Liver venous deprivation versus portal vein embolization before major hepatectomy:future liver remnant volumetric and functional changes

Background:We previously showed that embolization of portal inflow and hepatic vein(HV)outflow(liver venous deprivation,LVD)promotes future liver remnant(FLR)volume(FLR-V)and function(FLR-F)gain.Here,we compared FLR-V and FLR-F changes after portal vein embolization(PVE)and LVD.Methods:This study included all patients referred for liver preparation before major hepatectomy over 26 months.Exclusion criteria were:unavailable baseline/follow-up imaging,cirrhosis,Klatskin tumor,two-stage hepatectomy.99mTc-mebrofenin SPECT-CT was performed at baseline and at day 7,14 and 21 after PVE or LVD.FLR-V and FLR-F variations were compared using multivariate generalized linear mixed models(joint modelling)with/without missing data imputation.Results:Baseline FLR-F was lower in the LVD(n=29)than PVE group(n=22)(P<0.001).Technical success was 100%in both groups without any major complication.Changes in FLR-V at day 14 and 21(+14.2%vs.+50%,P=0.002;and+18.6%vs.+52.6%,P=0.001),and in FLR-F at day 7,14 and 21(+23.1%vs.+54.3%,P=0.02;+17.6%vs.+56.1%,P=0.006;and+29.8%vs.+63.9%,P<0.001)differed between PVE and LVD group.LVD(P=0.009),age(P=0.027)and baseline FLR-V(P=0.001)independently predicted FLR-V variations,whereas only LVD(P=0.01)predicted FLR-F changes.After missing data handling,LVD remained an independent predictor of FLR-V and FLR-F variations.Conclusions:LVD is safe and provides greater FLR-V and FLR-F increase than PVE.These results are now evaluated in the HYPERLIV-01 multicenter randomized trial.

Novel liver vein deprivation technique that promotes increased residual liver volume(with video):A case report

BACKGROUND Inadequate volume of future liver remnant(FLR)is a major challenge for hepatobiliary surgeons treating large or multiple liver tumors.As an alternative to associating liver partition and portal vein ligation(ALPPS)for staged hepatectomy and liver venous deprivation(LVD)using stage 1 interventional radiology for vascular embolization combined with stage 2 open liver resection have been used.CASE SUMMARY A novel modified LVD technique was performed in a patient with pancreatic neuroendocrine tumor with liver metastases by using stage 1 laparoscopic ligation of the right hepatic vein,right posterior portal vein,and short hepatic veins combined with local excision of three liver metastases in the left hemiliver.The operation was followed three days later by interventional radiology to embolize an anomalous right anterior portal vein to complete LVD.A stage 2 laparoscopic right hemihepatectomy and pancreaticosplenectomy were then carried out.CONCLUSION The minimally invasive technique promoted a rapid increase,comparable to ALPPS,in volume of the FLR after the stage 1 operation to allow the laparoscopic stage 2 resection to be performed.

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

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