Volume and flow modulation strategies to mitigate post-hepatectomy liver failure

Abstract

IntroductionPost hepatectomy liver failure is the most common cause of death following major hepatic resections with a perioperative mortality rate between 40% to 60%. Various strategies have been devised to increase the volume and function of future liver remnant (FLR). This study aims to review the strategies used for volume and flow modulation to reduce the incidence of post hepatectomy liver failure.MethodAn electronic search was performed of the MEDLINE, EMBASE and PubMed databases from 2000 to 2022 using the following search strategy “Post hepatectomy liver failure”, “flow modulation”, “small for size flow syndrome”, “portal vein embolization”, “dual vein embolization”, “ALPPS” and “staged hepatectomy” to identify all articles published relating to this topic.ResultsVolume and flow modulation strategies have evolved over time to maximize the volume and function of FLR to mitigate the risk of PHLF. Portal vein with or without hepatic vein embolization/ligation, ALPPS, and staged hepatectomy have resulted in significant hypertrophy and kinetic growth of FLR. Similarly, techniques including portal flow diversion, splenic artery ligation, splenectomy and pharmacological agents like somatostatin and terlipressin are employed to reduce the risk of small for size flow syndrome SFSF syndrome by decreasing portal venous flow and increasing hepatic artery flow at the same time.ConclusionThe current review outlines the various strategies of volume and flow modulation that can be used in isolation or combination in the management of patients at risk of PHLF.

The Impact of Liver Resection Volume on Pancreatic Function: Novel Insights into Acute Liver-Pancreas Crosstalk After Hepatectomy

“…15 Following hepatectomy, diverting the whole portal ow to the remnant liver causes an increase in portal venous pressure. 21,22 This transitional portal venous overpressure can lead to postoperative liver failure as well as pancreatic vein congestion. Moreover, pancreatic congestion can be linked to impaired pancreatic function.…”

Metodologías de Medición de Volumetría Hepática

“…Desde el mito de Prometeo, se sabe que el hígado puede soportar sucesivas amputaciones y regenerarse. Incluso se ha sobrestimado esta capacidad, reportándose resecciones de hasta el 90 % del órgano; sin embargo, existe evidencia que soporta el hecho que las resecciones que superan las dos terceras partes del volumen hepático funcional se asocian con un riesgo significativo de morbimortalidad (Xu et al, 2017;Bell et al, 2022).…”

Navigating Complex Challenges: Preoperative Assessment and Surgical Strategies for Liver Resection in Patients with Fibrosis or Cirrhosis

“…Portal flow modulation is a surgical technique used to optimize blood flow to the liver after hepatic resection. It involves adjusting the hepatic artery and portal vein inflow to ensure optimal perfusion to the liver remnant to prevent irreversible sinusoidal injury from high portal vein pressures [ 76 ]. This concept was initially applied in living donor liver transplantation but has shown positive outcomes when used in patients with cirrhosis [ 76 , 77 , 78 ].…”

“…It involves adjusting the hepatic artery and portal vein inflow to ensure optimal perfusion to the liver remnant to prevent irreversible sinusoidal injury from high portal vein pressures [ 76 ]. This concept was initially applied in living donor liver transplantation but has shown positive outcomes when used in patients with cirrhosis [ 76 , 77 , 78 ]. Commonly employed techniques to accomplish portal flow modulation include portal flow diversion, splenectomy, and splenic artery ligation [ 76 ].…”

“…This concept was initially applied in living donor liver transplantation but has shown positive outcomes when used in patients with cirrhosis [ 76 , 77 , 78 ]. Commonly employed techniques to accomplish portal flow modulation include portal flow diversion, splenectomy, and splenic artery ligation [ 76 ].…”