Liver Augmentation: Rationale, Current Status, and Future Directions

Liver augmentation techniques are critical in managing primary liver cancer and liver metastases, particularly for patients with insufficient future liver remnants (FLR). These methods aim to reduce the risk of post hepatectomy liver failure (PHLF), a major cause of postoperative mortality. Techniques such as portal vein embolization (PVE), liver venous deprivation (LVD), and associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) induce hypertrophy of the FLR, enabling curative surgery for patients previously deemed inoperable. Functional assessment tools, including hepatobiliary scintigraphy and MRI with hepatocyte-specific contrast, are increasingly utilized to evaluate liver function and predict postoperative outcomes. Pathophysiology and factors influencing liver regeneration including patient-specific conditions are explored. Additionally, tumor-specific considerations, such as hepatocellular carcinoma in cirrhotic livers, and biliary malignancies with cholestasis, highlight the need for tailored approaches. Emerging innovations, including artificial intelligence, show promise in improving volumetric assessments and patient selection. Advancements in liver augmentation techniques have expanded surgical eligibility, improved oncologic outcomes, and reduced complications, marking a transformative shift in the management of liver cancers.