Dynamic Evaluation of Liver Volume and Function in Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy

Ernesto Sparrelid, Eduard Jonas, Antonios Tzortzakakis, Ulrika Dahlén, Gustav Murquist, Torkel Brismar, Rimma Axelsson, Bengt Isaksson, Ernesto Sparrelid, Eduard Jonas, Antonios Tzortzakakis, Ulrika Dahlén, Gustav Murquist, Torkel Brismar, Rimma Axelsson, Bengt Isaksson

Abstract

Background: Despite a fast and potent growth of the future liver remnant (FLR), patients operated with associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) are at risk of developing posthepatectomy liver failure. In this study, the relation between liver volume and function in ALPPS was studied using a multimodal assessment.

Methods: Nine patients with colorectal liver metastases treated with neoadjuvant chemotherapy and operated with ALPPS were studied with hepatobiliary scintigraphy, computed tomography, indocyanine green clearance test, and serum liver function tests. A comparison between liver volume and function was conducted.

Results: The preoperative FLR volume of 19.5% underestimated the preoperative FLR function of 25.3% (p = 0.011). The increase in FLR volume exceeded the increase in function at day 6 after stage 1 (FLR volume increase 56.7% versus FLR function increase 28.2%, p = 0.021), meaning that the increase in function was 50% of the increase in volume. After stage 2, functional increase exceeded the volume increase, resulting in similar values 28 days after stage 2.

Conclusions: In the inter-stage period of ALPPS, the high volume increase is not paralleled by a corresponding functional increase. This may in part explain the high morbidity and mortality rates associated with ALPPS. Functional assessment of the FLR is advised.

Keywords: ALPPS; Colorectal cancer; Liver function tests; Liver metastases.

Conflict of interest statement

The authors do not have any disclosures to report and no financial support was received for this study.

Figures

Fig. 1
Fig. 1
HBS with SPECT/CT in a patient with insufficient growth after previous PVE before stage 1 (a), on day 6 after stage 1 (b), day 7 (c), and day 28 (d) after stage 2
Fig. 2
Fig. 2
Indocyanine green retention at 15 min (ICG-R15%) at six time points before and after both stages of the ALPPS procedure. Data are presented as median with inter-quartile range. *p < 0.05, **p < 0.01
Fig. 3
Fig. 3
a FLR volume (FLR-V in ml) compared to kinetic growth rate (KGR) of volume increase (%/day) at the four time points: pre-stage 1, day 6 after stage 1, day 7 and 28 after stage 2. b FLR function (FLR-F as %/min/m2) compared to KGR of function increase (%/day) at the four time points: pre-stage 1, day 6 after stage 1, day 7 and 28 after stage 2. Data are presented as median with inter-quartile range
Fig. 4
Fig. 4
Comparison of percentage increase in FLR volume (FLR-V) and function (FLR-F) day 6 after stage 1 and days 7 and 28 after stage 2, with preoperative FLR-V and FLR-F as reference. Data are presented as median with range. ns not significant
Fig. 5
Fig. 5
Median percentage change per day (KGR) in FLR volume (FLR-V) and function (FLR-F) between stage 1 and 2 operations, during the first 7 days after stage 2 and during days 8–28 after stage 2 as measured on CT volumetry (FLR-V) and planar dynamic scintigraphy (FLR-F). Data are presented as median with inter-quartile range

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