Outcomes following 2-stage hepatectomy: Systematic review and meta-analysis exploring liver regeneration strategies

Insufficient future liver remnant volume remains a critical challenge in 2-stage hepatectomy. This meta-analysis aimed to evaluate the outcome in distinct 2-stage hepatectomies with a focus on hepatic vein occlusion combined with portal vein embolization and associating liver partition and portal vein ligation for staged hepatectomy.

A systematic literature search was conducted in MEDLINE (PubMed) up to December 2024. Comparative and noncomparative studies were included. The primary outcome was the observed increase in future liver remnant. Secondary outcomes included feasibility of stage 2, morbidity, and mortality.

The meta-analysis included 103 studies (5,891 patients). Noncomparative hepatic vein occlusion combined with portal vein embolization studies showed a mean future liver remnant increase of 36.8%. Compared with portal vein embolization, hepatic vein occlusion combined with portal vein embolization resulted in a significantly greater future liver remnant increase (mean difference 24.5%, P < .01) despite a smaller initial future liver remnant volume. The feasibility of stage 2 was 78% after hepatic vein occlusion combined with portal vein embolization and similar to portal vein embolization alone. Associating liver partition and portal vein ligation for staged hepatectomy demonstrated a substantial mean future liver remnant increase (68.5%) and a high stage 2 feasibility rate (95%). Morbidity and mortality rates following associating liver partition and portal vein ligation for staged hepatectomy were not significantly different from those of portal vein embolization and hepatic vein occlusion combined with portal vein embolization.

Hepatic vein occlusion combined with portal vein embolization was associated with a more pronounced hypertrophy response compared with portal vein embolization in terms of future liver remnant growth, although a clear advantage in second-stage feasibility was not observed. Within the limitations of the analyzed data, associating liver partition and portal vein ligation for staged hepatectomy was associated with the highest future liver remnant increase and completion rates, whereas mortality rates showed no statistically significant difference compared with other strategies. Careful patient selection and further prospective studies are warranted to define the optimal role of hepatic vein occlusion combined with portal vein embolization and associating liver partition and portal vein ligation for staged hepatectomy in 2-stage hepatectomy.