Salvage parenchymal liver transection for patients with insufficient volume increase after portal vein occlusion -- an extension of the ALPPS approach

Abstract

Background: Portal vein ligation (PVL) or embolization (PVE) are standard approaches to induce liver hypertrophy of the future liver remnant (FLR) prior to hepatectomy in primarily non-resectable liver tumors. However, this approach fails in about one third of patients. Recently, the new "ALPPS" approach has been described that combines PVL with parenchymal transection to induce rapid liver hypertrophy. This series explores whether isolated parenchymal transection boosts liver hypertrophy in scenarios of failed PVL/PVE.

Methods: A multicenter database with 170 patients undergoing portal vein manipulation to increase the size of the FLR was screened for patients undergoing isolated parenchymal transection as a salvage procedure. Three patients who underwent PVL/PVE with subsequent insufficient volume gain and subsequently underwent parenchymal liver transection as a salvage procedure were identified. Patient characteristics, volume increase, postoperative complications and outcomes were analyzed.

Results: The first patient underwent liver transection 16 weeks after failed PVL with a standardized FLR (sFLR) of 30%, which increased to 47% in 7 days. The second patient showed a sFLR of 25% 28 weeks after PVL and subsequent PVE of segment IV, which increased to 41% in 7 days after transection. The third patient underwent liver partition 8 weeks after PVE with a sFLR of 19%, which increased to 37% in six days. All patients underwent a R0 resection.

Conclusion: Failed PVE or PVL appears to represent a good indication for the isolated parenchymal liver transection according to the newly developed ALPPS approach.

Keywords: ALPPS; CRLM; CT; FLR; Hepatectomy; INR; International normalized ratio; Liver neoplasms; Liver regeneration; Liver transection; MRI; PVE; PVL; PVO; SOS; Salvage; associating liver partition and portal vein ligation for staged hepatectomy; colorectal liver metastases; computer tomography; future liver remnant; magnetic resonance imaging; portal vein embolization; portal vein ligation; portal vein occlusion; sFLR; sFLR0; sFLR1; sFLR2; sinusoidal obstruction syndrome; standardized future liver remnant; standardized future liver remnant prior to PVO; standardized future liver remnant prior to resection; standardized future liver remnant prior to transection.