Preoperative embolization of the portal vein in malignant tumors of the liver: preliminary results

Preoperative embolization of the right portal vein and following hepatic resection were performed in seven patients with primary and secondary liver malignancies. The indication for the procedure was a small amount (30%) of the future remnant liver (FRL). The ultrasound-guided percutaneous transhepatic puncture of the portal vein and its embolization with gelatin sponge or silicon polymer was used. No complications of the procedure were noted. In 19-56 (mean 33) days computed or magnetic resonance tomography showed a significantly increased FRL volume (mean 40%). Right or extended right hepatectomy was performed in 5 and 2 patients respectively without lethal outcomes. A conclusion is made that the preoperative portal vein embolization is a safe and technically simple procedure that reduces the risk of postoperative hepatic failure after major liver resection.     

Contribution of hepatobiliary scintigraphy in assessing ALPPS most suited timing

To reduce post-hepatectomy liver failure (PHLF), associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) has been recently developed for patients with a limited future remnant liver (FRL). Nevertheless, high morbi-mortality rates have been reported . The current study aimed to analyze the kinetics of FRL function in patients who were offered ALPPS. Serial SPECT (99 m)Tc-mebrofenin hepatobiliary scintigraphy (HBS) was performed in all patients before and after surgery as well as at inter-stage to quantitatively assess hepatic function [total liver (TL) and FRL]. Patients were offered ALPPS for colorectal liver metastases (CLMs) (n = 6) and gallbladder carcinoma (n = 1). The data of delta of function or volume, expressed as (postoperative FRL ? preoperative FRL/preoperative FRL) were compared to those derived from HBS of patients referred to the university hospital of Lille for one-stage major hepatectomy (n = 93). Additionally, the intrinsic liver function (i.e. function per unit of volume) was used to assess the regeneration rate. All but one patient had an anticipated FRL to body weight ratio (FRLBWR) ≤0.5%. Inter-stages HBS showed a progressive attenuation of the functional value of the excluded hepatic segments in favour of the FRL for all patients. Overall, there was a drop of total liver function contrasting with subnormal passive biochemical tests. Notably, the increase in FRL function between ALPPS stages [+12.5% (4.2–28.6%)] was lower than the volumetric gain [+42.6% (18.3–110.2%)] and inferior to that observed after one-stage major hepatectomy [+41.7% (?38.6 to +158.33%)]. This resulted in a drop of the FRL intrinsic liver function in ALPPS patients, of whom one died from PHLF. Our study enhances the importance of assessing liver function along with volume during ALPPS procedure and supports HBS as a suitable and reliable method, including a valuable contribution to determine most appropriate stage 2 surgical timing.     

Postoperative Liver Dysfunction and Future Remnant Liver: Where Is the Limit?

Background The future remnant liver (FRL) limit for safe major hepatectomy with low risk of postoperative liver failure has not yet been well defined. Methods Between April 2000 and September 2004, every patient scheduled for major hepatectomy in our institution underwent CT-volumetry of FRL. Patients with FRL <25% underwent portal vein embolization (PVE). Exclusion criteria were PVE, associated vascular resection and liver cirrhosis. The FRL was correlated with short-term results in patients with normal liver (group A) and those with impaired liver function secondary to neoadjuvant chemotherapy or cholestasis (bilirubin >2 mg/100 ml) (group B). Liver dysfunction was defined as both PT <50% and serum bilirubin level >5 mg/100 ml for three or more consecutive days. Results A total of 119 patients were analyzed, 72 in group A and 47 in group B. The FRL value was the only significant risk factor for postoperative liver dysfunction in the univariate and multivariate analysis (p = 0.009). The FRL did not correlate with postoperative mortality and morbidity. Bilirubin and prothrombin time (PT) on days 3 and 7 were significantly correlated to FRL in both groups. In group A, patients with postoperative liver dysfunction had a FRL<30% (3 versus 0; p = 0.005). According to receiving operator characteristic (ROC) curve analysis, a FRL value of 26.5% predicted postoperative liver dysfunction with 66.7% sensitivity, 97.1% specificity, 50% positive predictive value (PPV), and 98.5% negative predictive value (NPV). In group B, patients with postoperative liver dysfunction had a FRL <35% (4 versus 0; p = 0.027). According to ROC curve analysis, a FRL value of 31.05% predicted postoperative liver dysfunction with 75% sensitivity, 79.1% specificity, 25% PPV, and 97.1% NPV. Conclusions Hepatectomy can be considered safe when FRL is >26.5% in patients with healthy liver and >31% in patients with impaired liver function.     

余肝不足肝癌手术治疗争议与共识

手术切除是肝癌病人获得长期生存的主要治疗方式。近年来肝脏外科进展迅速,手术适应证不断扩大。肝脏解剖复杂性和手术操作已不再是肝脏外科发展的障碍,剩余肝足够与否成为限制肝脏手术的瓶颈。目前,人工肝支持技术尚不成熟,余肝不足肝癌手术的主要策略是诱导余肝增生然后再切除肿瘤的二步切除法,以及针对原发或转移性肿瘤的降期或转化治疗。二步切除的主要方法目前仍为门静脉栓塞（PVE）或门静脉结扎（PVL）的二步肝切除术。对于肝细胞肝癌,联合肝动脉化疗栓塞可进一步改善治疗效果。近年来,联合肝脏分隔和门静脉结扎的二步肝切除术（ALPPS）的出现为余肝不足的肝癌手术带来新的突破。该方法可在短时间内诱导显著的肝脏增生,但是术后并发症发生率和手术死亡率较高,在手术安全性及肿瘤转归方面尚有争议。近年来原发或转移性肝癌的降期或转化治疗伴随着非手术技术的进步,亦有很大进展,已使越来越多的病人能够手术获益。     

A two-stage hepatectomy procedure combined with portal vein embolization to achieve curative resection for initially unresectable multiple and bilobar colorectal liver metastases

OBJECTIVE: To assess outcome after a 2-stage hepatectomy procedure (TSHP) combined with portal vein embolization (PVE) in the treatment of patients with unresectable multiple and bilobar colorectal liver metastases (MBCLM). BACKGROUND: Patients with MBCLM are often considered for palliative chemotherapy only, due to too small future remnant liver (FRL). Recently, right hepatectomy with simultaneous left liver wedge resections after previous right PVE has been reported in a curative intent. However, the growth of metastatic nodules in FRL after PVE can be more rapid than that of the nontumoral remnant hepatic parenchyma. Therefore, metastases located in the FRL should be ideally resected before PVE. Then, a right (or extended right) hepatectomy can be safely performed during a second-stage hepatectomy. Therefore, we analyzed our experience with the use of TSHP combined with PVE in treatment of MBCLM. PATIENTS AND METHODS: Between December 1996 and April 2003, 33 patients with unresectable MBCLM were selected for a TSHP. A right or an extended right hepatectomy was planned after treatment of left FRL metastases to achieve a curative resection. The first-stage hepatectomy consisted in a clearance of the left hemiliver by resection or radiofrequency destruction of metastases of the left FRL. Subsequently, a right PVE was performed to induce atrophy of the right hemiliver and hypertrophy of the left hemiliver. Finally, a second-stage hepatectomy was planned to resect the right liver metastases. RESULTS: There was no operative mortality. Post-PVE morbidity was 18.1%; postoperative morbidity was 15.1% and 56.0% after first- and second-stage hepatectomy, respectively. TSHP could be achieved in 25 of 33 patients (75.7%). The 1- and 3-year survival rates were 70.0% and 54.4%, respectively, in the 25 patients in whom the TSHP was completed. CONCLUSIONS: In selected patients with initially unresectable MBCLM, a TSHP combined with PVE can be achieved safely with long-term survival similar to that observed in patients with initially resectable liver metastases.     

Sinusoidal obstruction syndrome compromises liver regeneration in patients undergoing two-stage hepatectomy with portal vein embolization

Purpose

Several factors have been reported to affect liver regeneration after portal vein embolization (PVE); however, the effect of sinusoidal obstruction syndrome (SOS) has not been evaluated. Therefore, we assessed the effect of SOS on liver regeneration after PVE in patients with multiple bilobar colorectal liver metastases scheduled to undergo two-stage hepatectomy (TSH) combined with PVE.

Methods

The subjects of this study were 78 patients prospectively scheduled to undergo TSH between December 1996 and August 2009. Archived formalin-fixed, paraffin-embedded nontumoral tissue samples were collected from the 1st- and 2nd-stage hepatectomies in 42 and 45 patients, respectively, and SOS and steatohepatitis were diagnosed pathologically. We analyzed the clinicopathological variables affecting liver regeneration after PVE.

Results

Sinusoidal obstruction syndrome was diagnosed in 11 (26.2%) and 20 patients (44.4%) at the time of the 1st- and 2nd-stage hepatectomy, respectively. Patients with SOS at the 1st-stage hepatectomy had a significantly lower hypertrophy ratio of the future remnant liver (FRL) after PVE than patients without SOS (16.8 ± 24.0 vs 55.6 ± 32.5; P < 0.001). Multivariate logistic regression analysis revealed that SOS was an independent factor predicting lower FRL hypertrophy after PVE (??% FRL <20: hazard ratio 31.7, 95% confidence interval 2.84?C355.12; P = 0.005). The incidence of postoperative transient liver failure after the 2nd-stage hepatectomy in patients presenting with SOS was higher than that in those without SOS, but the difference did not reach significance (25.0% vs 4.0%; P = 0.052). Steatohepatitis was confirmed at the 1st- and 2nd-stage hepatectomy in 6 (14.3%) and 3 (6.7%) patients, respectively.

Conclusion

Sinusoidal obstruction syndrome inhibits FRL hypertrophy after PVE and induces postoperative liver failure. Therefore, an alternative strategy is needed to perform TSH safely in the presence of SOS.     

Hepatic Hemodynamic Changes Following Stepwise Liver Resection

Aim

Extended liver resection has increased during the last decades. However, hepatic hemodynamic changes after resection and the consequent complications like post hepatectomy liver failure are still a challenging issue. The aim of this study was to systematically evaluate the role of stepwise liver resection on hepatic hemodynamic changes.

Methods

To evaluate this effect we performed 25, 50, and 75 % sequential liver resections in 10 pigs. Before and after each resection, the hepatic artery flow and portal vein flow in relation to the remnant liver volume (RLV) as well as hepatic vascular pressures were measured and compared between the groups.

Results

Following sequential liver resection, the hepatic artery flow /100 g decreases and the portal vein flow increases up to 17 and 167 % following extended liver resection (75 %), respectively. Also, during stepwise liver resection, the portal vein pressure increases gradually up to 33 % following extended hepatectomy (75 %).

Conclusion

Sequential decrease in the RLV decreases the hepatic artery flow /100 g and increases the portal vein flow /100 g and portal vein pressure. As the consequence, the liver goes under more poor-oxygenated blood supply and higher pressure. This may be one of the most important mechanisms of the post hepatectomy liver failure in case of extended liver resection.

     

Associating liver partition and portal vein ligation for staged hepatectomy in the treatment of colorectal cancer liver metastases

Colorectal cancer (CRC) is a common malignancy of the digestive system. Colorectal liver cancer metastasis (CRLM) occurs in approximately 50% of the patients and is the main cause of CRC mortality. Surgical resection is currently the most effective treatment for CRLM. However, given that the remnant liver volume after resection should be adequate, only a few patients are suitable for radical resection. Since Dr. Hans Schlitt first performed the associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) for CRLM in 2012, ALPPS has received considerable attention and has continually evolved in recent years. This review explains the technical origin of the ALPPS procedure for CRLM and evaluates its efficacy, pointing to its favorable postoperative outcomes. We also discuss the patient screening strategies and optimization of ALPPS to ensure long-term survival of patients with CRLM in whom surgery cannot be performed. Finally, further directions in both basic and clinical research regarding ALPPS have been proposed. Although ALPPS surgery is a difficult and high-risk technique, it is still worth exploration by experienced surgeons.     

Selective versus total biliary drainage for obstructive jaundice caused by a hepatobiliary malignancy

BACKGROUND: Controversy exists regarding which approach is preferable among types of biliary drainage for obstructive jaundice before major hepatectomy: selective biliary drainage (SBD) only on the future remnant liver (FRL) or total biliary drainage (TBD). METHODS: There were 42 consecutive patients who underwent SBD (n = 15) or TBD (n = 27) for obstructive jaundice caused by a hepatobiliary malignancy, and subsequent portal vein embolization (PVE) before extended hemihepatectomy. The hypertrophy ratio, defined as the ratio of the FRL volume after PVE to that before PVE, was evaluated. The bilirubin clearance also was calculated. RESULTS: The hypertrophy ratio was higher in patients with SBD than in those with TBD (median, 128%; range, 111-152% vs median, 121%; range, 102-138%; P = .013). The bilirubin clearance of FRL with SBD was markedly improved after PVE compared with that in patients with TBD. CONCLUSIONS: SBD is superior to TBD in promoting hypertrophy of the FRL induced by PVE and in guaranteeing good liver function before major hepatectomy.     

Functional portal flow competition after auxiliary partial orthotopic living donor liver transplantation in noncirrhotic metabolic liver disease

Auxilliary partial orthotopic liver transplantation (APOLT) was introduced initially as a tentative or permanent support for patients with potentially reversible fulminant hepatic failure and has extended its indication to congenital metabolic disorder of the liver that has otherwise normal functional integrity. Postoperative management of APOLT is complicated because of functional portal flow competition between the native and graft liver. The native portal vein diversion to the graft is sometimes indicated to prevent functional competition; however, it is still an open question whether this technique can be theoretically indicated for APOLT patients. The authors report a on patient with ornithine transcarbamylase deficiency who received APOLT from a living donor without native portal vein diversion. Because of functional portal vein competition between the native and graft liver, the patient had to have portal vein diversion, portal vein embolization, and finally native hepatectomy to induce the graft regeneration after APOLT. After the experience of the current case, primary portal vein diversion for APOLT with noncirrhotic metabolic liver disease patients to prevent functional portal flow competition is recommended.     

肝静脉剥夺术——残余肝脏不足时手术新思路

肝静脉剥夺术（liver venous deprivation,LVD）是近年来两步法肝切除最新开展的手术方式,以联合应用门静脉栓塞（portal vein embolization,PVE）和肝静脉栓塞（hepatic vein embolization,HVE）的方式来达到使残余肝脏（future liver remnant,FLR）快速增生的目的。LVD相比于之前开展的单纯PVE和联合肝脏分隔和门静脉结扎二步肝切除术（associating liver partition and portal vein ligation for staged hepatectomy,ALPPS）,在达到了FLR迅速增生的同时,对病人造成更小的损伤,其并发症发生率和病死率也远远低于ALPPS。这也使得更多的肝脏恶性肿瘤病人获得了R0切除的机会。     

Nonsuperiority of technetium-99m-galactosyl human serum albumin scintigraphy over conventional volumetry for assessing the future liver remnant in patients undergoing hepatectomy after portal vein embolization

BackgroundTechnetium-99m-galactosyl human serum albumin scintigraphy is preferred for assessing the liver functional reserve in patients undergoing hepatectomy, but its superiority over computed tomography volumetry after portal vein embolization and subsequent hepatectomy remains elusive. We aimed to compare technetium-99m-galactosyl human serum albumin scintigraphy with conventional computed tomography volumetry for predicting posthepatectomy liver failure in patients after portal vein embolization.MethodsThis retrospective study analyzed 152 consecutive patients who underwent hepatobiliary cancer resection after portal vein embolization between 2006 and 2021. Posthepatectomy liver failure was graded according to the International Study Group of Liver Surgery criteria. The predictive abilities for posthepatectomy liver failure were compared between the future remnant uptake (%) by technetium-99m-galactosyl human serum albumin scintigraphy and the future remnant volume (%) by computed tomography volumetry.ResultsFuture remnant uptake (%) was significantly greater than future remnant volume (%) after portal vein embolization (47.9% vs 40.8%; P < .001), while the values were comparable before portal vein embolization (32.7% vs 31.2%; P = .116). Receiver operating characteristic curve analysis revealed that post–portal vein embolization future remnant volume (%) had a significantly higher area under the curve than post–portal vein embolization future remnant uptake (%) (0.709 vs 0.630; P = .046) for predicting posthepatectomy liver failure. Multivariable analysis revealed that post–portal vein embolization future remnant volume (%) independently predicted posthepatectomy liver failure, but future remnant uptake (%) did not. Although the incidence of posthepatectomy liver failure grade ≥B was 17.8% when indocyanine green–clearance of the future liver remnant based on both future remnant volume (%) and future remnant uptake (%) was ≥0.05, it was higher in other combinations: 55.6% for indocyanine green clearance of the remnant volume ≥0.05/indocyanine green clearance of the remnant uptake ≤0.05; 50.0% for indocyanine green clearance of the remnant volume ≤0.05/indocyanine green clearance of the remnant uptake ≥0.05; and 50% for indocyanine green clearance of the remnant volume ≤0.05/indocyanine green clearance of the remnant uptake ≤0.05.ConclusionsTechnetium-99m-galactosyl human serum albumin scintigraphy is not superior to computed tomography volumetry for assessing the future liver remnant in patients undergoing major hepatectomy after portal vein embolization.     

Successful treatment of CCl4-induced acute liver failure with portal vein arterialization in the rat

BACKGROUND: Optimization of the conditions for regeneration is a major goal in the management of patients with acute liver failure (ALF). Previous observations suggested that hyperoxygenation of the liver may improve its regenerative capacity. Thus, this study aimed to determine whether an additional supply of oxygenated blood achieved by portal vein arterialization (PVA) is protective in rat ALF caused by toxin administration or hepatectomy. METHODS: Sprague-Dawley rats were subjected or not to PVA after CCl(4) intoxication or extended hepatectomy. PVA was performed by interposing a stent between the left renal artery and splenic vein after left nephrectomy and splenectomy. Liver injury was evaluated by the serum ALT level and necrotic cell count. Hepatocyte regeneration was assessed by calculating the mitotic index and bromodeoxyuridine (BrdU) staining. The 10-day survival was assessed in separate experimental groups. RESULTS: The pO(2) in portal blood increased significantly following PVA. In the CCl(4)-induced ALF, serum ALT levels and necrosis were significantly reduced in arterialized than non-arterialized rats. PVA greatly promotes liver regeneration in both models. Finally, PVA significantly improved survival compared to controls (CCl(4): 100 versus 40%; 90% hepatectomy: 90 versus 30%). Interestingly, in the CCl(4)-induced ALF, survival was 100% even when the shunt was closed after 48 h. CONCLUSION: These data indicate that the additional supply of arterial oxygenated blood through PVA promotes a rapid regeneration leading to the resolution of toxic-induced massive liver necrosis and a faster restoration of liver mass after partial hepatectomy in rats. Thus, PVA may represent a novel tool for optimizing hepatocyte regeneration.     

猪急性缺血性肝衰模型的建立和辅助性异位部分肝移植的作用

目的: 探讨急性缺血性肝衰模型的制备、辅助性异位部分肝移植的作用. 方法: 用家猪配对开展辅助性异位部分肝移植.分三组,A组:受体肝脏和肝动脉保持原状,其门静脉缩窄;供肝植入受体右肝下,仅建立门静脉血供,不建立动脉血供.B组:受体肝动脉结扎,其他手术内容与A组相同.C组:受体肝动脉结扎,供肝动脉和门静脉血供均建立,其他手术内容与A组相同.监测各组受体存活情况,肝功能和肝脏血流情况,病理及供肝胆汁分泌情况. 结果: A组、C组受体3 d以上成活率显著高于B组.A组、C组手术前后胆红素无显著改变,B组术后胆红素显著高于术前,术后第二天B组胆红素显著高于A组、C组.C组供肝胆汁分泌和血供良好,肝细胞存活并有活跃的代偿性增生;A组、B组供肝无或仅有少量胆汁分泌,肝细胞大片坏死. 结论: 受体肝动脉结扎、门静脉缩窄足以造成急性肝衰模型;保留受体肝脏动脉血供、减少门静脉血供对受体肝脏功能无严重影响;辅助性异位部分肝移植能取得良好的效果,足以纠正急性肝衰.     

Usefulness of measuring hepatic functional volume using Technetium-99m galactosyl serum albumin scintigraphy in bile duct carcinoma: report of two cases

We report the usefulness of measuring functional liver volume in two patients undergoing hepatectomy. Case 1 involved a 47-year-old man with hepatitis B virus infection. The indocyanine green test retention rate at 15 min (ICGR15) was 14%. Liver uptake ratio (LHL15) by technetium-99 m galactosyl human serum albumin (^99mTc-GSA) liver scintigraphy was 0.91. The patient displayed hilar bile duct carcinoma necessitating right hepatectomy. After preoperative portal vein embolization (PVE), future remnant liver volume became 54% and functional volume by ^99mTc-GSA became 79%. Although the permitted resected liver volume was lower than the liver volume, scheduled hepatectomy was performed following the results of functional liver volume. Case 2 involved a 75-year-old man with diabetes. ICGR15 was 27.4% and LHL15 was 0.87. The patient displayed bile duct carcinoma located in the upper bile duct with biliary obstruction in the right lateral sector. The right hepatectomy was scheduled. After PVE, future remnant volume became 68% and functional volume became 88%. Although ICGR15 was worse as 31%, planned hepatectomy was performed due to the results of functional volume. In the liver with biliary obstruction or portal embolization, functional liver volume is decreased more than morphological volume. Measurement of functional volume provides useful information for deciding operative indication.     

Preoperative selective portal vein embolization before hepatectomy for liver metastases: long-term results and impact on survival

BACKGROUND: Some patients cannot undergo curative surgical procedures for liver metastases because of the risk of severe postoperative hepatic failure, which stems from a too-small future remaining liver (FRL). Preoperative portal vein embolization (PVE) is an effective means of creating hypertrophy of the FRL, thus permitting safe hepatic resection. The aim of this retrospective study was to investigate the long-term results of this technique. METHODS: Sixty-eight patients underwent PVE. Of those, 60 (88%) subsequently underwent hepatic resection. Indication for PVE was an estimated FRL ratio (assessed by volumetric computed tomography) of less than 30%. However, if the patient had undergone multiple courses of chemotherapy, the threshold was 40%. The origin of the primary neoplasm was colorectal in 41 patients (68%); in the remaining 19 (32%), the primary neoplasms originated at other sites. RESULTS: Mean growth of the estimated FRL measured by computed tomography 1 month after PVE was 13%. Major complications after hepatectomy occurred in 27% of the patients, and the operative mortality rate was 3%. For the 60 patients who underwent PVE followed by hepatic resection, the 5-year overall survival rate and the disease-free survival rate were 34% and 24%, respectively. The 5-year overall survival rate and the disease-free survival rate of patients with colorectal metastases only were 37% and 21%, respectively. CONCLUSIONS: The long-term survival rate after PVE followed by resection is comparable with the survival rate obtained after resection without preoperative PVE. The 5-year survival rate of patients undergoing PVE followed by hepatectomy justifies the use of this technique. This technique thus increases the suitability of resection as a treatment choice for patients with liver metastases. PVE should number among the therapeutic options available to every hepatic surgeon.     

联合肝脏分隔和门静脉结扎二步肝切除术治疗传统不可切除肝癌之进展

近年来,肝癌综合治疗进展显著,但手术切除仍为肝癌病人获得长期生存的主要治疗方式。随着肝脏外科的快速发展,肝脏解剖学的复杂性和手术操作已不再是肝脏手术的主要障碍,肝切除术后剩余肝脏体积不足成为肝脏手术的主要限制因素。临床上多数肝癌病人因此无法行一期根治性切除术,只能接受非手术治疗,长期预后较差。联合肝脏分隔和门静脉结扎二...     

Efficacy of preoperative portal vein embolization prior to major hepatectomy for patients with impaired liver function: A retrospective study

Hepatocellular carcinoma (HCC) is often associated with chronic liver disease, such as hepatitis or cirrhosis, and this association may limit the use of surgery as a therapy, and if surgery is pursued, may give rise to postoperative hepatic failure. We evaluated the outcome in patients with HCC given preoperative portal vein embolization (PVE) before they underwent major hepatectomy. After PVE, portal pressure increased significantly. Two weeks after PVE, both the volume of the non-embolized lobe and the 15-min indocyamine green retention rate (ICG R15) were significantly increased. The prognostic score, calculated on the basis of age, ICG R15, and the resection rate, was significantly decreased. The operative mortality rate was significantly lower in patients who underwent PVE before surgery than in patients who did not receive PVE. The cumulative survival rate of the PVE patients, even those with cirrhosis of the liver, was significantly higher. Prior PVE appears to allow more extensive major hepatectomy and to lessen the risk of this invasive surgery. However, patients in whom the portal pressure immediately after PVE was more than 30cm H₂O and/or whose prognostic score exceeded 50 points developed postoperative hepatic failure. These features should be kept in mind when it is decided whether surgery is indicated. Nevertheless, preoperative PVE appears to be a beneficial procedure for patients undergoing major hepatectomy, particularly those with chronic liver disease.     

Is there new hope for patients with marginally resectable liver malignancies

Advances in surgical technique and better perioperative management have significantly improved patient outcomes after liver surgery. Even major hepatectomy can be performed safely with low morbidity and mortality. Post-resection liver failure is among the most feared complications after extended hepatectomy. In order to increase the future liver remnant (FLR) and to expand the pool of candidates for surgical resection, Schnitzbauer et al recently presented a new 2-stage surgical approach which combines right portal vein ligation (rPVL) with in situ splitting (ISS) of the liver parenchyma. In comparison to other current strategies, such as interventional portal vein embolization, hypertrophy of the FLR was more pronounced (median volume increase = 74%; range: 21%-192%) and more rapid (after a median of 9 d; range:5-28 d) after rPVL and ISS. In this commentary, we discuss the technical aspects and clinical impact of rPVL combined with ISS. Based on the reported data, this new 2-stage therapeutic approach represents a promising new strategy for patients with locally advanced liver disease, previously regarded as marginally resectable or even unresectable, potentially enabling curative resection. However, morbidity is significant and mortality not negligible.