title: Right portal vein ligation combined with in situ splitting induces rapid left lateral liver lobe hypertrophy enabling 2-staged extended right hepatic resection in small-for-size settings.
abstract: OBJECTIVE
  To evaluate a new 2-step technique for obtaining adequate but short-term parenchymal hypertrophy in oncologic patients requiring extended right hepatic resection with limited functional reserve.
  
  
  BACKGROUND
  Patients presenting with primary or metastatic liver tumors often face the dilemma that the remaining liver tissue may not be sufficient. Preoperative portal vein embolization has thus far been established as the standard procedure for achieving resectability.
  
  
  METHODS
  Two-staged hepatectomy was performed in patients who preoperatively appeared to be marginally resectable but had a tumor-free left lateral lobe. Marginal respectability was defined as a left lateral lobe to body weight ratio of less than 0.5. In the first step, surgical exploration, right portal vein ligation (PVL), and in situ splitting (ISS) of the liver parenchyma along the falciform ligament were performed. Computed tomographic volumetry was performed before ISS and before completion surgery.
  
  
  RESULTS
  The study included 25 patients with primary liver tumors (hepatocellular carcinoma: n = 3, intrahepatic cholangiocarcinoma: n = 2, extrahepatic cholangiocarcinoma: n = 2, malignant epithelioid hemangioendothelioma: n = 1, gallbladder cancer: n = 1 or metastatic disease [colorectal liver metastasis]: n = 14, ovarian cancer: n = 1, gastric cancer: n = 1). Preoperative CT volumetry of the left lateral lobe showed 310 mL in median (range = 197-444 mL). After a median waiting period of 9 days (range = 5-28 days), the volume of the left lateral lobe had increased to 536 mL (range = 273-881 mL), representing a median volume increase of 74% (range = 21%-192%) (P < 0.001). The median left lateral liver lobe to body weight ratio was increased from 0.38% (range = 0.25%-0.49%) to 0.61% (range = 0.35-0.95). Ten of 25 patients (40%) required biliary reconstruction with hepaticojejunostomy. Rapid perioperative recovery was reflected by normalization of International normalized ratio (INR) (80% of patients), creatinine (84% of patients), nearly normal bilirubin (56% of patients), and albumin (64% of patients) values by day 14 after completion surgery. Perioperative morbidity was classified according to the Dindo-Clavien classification of surgical complications: grade I (12 events), grade II (13 events), grade III (14 events, III a: 6 events, III b: 8 events), grade IV (8 events, IV a: 3 events, IV b: 5 events), and grade V (3 events). Sixteen patients (68%) experienced perioperative complications. Follow-up was 180 days in median (range: 60-776 days) with an estimated overall survival of 86% at 6 months after resection.
  
  
  CONCLUSIONS
  Two-step hepatic resection performing surgical exploration, PVL, and ISS results in a marked and rapid hypertrophy of functional liver tissue and enables curative resection of marginally resectable liver tumors or metastases in patients that might otherwise be regarded as palliative.
authors.affiliation: Department of Surgery, University Hospital Regensburg, Regensburg, Germany.
authors.forename: Andreas A
authors.initials: AA
authors.lastname: Schnitzbauer
authors.forename: Sven A
authors.initials: SA
authors.lastname: Lang
authors.forename: Holger
authors.initials: H
authors.lastname: Goessmann
authors.forename: Silvio
authors.initials: S
authors.lastname: Nadalin
authors.forename: Janine
authors.initials: J
authors.lastname: Baumgart
authors.forename: Stefan A
authors.initials: SA
authors.lastname: Farkas
authors.forename: Stefan
authors.initials: S
authors.lastname: Fichtner-Feigl
authors.forename: Thomas
authors.initials: T
authors.lastname: Lorf
authors.forename: Armin
authors.initials: A
authors.lastname: Goralcyk
authors.forename: Rüdiger
authors.initials: R
authors.lastname: Hörbelt
authors.forename: Alexander
authors.initials: A
authors.lastname: Kroemer
authors.forename: Martin
authors.initials: M
authors.lastname: Loss
authors.forename: Petra
authors.initials: P
authors.lastname: Rümmele
authors.forename: Marcus N
authors.initials: MN
authors.lastname: Scherer
authors.forename: Winfried
authors.initials: W
authors.lastname: Padberg
authors.forename: Alfred
authors.initials: A
authors.lastname: Königsrainer
authors.forename: Hauke
authors.initials: H
authors.lastname: Lang
authors.forename: Aiman
authors.initials: A
authors.lastname: Obed
authors.forename: Hans J
authors.initials: HJ
authors.lastname: Schlitt
mesh_terms: D000328:Adult; D000368:Aged; D005260:Female; D006498:Hepatectomy / Q000379:methods*; D006801:Humans; D006984:Hypertrophy; D008026:Ligation / Q000379:methods; D008099:Liver / Q000473:pathology; D008113:Liver Neoplasms / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D011169:Portal Vein / Q000601:surgery*; D012189:Retrospective Studies