Major hepatectomy after preoperative liver regeneration—Experience in MDACC

In MDACC the most common etiology for hepatectomy is colorectal liver metastases. Because we have initiatively performed preoperative chemotherapy, chemotherapy-associated injured liver has been concerned. As the minimal threshold of future liver remnant (FLR) volume reported so far, we proposed >20% and >30% of standard liver volume (SLV) as safe criteria for normal and injured liver, respectively. Portal vein embolization (PVE) is mandatory in the patients with sFLR (FLR/SLV×100) below these cutoffs. We introduced two novel indices of FLR hypertrophy; degree of hypertrophy (DH) as increase of sFLR (%) after PVE, and kinetic growth rate as DH/week. For the extensive bilobular disease, two-stage hepatectomy is feasible. We have not adopted ALPPS. Instead, we advocated right PVE including segment 4, liver venous deprivation, and simultaneous first-stage hepatectomy and PVE using hybrid interventional radiology/operating suite to maximize FLR hypertrophy in limited interval before the second hepatectomy.