Salvage in situ liver transection (ISLT) for patients with unresectable liver tumors and insufficient volume increase of the future liver remnant after portal vein embolization

Introduction: In about one third of patients, portal vein embolization (PVE) fails to increase the future liver remnant (FLR) prior to extended hepatectomy, leaving these patients non-resectable. The newly established in situ liver transection (ISLT or ALPPS) procedure for extended hepatectomy, that combines portal vein ligation and parenchymal transection prior to second stage resection, proved to induce rapid volume increase of the FLR. The feasibility of ISLT as salvage procedure after failed PVE has been explored. Patients & Methods: 17 ISLT procedures in non-cirrhotic livers were performed and analyzed, including 4 salvage ISLT subsequently after insufficient volume gain following PVE. ISLT was indicated when FLR/body weight (BW) ratio was below 0.5. Follow up CT-scan for FLR volume evaluation was routinely performed on postoperative day 3, to determine date of stage two operation. Patient characteristics, volume increase, postoperative complications and outcomes were analyzed. Results: The FLR volume after ISLT exceeded in all patients the critical FLR/BW ratio of 0.5 and subsequent R0 resection could be achieved. The mean FLR volume gain was 60% (± 23%) on day 3 post ISLT. Even after failed PVE, salvage ISLT achieved a mean volume gain of 62% (± 15%) and the mean FLR increased by 229 ml (± 68 ml) in these four patients. Mean time to second stage operation after ISLT was 7 days (range 4 – 14 days). 13 patients (76%) experienced post operative complications grade III and higher according to Clavien-Dindo classification. Median and 1y/2y overall survival were 6.3 months and 47.1%/35.3% respectively. Conclusion: ISLT has become an established surgical technique, which allows curative resection of initially unresectable liver tumors. It is an effective and reliable alternative to PVE. Isolated transection of the liver after failed PVE (salvage ISLT or ALPPS) represents a very helpful procedure, leading to similar results as primary ISLT in theses otherwise non-resectable patients.

Corresponding author: Topp, Stefan A.

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