Augmenting the Future Liver Remnant Prior to Major Hepatectomy: A Review of Options on the Menu

The optimization of the future liver remnant (FLR) is paramount in improving outcomes for patients undergoing liver surgery, as post-hepatectomy liver failure remains a major source of postoperative morbidity and mortality. A wide collection of techniques has been introduced with the goal of augmenting the FLR prior to hepatectomy for primary and secondary liver malignancies, and these modalities include portal vein embolization (PVE), portal vein ligation (PVL), liver venous deprivation (LVD), associating liver partition and portal vein ligation for staged hepatectomy (ALPPS), and radioembolization (e.g., Y-90). There are advantages and drawbacks for each of these methods regarding the capacity for FLR hypertrophy sufficient for resection, perioperative morbidity/mortality, and long-term oncologic outcomes. In the context of technical variations when performing the procedures, there have been comparative studies between the various methods of FLR optimization, however, not many in a controlled fashion. Results from ongoing and future randomized controlled trials will help refine these techniques, directly compare outcomes, and personalize strategies based on patient-specific factors. In this review, the benefits of the various FLR augmentation approaches are summarized and the current literature and trials are reviewed.