Induction of liver hypertrophy for extended liver surgery and partial liver transplantation: State of the art of parenchyma augmentation–assisted liver surgery

Abstract

Background Liver surgery and transplantation currently represent the only curative treatment options for primary and secondary hepatic malignancies. Despite the ability of the liver to regenerate after tissue loss, 25–30% future liver remnant is considered the minimum requirement to prevent serious risk for post-hepatectomy liver failure. Purpose The aim of this review is to depict the various interventions for liver parenchyma augmentation–assisting surgery enabling extended liver resections. The article summarizes one- and two-stage procedures with a focus on hypertrophy- and corresponding resection rates. Conclusions To induce liver parenchymal augmentation prior to hepatectomy, most techniques rely on portal vein occlusion, but more recently inclusion of parenchymal splitting, hepatic vein occlusion, and partial liver transplantation has extended the technical armamentarium. Safely accomplishing major and ultimately total hepatectomy by these techniques requires integration into a meaningful oncological concept. The advent of highly effective chemotherapeutic regimen in the neo-adjuvant, interstage, and adjuvant setting has underlined an aggressive surgical approach in the given setting to convert formerly “palliative” disease into a curative and sometimes in a “chronic” disease.

Synchronous Two-Stage Hepatectomy With Associated Liver Partition and Portal Vein Ligation in Addition to Low Anterior Resection for Metastatic Rectal Cancer

“…A recent systematic review and meta-analysis on ALPPS and p-ALPPS showed that p-ALPPS is safer than ALPPS in patients without cirrhosis and exhibits the same rate of liver remnant hypertrophy. ALPPS appeared to have better outcomes in cirrhotic patients [ 11 , 12 ]. The best technique is yet to be determined.…”

Operative Therapiestrategien bei primären Lebertumoren, hepatozellulären und Cholangio- inkl. Gallenblasenkarzinomen

“…Restlebervolumen: Entweder wird das Restlebervolumen (RLV) in Prozent des Gesamtlebervolumens („future liver remnant volume to total liver volume percentage“, FLR/TLV) oder in Relation zum Körpergewicht („rest volume to body weight ratio“, RVBWR) angegeben. Bei nicht genügend RLV sind folgende Augmentationsverfahren des RLV möglich: Two-Stage-Hepatectomy, Pfortaderembolisation, Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy (ALPPS) 8 . Grundvoraussetzung für alle Verfahren ist eine vorbestehende regenerative Fähigkeit der Restleber, welche von grundliegender Qualität, Funktion und Durchblutung beeinträchtigt wird.…”

The Influence of Interdisciplinary Work towards Advancing Knowledge on Human Liver Physiology

“…Supported by the vast knowledge acquired throughout the years about liver regeneration and the improvement in surgical techniques, extensive hepatectomies are currently performed in patients with advanced liver cancer. In extreme cases, where surgeons anticipate that the size of the liver after resection will be too small, they have the ability to perform right portal vein embolization or ligation alone among other procedures, in order to promote liver parenchyma augmentation through a hypertrophic mechanism [ 35 ] ( Figure 2 B). These techniques have been developed based on the observation made a century ago, when it was recognized that the occlusion of a segment of the portal vein or the hepatic artery of the rabbit produces hypertrophy in the contralateral lobe while atrophy occurs in the side of occlusion [ 36 ].…”

“…These techniques have been developed based on the observation made a century ago, when it was recognized that the occlusion of a segment of the portal vein or the hepatic artery of the rabbit produces hypertrophy in the contralateral lobe while atrophy occurs in the side of occlusion [ 36 ]. Together, portal and hepatic vein embolization induce faster growth of the contralateral liver than portal vein embolization alone [ 35 ].…”