Is conventional functional liver remnant volume higher than 40% still sufficient to prevent post-hepatectomy liver failure in jaundiced patients with hilar cholangiocarcinoma? A single-center experience in China.

OBJECTIVE: Our study aims to evaluate the predictive accuracy of functional liver remnant volume (FLRV) in post-hepatectomy liver failure (PHLF) among surgically-treated jaundiced patients with hilar cholangiocarcinoma (HCCA). METHODS: We retrospectively reviewed surgically-treated jaundiced patients with HCCA between June, 2000 and June, 2018. The correlation between FRLV and PHLF were analyzed. The optimal cut off value of FLRV in jaundiced HCCA patients was also identified and its impact was furtherly evaluated. RESULTS: A total of 224 jaundiced HCCA patients who received a standard curative resection (43 patients developed PHLF) were identified. Patients with PHLF shared more aggressive clinic-pathological features and were generally in a more advanced stage than those without PHLF. An obvious inconsistent distribution of FLRV in patients with PHLF and those without PHLF were detected. FLRV (continuous data) had a high predictive accuracy in PHLF. The newly-acquired cut off value (FLRV = 53.5%, sensitivity = 81.22%, specificity = 81.4%) showed a significantly higher predictive accuracy than conventional FLRV cut off value (AUC: 0.81 vs. 0.60, p < 0.05). Moreover, patients with FLRV lower than 53.5% also shared a significantly higher major morbidity rate as well as a worse prognosis, which were not detected for FLRV of 40%. CONCLUSION: For jaundiced patients with HCCA, a modified FLRV of 53.5% is recommended due to its great impact on PHLF, as well as its correlation with postoperative major morbidities as well as overall prognosis, which might help clinicians to stratify patients with different therapeutic regimes and outcomes. Future multi-center studies for training and validation are required for further validation.

Promising Outcomes of Modified ALPPS for Staged Hepatectomy in Cholangiocarcinoma.

Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) is a two-stage procedure that can potentially cure patients with large cholangiocarcinoma. The current study evaluates the impact of modifications on the outcomes of ALPPS in patients with cholangiocarcinoma. In this single-center study, a series of 30 consecutive patients with cholangiocarcinoma (22 extrahepatic and 8 intrahepatic) who underwent ALPPS between 2011 and 2021 was evaluated. The ALPPS procedure in our center was modified in 2016 by minimizing the first stage of the surgical procedure through biliary externalization after the first stage, antibiotic administration during the interstage phase, and performing biliary reconstructions during the second stage. The rate of postoperative major morbidity and 90-day mortality, as well as the one- and three-year disease-free and overall survival rates were calculated and compared between patients operated before and after 2016. The ALPPS risk score before the second stage of the procedure was lower in patients who were operated on after 2016 (before 2016: median 6.4; after 2016: median 4.4; p = 0.010). Major morbidity decreased from 42.9% before 2016 to 31.3% after 2016, and the 90-day mortality rate decreased from 35.7% before 2016 to 12.5% after 2016. The three-year survival rate increased from 40.8% before 2016 to 73.4% after 2016. Our modified ALPPS procedure improved perioperative and postoperative outcomes in patients with extrahepatic and intrahepatic cholangiocarcinoma. Minimizing the first step of the ALPPS procedure was key to these improvements.

Donor safety of remnant liver volumes of less than 30% in living donor liver transplantation: A systematic review and meta-analysis.

PURPOSE: This meta-analysis aimed to investigate the acceptability of donor remnant liver volume (RLV) to total liver volume (TLV) ratio (RLV/TLV) being <30% as safe in living donor liver transplantations (LDLTs). METHODS: Online databases were searched from January 2000 to June 2022. Pooled odds ratios (ORs) and standardized mean differences (SMDs) with 95% confidence intervals (CIs) were calculated using fixed- or random-effects model. RESULTS: One prospective and seven retrospective studies comprising 1935 patients (164 RLV/TLV <30% vs. 1771 RLV/TLV ≥30%) were included. Overall (OR = 1.82; 95% CI [1.24, 2.67]; p = .002) and minor (OR = 1.88; 95% CI [1.23, 2.88]; p = .004) morbidities were significantly lower in the RLV/TLV ≥30% group than in the RLV/TLV <30% group (OR = 1.82; 95% CI [1.24, 2.67]; p = .002). No significant differences were noted in the major morbidity, biliary complications, and hepatic dysfunction. Peak levels of bilirubin (SMD = .50; 95% CI [.07, .93]; p = .02) and international normalized ratio (SMD = .68; 95% CI [.04, 1.32]; p = .04) were significantly lower in the RLV/TLV ≥ 30% group than in the RLV/TLV <30% group. No significant differences were noted in the peak alanine transferase and aspartate transaminase levels and hospital stay. CONCLUSIONS: Considering the safety of the donor as the top priority, the eligibility of a potential liver donor in LDLT whose RLV/TLV is expected to be <30% should not be accepted.

Elevated intramuscular adipose tissue content with a high Ishak fibrosis stage (>3) had a negative effect on liver regeneration in cirrhotic patients undergoing portal vein embolization.

This study investigated the relationship between body composition parameters and changes in future liver remnant volume (FLRV) in hepatocellular carcinoma (HCC) patients undergoing portal vein embolization (PVE) in preparation for right hepatectomy. This retrospective study enrolled 21 patients between May 2013 and October 2020. Body composition parameters, including skeletal muscle attenuation (SMA), skeletal muscle mass index (SMI), intramuscular adipose tissue content (IMAC), and visceral-to-subcutaneous adipose tissue area ratio (VSR), were measured by computed tomography (CT) prior to PVE. Liver volumetry was measured before and at least 5 weeks after PVE. The mean interval between two CT volumetries was 9.1 ± 4.9 weeks, the mean value of increase in FLRV (ΔFLRV) was 236.0 ± 118.3 cm3 , the ratio of increased FLRV (ΔFLRV%) was 55.7 ± 29.4%, and the rate of increased FLRV was 31.0 ± 18.8 (cm3 /week). Subjects with high IMAC showed significantly lower (p = 0.044) ΔFLRV% than those with normal IMAC. Furthermore, ΔFLRV% was linearly reduced (p for trend = 0.043) among those with low Ishak fibrosis stage (<3) + normal IMAC (76.1 ± 36.8%), those with low Ishak fibrosis stage (<3) + high IMAC or high Ishak fibrosis stage (>3) + normal IMAC (54.0 ± 24.1%), and those with high Ishak fibrosis stage (>3) + low IMAC (28.7 ± 1.6%) (p for trend = 0.043). Our data indicated that high IMAC with a high Ishak fibrosis stage (>3) had a significant negative effect on ΔFLRV%.

Application of hepatic lobe hyperplasia techniques in the treatment of advanced hepatic alveolar echinococcosis: a single-centre experience.

BACKGROUND: This study was designed to investigate clinical efficiency and application indications of hepatic lobe hyperplasia techniques for advanced hepatic alveolar echinococcosis (AE) patients. METHODS: A retrospective case series covering 19 advanced hepatic AE patients admitted to the First Affiliated Hospital of Xinjiang Medical University from September 2014 to December 2021 and undergoing hepatic lobe hyperplasia techniques due to insufficient remnant liver volume were analyzed. Changes of liver function, lesions volume, remnant liver volume, total liver volume before and after operation have been observed. RESULTS: Among the patients, 15 underwent portal vein embolization (PVE). There was no statistical difference in total liver volume and lesions volume before and after PVE (P > 0.05). However, the remnant liver volume was significantly increased after PVE (P < 0.05). The median monthly increase rate in future liver remnant volume (FLRV) after PVE stood at 4.49% (IQR 3.55-7.06). Among the four patients undergoing two-stage hepatectomy (TSH), FLRV was larger than that before the first stage surgery, and the median monthly increase rate in FLRV after it stood at 3.34% (IQR 2.17-4.61). Despite no statistical difference in total bilirubin (TBil), albumin (Alb), alanine aminotransferase (ALT), aspartate aminotransferase (AST) and gamma-glutamyl transpeptidase (GGT) in all patients with PVE, four patients who underwent TSH showed a decrease in ALT, AST and GGT. During the waiting process before the second stage operation, no serious complications occurred in all patients. CONCLUSIONS: For patients suffering from advanced hepatic AE with insufficient FLRV, PVE and TSH are safe and feasible in promoting hepatic lobe hyperplasia.

[Application of liver venous deprivation in secondary hepatic resection of primary liver cancer].

Objective: To investigate the efficacy and safety of liver venous deprivation (LVD) before secondary resection of primary liver cancer. Methods: 56 patients with advanced primary liver cancer who were not suitable for primary resection in Liver Surgery Department of Xinxiang Central Hospital from January 2018 to January 2019 were analyzed retrospectively. They were divided into liver vein deprivation group (LVD group: LVD+ PVE, n=26) and portal vein embolization group (PVE group, n=30). The dynamic changes of liver reserve function and future liver remnant volume (FLR-V), R0 resection rate, surgical complications, postoperative recurrence rate and overall survival rate of two groups before and after LVD/PVE were compared. Results: The success rate of puncture and embolization in LVD group and PVE group was 100%. There were no grade Ⅳ complications, and there was no significant difference of grades Ⅰ, Ⅱ and Ⅲ complications between the groups (P=0.808). The FLR-V of LVD group before embolization, 7, 14 and 21 days after embolization was (493.1±25.8), (673.2±56.1), (779.5±81.6) and (853.3±85.2) cm(3), respectively. The FLR-V of PVE group before embolization, 7, 14 and 21 days after embolization were (502.4±20.1), (688.6±43.9), (656.8±73.7) and (563.5±69.1) cm(3), respectively. There was no significant difference in FLR-V between the two groups before and 7 days after embolization (P>0.05). The FLR-V of LVD group was higher than that of PVE group at 14 and 21 days after embolization (P<0.01). The preparation time of LVD group was (20.4±6.3) days, which was shorter than that of PVE group [(31.5±8.8) days, P=0.045]. The rate of secondary hepatectomy was 92.3% (24/26), which was higher than that of PVE group [70.0% (21/30), P=0.036]. The R0 resection rate was 87.5% (21/24), which was higher than that of the PVE group [57.1% (12/21), P=0.022]. However, there were no significant differences in surgical methods, operation time, intraoperative blood loss, Clavien-Dindo complication grade and length of hospital stay between the two groups (P>0.05). After hepatectomy, the median recurrence time and median survival time of LVD group were 12.6 months and 21.3 months, respectively, which were longer than those of PVE group (9.4 months and 13.5 months, respectively, P<0.01). Conclusions: For patients with advanced liver cancer who are not suitable for primary hepatectomy, preoperative LVD can significantly increase FLR-V, improve the resection rate of secondary surgery, shorten the preparation time of two operations, and do not increase surgical complications. Moreover, patients with LVD can improve the R0 resection rate of secondary surgery. The postoperative recurrence time and overall survival rate of patients with LVD are better than those of patients with PVE, and LVD has a good long-term effect.

Radiographic Measurement of Gastric Remnant Volume After Laparoscopic Sleeve Gastrectomy: Assessment of Reproducibility and Correlation with Weight Loss.

BACKGROUND: As a restrictive procedure, laparoscopic sleeve gastrectomy (LSG) relies primarily on the reduction of gastric volume. It has been suggested that an immediate postoperative gastric remnant volume (GRV) may influence long-term results of LSG; however, there are no consensus in this matter. The aim of this study was to assess the reproducibility of different radiographic methods of GRV calculation and evaluate their correlation with the weight loss (WL) after surgery. METHODS: This retrospective study evaluated 174 patients who underwent LSG in the period from 2014 to 2017. Using UGI, GRV was measured with 3 different mathematical methods by 2 radiologists. Intraobserver and interobserver calculations were made. Correlation between GRV and WL were estimated with calculations percentage of total weight loss (%TWL) and percentage of excess weight loss (%EWL) after 1, 3, 6, 12, 18, and 24 months postoperatively. RESULTS: During analysis of intraobserver similarities, the results of ICC calculation showed that reproducibility was good to excellent for all GRV calculation methods. The intraobserver reproducibility for Reader I was highest for cylinder and truncated cone formula and for Reader II for ellipsoid formula. The interobserver reproducibility was highest for ellipsoid formula. Regarding correlation between GRV and WL, significant negative correlation has been shown on the 12th month after LSG in %TWL and %EWL for every method of GRV calculation, most important for ellipsoid formula (%TWL - r(X,Y) = -0.335, p < 0.001 and %EWL - r(X,Y) = -0.373, p < 0.001). CONCLUSION: Radiographic methods of GRV calculation are characterized by good reproducibility and correlate with the postoperative WL.

Rescue Partial ALPPS for Left Hemihepatectomy with Reconstruction of the Middle Hepatic Vein.

Major hepatectomy in patients with insufficient future liver remnant (FLR) volume and impaired liver functional reserve has considerable risks for posthepatectomy liver failure (PHLF). The patient was a male in his 70s with an intrahepatic cholangiocarcinoma in left hemiliver, involving the middle hepatic vein (MHV). Although FLR volume after left hemihepatectomy was estimated to be 64.4% of the total liver volume, an indocyanine green retention rate at 15 min (ICG-R15) value was 24.2%, thus the patient underwent left portal vein embolization. The FLR volume increased to 71.3%; however, the noncongestive FLR volume was re-estimated as 45.8% after resection of the MHV, the ICG-R15 value was 29.0%, and ICG-Krem was calculated as 0.037. We performed partial rescue Associating Liver Partition and Portal vein occlusion for Staged hepatectomy (ALPPS) for left hemihepatectomy with the MHV reconstruction. On the first stage, partial liver partition was done along Rex-Cantlie's line, preserving the MHV and sacrificing the remaining branches to segment 8. The FLR volume increased to 77.4% on day 14. The ICG-R15 value was 29.6%, but ICG-Krem after MHV reconstruction was estimated to be 0.059. The second-stage operation on day 21 was left hemihepatectomy with the MHV reconstruction using the left superficial femoral vein graft. The usage of rescue partial ALPPS may contribute to preventing PHLF by introducing occlusion of the portal and/or venous branches in the left hemiliver before curative hepatectomy.

Functional transition: Inconsistently parallel to the increase in future liver remnant volume after preoperative portal vein embolization.

BACKGROUND: Preoperative portal vein embolization (PVE) is a widely used strategy to enable major hepatectomy in patients with insufficient liver remnant. PVE induces hypertrophy of the future liver remnant (FLR) and a shift of the functional reserve to the FLR. However, whether the increase of the FLR volume (FLRV) corresponds to the functional transition after PVE remains unclear. AIM: To investigate the sequential relationship between the increase in FLRV and functional transition after preoperative PVE using 3-dimensional (3D) computed tomography (CT) and 99mTc-galactosyl-human serum albumin (99mTc-GSA) single-photon emission computed tomography (SPECT) fusion images. METHODS: Thirty-three patients who underwent major hepatectomy following PVE at the Department of Gastroenterological Surgery I, Hokkaido University Hospital between October 2013 and March 2018 were enrolled. Three-phase dynamic multidetector CT and 99mTc-GSA SPECT scintigraphy were performed at pre-PVE, and at 1 and 2 wk after PVE; 3D 99mTc-GSA SPECT CT-fused images were constructed from the Digital Imaging and Communications in Medicine data using 3D image analysis system. Functional FLRV (FFLRV) was defined as the total liver volume × (FLR volume counts/total liver volume counts) on the 3D 99mTc-GSA SPECT CT-fused images. The calculated FFLRV was compared with FLRV. RESULTS: FFLRV increased by a significantly larger extent than FLRV at 1 and 2 wk after PVE (P < 0.01). The increase in FFLRV and FLRV was 55.1% ± 41.6% and 26.7% ± 17.8% (P < 0.001), respectively, at 1 wk after PVE, and 64.2% ± 33.3% and 36.8% ± 18.9% (P < 0.001), respectively, at 2 wk after PVE. In 3 of the 33 patients, FFLRV levels decreased below FLRV at 2 wk. One of the three patients showed rapidly progressive fatty changes in FLR. The biopsy at 4 wk after PVE showed macro- and micro-vesicular steatosis of more than 40%, which improved to 10%. Radical resection was performed at 13 wk after PVE. The patient recovered uneventfully without any symptoms of pos-toperative liver failure. CONCLUSION: The functional transition lagged behind the increase in FLRV after PVE in some cases. Evaluating both volume and function is needed to determine the optimal timing of hepatectomy after PVE.

Relationship of vascular variations with liver remnant volume in living liver transplant donors.

BACKGROUND: In this study, we investigated the relationship between the portal vein and hepatic artery variations and the remaining liver volume in living donors in liver transplantation. MATERIALS AND METHODS: In the study, triphasic abdominal computed tomography images of 180 live liver donor candidates were analysed retrospectively. Portal veins were divided into four groups according to the Nakamura classification and seven groups according to the Michels classification. The relationship between vascular variations and remnant liver volume was compared statistically. RESULTS: According to the Nakamura classification, there were 143 (79.4%) type A, 23 (12.7%) type B, 7 (3.9%) type C and 7 (3.9%) type D cases. Using the Michels classification, 129 (71%) type 1, 12 (6.7%) type 2, 24 (13%) type 3, 2 (2.2%) type 4, 10 (5.6%) type 5, 1 (0.6%) type 6, and 2 (1.1%) type 7 cases were detected. There was no significant difference in the percentage of the remaining volume of the left liver lobe between the groups (p = 0.055, p = 0.207, respectively). CONCLUSIONS: Variations in the hepatic artery and portal vein do not affect the remaining liver volume in liver transplantation donors.

Pros and Cons of Portal Vein Embolization With Hematopoietic Stem Cells Application in Colorectal Liver Metastases Surgery.

BACKGROUND/AIM: Portal vein embolization (PVE) with autologous stem cells application (aHSC) is a method for future liver remnant volume (FLRV) increase. The aim of the study was to evaluate the positivite and negativite aspects of the method in clinical practice. PATIENTS AND METHODS: PVE with aHSC application was used in 32 patients with colorectal liver metastases and insufficient FLRV. Preoperative number of colorectal liver metastases (CLMs) was 5.2±3.6, CLMs volume 70.1±102.3 mm3 Results: FLRV growth occurred after 2-3 weeks in 31 (96.9%) patients, with volume increase from 528.2±170.5 to 715.4±143.3 ml (p=0.0001). Postoperative thirty days mortality, morbidity was 0% and 3.1%, respectively. Insufficient FLRV growth occurred in one patient. R0 liver resection was performed in 27(87.1%) patients. CLMs volume progression was in 5 (15.6%) patients from 680.0±59.4 to 723.1±57.1 ml (p=0.01). One and two-year overall survival were 88% and 62.9% respectively. Six and twelve-month recurrence-free survival rates were 50.7% and 39.6% respectively. CONCLUSION: PVE with aHSC application is a safe and useful method for FLRV growth. It significantly increases secondary CLMs resectability. However, it can cause CLMs progression. Liver resection should, therefore, be performed as soon as possible after achieving optimal increase of FLRV.

CD133 + cell infusion in patients with colorectal liver metastases going to be submitted to a major liver resection (CELLCOL): A randomized open label clinical trial.

BACKGROUND: Treatment of liver metastases of colorectal carcinoma is surgical resection. However, only 10-15% of the patients in this context will be candidate for curative resection arising other 10-13% after response to neoadyuvant chemotherapy. In order to perform the liver metastases surgery, it is necessary to have a sufficient remnant liver volume (RLV) which allows maintaining an optimal liver function after resection. Studies on liver regeneration have determined that CD133 + stem cells are involved in liver hypertrophy developed after an hepatectomy with encouraging results. As presented in previous studies, CD133 + stem cells can be selected from peripheral blood after stimulation with G-CSF, being able to obtain a large number of them. We propose to treat patients who do not meet criteria for liver metastases surgery because of insufficient RLV (<40%) with CD133 + cells together with portal embolization, in order to achieve enough liver volume which avoids liver failure. METHODS: /Design: The aim of this study is to evaluate the effectiveness of preoperative PVE plus the administration of CD133 + mobilized from peripheral blood with G-CSF compared to PVE only. SECONDARY AIMS ARE: to compare the grade of hypertrophy, speed and changes in liver function, anatomopathological study of hypertrophied liver, to determine the safety of the treatment and analysis of postoperative morbidity and surveillance. STUDY DESIGN: Prospective randomized longitudinal phase IIb clinical trial, open, to evaluate the efficacy of portal embolization (PVE) together with the administration of CD133 + cells obtained from peripheral blood versus PVE alone, in patients with hepatic metastasis of colorectal carcinoma (CCRHM). DISCUSSION: The number of CD133 + obtained from peripheral blood after G -CSF stimulation will be far greater than the number obtained with direct puncture of bone marrow. This will allow a greater intrahepatic infusion, which could have a direct impact on achieving a larger and quicker hypertrophy. Consequently, it will permit the treatment of a larger number of patients with an increase on their survival. TRIAL REGISTRATION: ClinicalTrials.gov, ID NCT03803241.

Risk factors of posthepatectomy liver failure for perihilar cholangiocarcinoma: Risk score and significance of future liver remnant volume-to-body weight ratio.

BACKGROUND: Surgery for perihilar cholangiocarcinoma (PHCC) is associated with high morbidity. This study aimed to investigate the clinical value of the future liver remnant volume-to-body weight (FLRV/BW) and propose a risk score for predicting the risk of patients with PHCC developing posthepatectomy liver failure (PHLF). METHODS: This study included 348 patients who underwent major hepatectomy with bile duct resection for PHCC during 2008-2015 at a single center in Korea and they were retrospectively analyzed. RESULTS: Clinically relevant PHLF was noted in 40 patients (11.4%). The area under the curve (AUC) for FLRV/BW was not significantly different from that for FLRV/total liver volume (P = .803) or indocyanine green clearance of the future liver remnant (P = .629) in terms of predicting PHLF. On multivariate analysis, predictors of PHLF (P < .05) were male sex, albumin less than 3.5 g/dL, preoperative cholangitis, portal vein resection, FLRV/BW less than 0.5%, and FLRV/BW 0.5% to 0.75%. These variables were included in the risk score that showed good discrimination (AUC, 0.853; 95% CI, 0.802-0.904). It will help rank patients into three risk subgroups with a predicted liver failure incidence of 4.75%, 18.73%, and 51.58%, respectively. CONCLUSIONS: FLRV/BW is a comparable risk prediction factor of PHLF and the proposed risk score can help to predict the risk of planned surgery in PHCC.

Portal Vein Embolization (PVE) Versus PVE with Haematopoietic Stem Cell Application in Patients with Primarily Non-resectable Colorectal Liver Metastases.

BACKGROUND: Portal vein embolization (PVE) and PVE with autologous mesenchymal stem cell application (PVE-MSC) increases future liver remnant volume (FLRV). The aim of this study was to compare both methods from the aspect of FLRV growth, progression of colorectal liver metastases (CLM), CLM resectability and long-term results. PATIENTS AND METHODS: Fifty-five patients with CLM and insufficient FLRV were included in the study. FLVR growth and CLM volume were evaluated using computed tomography. Liver resection was performed in patients with FLVR >30% of total liver volume. RESULTS: In the PVE (N=27) group, FLRV growth was observed in 23 patients (85.2%) and in 100% of patients in the PVE-MSC (N=28) group (p<0.05). The rapidity of FLRV and CLM growth did not differ between groups. R0 resection was performed in 14 (51.8%) and 24 (85.7%) patients from the PVE and PVE-MSC (p<0.02) groups, respectively. The 3-year overall and progression-free survival rates were 85.75% and 9.3% in the PVE group and 68.7% and 17.1% in the PVE-MSC group, respectively (p<0.67 and p<0.84, respectively). CONCLUSION: PVE-MSC allows for more effective growth of FLRV and resectability of CLM compared to PVE. The two methods do not differ in their long-term results.

Future Liver Remnant Indocyanine Green Plasma Clearance Rate as a Predictor of Post-hepatectomy Liver Failure After Portal Vein Embolization.

PURPOSE: To evaluate the utility of future liver remnant plasma clearance rate of indocyanine green (ICGK-F) for predicting post-hepatectomy liver failure (PHLF) compared with percentage future liver remnant volume-to-total liver volume ratio (%FLR) after portal vein embolization (PVE). MATERIALS AND METHODS: PVE procedures in 20 patients (15 patients underwent PVE with absolute ethanol; 5 patients with gelatin particles) from 2010 to 2017 were analyzed. %FLR = future liver remnant volume (ml)/[total liver volume (ml) - tumor volume (ml)] × 100; ICGK-F = plasma clearance rate of indocyanine green (ICGK) × %FLR/100 were calculated before and after PVE. PHLF was categorized according to the criteria of the International Study Group of Liver Surgery. For predicting PHLF, we compared the ICGK-F and %FLR after PVE between the grade A PHLF group and the non-grade A PHLF (grades B and C) group. RESULTS: All PVE procedures were successful. While the ICGK-F of the grade A PHLF group (median 0.073, n = 16) was about twice that of the non-grade A PHLF group (median 0.043, n = 4), showing a significant difference (Mann-Whitney U test: P = 0.002), there was no significant difference in %FLR between the grade A PHLF group and the non-grade A PHLF group (Mann-Whitney U test: P = 0.335). CONCLUSION: ICGK-F was significantly higher in the grade A PHLF group than in the non-grade A PHLF group (grades B and C), and ICGK-F was more useful for predicting PHLF than %FLR.

Portal Vein Embolization with Contralateral Application of Stem Cells Facilitates Increase of Future Liver Remnant Volume in Patients with Liver Metastases.

OBJECTIVES: This study aimed to evaluate the progress of future liver remnant volume (FLRV) in patients with liver metastases after portal vein embolization (PVE) with the application of hematopoietic stem cells (HSCs) and compare it with a patients control group after PVE only. METHODS: Twenty patients (group 1) underwent PVE with contralateral HSC application. Subsequently, CT volumetry with the determination of FLRV was performed at weekly intervals, in total three weeks. A sample of twenty patients (group 2) who underwent PVE without HSC application was used as a control group. RESULTS: The mean of FLRV increased by 173.2 mL during three weeks after the PVE/HSC procedure, whereas by 98.9 mL after PVE only (p = 0.015). Furthermore, the mean daily growth of FLRV by 7.6 mL in group 1 was significantly higher in comparison with 4.1 mL in group 2 (p = 0.007). CONCLUSIONS: PVE with the application of HSC significantly facilitates growth of FLRV in comparison with PVE only. This method could be one of the new suitable approaches to increase the resectability of liver tumours.

Methods to Increase Future Liver Remnant Volume in Patients with Primarily Unresectable Colorectal Liver Metastases: Current State and Future Perspectives.

Radical liver resection of colorectal liver metastases (CLMs) is the only potentially curative treatment. But primary resectability of CLMs ranges from 15% to 20%. Insufficient future liver remnant volume (FLRV) is the main cause of primary unresectability of CLMs. Currently, there are several methods that can optimize FLRV and permit radical resection of CLMs. The basic methods include two-stage liver resection, portal vein embolization (PVE) and portal vein ligation. These methods have very low morbidity and mortality rate. Their disadvantage is the relatively long interval for increase of FLRV, with danger of tumour growth, and also the significant number of patients in whom optimal FLRV increase does not occur. For this reason, two other methods were developed - associating liver partition with portal vein ligation for staged hepatectomy (ALPPS) and PVE with application of hematopoietic stem cells (HSCs). The advantage of ALPPS is the very rapid increase of FLRV, but the method is burdened by higher morbidity and mortality. PVE with HSC application is not associated with complications, it has a faster increase of FLRV compared to PVE and two-staged liver resection, but the role of autologous HSCs in carcinogenesis is not yet clear. All the methods offer secondary resectability for patients with primarily inoperable CLMs, with long-term survival comparable to primary CLM resections. The optimal choice of specific method must be made on a strictly individual basis for the given patient, and depends on the decision of the multidisciplinary team.

Risk of venous congestion in live donors of extended right liver graft.

AIM: To investigate middle hepatic vein (MHV) management in adult living donor liver transplantation and safer remnant volumes (RV). METHODS: There were 59 grafts with and 12 grafts without MHV (including 4 with MHV-5/8 reconstructions). All donors underwent our five-step protocol evaluation containing a preoperative protocol liver biopsy Congestive vs non-congestive RV, remnant-volume-body-weight ratios (RVBWR) and postoperative outcomes were evaluated in 71 right graft living donors. Dominant vs non-dominant MHV anatomy in total liver volume (d-MHV/TLV vs nd-MHV/TLV) was constellated with large/small congestion volumes (CV-index). Small for size (SFS) and non-SFS remnant considerations were based on standard cut-off- RVBWR and RV/TLV. Non-congestive RVBWR was based on non-congestive RV. RESULTS: MHV and non-MHV remnants showed no significant differences in RV, RV/TLV, RVBWR, total bilirubin, or INR. SFS-remnants with RV/TLV < 30% and non-SFS-remnants with RV/TLV ≥ 30% showed no significant differences either. RV and RVBWR for non-MHV (n = 59) and MHV-containing (n = 12) remnants were 550 ± 95 mL and 0.79 ± 0.1 mL vs 568 ± 97 mL and 0.79 ± 0.13, respectively (P = 0.423 and P = 0.919. Mean left RV/TLV was 35.8% ± 3.9%. Non-MHV (n = 59) and MHV-containing (n = 12) remnants (34.1% ± 3% vs 36% ± 4% respectively, P = 0.148. Eight SFS-remnants with RVBWR < 0.65 had a significantly smaller RV/TLV than 63 non-SFS-remnants with RVBWR ≥ 0.65 [SFS: RV/TLV 32.4% (range: 28%-35.7%) vs non-SFS: RV/TLV 36.2% (range: 26.1%-45.5%), P < 0.009. Six SFS-remnants with RV/TLV < 30% had significantly smaller RVBWR than 65 non-SFS-remnants with RV/TLV ≥ 30% (0.65 (range: 0.6-0.7) vs 0.8 (range: 0.6-1.27), P < 0.01. Two (2.8%) donors developed reversible liver failure. RVBWR and RV/TLV were concordant in 25%-33% of SFS and in 92%-94% of non-SFS remnants. MHV management options including complete MHV vs MHV-4A selective retention were necessary in n = 12 vs n = 2 remnants based on particularly risky congestive and non-congestive volume constellations. CONCLUSION: MHV procurement should consider individual remnant congestive- and non-congestive volume components and anatomy characteristics, RVBWR-RV/TLV constellation enables the identification of marginally small remnants.

Portal vein embolisation with application of haematopoietic stem cells in patients with primarily or non-resectable colorectal liver metastases.

BACKGROUND: Insufficient future liver remnant volume (FLRV) is the main cause of low resectability of liver metastases from colorectal cancer (CLMs). One option for enhancing FLVR growth is the use of portal vein embolisation (PVE) with the application of autologous haematopoietic stem cells (HSCs). PATIENTS AND METHODS: PVE with the application of HSCs was used in 11 patients (group 1) with primarily non-resectable CLMs due to insufficient FLRV without signs of extrahepatic metastases. The control group (group 2) consisted of 14 patients in whom only PVE was performed. We evaluated the product quality, FLRV growth, CLM volume, median survival and progression-free survival (PFS). RESULTS: Product quality was achieved in all collections. In all group-I patients, sufficient FLRV growth occurred within three weeks. In the first and second weeks, FLRV increased optimally in most patients (p<0.006). In 13 out of the 14 group-2 patients, optimum FLVR growth was observed within three weeks following PVE (p<0.002). More rapid FLVR growth was observed in group 1 patients (p<0.01). CLM volume was significantly increased in both the group-2 (p<0.0005) and group-1 (p<0.008) patients at the time of liver resection. There was no significant difference in the growth of the CLM volume between the groups (p<0.18). The median survival was 7.3 and 6.8 months for group 1 and 2 patients, respectively, and the two-year PFS was 28% and 22% (p<0.18), respectively. CONCLUSION: PVE with HSC application is a promising method for effectively stimulating FLRV growth in patients with primarily non-resectable CLMs.

The surgical treatment of patients with colorectal cancer and liver metastases in the setting of the "liver first" approach.

A surgical resection is the only curative method in the therapy of colorectal carcinoma and liver metastases. Along with the development of interventional radiological techniques the indications for surgery widen. The number of metastases and patients age should not present a contraindication for surgical resection. However, there are still some doubts concerns what to resect first in cases of synchronous colorectal carcinoma and liver metastases and how to ensure the proper remnant liver volume in order to avoid postoperative liver failure and achieve the best results. Through this review the surgical therapy of colorectal carcinoma and liver metastases was revised in the setting of "liver-first" approach and the problem of ensuring of remnant liver volume.