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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

Schnitzbauer, Andreas A. MD; Lang, Sven A. MD; Goessmann, Holger MD; Nadalin, Silvio MD; Baumgart, Janine MD; Farkas, Stefan A. MD; Fichtner-Feigl, Stefan MD; Lorf, Thomas MD; Goralcyk, Armin MD; Hörbelt, Rüdiger MD; Kroemer, Alexander MD; Loss, Martin MD; Rümmele, Petra MD; Scherer, Marcus N. MD; Padberg, Winfried MD; Königsrainer, Alfred MD; Lang, Hauke MD; Obed, Aiman MD; Schlitt, Hans J. MD

doi: 10.1097/SLA.0b013e31824856f5

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.

Twenty-five patients with marginally resectable liver tumors underwent 2-stage extended right hepatectomy utilizing in situ split and right portal vein ligation with completion surgery after lateral lobe hypertrophy of 74% after 9 days in median. This novel technique provides rapid left lateral lobe hypertrophy, allowing safe extended liver resection.

*Departments of Surgery


Institute for Pathology, University Hospital Regensburg, Regensburg

§Eberhard Karls University of Tübingen, Department of General Visceral and Transplant Surgery, Tübingen

Johannes-Gutenberg University Mainz, Department of General and Abdominal Surgery, Mainz

Georg-August Univeristy Göttingen, Department of General and Visceral Surgery, Göttingen

#Justus Liebig University of Giessen, Department of Thoracic and General Surgery, Giessen, Germany.

Reprints: Hans J. Schlitt, FACS, FRACS, FRCS, MHM, Department of Surgery, University Hospital Regensburg, Franz-Josef-Strauss-Allee 11, 93053 Regensburg, Germany. E-mail:

A.A.S. and S.A.L. contributed equally.

Disclosure: The authors declare that they have nothing to disclose.

Copyright © 2012 Wolters Kluwer Health, Inc. All rights reserved.