Introduction Today only 20%–25% of colorectal liver metastasis are resectable at initial presentation, despite the progress made in liver surgery over the last 25 years.¹ The induction of liver hypertrophy by preoperative portal vein occlusion (Embolisation or Ligation) is the most used tool to prevent postoperative liver failure allows a Future Liver Remnant (FLR) growth of up to 20%–35% in 45 days.² For 1 year we have engaged a new method of achieving resectability in patients affected by extensive disease involving both lobes with insufficient future remnant liver volume (FRLV).³

Methods Between March and November 2011 six patients affected by liver tumours (4 colorectal liver metastasis (CRLM), 1 GIST-metastasis, 1 gallbladder carcinoma) were judged to be irresectable because of an insufficient RLV (<20%). Therefore all those patients were submitted to a two staged procedure: (1) Right portal vein ligation, in situ split procedure and additionally atypical resection of a metastasis in the FRL if needed. After CT controls with 3D reconstruction and volumetry (2) Extended right hemihepatectomy.³

Results Resectability was achieved in all patients around 2 weeks after step 1 (range 10–21 days). In five patients the FRL gained about 66% in volume (range 45%–95%); the patients were operated and discharged without complications. One Patient (gallbladder carcinoma)—despite good volumetry (42%)—suffered severe cholangitis postoperatively and died of consecutive liver failure 58 days after the second step operation.

Conclusion This method showed to be effective in patients initially judged to be irresectable. One possible explanation could be that the in-situ liver transection, causing disruption of intrahepatic portal collaterals, increases portal flow deprivation to the excluded segments and redistribution of hepatotrophic factors, accelerating future remnant liver growth. Patients with jaundice from biliary tract tumours seem not to be good candidates for this approach. The proposed new strategy has had value in extending resectability in patients suffering from extensive CRLM,³ reducing the risk of postoperatory liver failure, in our preliminary experience, more than other established methods.

Competing interests None declared.

References 1. Capussotti L. Evolution of resectability criteria. In: Surgical treatment of colorectal liver metastases. Milan, Italy: Springer, 2011:27–34.

2. Hemming AW, Reed AI, Howard RJ, et al. Preoperative portal vein embolization for extended hepatectomy. Ann Surg 2003;237:686–91.

3. Oldhafer KJ, Donati M, Maghsoudi T, et al. Integration of 3D Volumetry, Portal Vein Transection and In Situ Split Procedure: A New Surgical Strategy for Inoperable Liver Metastasis. J Gastrointest Surg 2011.