Evidence on Indications and Techniques to Increase the Future Liver Remnant in Children Undergoing Extended Hepatectomy: A Systematic Review and Meta-Analysis of Individual Patient Data

Abstract

BackgroundTechniques to increase the future liver remnant (FLR) have fundamentally changed the indications and criteria of resectability in adult liver surgery. In pediatric patients however, these procedures have rarely been applied and the potential benefit or harm as well as suited indications are unclear.MethodsA systematic literature search of MEDLINE, Web of Science, and CENTRAL was conducted. Based on a PRISMA-compliant, predefined methodology, all studies reporting pediatric patients (< 18y) undergoing liver resection with either associating liver partition and portal vein ligation for stages hepatectomy (ALPPS) or preoperative portal vein embolization or ligation (PVE/PVL) were included. Baseline data, periinterventional morbidity, increase of FLR and outcomes were analyzed.Results15 studies reporting on 21 pediatric patients with a mean age of 4 years and 7 months (range 1.8 months – 17 years) were included. 12 ALPPS procedures, 8 PVE and 1 PVL were performed. The applied criteria for performing ALPPS or PVE were heterogenous and thresholds for minimally acceptable FLR varied. Mean FLR [% of total liver volume] before the intervention was 23.6% (range 15.0 – 39.3%) in the ALPPS group and 31.4% (range 21.5 – 56.0%) in the PVE group. Mean increase of FLR before stage 2 resection was 69.4% (range 19.0 – 103.8%) for ALPPS and 62.8% (range 25.0 – 108.0%) after PVE. No postoperative death occurred, one early intrahepatic recurrence after an ALPPS procedure was reported. Overall postoperative morbidity was 23.8%.ConclusionValidated criteria for minimal FLR in pediatric liver resection are lacking and so are clear indications for ALPPS or PVE. In special cases, ALPPS and PVE can be valuable techniques to achieve complete resection of pediatric liver tumors. However, more data are needed, and future studies should focus on a definition and validation of posthepatectomy liver failure as well as the minimally needed FLR in pediatric patients undergoing extended hepatectomy.Systematic Review Registration[www.clinicaltrials.gov], identifier [PROSPERO 2021 CRD42021274848].

Case Report: ALPPS hepatectomy, an alternative to liver transplantation in central PRETEXT III hepatoblastomas: a case series

“…This 25% threshold, primarily based on adult patient data, forms the most compelling argument for utilizing the ALPPS procedure in pediatric patients, despite the lack of contrasting information in this group. The procedure has been performed in cases with higher FLR-V; however, without specific pediatric data on acceptable thresholds, such decisions are heavily dependent on clinical expertise and judgment ( 14 ). In the scenario of hepatoblastoma patients, the preoperative use of chemotherapy places stress on the liver.…”

Case report: Portal vein ligation: lessons from patients with PRETEXT III hepatoblastoma in restoring future liver remnant before major hepatectomy and literature review

“…PVE and ALPPS have expanded the resectability of hepatic tumors. However, these techniques have not gained popularity in the pediatric population because extensive hepatectomy occurs less often, and preoperative hepatic function is usually preserved ( 6 ). Moreover, liver transplantation is now the standard treatment in pediatric patients with extensive hepatic tumors.…”

“…In a meta-analysis by Fuchs et al, eight cases of PVE, one case of PVL, and 12 cases of ALPPS were reviewed ( 4 , 6 , 7 ). A small-caliber portal vein and scarce experience with the embolic materials used in the adult population limit the expansion of PVE application to children.…”

“…This has been improved to associated liver partition and portal vein ligation (ALPPS) in recent years ( 5 ). However, few PVE cases have been attempted in the pediatric population as several difficulties exist relating to embolization ( 6 ). Challenges associated with the procedure and concerns about potential side effects have prevented the expansion of PVE application.…”

Surgical management in hepatoblastoma: points to take

“…Unfortunately, there is no clear definition of FLR in children and different limits were applied across the studies: FLR/TLV (total liver volume) < 15%, < 25%, < 30%, < 40% and FLR < 1.5% of body weight. [ 31 ] ALPPS allows for rapid hypertrophy of the FLR, and therefore, helps to avoid postoperative hepatic insufficiency [ 32 ].…”