Optimizing Outcomes for Liver and Pancreas Surgery by Flavio G. Rocha & Perry Shen

Author:Flavio G. Rocha & Perry Shen
Language: eng
Format: epub
Publisher: Springer International Publishing, Cham

Strategies to Prevent PHLF

Given the high postoperative mortality associated with PHLF, great effort should be placed into prevention.

Preoperative Prevention

Consider the correlation between quality and quantity of liver volume and risk of PHLF. Increasing the remnant volume and preserving the function of future liver remnant has been the rationale behind several preoperative strategies. In particular portal vein embolization (PVE) , while reducing the blood flow to the liver to be resected and increasing the blood flow of the remnant liver, allows for preoperative hypertrophy of the FLR. PVE is typically performed as an ultrasound-guided percutaneous procedure with embolization of the ipsilateral liver with coils, embospheres, foam, or glue. This embolization induces hypertrophy of the contralateral side of the liver, increasing the FLR volume. PVE allows for hypertrophy of the FLR by 30–40% within 4–6 weeks in more than 80% of patients, as reported by CT volumetry usually performed 3–4 weeks after PVE [22]. PVE also stimulates the production of hepatic growth factor and tumor growth factors, along with the redistribution of the portal blood flow to the FLR.

In some cases, a portal vein ligation (PVL) rather than PVE is preferred. In particular, those patients who require a two-stage hepatectomy approach may benefit from PVL that usually occurs during the first operation, when a parenchymal-sparing liver resection is performed [94, 95]. The second stage is usually performed within 3–6 weeks after the first resection and usually consists of an extended hepatectomy.

When PVE is not technically feasible, some surgeons have advocated for the association of liver partition and portal vein ligation for staged hepatectomy (ALPPS) procedure [96]. The rationale behind ALPPS is the clearance of one side of the liver while maintaining the main liver mass to prevent PHLF, combined with portal vein ligation to induce FLR hypertrophy. By portioning the liver at the time of the first operation, ALPPS allows a more rapid hypertrophy of the liver. The results with ALPPS have been mixed, however. A recent meta-analysis noted that ALPPS provided an additional 17% increment hypertrophy of the FLR compared with PVE [97]; however, the high perioperative mortality of ALPPS (12–23% of patients) has prevented it from becoming widely adopted [98].

As previously noted, cholestasis is an important preoperative risk factor for PHLF, and therefore, preoperative endoscopic or percutaneous transhepatic biliary drainage (PTBD) should be strongly considered before extending hepatic resection in those patients who have a bilirubin >7 ng/dL.

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