Arterial ischemia in the deportalized liver following associating liver partition and portal vein ligation for staged hepatectomy

Circulating proliferative factors versus portal inflow redistribution: mechanistic insights of ALPPS-derived rapid liver regeneration

Background

Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) can induce accelerated regeneration of future liver remnant (FLR) and effectively reduce the occurrence of liver failure due to insufficient FLR after hepatectomy, thereby increasing the probability of radical resection for previously inoperable patients with liver cancer. However, the exact mechanism by which ALPPS accelerates liver regeneration remains elusive.

Methods

A review of the literature was performed utilizing MEDLINE/PubMed and Web of Science databases in March of 2024. The key words "liver regeneration/hypertrophy", "portal vein ligation/embolization", "two-stage hepatectomy", "liver partition/split" and "future liver remnant" in combination with "mechanisms", "hemodynamics", "cytokines", "growth factors" or "collaterals" were searched in the title and/or abstract. The references of relevant articles were reviewed to identify additional eligible publications.

Results

Previously, a widely accepted view is that the primary role of liver splitting in ALPPS stage 1 is to accelerate liver regeneration by promoting proliferative factor release, but increasing evidence in recent years reveal that not the circulating factors, but the portal hemodynamic alternations caused by liver parenchyma transection play a pivotal role in ALPPS-associated rapid liver hypertrophy.

Conclusion

Parenchyma transection-induced portal hemodynamic alternations are the main triggers or driving forces of accelerated liver regeneration following ALPPS. The release of circulating proliferative factors seems to be a secondary response to liver splitting and plays an auxiliary role in this process.

Scoring criteria for determining the safety of liver resection for malignant liver tumors

BACKGROUND

Liver resection has become safer as it has become less invasive. However, the minimum residual liver volume (RLV) required to maintain homeostasis is unclear. Furthermore, the formulae used to calculate standard liver volume (SLV) are complex.

AIM

To review previously reported SLV formulae and the methods used to evaluate the minimum RLV, and explore the association between liver volume and mortality.

METHODS

A systematic review of Medline, PubMed, and grey literature was performed. References in the retrieved articles were cross-checked manually to obtain further studies. The last search was conducted on January 20, 2019. We developed an SLV formula using data for 86 consecutive patients who underwent hepatectomy at our institution between July 2009 and August 2011.

RESULTS

Linear regression analysis revealed the following formula: SLV (mL) = 822.7 × body surface area (BSA) − 183.2 (R² = 0.419 and R = 0.644, P < 0.001). We retrieved 25 studies relating to SLV formulae and 12 studies about the RLV required for safe liver resection. Although the previously reported formulae included various coefficient and constant values, a simplified version of the SLV, the common SLV (cSLV), can be calculated as follows: cSLV (mL) = 710 or 770 × BSA. The minimum RLV for normal and damaged livers ranged from 20%-40% and 30%-50%, respectively. The Sapporo score indicated that the minimum RLV ranges from 35%-95% depending on liver function.

CONCLUSION

We reviewed SLV formulae and the minimum RLV required for safe liver resection. The Sapporo score is the only liver function-based method for determining the minimum RLV.