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.

Keywords: Associating liver partition and portal vein ligation for staged hepatectomy; Liver augmentation; Liver surgery; Portal vein embolization; Transarterial chemoembolization; Two-staged hepatectomy.

Fig. 1

Patient with a large single tumor potentially resectable by single stage hepatectomy but with a small FLR (A). Portal vein embolization of the tumor-bearing side can be used for tissue augmentation (B). After sufficient hypertrophy (C), typically 4–8 weeks after embolization, completion hepatectomy is performed (D)

Fig. 2

Patient with a large single tumor (A) that is amenable to a single stage hepatectomy, but has an insufficient FLR requires tissue augmentation by combined portal vein- and hepatic vein embolization of the tumor-bearing side (B). After sufficient hypertrophy (C), typically 4–8 weeks after embolization, completion hepatectomy is performed (D)

Fig. 3

Clinical case of transarterial chemoembolization and sequential portal vein embolization (University of Zurich). This 69-year-old patient presented with a 7-cm hepatocellular carcinoma (HCC) in liver segments V/VIII and an alpha-fetoprotein (AFP) of 42.649 μg/l (A/B). No portal hypertension or liver cirrhosis was present. For a right hemihepatectomy, a sFLR of 27% was calculated. Since the indocyanine green (ICG) test showed impaired liver function with a plasma disappearance rate (PDR) of 12.1%/min (normal value >18%/min) and ICG retention rate (R₁₅) of 14.7% (normal value <10%), we opted for transarterial chemoembolization (C/D)followed by portal vein embolization 2 weeks later (E/F). After the successful embolization, the AFP dropped to 209 μg/l and the sFLR increased to 39% (G/H). We then performed a right hemihepatectomy (I/J). Three months postoperatively, the patient is tumor-free and in a good general condition

Fig. 4

In patients with large hepatic tumors, underlying liver disease, and small FLR (A), portal vein embolization can be combined with sequential transarterial chemoembolization. For this approach, selective catheterization of the right hepatic artery is performed, then chemotherapy is infused into the selected feeding artery (B). Two to 4 weeks later, this procedure is followed by portal vein embolization (C). After sufficient hypertrophy (D), completion hepatectomy is performed (E)

Fig. 5

In case of extensive bilobar tumorload (A), a two-staged approach may be necessary. This can be a conventional TSH with portal vein ligation and clearing of the FLR in a first step (B). After an interstage interval of 4–8 weeks (C), completion hepatectomy is performed after sufficient hypertrophy of the FLR (D)

Fig. 6

As an alternative to a conventional TSH, associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) can be performed for extensive bilobar tumorload (A). In the first stage portal vein ligation, clearing of the FLR and liver transection is performed (B). After an interstage interval of 1–2 weeks (C), sufficient hypertrophy is observed and completion hepatectomy is performed (D)

Fig. 7

Clinical case of associating liver partition and portal vein ligation for staged hepatectomy (University of Zurich). We present the case of a 61-year-old patient with synchronous bilobar colorectal liver metastases (A/B). After neo-adjuvant therapy with folinic acid, oxaliplatin, fluorouracil (FOLFOX), and panitumumab, a liver first approach was chosen (C/D). Due to a small sFLR of 18% (E), we decided to perform a two-staged hepatectomy. In the first stage, clearing of the left hemi-liver with four atypical resections, 50% parenchymal transection, and right-sided portal vein ligation were performed (C). Eight days later, and after an increase of the sFLR to 29% (F), we performed completion hepatectomy (G) (H). Two months after ALPPS, the patient was scheduled for adjuvant chemotherapy

Fig. 8

The RAPID approach combines resection with partial liver segment 2/3 transplantation and delayed total hepatectomy for bilobar liver metastases (A). In a first step, segments 1–3 are removed, in combination with right portal vein ligation (B) and transplantation of a left partial allograft (C). After sufficient regeneration, the native right hemi-liver is removed in a second step (D)

Fig. 9

Clinical case of RAPID approach in a cirrhotic patient with portal hypertension and hepatocellular carcinoma (Ankara University School of Medicine) [106]. After removing segments 1–3 (A/B), a small left lobe graft (segments 2, 3, 4; graft-to-recipient weight ratio 0.35) was transplanted (C). Due to the portal hypertension, inflow modification was necessary and a hemiportocaval shunt was created that re-routed approximately two-thirds of portal flow to the inferior vena cava decreasing the portal pressure from 24 to 14 mmHg. After 22 days, hepatobiliary scintigraphy showed an almost 70% functional shift to the left lobe graft (D), and there was a 56% graft volume hypertrophy (E, F). In the second stage, the right hemi-liver was removed, with closure of the hemiportocaval shunt. To control potential portal hyperflow and arterial buffer response, splenic artery ligation was added at the end of the operation. The patient recovered without liver failure and is without tumor recurrence almost 2 years after the 1st-stage operation (G/H)