Associated liver partition and portal vein ligation for staged hepatectomy: a review

Evolution and current trends in the management of colorectal cancer liver metastasis

Metastatic colorectal cancer (mCRC) is a major cause of cancer-related death, with a 5-year relative overall survival of up to 20%. The liver is the most common site of distant metastasis in colorectal cancer (CRC), with about 50% of CRC patients metastasizing to their liver over the course of their disease. Complete liver resection is the primary modality of treatment for resectable colorectal cancer liver metastasis (CRLM), with an overall 5-year survival rate of up to 58%. However, only 15% to 20% of patients with CRLM are deemed suitable for resection at presentation. For unresectable diseases, the median survival of patients remains low even with the best chemotherapy. In recent decades, the management of CRLM has continued to evolve with the expansion of resection criteria, novel targeted systemic therapies, and improved locoregional therapies. However, due to the heterogeneity of the CRC patient population, the optimal evaluation of treatment options for CRLM remains complex. Therefore, effective management requires a multidisciplinary team to help define resectability and devise a personalized treatment approach, from the initial diagnosis to the final treatment.

Correlation between the liver transection line localization and future liver remnant hypertrophy in associating liver partition and portal vein ligation for staged hepatectomy

Background and aims

Colorectal liver metastases (CRLMs) represent the most prevalent form of secondary liver tumors, and insufficient future liver remnant (FLR) often leads to unresectability. To tackle this challenge, various methods for stimulating liver hypertrophy have been developed including portal vein embolization (PVE), associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) and the newest one, liver venous deprivation (LVD). ALPPS was thoroughly studied over the last decade and it has been shown to induce rapid and intensive FLR hypertrophy. The objective of this study was to assess whether the localization of the liver transection line during the initial stage of ALPPS correlates with the degree of FLR hypertrophy.

Methods

A retrospective, multicentric study was conducted, and we analyzed all consecutive patients with CRLMs who underwent ALPPS over the eight-year period. Patients were categorized into two groups based on the type of resection-right trisectionectomy (ERH) or right hemihepatectomy (RH) respectively. The degree of hypertrophy (DH), its correlation with FLR and postoperative outcomes were assessed.

Results

The cohort consisted of 136 patients (72 in the ERH group and 64 in the RH group). Baseline characteristics, hypertrophy interval, and total liver volume showed no significant differences between the groups. DH was greater in the ERH group (83.2% vs. 62.5%, p = 0.025). A strong negative correlation was observed between FLR volume and DH in both groups. Postoperative outcomes and one-year survival were comparable between the groups.

Conclusions

FLR hypertrophy is influenced by the localization of the liver transection line in ALPPS. Furthermore, correlation analysis indicated that a smaller estimated FLR is associated with greater DH. No statistical difference in outcomes was noted between the groups.

Impact of the extent and location of liver split on future liver remnant hypertrophy after portal vein ligation in a rat model

BACKGROUND

To investigate the role and mechanism of liver parenchyma transection in accelerating the regeneration of future liver remnants in rats with portal vein ligation (PVL).

METHODS

Rats were randomly divided into the PVL group (90% PVL at the caudate lobe, right lobe , left lateral lobe and left median lobe), associating liver partition and portal vein ligation for staged hepatectomy (portal vein ligation with complete liver parenchyma transection [ALPPS]) group (90% PVL with 80 to 90% liver parenchyma transection), PVL + partial liver partition (PLP) group (90% PVL with 30 to 50% liver parenchyma transection), PVL + partition in the ligated lobe (PLL) group (90% PVL with 40 to 60% liver parenchyma transection in the portal vein ligated lobe), PVL + partition in the remnant lobe (PRL) group (90% PVL with 40 to 60% liver parenchyma transection in the remnant lobe), PVL + radiofrequency ablation (RFA) group (90% PVL with splenic ablation) and sham operation (sham) group. The animals were killed at 4 time points of postoperative days 1, 3, 5, and 7. Six rats were killed at each time point, with 24 rats in each group. The weights of the future liver remnant and whole liver were measured. Serum alanine aminotransferase, aspartate aminotransferase, and total bilirubin were analyzed by using an automatic biochemical analyzer. Serum tumor necrosis factor-α, interleukin-6, and hepatocyte growth factor were measured by enzyme-linked immunosorbent assay. The expression of cell proliferating nuclear antigen (Ki67) and phosphorylated histone H3 was detected by immunohistochemistry, and the positive rate was calculated.

RESULTS

The ALPPS group displayed the highest FLR weight to body weight ratio compared with that of the other groups (P < .05), and the partial liver split (PVL + PLP) group also displayed higher remnant weight to body weight ratio than the ectopic liver split (PVL + PLL and PVL + PRL) groups (P < .05). During the first 7 days after surgery the cytokine levels of the ALPPS, PVL + PLP, PVL + PLL and PVL + PRL groups were comparable (P > .05). The PVL + PLP, PVL + PLL, PVL + PRL and PVL + RFA groups showed similar necrotic areas in the portal vein ligated lobe (P > .05). A hemodynamic study revealed that a liver split along the demarcation line could further increase the portal pressure of the FLR and both the split site and completeness were associated with portal hemodynamic alternations and liver hypertrophy. Extrahepatic organ injury (eg, spleen ablation) also has a significant impact on portal hemodynamics and liver regeneration.

CONCLUSION

Complete liver splitting along the demarcation line induced higher portal vein pressure and more rapid FLR hypertrophy than partial or ectopic liver splitting after PVL. The portal hemodynamic alterations after liver split rather than inflammatory cytokine release may be the major cause of ALPPS-induced rapid liver hypertrophy.

The impact of waiting time and delayed treatment on the outcomes of patients with hepatocellular carcinoma: A systematic review and meta-analysis

Hepatocellular carcinoma (HCC) is the sixth most diagnosed cancer worldwide. Healthcare resource constraints may predispose treatment delays. We aim to review existing literature on whether delayed treatment results in worse outcomes in HCC. PubMed, Embase, The Cochrane Library, and Scopus were systematically searched from inception till December 2022. Primary outcomes were overall survival (OS) and disease-free survival (DFS). Secondary outcomes included post-treatment mortality, readmission rates, and complications. Fourteen studies with a total of 135,389 patients (delayed n = 25,516, no delay n = 109,873) were included. Age, incidence of male patients, Child-Pugh B cirrhosis, and Barcelona Clinic Liver Cancer Stage 0/A HCC were comparable between delayed and no delay groups. Tumor size was significantly smaller in delayed versus no delay group (mean difference, -0.70 cm; 95% confidence interval [CI]: -1.14, 0.26; p = 0.002). More patients received radiofrequency ablation in delayed versus no delay group (OR, 1.22; 95% CI: 1.16, 1.27; p < 0.0001). OS was comparable between delayed and no delay in HCC treatment (hazard ratio [HR], 1.13; 95% CI: 0.99, 1.29; p = 0.07). Comparable DFS between delayed and no delay groups (HR, 0.99; 95% CI: 0.75, 1.30; p = 0.95) was observed. Subgroup analysis of studies that defined treatment delay as > 90 days showed comparable OS in the delayed group (HR, 1.04; 95% CI: 0.93, 1.16; p = 0.51). OS and DFS for delayed treatment were non-inferior compared to no delay, but might be due to better tumor biology/smaller tumor size in the delayed group.

Liver Transplantation for Colorectal Liver Metastases: Is It Appropriate?

Colorectal cancer with liver metastases is a condition with significant morbidity and mortality that affects many people around the world. Many treatments exist to target liver metastases, including surgical resection, chemotherapy, nonsurgical liver-directed therapies, and liver transplantation. The field of transplant oncology is emerging as a promising alternative to palliative chemotherapy alone in appropriately selected patients. Though few clinical trials have been completed to evaluate safety of liver transplant for colorectal cancer metastases, there are several ongoing trials to hopefully make transplant a viable option for more patients with limited options.

Preoperative Value of Contrast-Enhanced Ultrasound in Totally Laparoscopic Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy for Liver Tumors: A Preliminary Study

ABSTRACT

The clinical data of 15 cases that planned to receive totally laparoscopic associating liver partition and portal vein ligation for staged hepatectomy were retrospectively collected. Before the stage 1 operation, the size and number of the tumors in future liver remnant (FLR) and the presence of cancer embolus in the portal vein were assessed using contrast-enhanced ultrasound (CEUS) and contrast-enhanced computed tomography (CECT). Before the stage 2 operation, CEUS was performed to assess the presence of traffic blood flow between the diseased liver and FLR after round-the-liver ligation. Before the stage 1 operation, 5 cases with tumors in FLR were found by CEUS and 6 cases were found by CECT ( P > 0.05). Similarly, CEUS found 5 cases with cancer thrombus in portal vein, and CECT found 7 cases ( P = 0.500). The consistency between the 2 modalities was good (κ = 0.857, P < 0.05, κ = 0.727, P < 0.05, respectively). Before the stage 2 operation, CEUS confirmed that there were 7 cases without traffic blood flow between the diseased liver and FLR, and 3 cases with residual traffic blood flow. The daily growth rate of FLR in the group without traffic blood flow (mean rank = 7.00) was higher than that in the group with traffic blood flow (2.00) significantly ( P < 0.05). Contrast-enhanced ultrasound is a promising application in the preoperative evaluation of totally laparoscopic associating liver partition and portal vein ligation for staged hepatectomy.

Efficacy and safety of different options for liver regeneration of future liver remnant in patients with liver malignancies: a systematic review and network meta-analysis

BACKGROUND

Several treatments induce liver hypertrophy for patients with liver malignancies but insufficient future liver remnant (FLR). Herein, the aim of this study is to compare the efficacy and safety of existing surgical techniques using network meta-analysis (NMA).

METHODS

We searched PubMed, Web of Science, and Cochrane Library from databases for abstracts and full-text articles published from database inception through Feb 2022. The primary outcome was the efficacy of different procedures, including standardized FLR (sFLR) increase, time to hepatectomy, resection rate, and R0 resection margin. The secondary outcome was the safety of different treatments, including the rate of Clavien-Dindo≥3a and 90-day mortality.

RESULTS

Twenty-seven studies, including three randomized controlled trials (RCTs), three prospective trials (PTs), and twenty-one retrospective trials (RTs), and a total number of 2075 patients were recruited in this study. NMA demonstrated that the Associating Liver Partition and Portal vein ligation for Staged hepatectomy (ALPPS) had much higher sFLR increase when compared to portal vein embolization (PVE) (55.25%, 95% CI 45.27-65.24%), or liver venous deprivation(LVD) (43.26%, 95% CI 22.05-64.47%), or two-stage hepatectomy (TSH) (30.53%, 95% CI 16.84-44.21%), or portal vein ligation (PVL) (58.42%, 95% CI 37.62-79.23%). ALPPS showed significantly shorter time to hepatectomy when compared to PVE (-32.79d, 95% CI -42.92-22.66), or LVD (-34.02d, 95% CI -47.85-20.20), or TSH (-22.85d, 95% CI -30.97-14.72), or PVL (-43.37d, 95% CI -64.11-22.62); ALPPS was considered as the highest resection rate when compared to TSH (OR=6.09; 95% CI 2.76-13.41), or PVL (OR =3.52; 95% CI 1.16-10.72), or PVE (OR =4.12; 95% CI 2.19-7.77). ALPPS had comparable resection rate with LVD (OR =2.20; 95% CI 0.83-5.86). There was no significant difference between them when considering the R0 marge rate. ALPPS had a higher Clavien-Dindo≥3a complication rate and 90-day mortality compared to other treatments, although there were no significant differences between different procedures.

CONCLUSIONS

ALPPS demonstrated a higher regeneration rate, shorter time to hepatectomy, and higher resection rate than PVL, PVE, or TSH. There was no significant difference between them when considering the R0 marge rate. However, ALPPS developed the trend of higher Clavien-Dindo≥3a complication rate and 90-day mortality compared to other treatments.

Advances in the surgical treatment of liver cancer

Liver resection is the standard curative treatment for liver cancer. Advances in surgical techniques over the last 30 years, including the preoperative assessment of the future liver remnant, have improved the safety of liver resection. In addition, advances in nonsurgical multidisciplinary treatment have increased the opportunities for tumor downstaging. Consequently, the indications for resection of more advanced liver cancer have expanded. Laparoscopic and robot-assisted liver resections have also gradually become more widespread. These techniques should be performed in stages, depending on the difficulty of the procedure. Advances in preoperative simulation and intraoperative navigation technology may have also lowered the threshold for their performance and may have promoted their widespread use. New insights and experiences gained from laparoscopic surgery may be applicable in open surgery. Liver transplantation, which is usually indicated for patients with poor liver function, has also become safer with advances in perioperative management. The indications for liver transplantation in liver cancer are also expanding. Although the coronavirus disease 2019 pandemic has forced the postponement of liver resection and transplantation procedures, liver surgeons should appropriately tailor the surgical plan to the individual patient as part of multidisciplinary treatment. This review may provide an entry point for future clinical research by identifying currently unresolved issues regarding liver cancer, and particularly hepatocellular carcinoma.

Liver Surgery: Important Considerations for Pre- and Postoperative Imaging

Liver surgery may be a curative treatment option not only for primary liver neoplasms but also for liver metastases in selected patients. The number of liver surgeries performed worldwide has increased, but surgical morbidity associated with these surgeries remains significant. Therefore, radiologists need to understand the terminology, surgical techniques, resectability and unresectability criteria, and possible postoperative complications as these are part of the decision-making process. Because vascular and biliary variations are common, an adequate preoperative anatomic evaluation determines the best surgical technique, helps identify patients in whom additional surgical steps will be required, and reduces the risk of inadvertent injury. The surgeon must ensure that the future liver remnant is sufficient to maintain adequate function, aided by the radiologist who can provide valuable information such as the presence of steatosis, biliary dilatation, signs of cirrhosis, and portal hypertension, in addition to the volume of the future liver remnant. Postoperative complications must also be understood and evaluated. The most common postoperative complications are vascular (bleeding, thrombosis, and ischemia), biliary (fistulas, bilomas, and strictures), infectious (incisional or deep), those related to liver failure, and even tumor recurrence. An invited commentary by Winslow is available online. Online supplemental material is available for this article. ^©RSNA, 2022.

Case Report: Massive Hepatocellular Carcinoma Complete Surgical Resection After Portal Vein Embolization and Multimodality Therapy

A high proportion of massive patients with hepatocellular carcinoma (HCC) are not amenable for surgical resection at initial diagnosis, owing to insufficient future liver remnant (FLR) or an inadequate surgical margin. For such patients, portal vein embolization (PVE) is an essential approach to allow liver hypertrophy and prepare for subsequent surgery. However, the conversion resection rate of PVE only is unsatisfactory because of tumor progression while awaiting liver hypertrophy. We report here a successfully treated case of primary massive HCC, where surgical resection was completed after PVE and multimodality therapy, comprising hepatic artery infusion chemotherapy (HAIC), Lenvatinib plus Sintilimab. A pathologic complete response was achieved. This case demonstrates for the first time that combined PVE with multimodality therapy appears to be safe and effective for massive, potentially resectable HCC and can produce deep pathological remission in a primary tumor.

Predictors of mortality within the first year post-hepatectomy for hepatocellular carcinoma

BACKGROUND

Hepatic resection (HR) for hepatocellular carcinoma (HCC) is safe with good perioperative and long-term oncologic outcomes. There is a paucity of data with regards to intermediate-term outcomes (i.e., beyond 90-day and within 1-year mortality). This paper studies the risk factors for within 1-year mortality after elective HR with curative intent in patients with HCC.

METHODS

An audit of patients who underwent curative HR for HCC from January 2007 to April 2016 was conducted. Univariate and multivariate analysis were sequentially performed on perioperative variables using Cox-regression analysis to identify factors predicting intermediate-term outcomes defined as within 1-year mortality. Kaplan-Meier survival curves and hazard ratios were obtained.

RESULTS

Three hundred forty-eight patients underwent HR during the study period and 163 patients had curative hepatectomy for HCC. Fifteen patients (9.2%) died within 1-year after HR. Multivariate analysis identified Child-Pugh class B/C (HR 5.5, p = 0.035), multinodularity (HR 7.1, p = 0.001), macrovascular invasion (HR 4.2, p = 0.04) postoperative acute renal failure (HR 5.8, p = 0.049) and posthepatic liver failure (HR 9.6, p = 0.009) as significant predictors of 1-year mortality.

CONCLUSION

One-year mortality following HR for HCC remains high and can be predicted preoperatively by multinodularity, Child-Pugh class, and macrovascular invasion. Postoperative acute renal failure and liver failure are associated with 1-year mortality.

Minimizing the risk of small-for-size syndrome after liver surgery

BACKGROUND

Primary and secondary liver tumors are not always amenable to resection due to location and size. Inadequate future liver remnant (FLR) may prevent patients from having a curative resection or may result in increased postoperative morbidity and mortality from complications related to small-for-size syndrome (SFSS).

DATA SOURCES

This comprehensive review analyzed the principles, mechanism and risk factors associated with SFSS and presented current available options in the evaluation of FLR when planning liver surgery. In addition, it provided a detailed description of specific modalities that can be used before, during or after surgery, in order to optimize the conditions for a safe resection and minimize the risk of SFSS.

RESULTS

Several methods which aim to reduce tumor burden, preserve healthy liver parenchyma, induce hypertrophy of FLR or prevent postoperative complications help minimize the risk of SFSS.

CONCLUSIONS

With those techniques the indications of radical treatment for patients with liver tumors have significantly expanded. The successful outcome depends on appropriate patient selection, the individualization and modification of interventions and the right timing of surgery.

Role of CT in Two-Stage Liver Surgery

Complete resection is the only potentially curative treatment for primary or metastatic liver tumors. Improvements in surgical techniques such as conventional two-stage hepatectomy (TSH) with portal vein embolization and ALPPS (associating liver partition and portal vein ligation for staged hepatectomy) promote hypertrophy of the future liver remnant (FLR), expanding resection criteria to include patients with widespread hepatic disease who were formerly not considered candidates for resection. Radiologists are essential in the multidisciplinary approach required for TSH. In particular, multidetector CT has a critical role throughout the various stages of this surgical process. The aims of CT before the first stage of TSH are to define the feasibility of surgery, assess the number and location of liver tumors in relation to relevant anatomy, and provide a detailed anatomic evaluation, including vascular and biliary variants. Volume calculation with CT is also essential to determine if the FLR is sufficient to avoid posthepatectomy liver failure. The objectives of CT between the first and second stages of TSH are to recalculate liver volumes (ie, assess FLR hypertrophy) and depict expected liver changes and complications that could modify the surgical plan or preclude the second stage of definitive resection. In this review, the importance of CT throughout different stages of TSH is discussed and key observations that contribute to surgical planning are highlighted. In addition, the advantages and limitations of MRI for detection of liver metastases and assessment of complications are briefly described. ^©RSNA, 2022.

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.

Portal vein embolization: rationale, techniques, outcomes and novel strategies

The incidence of liver cancer has grown in the past decade, with 905,677 new cases and 830,180 deaths in 2020. According to the highest annual fatality ratio, liver cancer is the third-leading cause of cancer-related deaths worldwide. Surgical resection is the mainstay treatment for long-term survival. However, only 25% of patients are surgical candidates. Recent surgical concepts, techniques and multidisciplinary management were developed, including interventional radiology procedures that improve the management algorithm, expand the indications and limit dropouts from curative treatment. This review summarizes up-to-date information on interventional radiology in the management of liver tumors.

Simultaneous Dual Hepatic Vascular Embolization (DHVE) for Massive Hepatectomy

BACKGROUND

Simultaneous dual hepatic vein embolization (DHVE) has been proposed for safe right-side massive hepatectomy, (Kobayashi et al. in Surgery 167:917-923, 2020, Heil J, Schadde E. in Langenbecks Arch Surg 2020, Narita et al. in Ann Surg 256:e7-8, 2012) and has demonstrated comparable results to associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) (Chan et al. in Transl Gastroenterol Hepatol 5:37, 2020) in terms of liver hypertrophy. In this video, we describe our DHVE techniques to perform a safe right trisectionectomy.

METHODS

A 40-year-old man with unresectable intrahepatic cholangiocarcinoma with multiple intrahepatic metastases and vena cava invasion received 20 cycles of gemcitabine plus cisplatin, resulting in remarkable shrinkage of the tumor. Conversion surgery was planned to achieve no evidence of disease status. The future liver remnant (FLR) after right trisectionectomy was 363 ml (29.6% of the whole liver) and simultaneous DHVE was performed. The right portal vein embolization was performed via a transhepatic approach, while the right and middle hepatic veins were accessed via a transjugular approach and self-expandable mesh devices were deployed. Remarkable atrophy of the right lobe and hypertrophy of the left lobe was observed 2 weeks after the procedure. Volumetry showed the FLR increased to 485 ml (40.2% of the whole liver). Three weeks after DHVE, right trisectionectomy with combined resection of the vena cava was performed.

RESULTS

The operation time was 311 min, and the blood loss was 420 ml. Pathological examination revealed complete resection of liver tumors, and the volumetry on postoperative day 7 revealed an increased remnant liver volume of 874 ml. He was discharged on postoperative day 10 without any complications.

CONCLUSION

Simultaneous DHVE could be an effective procedure to increase FLR with safety for massive hepatectomy.

Ligation of the middle hepatic vein to increase hypertrophy induction during the ALPPS procedure

PURPOSE

Here, we analyse the technical modification of the ALPPS procedure, ligating the middle hepatic vein during the first step of the operation to enhance remnant liver hypertrophy.

METHODS

In 20 of 37 ALPPS procedures, the middle hepatic vein was ligated during the first step. Hypertrophy of the functional remnant liver volume was assessed in addition to postoperative courses.

RESULTS

Volumetric analysis showed a significant volume increase, especially for patients with colorectal metastases. Pre-existing liver parenchyma damage (odds ratio = 0.717, p = 0.017) and preoperative chemotherapy were found to be significant predictors (odds ratio = 0.803, p = 0.045) of higher morbidity and mortality. In addition, a survival benefit for maintenance of middle hepatic vein was shown.

CONCLUSION

This technical modification of the ALPPS procedure can accentuate future liver remnant volume hypertrophy. The higher morbidity and mortality observed are most likely associated with pre-existing parenchymal damage within this group.

Predictors of 90-Day Mortality following Hepatic Resection for Hepatocellular Carcinoma

BACKGROUND/PURPOSE

90-day mortality is a key performance indicator for short-term perioperative outcome of hepatic resection (HR). Although many preoperative, intraoperative, and postoperative variables predict 90-day mortality following elective HR, only few are specific to hepatocellular carcinoma (HCC). This study aims to determine the predictors of 90-day mortality following elective HR for HCC.

METHODS

We report a retrospective analysis of patients who underwent elective HR between January 1, 2007, and December 31, 2017. Health status, perioperative variables, and the presence of post-hepatectomy liver failure (PHLF) were studied. Cox's regression evaluated factors predicting 90-day mortality.

RESULTS

Two hundred and forty-four patients diagnosed with HCC underwent HR; 102 (41.8%) underwent a major HR. The postoperative 90-day mortality rate was 5.3%. Multivariate analysis demonstrated that Child-Pugh score (p < 0.001), intraoperative blood loss (p = 0.013), the 50-50 criteria for PHLF (p < 0.001) on postoperative day 5, and peak serum bilirubin >119 µmol/L (p = 0.007) on postoperative day 3 predict 90-day mortality.

CONCLUSION

In patients with HCC undergoing HR, Child-Pugh score, intraoperative blood loss, the 50-50 criteria for PHLF on postoperative day 5, and peak serum bilirubin >119 µmol/L on postoperative day 3 predict 90-day mortality following elective HR for HCC.

Portal and hepatic vein embolization prior to major hepatectomy

PURPOSE

 To analyze safety and effectiveness of simultaneous portal and hepatic vein embolization (PHVE) or sequential hepatic vein embolization (HVE) compared to portal vein embolization (PVE) for future remnant liver (FRL) hypertrophy prior to major hepatic surgery.

METHODS

 Patients undergoing PVE, PHVE or HVE at our tertiary care center between 2018 and 2020 were retrospectively included. FRLV, standardized FRLV (sFRLV) and sFRLV growth rate per day were assessed via volumetry, as well as laboratory parameters.

RESULTS

 36 patients (f = 15, m = 21; median 64.5 y) were included, 16 patients received PHVE and 20 patients PVE, of which 4 received sequential HVE. Significant increase of FRLV was achieved with both PVE and PHVE compared to baseline (p < 0.0001). sFRLV growth rate did not significantly differ following PHVE (2.2 ± 1.2 %/d) or PVE (2.2 ± 1.7 %/d, p = 0.94). Left portal vein thrombosis (LPVT) was observed after PHVE in 6 patients and in 1 patient after PVE. Sequential HVE showed a considerably high growth rate of 1.42 ± 0.45 %/d after PVE.

CONCLUSION

 PHVE effectively induces FRL hypertrophy but yields comparable sFRLV to PVE. Sequential HVE further induces hypertrophy after insufficient growth due to PVE. Considering a potentially higher rate of LPVT after PHVE, PVE might be preferred in patients with moderate baseline sFRLV, with optional sequential HVE in non-sufficient responders.