What is the best way to decrease the risk of post-hepatectomy liver failure in a patient undergoing extended right hepatectomy with a future remnant liver volume to total liver volume ratio of 0.19?

Optimizing Future Liver Remnant to Prevent Post-Hepatectomy Liver Failure

Portal vein embolization (PVE) is the best intervention to decrease risk of post-hepatectomy liver failure in a patient with future remnant liver volume to total liver volume ratio of 0.19 undergoing extended right hepatectomy. 1

Assessment of Risk

The patient's future remnant liver volume to total liver volume (FLR/TLV) ratio of 0.19 is significantly below the safe threshold for major hepatectomy:

• For patients with normal liver parenchyma, a minimum FLR/TLV ratio of 20% is recommended 1
• For patients with chronic liver disease, a minimum FLR/TLV ratio of 30-40% is required 1
• The patient's current ratio (19%) indicates high risk for post-hepatectomy liver failure (PHLF), especially with extended right hepatectomy 2

Volume Optimization Strategies

First-Line Approach: Portal Vein Embolization (PVE)

• PVE redirects portal blood flow toward the future liver remnant, inducing hypertrophy in the segments that will remain after surgery 1
• The embolized portion of the liver undergoes atrophy while the FLR grows 1
• PVE is considered the safest and most established technique for FLR augmentation 1
• Typically requires 4-8 weeks for adequate hypertrophy before proceeding with resection 1

Alternative Approaches (if PVE insufficient):

1. Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy (ALPPS)

   • More rapid hypertrophy than PVE alone 1
   • However, carries significantly higher morbidity (73% vs 59%) and mortality (14% vs 7%) compared to PVE 1
   • Should be reserved for cases where PVE fails to achieve adequate hypertrophy 1

2. Two-Stage Hepatectomy with Portal Vein Ligation (PVL)

   • Alternative to PVE when anatomically appropriate 1
   • May be considered if percutaneous access for PVE is technically challenging 1

3. Yttrium-90 Radioembolization

   • Can induce contralateral hypertrophy while simultaneously treating tumors 1
   • Less established than PVE for FLR augmentation 1

Monitoring Response to Volume Optimization

• Follow-up CT/MRI volumetry should be performed 3-4 weeks after PVE 1
• Target FLR/TLV ratio should be ≥30% before proceeding with extended right hepatectomy 1, 2
• For high-risk patients (diabetes, cirrhosis), even a 30% FLR may be insufficient - consider targeting 40% 2
• Consider additional functional assessment with indocyanine green retention test 1, 3

Perioperative Considerations

• Minimize intraoperative blood loss through judicious use of intermittent Pringle maneuver 1
• Avoid excessive and prolonged portal inflow occlusion which can impair hepatocyte function and regeneration 1
• Consider FLR/body weight ratio - values <0.65% are associated with significantly higher PHLF risk 4

Pitfalls and Caveats

• Volume does not always correlate with function - functional assessment should complement volumetric analysis 3
• Diabetes mellitus significantly increases PHLF risk even with adequate remnant volume 5
• Failure of FLR to hypertrophy after PVE may indicate underlying parenchymal disease and should prompt reconsideration of surgical approach 1
• PHLF can occur despite adequate FLR volume if there are other risk factors such as excessive blood loss, sepsis, or hemodynamic instability 1