Approach to small liver remnant – strategies to increase resectability

A shift has occurred in the management of liver metastasis from colon and rectal cancer to parenchymal sparing resection with curative intent. With clearance of metastatic disease from the liver comes the concern for leaving an adequate liver volume to prevent post-hepatectomy liver failure (PHLF). Therefore, measuring FLR volume is essential for pre-operative planning and prevention of PHLF from a small liver remnant. For those with normal background liver, >20 percent total liver volume after resection is associated with lower PHLF. For those who have undergone long-course (>12 weeks) of pre-resection chemotherapy, >30 percent total liver volume is necessary. For those with cirrhosis or severe fibrosis, >40 percent total liver volume is necessary. In the event that the expected liver remnant is small, there are options to increase volume of the liver remnant pre-operatively, namely portal vein embolization (PVE). In those with very small FLR, hepatic vein embolization in addition to PVE has been found to increase hypertrophy beyond that which is seen with PVE alone. Additional surgical options include Associating Liver Partition and Portal Vein Ligation (ALPPS) - a surgical technique that results in faster hypertrophy, but requires two operative procedures.