partition have been reportedly responsible. If this were true, rapid liver hypertrophy should be achieved regardless of where the liver was split. A male Sprague-Dawley rat model was created, in which a liver split was placed inside the portal vein ligated lobe (PiLL), in addition to the ALPPS and portal vein ligation (PVL) models. Liver regeneration rate, inflammatory cytokine levels, activation status of the Janus kinase 2/signal transducer and activator of transcription 3 (JAK2/STAT3) pathway and expressions of regenerating islet-derived (Reg)3α and Reg3β were investigated. The liver regeneration rate was significantly higher in the ALPPS group than in the PiLL group, whereas inflammatory cytokine levels were nearly equal. Additional volume increase in ALPPS group over PVL and PiLL groups was JAK2/STAT3-dependent. Reg3α and Reg3β expressions were observed only in the ALPPS group. An increase in inflammatory cytokines was not enough to describe the mechanism of rapid liver hypertrophy in ALPPS. Expressions of Reg3α and Reg3β could play an important role in conjunction with an activation of the JAK2/STAT3 pathway.

Assessment of remnant liver function and volume after selective ligation of portal vein and hepatic artery in a rat model

Purpose:

To evaluate liver regeneration after selective ligation of portal vein and hepatic artery by 3D Computed Tomography in an experimental model.

Methods:

Sixteen Wistar rats were randomized into four equal groups: Group I- control (sham), Group II- isolated selective ligation of the hepatic artery, Group III- isolated selective ligation of the portal vein and Group IV- combined ligation of portal vein and hepatic artery. Before procedure and five days after a 3D CT Scan was performed to analyze the hypertrophy, weight and function of the remnant liver.

Results:

The largest regeneration rate and increase of weight in the hypertrophied lobe was detected in group IV, the first with an average of 3.99 (p=0.006) and the last varying from 6.10g to 9.64g (p=0.01). However, total liver weight and the R1 ratio (Hypertrophied Lobe Weight/Total Liver Weight) was higher in group III (P<0.001) when compared with groups I, II and IV and showed no difference between them. The immunohistochemical examination with PCNA also found higher percentages with statistical significance differences in rats of groups III and IV. It was possible to confirm a strong correlation between hypertrophied lobe weight and its imaging volumetric study. Liver function tests only showed a significant difference in serum gamma-glutamyltransferase and phosphorous.

Conclusion:

There is a largest liver regeneration after combined ligation of portal vein and hepatic artery and this evidence may improve the knowledge of surgical treatment of liver injuries, with a translational impact in anima nobile.

[Role of the radiologist in surgery of colorectal liver metastases : What should be removed and what must remain]

BACKGROUND

The radical resection of colorectal liver metastases is the only curative option for affected patients. If properly performed, surgery provides the chance of long-term tumor-free survival.

OBJECTIVE

Summary of the critical interaction points between radiology and surgery in the planning and performance of (complex) liver resections.

RESULTS

There are many interaction points between radiology and surgery in the treatment of patients with colorectal liver metastases. Radiology supports surgery by providing detailed information of the localization of metastases, information on liver inflow and outflow as well as basic information on liver quality and function. Perioperatively, it provides interventional treatment options for postoperative complications as well as ablation of non-resectable metastases.

CONCLUSION

Complex liver resections can only be performed properly and successfully after thorough planning by an interdisciplinary board of surgeons, radiologists and associated disciplines.

The outcome of the HCC patients underwent ALPPS: Retrospective study

The complete resection offers the best long-term survival for advanced hepatocellular carcinoma patients. ALPPS as a choice of resection, how is its outcome compared to one-stage resection, liver transplantation and TACE? This retrospective study included 20 ALPPS patients. To minimize the effect of confounding influences of measured covariates, PSM was performed. The overall survival (OS), morbidity, mortality and the increasing rate, KGR were analyzed. The OS in ALPPS group is 27.4 (±3.8 months) moths and the TACE group is 13.5(±1.2 months) (P < .001), LT group is 41.3 (±3.2 months) (P = .048), Resection group is 31.8 (±2.6 months) (P = .368). And the medium increasing volume is 209.5 cm (±61.5 cm) with the increasing ratio 52.4% (+26.9%). The ALPPS is a feasible treatment for HCC patients and it provides a better long-term survival than TACE and it is similar to Resection, less than LT.

Future liver remnant growth after various portal vein embolization regimens: a quantitative comparison

Purpose: To compare the efficacy of right portal vein embolization using ethylene vinyl alcohol (EVOH-PVE) compared to other embolic agents and surgical right portal vein ligation (PVL).Material and methods: Patients with right sided liver malignancies scheduled for extensive surgery and receiving induction of liver hypertrophy via right portal vein embolization/ligature between 2010-2016 were retrospectively evaluated. Treatments included were ethylene vinyl alcohol copolymer (Onyx®, EVOH-PVE), ethiodized oil (Lipiodol^®, Lipiodol/PVA-PVE), polyvinyl alcohol (PVA-PVE) or surgical ligature (PVL). Liver segments S2/3 were used to assess hypertrophy. Primary outcome was future liver remnant growth in ml/day.Results: Forty-one patients were included (EVOH-PVE n = 11; Lipiodol/PVA-PVE n = 10; PVA-PVE n = 8; PVL n = 12), the majority presenting with cholangiocarcinoma and colorectal metastases (n = 11; n = 27). Pre-interventional liver volumes were comparable (p = .095). Liver hypertrophy was successfully induced in all but one patient receiving Lipiodol/PVA-PVE. Liver segment S2/3 growth was largest for EVOH-PVE (5.38 ml/d) followed by PVA-PVE (2.5 ml/d), with significantly higher growth rates than PVL (1.24 ml/d; p < .001; p = .007). No significant difference was evident for Lipiodol/PVA-PVE (1.43 ml/d, p = .809).Conclusions: Portal vein embolization using EVOH demonstrates fastest S2/3 growth rates compared to other embolic agents and PVL, potentially due to its permanent portal vein embolization and induction of hepatic inflammation.

Portal vein ligation and in situ liver splitting in metastatic liver cancer

The most serious complication after major liver resection is liver failure. Depending on preoperative liver function, a future liver remnant of 25%-40% is considered sufficient to avoid postoperative liver failure. A new technique known as portal vein ligation combined with in situ splitting has been developed to obtain rapid liver hypertrophy. Herein, we present a case where we performed portal vein ligation combined with in situ splitting. A 37-year-old male patient with a diagnosis of sigmoid adenocarcinoma and liver metastasis underwent anterior resection because of an obstructing sigmoid tumor and received palliative chemotherapy. After chemotherapy, abdominal computed tomography revealed a lesion, 50 mm in diameter, localized between segments 5-8 of the liver on the bifurcation of the anteroposterior segmental branch of the right portal vein. Computed tomography volumetric assessments of the liver were performed in the preoperative period, and it was found that the remnant left liver volume was less than 25%. In the first stage, portal vein ligation and in situ splitting of the liver parenchyma were performed. On the second and sixth postoperative days, computed tomography revealed hypertrophy of the left liver lobe. On the sixth day, a right hepatectomy was performed. Portal vein ligation combined with in situ splitting has been used by surgeons worldwide to obtain rapid and adequate liver hypertrophy. This new approach yields hope for patients with locally advanced liver tumors and may increase the number of curative resections for primary or metastatic liver tumors.

Mitochondrial function after associating liver partition and portal vein ligation for staged hepatectomy in an experimental model

BACKGROUND

Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) is a two-stage strategy to induce rapid regeneration of the remnant liver. The technique has been associated with high mortality and morbidity rates. This study aimed to evaluate mitochondrial function, biogenesis and morphology during ALPPS-induced liver regeneration.

METHODS

Male Wistar rats (n = 100) underwent portal vein ligation (PVL) or ALPPS. The animals were killed at 0 h (without operation), and 24, 48, 72 or 168 h after intervention. Regeneration rate and proliferation index were assessed. Mitochondrial oxygen consumption and adenosine 5'-triphosphate (ATP) production were measured. Mitochondrial biogenesis was evaluated by protein level measurements of peroxisome proliferator-activated receptor γ co-activator (PGC) 1-α, nuclear respiratory factor (NRF) 1 and 2, and mitochondrial transcription factor α. Mitochondrial morphology was evaluated by electron microscopy.

RESULTS

Regeneration rate and Ki-67 index were significantly raised in the ALPPS group compared with the PVL group (regeneration rate at 168 h: mean(s.d.) 291·2(21·4) versus 245·1(13·8) per cent, P < 0·001; Ki-67 index at 24 h: 86·9(4·6) versus 66·2(4·9) per cent, P < 0·001). In the ALPPS group, mitochondrial function was impaired 48 h after the intervention compared with that in the PVL group (induced ATP production); (complex I: 361·9(72·3) versus 629·7(165·8) nmol per min per mg, P = 0·038; complex II: 517·5(48·8) versus 794·8(170·4) nmol per min per mg, P = 0·044). Markers of mitochondrial biogenesis were significantly lower 48 and 72 h after ALPPS compared with PVL (PGC1-α at 48 h: 0·61-fold decrease, P = 0·045; NRF1 at 48 h: 0·48-fold decrease, P = 0·028). Mitochondrial size decreased significantly after ALPPS (0·26(0·05) versus 0·40(0·07) μm² ; P = 0·034).

CONCLUSION

Impaired mitochondrial function and biogenesis, along with the rapid energy-demanding cell proliferation, may cause hepatocyte dysfunction after ALPPS. Surgical relevance Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) is a well known surgical strategy that combines liver partition and portal vein ligation. This method induces immense regeneration in the future liver remnant. The rapid volume increase is of benefit for resectability, but the mortality and morbidity rates of ALPPS are strikingly high. Moreover, lagging functional recovery of the remnant liver has been reported recently. In this translational study, ALPPS caused an overwhelming inflammatory response that interfered with the peroxisome proliferator-activated receptor γ co-activator 1-α-coordinated, stress-induced, mitochondrial biogenesis pathway. This resulted in the accumulation of immature and malfunctioning mitochondria in hepatocytes during the early phase of liver regeneration (bioenergetic destabilization). These findings might explain some of the high morbidity if confirmed in patients.

Insight on ALPPS - Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy - mechanisms: activation of mTOR pathway

BACKGROUND

ALPPS procedure has been introduced to increase the volume of future liver remnant. The mechanisms underlying the accelerated regeneration observed with ALPPS are unknown. It was hypothesized that AMPK/mTOR is activated as an integrating pathway for metabolic signals leading to proliferation and cell growth. Our aim was to analyze increase in liver volume, proliferation parameters and expression of AMPK/mTOR pathway-related molecules in patients undergoing ALPPS.

METHODS

A single center prospective study of patients undergoing ALPPS was performed from 2013 to 2015. Liver and serum samples, clinical laboratory results and CT-scan data were obtained. ELISA, Ki-67 immunostaining and qRT-PCR were performed in deportalized and remnant liver tissue in both stages of the procedure.

RESULTS

11 patients were enrolled. Remnant liver volume increased 112 ± 63% (p < 0.05) in 9.1 ± 1.6 days. Proliferation-related cytokines IL-6, TNF-α, HGF and EGF significantly increased, while higher Ki-67 immunostaining and cyclin D expression were observed in remnant livers after ALPPS. mTOR, S6K1, 4E-BP1, TSC1 and TSC2 expression were significantly increased in remnant livers at second stage, while AMPK and Akt increased only in deportalized liver samples.

CONCLUSION

Rapid liver regeneration with ALPPS might be associated with hepatocyte proliferation induced by mTOR pathway activation.

Tourniquet-ALPPS is a promising treatment for very large hepatocellular carcinoma and intrahepatic cholangiocarcinoma

When very large hepatocellular carcinomas (HCCs) and intrahepatic cholangiocarcinoma (IHCCs) with insufficient future liver remnants are treated using associating liver partition and portal vein ligation for staged hepatectomy (ALPPS), the outcome is often poor. We therefore tested the efficacy of a modified version of that technique, tourniquet-ALPPS. A review of the literature examining outcomes of HCC and IHCC patients treated with ALPPS revealed the incidences of morbidity ≥ III and postoperative mortality to be respectively 20.7% and 16.1% among HCC patients and 50% and 45.4% among IHCC patients. In the present case series, in which HCC and IHCC patients were treated with tourniquet-ALPPS, median tumor size was 100 mm (range: 70–200 mm). After surgical stage I, there was no morbidity, no mortality and the median future liver remnant had increased at day 7 by 76%. In surgical stage II, 100% of tumors were resectable (8 right trisectionectomies, 5 with inferior vena cava resection). Two patients experienced serious morbidity ≥ IIIB and 1 patient died (11%). One- and 3-year overall survival was 75% and 60%, respectively. Thus tourniquet-ALPPS appears to be an effective alternative to classical ALPPS for the treatment of patients with HCC or IHCC.

In situ splitting after selective partial portal vein ligation or simultaneous hepatic artery ligation promotes liver regeneration

This study seeks to compare the impact of selective partial portal vein ligation (PPVL) or the combination of simultaneous hepatic artery ligation (PPVAL) with in situ splitting (ISS) on liver regeneration and injury. Rats were randomized into three groups; namely: selective PVL, PPVL + ISS and PPVAL + ISS. The changes in hepatic hemodynamics, liver regeneration and hepatocytic injury were examined. Blood flow to the left portal branch and the microcirculation of the left median lobe after PPVL or PPVAL was significantly reduced. Liver regeneration of PPVAL + ISS group was more pronounced than that in the PPVL + ISS and PVL groups at 48 and 72 hours as well as 7 d postoperatively. The serum biochemical markers and histopathological examination demonstrated reduced levels of liver injury in the PPVL + ISS group. Injury to hepatocytes was more pronounced with PPVAL + ISS than PVL. HGF, TNF-α and IL-6 expression in the regenerated lobes in both PPVAL + ISS and PPVL + ISS groups increased significantly when compared to the PVL group. We demonstrated that both PPVL + ISS and PPVAL + ISS were effective and feasible means of inducing remnant liver hypertrophy and could serve as a rapid clinical application for qualified patients.

The diagnostic value of 99m-Tc GSA scintigraphy for liver function and remnant liver volume in hepatic surgery: a retrospective observational cohort study in 27 patients

Background

The aim was to analyze hepatic hypertrophy after portal vein embolization (PVE) and Associating Liver Partition with Portal vein ligation for Staged hepatectomy (ALPPS) to determine whether clinical circumstances associated with major hepatic resections correlated with remnant growth.

Methods

Data was abstracted from a retrospectively maintained database on 27 patients undergoing hepatic resection followed by PVE and the ALPPS procedure between October 1, 2007 and December 31, 2016. The increasing rate of liver volume and remnant liver LU15 was defined as the percentage-point difference between the liver volume and remnant liver LU15 before and after the intervention or surgery. And correlation between kinetic growth rate (KGR) of liver and future remnant liver volume or remnant liver LU15 was analyzed.

Results

The degree of hypertrophy (DH) of volume and LU15 was significantly greater after ALPPS (volume: 40.3% and LU15: 65.0%) than after PVE (volume: 22.7% and LU15: 48.8%) (P < 0.05). KGR of volume and LU15 was significantly greater after ALPPS (volume: 19.0 cm³/day and 2.00%/day) (LU15: 0.61 /day and 1.82%/day) than after PVE (volume: 3.89 cm³/day and 0.42%/day) (LU15: 0.19 /day and 0.63%/day) (P < 0.001). An inverse correlation between KGR and initial remnant liver volume was observed. And a positive correlation between KGR and LU15 was observed.

Conclusion

Future remnant liver volume and KGR was greater after the ALPPS procedure than after PVE. Liver hypertrophy is related to the expected remnant liver volume and total liver function. This study suggested that total liver function and initial remnant liver volume might be a new indication of hepatectomy after PVE and ALPPS in the case of insufficient remnant liver volume.

Prospective study to determine early hypertrophy of the contra-lateral liver lobe after unilobar, Yttrium-90, selective internal radiation therapy in patients with hepatocellular carcinoma

BACKGROUND

Liver resection is a major curative option in patients presenting with hepatocellular carcinoma. An inadequate functional liver remnant is a major limiting factor precluding liver resection. In recent years, hypertrophy of the functional liver remnant after selective internal radiation therapy hypertrophy has been observed, but the degree of hypertrophy in the early postselective internal radiation therapy period has not been well studied.

METHODS

We conducted a prospective study on patients undergoing unilobar, Yttrium-90 selective internal radiation therapy for hepatocellular carcinoma to evaluate early hypertrophy at 4-6 weeks and 8-12 weeks after selective internal radiation therapy.

RESULTS

In the study, 24 eligible patients were recruited and had serial volumetric measurements performed. The median age was 66 years (38-75 years). All patients were either Child-Pugh Class A or B, and 6/24 patients had documented, clinically relevant portal hypertension; 15 of the 24 patients were hepatitis B positive. At 4-6 weeks, modest hypertrophy was seen (median 3%; range -12 to 42%) and this increased at 8-12 weeks (median 9%; range -12 to 179%). No preprocedural factors predictive of hypertrophy were identified.

CONCLUSION

Hypertrophy of the functional liver remnant after selective internal radiation therapy with Yttrium-90 occurred in a subset of patients but was modest and unpredictable in the early stages. Selective internal radiation therapy cannot be recommended as a standard treatment modality to induce early hypertrophy for patients with hepatocellular carcinoma. (Surgery 2017;160:XXX-XXX.).

Resection for Klatskin tumors: technical complexities and results

Klatskin's tumors, actually-redefined as perihilar cholangiocarcinoma (phCCA) do represent 50-70% of all CCAs and develop in a context of chronic inflammation and cholestasis of bile ducts. Surgical resection provides the only chance of cure for this disease but is technically challenging because of the complex, intimate and variable relationship between biliary and vascular structures at this location. Five years survival rates range between 25-45% (median 27-58 months) in case of R0 resection and 0-23% (median 12-21 months) in case of R1 resection respectively. It should be noted that the major costs of high radicality are represented by relative high morbidity and mortality rates (i.e., 20-66% and 0-9% respectively). Considering the fact that radical resection may represent the only curative treatment of phCCA, we focused our review on surgical planning and techniques that may improve resectability rates and outcomes for locally advanced phCCA. The surgical treatment of phCCA can be successful when following aspects have been fulfilled: (I) accurate preoperative diagnostic aimed to identify the tumor in all its details (localization and extension) and to study all the risk factors influencing a posthepatectomy liver failure (PHLF): i.e., liver volume, liver function, liver quality, haemodynamics and patient characteristics; (II) High end surgical skills taking in consideration the local extension of the tumor and the vascular invasion which usually require an extended hepatic resection and often a vascular resection; (III) adequate postoperative management aimed to avoid major complications (i.e., PHLF and biliary complications). These are technically challenging operations and must be performed in a high volume centres by hepato-biliary-pancreas (HBP)-surgeons with experience in microsurgical vascular techniques.

Feasibility and safety of EUS-guided selective portal vein embolization with a coil and cyanoacrylate in a live porcine model

Background and Objectives:

Preoperative portal vein (PV) embolization using the percutaneous transhepatic approach has been performed in patients with hepatobiliary malignancy before extensive liver resection. The aim of this study is to evaluate the technical feasibility and initial safety of EUS-guided selective PV embolization using a coil and cyanoacrylate in a live porcine model.

Methods:

EUS-guided selective intrahepatic PV embolization with a coil and cyanoacrylate was performed in 9 pigs. The selected PV was punctured with 19G fine-needle aspiration (FNA) needle, and the coil was inserted under EUS-guidance. The cyanoacrylate was then immediately injected through the same FNA needle. The blood flow change in the embolized PV was evaluated using color Doppler EUS. A necropsy was performed following the 1-week observation period.

Results:

The success rates for the coil and cyanoacrylate delivery were 88.9% (8/9) and 87.5% (7/8), respectively. In 1 case, the coil migrated into the hepatic parenchyma. In another case, the cyanoacrylate injection failed due to early clogging in the FNA needle. There was a complete blockage of blood flow confirmed by color Doppler EUS in the embolized PV after coil and cyanoacrylate treatment. There was coil migration into the hepatic parenchyma in 1 case. There was no animal distress observed during the 1-week observation period before necropsy. The necropsy showed no evidence of damage to the intra-abdominal organs, and the selected PV was totally occluded with embolus.

Conclusion:

The study findings indicate EUS-guided selective PV embolization is both technically feasible and initially safe in an animal model.

Totally laparoscopic associating liver partition and portal vein ligation for staged hepatectomy using anterior approach in HCC patient with Type II portal vein anomaly: a case report

Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) has gradually developed because of rapid hypertrophy of the future liver remnant volume (FLR) in spite of high morbidity. To minimize the patient's postoperative pain and morbidity including wound complication caused by two consecutive major abdominal operations, we adopted a totally laparoscopic approach and used a composite mesh graft. Also, to maximize the oncologic efficacy, we adopted the “anterior approach” technique. A 44-year-old woman with large hepatitis B-related hepatocellular carcinoma (HCC) in her right lobe was transferred to our hospital for surgical treatment. Preoperatively predicted FLR by a CT scan was 21% and type II portal vein anomaly was detected. A totally laparoscopic approach was planned. During the first stage operation, right anterior and posterior portal veins were meticulously dissected and tied. After parenchymal transection by the “anterior approach” technique, two glissonian pedicles of the right liver were individually isolated. A composite mesh graft was used to prevent severe adhesion on both liver partition surfaces. During the second-stage operation, 9 days after the first stage operation, the two isolated glissonian pedicles were initially transected. After full mobilization of the right lobe, the right hepatic vein was also transected. The right lobe was removed through the Pfannenstiel incision. She was discharged 7 days after the second stage operation. Her postoperative course was uneventful and there was no HCC recurrence for 15 months after hepatectomy. A totally laparoscopic ALPPS procedure can be a feasible technique that ensures patient safety and oncologic superiority, even in patients with complicated anatomical variation.

Factors associated with contralateral liver hypertrophy after unilateral radioembolization for hepatocellular carcinoma

INTRODUCTION

Radioembolization for the treatment of hepatocellular carcinoma (HCC) induces liver volume changes referred to as "atrophy-hypertrophy complex". The aim of this study was to investigate lobar liver volume changes after unilateral radioembolization and to search for factors associated with hypertrophy of the untreated lobe.

MATERIALS AND METHODS

Seventy-five patients were retrospectively evaluated. Inclusion criteria were: (1) right-lobar radioembolization for unresectable unilateral HCC, (2) available liver computed tomography scans before, 1, 3, and at least 6 months after radioembolization. Baseline patient characteristics included clinical features, laboratory results, spleen volume, and liver computed tomography. Absolute and relative (referred to the whole liver volume) liver lobe volumes (LLV) as well as relative LLV (rLLV) change per month were evaluated and compared.

RESULTS

Absolute and relative contralateral LLV continuously increased after radioembolization (p<0.001). Mean relative contralateral LLV increased from 36±11.6% before radioembolization to 50±15.3% 6 months after radioembolization. Median contralateral rLLV increase/month (within first 6 months) was 2.5%. Contralateral rLLV increase/month was significantly lower in patients with ascites (p = 0.017) or platelet count <100/nl (p = 0.009). An inverse correlation of contralateral rLVV increase/month with spleen volume (p = 0.017), patient age (p = 0.024), Child Pugh score (p = 0.001), and tumor burden (p = 0.001) was found.

CONCLUSIONS

Significant contralateral hypertrophy and ipsilateral atrophy were common after unilateral radioembolization. Small spleen volume, low patient age, low Child Pugh score, absence of ascites, platelet count ≥100/nl, and low tumor burden were associated with increased contralateral hypertrophy, indicating that younger patients with compensated cirrhosis might benefit most from radioembolization in a "bridge-to-resection" setting.

Feasibility, safety and efficacy of two-stage hepatectomy for bilobar liver metastases of colorectal cancer: a LiverMetSurvey analysis

BACKGROUND

The combination of liver resection and chemotherapy has become the standard of care for colorectal liver metastases (LM). The objective of the present study was to evaluate the impact of two-stage hepatectomy (TSH) on the long-term survival of patients with bilobar LM.

METHODS

We included adult (over-18) patients from the LiverMetSurvey registry with confirmed multiple colorectal LM and having undergone either one-stage hepatectomy or TSH with curative intent. The "TSH (2/2)" group (n = 625) comprised patients having completed both stages of TSH; the "TSH (1/2)" group (n = 244) comprised patients having undergone only the first stage of TSH; the "hepatectomy" group. The primary outcome criterion was the overall survival (OS). The secondary outcomes were the morbidity and mortality rates.

RESULTS

The 30- and 90-day mortality rates were respectively 3.8% and 9.3% in the TSH (2/2) group, 9.4% and 16.4% in the TSH (1/2) group, and 5.4% and 9.1% in the "hepatectomy" group. The three-year OS rate was 45% in the TSH (2/2) group, 30% in the TSH (1/2) group and 50.7% in the hepatectomy group.

CONCLUSION

The LiverMetSurvey registry's data indicate that TSH is associated with rather good long-term survival and acceptable morbidity and mortality rates.

Portal Vein Embolization with Contralateral Application of Stem Cells Facilitates Increase of Future Liver Remnant Volume in Patients with Liver Metastases

OBJECTIVES

This study aimed to evaluate the progress of future liver remnant volume (FLRV) in patients with liver metastases after portal vein embolization (PVE) with the application of hematopoietic stem cells (HSCs) and compare it with a patients control group after PVE only.

METHODS

Twenty patients (group 1) underwent PVE with contralateral HSC application. Subsequently, CT volumetry with the determination of FLRV was performed at weekly intervals, in total three weeks. A sample of twenty patients (group 2) who underwent PVE without HSC application was used as a control group.

RESULTS

The mean of FLRV increased by 173.2 mL during three weeks after the PVE/HSC procedure, whereas by 98.9 mL after PVE only (p = 0.015). Furthermore, the mean daily growth of FLRV by 7.6 mL in group 1 was significantly higher in comparison with 4.1 mL in group 2 (p = 0.007).

CONCLUSIONS

PVE with the application of HSC significantly facilitates growth of FLRV in comparison with PVE only. This method could be one of the new suitable approaches to increase the resectability of liver tumours.

Analysis of Portal Vein Embolization Using Absolute Ethanol Before Major Hepatectomy

Portal vein embolization (PVE) is widely considered to improve the safety and extend the indication of major hepatectomy. There are various embolization materials and techniques in each facility. The safety and efficacy of absolute ethanol (EOH) in PVE were analyzed. Fifty-one patients who underwent PVE prior to major hepatectomy were enrolled in this study. Two types of embolization techniques were performed: transileocolic portal vein embolization (TIPE) and percutaneous transhepatic portal vein embolization (PTPE). The embolization material consisted of 20 mL of EOH and 2 mL of iodized oil. Multislice computed tomography (CT) scans were performed before and after PVE. The mean time interval between PVE and the follow-up CT scan was 16.3 ± 5.0 days. The mean future liver remnant ratio to total liver (FLR%) significantly increased from 32.1% ± 7.6% to 43.5% ± 9.5% after PVE (P &lt; 0.001). The mean hypertrophy ratio was 41.1% ± 34.5%. There were 3 major complications, subcutaneous hematoma in the TIPE group, hemobilia, and bile leakage in the PTPE group. Although the levels of aspartate transaminase and alanine transaminase increased dramatically after PVE, they subsequently returned to pre-PVE levels. There were no patients whose liver dysfunction was prolonged until hepatectomy. In conclusion, PVE using EOH is a safe and effective method to induce hypertrophy in the future remnant liver before major hepatectomy.

Parenchymal-sparing liver surgery in patients with colorectal carcinoma liver metastases

Liver resection is the treatment of choice for patients with colorectal liver metastases (CLM). However, major resections are often required to achieve R0 resection, which are associated with substantial rates of morbidity and mortality. Maximizing the amount of residual liver gained increasing significance in modern liver surgery due to the high incidence of chemotherapy-associated parenchymal injury. This fact, along with the progressive expansion of resectability criteria, has led to the development of a surgical philosophy known as "parenchymal-sparing liver surgery" (PSLS). This philosophy includes a variety of resection strategies, either performed alone or in combination with ablative therapies. A profound knowledge of liver anatomy and expert intraoperative ultrasound skills are required to perform PSLS appropriately and safely. There is a clear trend toward PSLS in hepatobiliary centers worldwide as current evidence indicates that tumor biology is the most important predictor of intrahepatic recurrence and survival, rather than the extent of a negative resection margin. Tumor removal avoiding the unnecessary sacrifice of functional parenchyma has been associated with less surgical stress, fewer postoperative complications, uncompromised cancer-related outcomes and higher feasibility of future resections. The increasing evidence supporting PSLS prompts its consideration as the gold-standard surgical approach for CLM.

How we do it: double in situ split for staged mesohepatectomy in patients with advanced gall bladder cancer and marginal future liver remnant

PURPOSE

Associating liver partition with portal vein ligation for staged hepatectomy (ALPPS) has increased the rate of liver resections in patients with marginal future liver remnant. We here describe a modified ALPPS procedure with splitting-off the central liver segments for staged mesohepatectomy in patients with advanced gall bladder cancer.

METHODS

A double in situ split for ALPPS (DALPPS) is performed with splitting-off the central liver segments (segments 1, 4, 5, and 8). This induces a rapid hypertrophy of the left lateral (segments 2/3) and right posterior sectors (segments 6/7). An intrahepatic right posterior approach during splitting-off the right posterior sector is introduced as a part of this new procedure. This approach facilitates the dissection and ligation of the right anterior branch of the portal vein (segments 5 and 8) while the liver hilum remains untouched during the first step of surgery.

RESULTS

Two patients with advanced gall bladder cancer were treated with the DALPPS procedure till date. After a short interval (7-9 days), a rapid hypertrophy of the left lateral and right posterior sector was observed (hypertrophy up to 72.6 and 54.6 %, respectively). A staged mesohepatectomy including caudate lobectomy and resection of the extrahepatic bile duct was then performed safely. There was no surgical-technical morbidity. No signs of posthepatectomy liver failure according to the 50-50 criteria were seen. However, one patient died from severe ARDS attributed to the preoperative chemotherapy. Nevertheless, this complication is deemed to be surgery related.

CONCLUSIONS

The DALPPS procedure is a new surgical technique for staged mesohepatectomy for patients with small future liver remnant in size or in function. However, appropriate patient selection is mandatory to avoid morbidity and mortality.

A systematic review of contralateral liver lobe hypertrophy after unilobar selective internal radiation therapy with Y90

BACKGROUND

Curative liver resection is the treatment of choice for both primary and secondary liver malignancies. However, an inadequate future liver remnant (FLR) frequently precludes successful surgery. Portal vein embolization is the gold-standard modality for inducing hypertrophy of the FLR. In recent times, unilobar Yttrium-90 selective internal radiation therapy (SIRT) has been reported to induce hypertrophy of the contralateral, untreated liver lobe. The aim of this study is to review the current literature reporting on contralateral liver hypertrophy induced by unilobar SIRT.

METHODS

A systematic review of the English-language literature between 2000 and 2014 was performed using the search terms "Yttrium 90" OR "selective internal radiation therapy" OR "radioembolization" AND "hypertrophy".

RESULTS

Seven studies, reporting on 312 patients, were included. Two hundred and eighty four patients (91.0%) received treatment to the right lobe. Two hundred and fifteen patients had hepatocellular carcinoma (HCC), 12 had intrahepatic cholangiocarcinoma, and 85 had liver metastases from mixed primaries. Y90 SIRT resulted in contralateral liver hypertrophy which ranged from 26 to 47% at 44 days-9 months. All studies were retrospective in nature, and heterogeneous, with substantial variations relative to pathology treated, underlying liver disease, dosage and delivery of Y90, number of treatment sessions and time to measurement of hypertrophy.

CONCLUSION

Unilobar Y90 SIRT results in significant hypertrophy of the contralateral liver lobe. The rate of hypertrophy seems to be slower than that achieved by other methods.

ALPPS Procedure for Extended Liver Resections: A Single Centre Experience and a Systematic Review

Aim

To report a single-centre experience with the novel Associating Liver Partition and Portal vein ligation for Staged hepatectomy (ALPPS) technique and systematically review the related literature.

Methods

Since January 2013, patients with extended primary or secondary liver tumors whose future liver remnant (FLR) was considered too small to allow hepatic resection were prospectively assessed for the ALPPS procedure. A systematic literature search was performed using PubMed, Scopus and the Cochrane Library Central.

Results

Until July 2014 ALPPS was completed in 9 patients whose mean age was 60±8 years. Indications for surgical resection were metastases from colorectal cancer in 3 cases, perihilar cholangiocarcinoma in 3 cases, intrahepatic cholangiocarcinoma in 2 cases and hepatocellular carcinoma without chronic liver disease in 1 case. The calculated FLR volume was 289±122 mL (21.1±5.5%) before ALPPS-1 and 528±121 mL (32.2±5.7%) before ALLPS-2 (p<0.001). The increase in FLR between the two procedures was 96±47% (range: 24–160%, p<0.001). Additional interventions were performed in 4 cases: 3 patients underwent Roux-en-Y hepaticojejunostomy, and one case underwent wedge resection of a residual tumor in the FLR. The average time between the first and second step of the procedure was 10.8±2.9 days. The average hospital stay was 24.1±13.3 days. There was 1 postoperative death due to hepatic failure in the oldest patient of this series who had a perihilar cholangiocarcinoma and concomitant liver fibrosis; 11 complications occurred in 6 patients, 4 of whom had grade III or above disease. After a mean follow-up of 17.1±8.5 months, the overall survival was 89% at 3–6 and 12 months. The recurrence-free survival was 100%, 87.5% and 75% at 3-6-12 months respectively. The literature search yielded 148 articles, of which 22 articles published between 2012 and 2015 were included in this systematic review.

Conclusion

The ALPPS technique effectively increased the resectability of otherwise inoperable liver tumors. The postoperative morbidity in our series was high in accordance with the data from the systematic review. Age, liver fibrosis and presence of biliary stenting were predisposing factors for postoperative morbidity and mortality.

A systematic review of contralateral liver lobe hypertrophy after unilobar selective internal radiation therapy with Y90

BACKGROUND

A curative liver resection is the treatment of choice for both primary and secondary liver malignancies. However, an inadequate future liver remnant (FLR) frequently precludes successful surgery. Portal vein embolization is the gold-standard modality for inducing hypertrophy of the FLR. In recent times, unilobar Yttrium-90 selective internal radiation therapy (SIRT) has been reported to induce hypertrophy of the contralateral, untreated liver lobe. The aim of this study was to review the current literature reporting on contralateral liver hypertrophy induced by unilobar SIRT.

METHODS

A systematic review of the English-language literature between 2000 and 2014 was performed using the search terms 'Yttrium 90' OR 'selective internal radiation therapy' OR 'radioembolization' AND 'hypertrophy'.

RESULTS

Seven studies, reporting on 312 patients, were included. Two hundred and eighty-four patients (91.0%) received treatment to the right lobe. Two hundred and fifteen patients had hepatocellular carcinoma (HCC), 12 had intrahepatic cholangiocarcinoma and 85 had liver metastases from mixed primaries. Y90 SIRT resulted in contralateral liver hypertrophy that ranged from 26% to 47% at 44 days to 9 months. All studies were retrospective in nature, and heterogeneous, with substantial variations relative to pathology treated, underlying liver disease, dosage and delivery of Y90, the number of treatment sessions and time to measurement of hypertrophy.

CONCLUSION

Unilobar Y90 SIRT results in significant hypertrophy of the contralateral liver lobe. The rate of hypertrophy seems to be slower than that achieved by other methods.

mTOR-Dependent Suppression of Remnant Liver Regeneration in Liver Failure After Massive Liver Resection in Rats

BACKGROUND AND AIMS

Massive hepatectomy often leads to fatal liver failure because of a small remnant liver volume. The aim of this study was to investigate the potential mechanisms leading to liver failure.

METHODS

Sprague-Dawley rats had performed a sham operation, 85 % partial hepatectomy (PH) or 90 % PH, and all had free access to water with or without supplemented glucose. Liver function and survival were evaluated. Liver parenchymal injury was assessed by evaluating hepatic pathology, blood biochemistry, and apoptotic and necrotic alterations. The regeneration response was assessed by the weight gain of the remnant liver, hepatocyte proliferation markers, and regeneration-related molecules.

RESULTS

The 90 % hepatectomy resulted in a significantly lower survival rate and impaired liver function; however, no significant more serious liver parenchymal injuries were detected. TNF-α, HGF, myc and IL-6 were either similarly expressed or overexpressed; however, the increase in remnant liver weight, mitotic index, and the presence of Ki-67 and PCNA were significantly lower in the 90 %-hepatectomized rats. mTOR, p70S6K and 4EBP1 were not activated in the remnant liver after a 90 % hepatectomy as obviously as those after an 85 % hepatectomy, which was concomitant with the higher expression of phospho-AMPK and a lower intrahepatic ATP level. Glucose treatment significantly improved the survival rate of 90 %-hepatectomized rats.

CONCLUSIONS

Suppression of remnant liver regeneration was observed in the 90 % PH and contributed to fatal liver failure. This suppressed liver regenerative capacity was related to the inhibited activation of mTOR signaling.

Associating liver partition with portal vein ligation and staged hepatectomy (ALPPS) for the treatment of liver tumors in children

Resection is the only curative treatment option for primary and secondary malignant tumors of the liver. Although curative resection is associated with long-term survival rates, it can only be performed in 10% of patients with primary tumors and 25% of patients with liver metastases. Liver insufficiency is one of the most serious postoperative complications of patients undergoing extensive liver resections. When total liver resection is necessary liver transplant is mandatory, with the burden of long-term immunosuppression and its complications. Among several different strategies to increase the resectability of liver tumors, portal vein occlusion (embolization or ligature), bilateral tumor resection in two stages, and resection combined with loco regional therapy are the most popular. A new strategy for patients with marginally resectable liver tumors previously considered to be unresectable was formally reported by Baumgart et al. in 2011, originally developed by Hans Schlitt in 2007. This technique consists of a two-staged hepatectomy with initial portal vein ligation and in situ splitting of the liver parenchyma, and it is known as ALPPS (associating liver partition with portal vein ligation for staged hepatectomy). The aim of this study is to present the first series of pediatric patients with marginally resectable liver tumors previously considered to be unresectable treated with two-stage hepatectomy with initial portal vein ligation and in situ splitting of the liver parenchyma. Two patients were diagnosed with hepatoblastoma, and one each with rhabdomyosarcoma, hepatocellular carcinoma, and nodular focal hyperplasia. ALPPS technique was considered whenever the future liver remnant (FLR) was 40% or less of the total liver volume (TLV) determined by CT or MRI scans. The ratio of FLR to TLV before the first procedure ranged from 0.15 to 0.38, with a mean±sd of 0.253±0.07. In all patients, a rapid growth of the FLR was observed. Estimates of the FRL volume prior to surgical treatment ranged from 110cc to 750cc, with a mean±sd of 361.6±213.75cc. Just before the second procedure, the volume of the remnant liver ranged from 225cc to 910cc, with a mean±sd of 563.6cc±221.7cc. The FRL volume increase had a mean±sd of 72.56%±29.05%, with a median of 83.8%. The second procedure was performed after 7 to 12days with a median of 11days. The only postoperative complication observed in one patient was an asymptomatic right pleural effusion that was aspirated during the second procedure with no further complications. ALPPS was shown to be effective and a safe procedure to treat large tumors in children.

Impact of Neoadjuvant Chemotherapy on Hypertrophy of the Future Liver Remnant after Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy

BACKGROUND

Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) has been demonstrated as a feasible procedure in extended liver resections as a means of successfully increasing the volume of the future liver remnant (FLR). Neoadjuvant chemotherapy (CTx) is toxic to the organ and may impair hepatic regeneration. This study was performed to assess the procedure's effect on hypertrophy of the FLR, including the short-term survival.

STUDY DESIGN

We analyzed 19 consecutive ALPPS patients, of whom 58% (n = 11) received neoadjuvant CTx because of colorectal liver metastasis (CRM). Patients presented with multifocal CRM (n = 11, 58%); cholangiocarcinoma (n = 7, 37%), of which 5 were in the Klatskin position; and gallbladder carcinoma (n = 1, 5%). Hepatectomy was performed within 6 to 13 days after hepatic partition. Volumetry was performed before both liver partitioning and hepatectomy. A survival analysis was performed.

RESULTS

Liver partition and portal vein ligation induced sufficient hypertrophy of the FLR, with an increased volume of 74% ± 35%. Patients underwent hepatectomy after a median of 8 days; in all cases R0 resection was achieved. Neoadjuvant CTx was shown to significantly impair hypertrophy. The volume of the FLR in non-CTx patients increased by 98% ± 35%; an increase of 59% ± 22% was observed in patients who underwent CTx (p = 0.027). Chemotherapy did not have an impact on either morbidity or in-hospital mortality, which were 68% and 16%, respectively. One-year overall survival was 53%, with a 1-year survival of 67% in CRM patients and 38% in non-CRM patients (p > 0.05).

CONCLUSIONS

Data presented here demonstrate for the first time that neoadjuvant CTx significantly impairs hypertrophy of the FLR after ALPPS.

Is the liver kinetic growth rate in ALPPS unprecedented when compared with PVE and living donor liver transplant? A multicentre analysis

BACKGROUND

The clinical perspective on hepatic growth is limited. The goal of the present study was to compare hepatic hypertrophy and the kinetic growth rate(KGR) in patients after the ALPPS (Associating Liver Partition with Portal Vein Ligation for Staged Hepatectomy) procedure, portal vein embolization (PVE) and living donor liver transplantation.

METHODS

Volumetry and KGR of the future liver remnant (FLR) were compared from (15) patients undergoing ALPPS, (53) patients undergoing PVE, (90) recipients of living donor liver grafts and (93) donors of living donor liver grafts.

RESULTS

The degree of hypertrophy was significantly greater after ALPPS (84.3 ± 7.8%) than after PVE (36.0 ± 27.2%) (P < 0.001). The KGR was also significantly greater for ALPPS [32.7 ± 13.6 cubic centimetres (cc)/day] (10.8 ± 4.5%/day) compared with PVE (4.4 ± 3.2 cc/day) (0.98 ± 0.75%/day) (P < 0.001). The FLR of living donor donors had the greatest degree of hypertrophy (107.5 ± 39.2%) and was greater than after ALPPS (P = 0.02), PVE (P < 0.001) and in living donor-recipient grafts (P < 0.001). KGR (cc/day) was greater in FLR of living donor donors compared with both ALPPS (P < 0.001) and PVE (P < 0.001). The KGR in patients undergoing ALPPS and living donor liver transplantation had a linear relationship with the size of FLR.

CONCLUSION

FLR hypertrophy and KGR were greater after ALPPS than PVE. However, the degree of hypertrophy after ALPPS is not unprecedented, as KGR in the FLR from living donor donors is equal to or greater than after ALPPS. The KGR of the FLR in patients after ALPPS and living donor donors correlates directly with the size of the FLR.

Associating liver partition and portal vein ligation for staged hepatectomy offers high oncological feasibility with adequate patient safety: a prospective study at a single center

OBJECTIVE

To determine the safety, feasibility, and efficacy of associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) in a single high-volume hepatobiliary center.

BACKGROUND

The ALPPS approach allows achieving resectability of liver malignancies by a rapid and large future liver remnant (FLR) hypertrophy. However, this proposal has been associated with high morbidity and mortality rates.

METHODS

This was a single-cohort, prospective, observational study [NCT02164292]. Between June 2011 and April 2014, patients with liver malignancies considered unresectable due to an insufficient FLR who underwent ALPPS were included.

RESULTS

Thirty patients were treated. Median age was 58.6 years (range = 35-81) and 19 patients were males (63%). In a median of 6 days (range = 4-67), the median FLR hypertrophy was 89.7% (range = 21-287). Twenty-nine patients completed the second stage (97% feasibility). Morbidity according to the Dindo-Clavien classification was 53% (grade ≥IIIa 43% and grade ≥IIIb 31%). The mortality rate was 6.6%. Total parenchymal transection was identified as an independent risk factor for complications (P = 0.049). There was not significant difference in terms of FLR hypertrophy between total or partial parenchymal transection (P = 0.45). Median hospital stay was 16 days (range = 11-62). The overall and disease-free survival at 1 year was 78% and 67% and at 2 years was 63% and 40%, respectively.

CONCLUSIONS

This prospective study on the largest reported single-center experience shows that ALPPS has acceptable morbidity and mortality, together with a high oncological feasibility and hypertrophic efficacy. Partial parenchymal transection seems to reduce morbidity without negatively impacting FLR hypertrophy.

Hypertrophy of the Left Liver in Patients with Large Tumors in the Right Liver

BACKGROUND

It has been speculated that, when right-sided major hepatectomy (RSMH) is planned for patients with large tumors in the right liver, it may not lead to a marked decrease in normally functional hepatic mass.

METHODS

We collected data for patients who had undergone RSMH for tumors more than 8 cm in diameter (n=50) and compared them with control patients who had undergone RSMH for tumors less than 5 cm in diameter (n=21).

RESULTS

The ratio of the remnant left liver volume to the nontumorous liver volume (left liver ratio) in the patients with large tumors was significantly greater than that in the control group (50.0±12.8% vs. 40.2±8.3%, p=0.002). Left liver ratio was significantly correlated with tumor volume (p<0.001). Preoperative portal vein embolization was performed in only four of the 50 patients with large tumors. None of the patients with large tumors developed postoperative liver failure.

CONCLUSIONS

Left liver volume in patients with large tumors in the right liver was larger than usual, perhaps reducing the risk of postoperative liver insufficiency after RSMH.

Contra-lateral liver lobe hypertrophy after unilobar Y90 radioembolization: An alternative to portal vein embolization?

Liver resection (LR) with negative margins confers survival advantage in many patients with hepatic malignancies. However, an adequate future liver remnant (FLR) is imperative for safe LR. Presently, in patients with an inadequate FLR; the 2 most established clinical techniques performed to induce liver hypertrophy are portal vein embolization (PVE) and portal vein ligation. More recently, it has been observed that patients who undergo treatment via Y90 radioembolization experience hypertrophy of the contra-lateral untreated liver lobe. Based on these observations, several investigators have proposed the potential use of this modality as an alternative technique for increasing the FLR prior to liver resection. Y90 radioembolization induces hypertrophy at a slower rate than PVE but has the added advantage of concomitant local disease control and tumour down-staging.

Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS): impact of the inter-stages course on morbi-mortality and implications for management

BACKGROUND

Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) was recently developed to induce rapid hypertrophy and reduce post-hepatectomy liver failure in patients with insufficient remnant liver volume (RLV). However, mortality rates >12% have been reported. This study aimed to analyze the perioperative course of ALPPS and to identify factors associated with morbi-mortality.

METHODS

Between April 2011 and September 2013, 62 patients operated in 9 Franco-Belgian hepatobiliary centres underwent ALPPS for colorectal metastases (N = 50) or primary tumors, following chemotherapy (N = 50) and/or portal vein embolization (PVE; N = 9).

RESULTS

Most patients had right (N = 31) or right extended hepatectomy (N = 25) (median RLV/body weight ratio of 0.54% [0.21-0.77%]). RLV increased by 48.6% [-15.3 to 192%] 7.8 ± 4.5 days after stage1, but the hypertrophy decelerated beyond 7 days. Stage2 was cancelled in 3 patients (4.8%) for insufficient hypertrophy, portal vein thrombosis or death and delayed to ≥9 days in 32 (54.2%). Overall, 25 patients (40.3%) had major complication(s) and 8 (12.9%) died. Fourteen patients (22.6%) had post-stage1 complication of whom 5 (35.7%) died after stage2. Factors associated with major morbi-mortality were obesity, post-stage1 biliary fistula or ascites, and infected and/or bilious peritoneal fluid at stage2. The latter was the only predictor of Clavien ≥3 by multivariate analysis (OR: 4.9; 95% CI: 1.227-19.97; p = 0.025). PVE did not impact the morbi-mortality rates but prevented major cytolysis that was associated with poor outcome.

CONCLUSIONS

The inter-stages course was crucial in determining ALPPS outcome. The factors of high morbi-mortality rates associated with ALPPS are linked to the technique complexity.