Future Liver remnant: A challenge in liver resection surgery

Introduction and Objective: The frontiers of liver resection are expanding. Future Liver Remnant; its volume, function and complication have a predictive value in post resection outcome including post resection liver failure. This study is directed to discuss the issues related to future liver remnant.Objective: To discuss issues related to Future Liver Remnant in patients planned for major liver resectionMaterials and Methods: Data of patients admitted for liver resection at Kathmandu Medical College Teaching Hospital, Surgical Unit III with varied diagnosis, were collected prospectively over a period of 1 year. In our non transplant center, Future Liver Remnant was managed with varying methods. Of the 12 liver resections, 3 prototype cases with different FLR issues are discussed in this study.Results: The first case had issue related to the volume of the liver remnant for which she underwent a portal vein ligation followed by resection (after adequate volume increase) in the second surgery. The second case was a Hepatocellular Carcinoma with CTP 8 cirrhosis. Despite adequate liver volume, decision for liver resection was delayed due to possible postoperative decompensation. The third patient was a Hilar cholangiocarcinoma with obstructive jaundice. Biliary decompression (PTBD) was performed. However, inadequate fall in bilirubin caused dilemma for liver resection. Despite the dilemma, all 3 cases underwent liver resection with no postoperative liver failure.Conclusion: Issues related to the volume and function of future liver remnant in patient undergoing liver resection should be adequately addressed by various pre operative, intra operative, and post operative measures.

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Two-stage liver resection for intrahepatic cholangiocarcinoma

Annaly khirurgicheskoy gepatologii = Annals of HPB surgery ◽

10.16931/1995-5464.20201106-112 ◽

2020 ◽

Vol 25 (1) ◽

pp. 106-112

Author(s):

A. V. Chzhao ◽

B. N. Gurmikov ◽

V. A. Vishnevsky ◽

A. A. Olifir ◽

Ya. Ya. Gavrilov ◽

...

Keyword(s):

Liver Resection ◽

Portal Vein ◽

Liver Volume ◽

Liver Parenchyma ◽

Portal Vein Ligation ◽

Remnant Liver ◽

Liver Remnant ◽

Alternative Version ◽

The Right ◽

Cholangiocellular Cancer

The small remnant liver volume remains an urgent problem in liver resection surgery. The use of the method of twostage liver resection – the Associated Liver Partition and Portal vein ligation for Staged hepatectomy in most cases allows to solve this problem. However, this method is associated with a number of complications and limitations. The presented clinical observation shows the effectiveness of an alternative version of this technology – radiofrequency ablation of the liver parenchyma in the plane of the proposed resection with ligation of the right branch of the portal vein to increase the volume of the estimated liver remnant in intrahepatic cholangiocellular cancer.

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Case Report: Hepatic Artery Infusion Chemotherapy After Stage I ALPPS in a Patient With Huge HCC

Frontiers in Surgery ◽

10.3389/fsurg.2021.746618 ◽

2021 ◽

Vol 8 ◽

Author(s):

Wenfeng Zhuo ◽

Ang Li ◽

Weibang Yang ◽

Jinxin Duan ◽

Jun Min ◽

...

Keyword(s):

Portal Vein ◽

Liver Volume ◽

Future Liver Remnant ◽

Stage I ◽

Hepatic Artery Infusion ◽

Portal Vein Ligation ◽

Liver Remnant ◽

Infusion Chemotherapy ◽

Hepatic Artery Infusion Chemotherapy ◽

Staged Hepatectomy

Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) can induce rapid hypertrophy of the liver remnant. However, with a background of liver cirrhosis or other chronic liver diseases, patients with a huge hepatocellular carcinoma (HCC) may sometimes face insufficiency of hepatocellular regeneration after associating liver partition and portal vein ligation for staged hepatectomy (ALPPS). Herein, we report a 56-year-old male with a vast HCC (13.3 × 8.5 × 13 cm) whose ratio of the future liver remnant (FLR)/standard liver volume (SLV) was 28.7% when the disease was first diagnosed. Inadequate hypertrophy of FLR was shown in postoperative volumetric assessment a month after stage I ALPPS. After multidisciplinary team discussion (MDT), the patient was decided to follow three courses of hepatic arterial infusion chemotherapy (HAIC) with oxaliplatin, fluorouracil, and leucovorin (FOLFOX4). The last HAIC was performed together with transhepatic arterial embolization (TAE). Finally, ratio of the FLR/SLV increased from 28.7% to 40% during three-month intervals, meeting the requirements of the surgery. Stage II ALPPS, right trisectionectomy, was then successfully performed. There was no recurrence at half years of follow-up. In our case, HAIC seems to be more potent than transcatheter arterial chemoembolization (TACE) in maintaining the hyperplasia of the liver remnant, reducing tumor load, and preventing tumor progression in patients with a large HCC during ALPPS procedure. HAIC, following the first step of ALPPS, a pioneering treatment modality aiming for inadequate hypertrophy of FLR induced by ALPPS, could be an alternative procedure for patients with a vast HCC in clinical practice.

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Future liver remnant/total liver volume >30%: hyperbilirubinemia after donor liver resection has mutations of uridine diphosphate glucuronosyltransferase 1 (UGT1A1)

HPB ◽

10.1016/j.hpb.2016.03.526 ◽

2016 ◽

Vol 18 ◽

pp. e572-e573

Author(s):

J. Kaneko ◽

K. Hasegawa ◽

Y. Sakamoto ◽

Y. Maruo ◽

T. Tanaka ◽

...

Keyword(s):

Liver Resection ◽

Liver Volume ◽

Future Liver Remnant ◽

Uridine Diphosphate ◽

Donor Liver ◽

Liver Remnant ◽

Total Liver Volume ◽

Uridine Diphosphate Glucuronosyltransferase ◽

Total Liver

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In situliver transection with portal vein ligation for rapid growth of the future liver remnant in two-stage liver resection

British Journal of Surgery ◽

10.1002/bjs.8955 ◽

2012 ◽

Vol 100 (3) ◽

pp. 388-394 ◽

Cited By ~ 111

Author(s):

W. T. Knoefel ◽

I. Gabor ◽

A. Rehders ◽

A. Alexander ◽

M. Krausch ◽

...

Keyword(s):

Liver Resection ◽

Portal Vein ◽

Rapid Growth ◽

Future Liver Remnant ◽

Portal Vein Ligation ◽

Two Stage ◽

Liver Remnant ◽

The Future

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Intraoperative Conversion to ALPPS in a Case of Intrahepatic Cholangiocarcinoma

Case Reports in Surgery ◽

10.1155/2015/273641 ◽

2015 ◽

Vol 2015 ◽

pp. 1-5 ◽

Cited By ~ 2

Author(s):

F. Oldhafer ◽

K. I. Ringe ◽

K. Timrott ◽

M. Kleine ◽

W. Ramackers ◽

...

Keyword(s):

Liver Resection ◽

Ct Scan ◽

Treatment Option ◽

Intrahepatic Cholangiocarcinoma ◽

Liver Tumors ◽

Future Liver Remnant ◽

Portal Vein Ligation ◽

Liver Remnant ◽

Typical Lesion ◽

Intraoperative Conversion

Background. Surgical resection remains the best treatment option for intrahepatic cholangiocarcinoma (ICC). Two-stage liver resection combiningin situliver transection with portal vein ligation (ALPPS) has been described as a promising method to increase the resectability of liver tumors also in the case of ICC.Presentation of Case. A 46-year-old male patient presented with an ICC-typical lesion in the right liver. The indication for primary liver resection was set and planed as a right hepatectomy. In contrast to the preoperative CT-scan, the known lesion showed further progression in a macroscopically steatotic liver. Therefore, the decision was made to perform an ALPPS-procedure to avoid an insufficient future liver remnant (FLR). The patient showed an uneventful postoperative course after the first and second step of the ALPPS-procedure, with sufficient increase of the FLR. Unfortunately, already 2.5 months after resection the patient had developed new tumor lesions found by the follow-up CT-scan.Discussion. The presented case demonstrates that an intraoperative conversion to an ALPPS-procedure is safely applicable when the FLR surprisingly seems to be insufficient.Conclusion. ALPPS should also be considered a treatment option in well-selected patients with ICC. However, the experience concerning the outcome of ALPPS in case of ICC remains fairly small.

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Rapid Induction of Liver Regeneration for Major Hepatectomy (REBIRTH): A Randomized Controlled Trial of Portal Vein Embolisation versus ALPPS Assisted with Radiofrequency

Cancers ◽

10.3390/cancers11030302 ◽

2019 ◽

Vol 11 (3) ◽

pp. 302 ◽

Cited By ~ 8

Author(s):

Long Jiao ◽

Ana Fajardo Puerta ◽

Tamara Gall ◽

Mikael Sodergren ◽

Adam Frampton ◽

...

Keyword(s):

Randomized Controlled Trial ◽

Portal Vein ◽

Controlled Trial ◽

Liver Volume ◽

Future Liver Remnant ◽

Portal Vein Ligation ◽

Liver Remnant ◽

Randomized Controlled ◽

Portal Vein Embolisation ◽

Number Of Patients

To avoid liver insufficiency following major hepatic resection, portal vein embolisation (PVE) is used to induce liver hypertrophy pre-operatively. Associating liver partition with portal vein ligation for staged hepatectomy assisted with radiofrequency (RALPPS) was introduced as an alternative method. A randomized controlled trial comparing PVE with RALPPS for the pre-operative manipulation of liver volume in patients with a future liver remnant volume (FLRV) ≤25% (or ≤35% if receiving preoperative chemotherapy) was conducted. The primary endpoint was increase in size of the FLRV. The secondary endpoints were length of time taken for the volume gain, morbidity, operation length and post-operative liver function. Between July 2015 and October 2017, 57 patients were randomised to RALPPS (n = 29) and PVE (n = 28). The mean percentage of increase in the FLRV was 80.7 ± 13.7% after a median 20 days following RALPPS compared to 18.4 ± 9.8% after 35 days (p < 0.001) following PVE. Twenty-four patients after RALPPS and 21 after PVE underwent stage-2 operation. Final resection was achieved in 92.3% and 66.6% patients in RALPPS and PVE, respectively (p = 0.007). There was no difference in morbidity, and one 30-day mortality after RALPPS (p = 0.991) was reported. RALPPS is more effective than PVE in increasing FLRV and the number of patients for surgical resection.

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Rescue ALPPS: Intraoperative Conversion to ALPPS during Synchronous Resection of Rectal Cancer and Liver Metastasis

Case Reports in Surgery ◽

10.1155/2014/487852 ◽

2014 ◽

Vol 2014 ◽

pp. 1-4 ◽

Cited By ~ 3

Author(s):

Terence Jackson ◽

Kelly A. Siegel ◽

Christopher T. Siegel

Keyword(s):

Liver Resection ◽

Liver Metastasis ◽

Portal Vein ◽

Future Liver Remnant ◽

Dropout Rate ◽

Portal Vein Ligation ◽

Liver Remnant ◽

Patients At Risk ◽

Synchronous Resection ◽

Intraoperative Conversion

Future liver remnant (FLR) is the most important deciding factor in planning for liver resection. Portal vein embolization (PVE) was first introduced in the 1980s to induce liver hypertrophy, enabling removal of multiple/bilobar tumors. PVE was later combined with sequential hepatectomies with the aim of allowing the liver remnant to hypertrophy (15–20%) between procedures. However, the interval between the two procedures (3–8 weeks) put patients at risk for disease progression. With portal vein ligation alone or when combined with sequential hepatectomy, there is also a risk for inadequate liver hypertrophy because of intrahepatic portal collaterals leading to a high (19–30%) dropout rate. The ALPPS procedure (associating liver partition and portal vein ligation for staged hepatectomy) was recently developed as a feasible means to perform extensive/bilobar liver resections. It produces rapid, enormous hypertrophy of the remnant, making previously unresectable lesions resectable. Indications for ALPPS include any extensive liver resection with inadequate FLR. Here we present a novel indication for ALPPS as a rescue when inadequate FLR was faced intraoperatively, during a simultaneous resection of rectal primary and liver metastasis.

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“Reversal” ALPPS in patient with hepatocellular carcinoma and liver cirrhosis. First clinical case in Russia

Annaly khirurgicheskoy gepatologii = Annals of HPB surgery ◽

10.16931/1995-5464.2021-3-142-148 ◽

2021 ◽

Vol 26 (3) ◽

pp. 142-148

Author(s):

S. E. Voskanyan ◽

V. S. Rudakov ◽

M. V. Shabalin ◽

A. I. Artemyev ◽

A. N. Bashkov ◽

...

Keyword(s):

Portal Vein ◽

Clinical Case ◽

Future Liver Remnant ◽

Portal Vein Ligation ◽

Right Hepatectomy ◽

Portal Branch ◽

Liver Remnant ◽

First Case ◽

The Right ◽

Staged Hepatectomy

Liver resection in patients with HCC is the treatment of choice. In patients with insufficient future liver remnant (FLR) and compensated liver function performing the Associated Liver Partition and Portal vein ligation for Staged hepatectomy (ALPPS) is possible. The classic version of ALPPS consists in ligation of the right branch of the portal vein with transection of the parenchyma and then performing right hepatectomy or right trisegmentectomy. This paper describes the first case in Russia of performing ligation of the left portal branch with transection of the parenchyma and then performing left trisegmentectomy (“reversal” ALPPS) in a patient with HCC and cirrhosis. Reversal ALPPS can be successfully performed in patients with insufficient future liver remnant in well-selected patients.

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Rescue partial ALPPS for left hemihepatectomy with reconstruction of the middle hepatic vein

Digestive Surgery ◽

10.1159/000520695 ◽

2021 ◽

Author(s):

Masaharu Kogure ◽

Takaaki Arai ◽

Hirokazu Momose ◽

Ryota Matsuki ◽

Yutaka Suzuki ◽

...

Keyword(s):

Portal Vein ◽

Hepatic Vein ◽

Retention Rate ◽

Liver Volume ◽

Future Liver Remnant ◽

Middle Hepatic Vein ◽

Liver Remnant ◽

Total Liver Volume ◽

Left Hemihepatectomy ◽

Icg R15

Major hepatectomy in patients with insufficient future liver remnant (FLR) volume and impaired liver functional reserve has considerable risks for posthepatectomy liver failure (PHLF). The patient was a male in his 70 with an intrahepatic cholangiocarcinoma (ICC) in left hemiliver, involving the middle hepatic vein (MHV). Although FLR volume after left hemihepatectomy was estimated to be 64.4% of the total liver volume, an indocyanine green retention rate at 15 min (ICG-R15) value was 24.2%, thus the patient underwent left portal vein embolization (PVE). The FLR volume increased to 71.3%, however, the non-congestive FLR volume was re-estimated as 45.8% after resection of the MHV, the ICG-R15 value was 29.0%, and ICG-Krem was calculated as 0.037. We performed partial rescue ALPPS (Associating Liver Partition and Portal vein occlusion for Staged hepatectomy) for left hemihepatectomy with the MHV reconstruction. On the first stage, partial liver partition was done along Rex-Cantlie’s line, preserving the MHV and sacrificing the remaining branches to segment 8. The FLR volume increased to 77.4% on day 14. The ICG-R15 value was 29.6%, but ICG-Krem after MHV reconstruction was estimated to be 0.059. The second stage operation on day 21 was left hemihepatectomy with the MHV reconstruction using the left superficial femoral vein graft. The usage of rescue partial ALPPS may contribute to preventing PHLF by introducing occlusion of the portal and/or venous branches in the left hemiliver before curative hepatectomy.

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