Analysis of the Efficacy of Portal Vein Embolization for Patients with Extensive Liver Malignancy and Very Low Future Liver Remnant Volume, Including a Comparison with the Associating Liver Partition with Portal Vein Ligation for Staged Hepatectomy Approach

Abstract

Background The primary reported indication for the Associating Liver Partition with Portal vein Ligation for Staged hepatectomy (ALPPS) technique is in patients with very low future liver remnant volumes. Given the elevated incidence of major morbidity (40%) and liver-related mortality (12%) with ALPPS, we sought to determine the safety and efficacy of percutaneous portal vein embolization (PVE) in a similar patient population. Patients and Methods Tumor resectability and morbidity/mortality rates were reviewed for 144 consecutive liver tumor patients with future liver remnant to body weight ratios (LR/BW) less than 0.5%. All patients were referred for preoperative percutaneous right plus segment IV PVE using embolic microspheres, with planned reassessment of the LR/BW 30 days after PVE. Post-PVE outcomes were compared to reported outcomes for ALPPS. Results Percutaneous PVE was successfully performed in 141 of the 144 study patients (97.9%). Adequate regeneration was observed in 139 patients (98.5%) with median post-PVE LR/BW rising from 0.33% to 0.52% (p<0.0001), representing a per-patient median regeneration of 62% (range: 0.3 – 379%). In total, 104 patients underwent extended right hepatectomy (n=102) or right hepatectomy (n=2). The remaining 40 patients (27.8%) were not resectable due to short-interval disease progression (27 patients, 18.5%), insufficient liver regeneration (5 patients, 3.5%), and medical comorbidities (8 patients, 5.6%). After resection, the following outcomes were observed: major morbidity: 33.0% (34/104), liver insufficiency: 12.5% (13/104), and 90-day liver-related mortality: 5.8% (6/104). These oncologic and technical results compare favorably to those of ALPPS. Conclusion Based on its ability to select oncologically resectable patients and superior safety and efficacy profiles, percutaneous right+segment IV PVE and interval surgery remains the standard of care for patients with very low future liver remnant volumes.

Retraction: A systematic review and meta-analysis of feasibility, safety and efficacy of associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) versus two-stage hepatectomy (TSH)

“…Patients were carefully screened for double reporting. inclusion criteria (1,2,8). All studies were retrospective.…”

ALPPS readdresses the management of advanced liver tumors

“…So they recommended that percutaneous PVE and interval surgery remained the standard of management for patients with low FLR volume. 21 Furthermore, Schadde et al drawed conclusions from 202 cases that incidence of severe complications including mortalities (Clavien-Dindo ≥IIIb) was 27% while Ninety-day mortality was 9% (19/202). 3 They also found that the red blood cell transfusion, ALPPS stage I operating time greater than 300 minutes, age more than 60 years, and non-CRLM were all Independent factors for severe complications.…”

The role of bile salts in liver regeneration

“…Occlusion of the portal vein branches supplying the tumor-bearing segments results in atrophy of these segments and compensatory growth of the contralateral segments. With this technique the size of the FRLV can be increased up to 62 % of the original FRLV [5,6].…”