Should all patients be offered liver venous deprivation for insufficient future liver remnant hypertrophy prior to major hepatectomy?

In this issue of HepatoBiliary Surgery and Nutrition, Boubaddi et al. present the safety, feasibility, and efficacy of liver venous deprivation (LVD) in 192 patients from seven French expert centers (2016–2023) requiring major liver resection for primary or secondary liver malignancies (1). The study found that LVD, which involves embolization of both portal and hepatic veins, was technically successful in all cases, with 100% of procedures completed as intended. Severe complications following LVD were rare, occurring in only 2.6% of patients. The technique proved highly effective for inducing rapid hypertrophy of the future liver remnant (FLR), with an average increase in FLR volume of 61.7% observed over approximately 27 days and associated kinetic growth rate (KGR) of 6% per week. Of the 192 patients included, 83.8% underwent major hepatectomy, typically about 40 days after LVD, while surgery was not performed in 16.2% of patients, mainly due to disease progression. Postoperatively, severe complications (classified as Clavien-Dindo ≥ IIIA) including biliary wounds, sepsis, and liver failure occurred in 21.1% of patients, and the mortality rate after surgery was 4.3%. Overall, LVD was demonstrated to be a safe, reproducible, and effective method for significantly increasing FLR volume prior to major hepatectomy.

Portal vein embolization (PVE), first introduced by Makuuchi et al. in 1984, has become a well-established technique to promote FLR hypertrophy before major hepatectomy (2). Although PVE may effectively increase FLR, approximately 30% of patients are ultimately unable to undergo liver resection due to insufficient hypertrophy or disease progression (3). In 2016, Guiu et al. reported that combining PVE with hepatic vein embolization, a technique they termed LVD, was both safe and effective for optimizing FLR volume (4). While multiple studies have compared the outcomes of LVD versus PVE alone, most are limited by small patient cohorts (5-10). Across these studies, LVD has increased FLR hypertrophy and KGR with reportedly no significant increase in peri-procedural or post-operative complications. The current manuscript by Boubaddi et al. (1) adds to this body of work, confirming the efficacy and safety of LVD as performed by trained radiologists at major academic hospitals.

We commend the authors for their valuable contribution and significant expertise with this advanced technique. Their findings are consistent with data from our own group, as reported by Haddad et al., which showed that, despite achieving comparable post-procedure standardized FLR volumes, patients who underwent LVD, as opposed to PVE, demonstrated a significantly greater degree of hypertrophy (16% vs. 11%; P=0.017) and a markedly higher KGR (3.9% vs. 2.4% per week; P=0.006). This enhanced growth subsequently enabled a higher rate of extended right hepatectomies (93% vs. 55%; P=0.008) (11). Additionally, our group contributed to the largest multi-institutional LVD registry to date (EuroLVD), with data published in April 2025. The study included 749 patients from 13 centers across eight countries undergoing LVD for primary or secondary liver tumors, of whom 587 (78.4%) underwent resection after LVD. Consistent with the current study, the median FLR increase was 47.7%, with a KGR of 2.8%, and a 21.6% dropout rate, primarily due to disease progression. Notably, the rate of grade B or C post-hepatectomy liver failure (PHLF) was lower at 13.8%. While not comparing outcomes with PVE, this registry underscores the effectiveness of LVD in inducing hypertrophy and enabling resection (12).

The present study’s most compelling finding is the demonstration that LVD consistently achieves superior liver hypertrophy compared to historical PVE outcomes while maintaining an excellent safety profile. The 61.7% increase in FLR volume substantially exceeds the typical 20–40% hypertrophy seen with PVE alone, translating to a KGR of 6% per week. This hypertrophy enables surgery in a higher percentage of patients while reducing the time interval between intervention and surgery to approximately 40 days. The technique’s 100% technical success rate across seven different centers demonstrates its reproducibility, while the 2.6% severe complication rate compares favorably to PVE (13).

Despite the promising results, the study reveals critical areas requiring standardization to optimize LVD outcomes and reduce PHLF rates. Notably, the 21.1% incidence of clinically significant PHLF (grade B or C) underscores the limitation of relying solely on volumetric assessment without incorporating functional evaluation. This limitation is particularly evident in patients with cholangiocarcinoma, those undergoing extended right hepatectomy, and individuals with lower post-LVD FLR percentages, all of whom are typically classified as high-risk and unsurprisingly demonstrated higher rates of liver failure. Understanding the KGR in this subset of patients would be particularly helpful as we have previously demonstrated the risk of liver-failure-related death is essentially zero in patients with KGR of at least 2% per week (14). However, it is important to recognize that rapid volumetric growth does not necessarily promise comparable remnant function. In a similar clinical picture as associating liver partition and portal vein ligation for staged hepatectomy (ALPPS), patients with this very rapid hypertrophy may still have limited synthetic or filtration capacity, and caution should be exercised in interpreting liver volumetry in the setting of rapid growth. These findings highlight the need for more sophisticated patient selection criteria that integrate functional imaging, as volumetry alone may be a reasonable surrogate for liver function only in patients with healthy parenchyma. While various modalities exist, widespread use is currently limited by availability, cost, and logistical constriants. Moreover, it is for these reasons that we advocate for a selective approach of PVE or LVD for patients undergoing major hepatectomy initially unresectable due to insufficient FLR.

Although some advocate for routine LVD in all candidates for major hepatectomy, the procedure demands specialized expertise, additional procedural time, and higher costs compared to PVE, and there are currently no established guidelines to direct its use. To date, the multicenter, international DRAGON-1 trial—a prospective, single-arm study assessing combined LVD in patients with unresectable colorectal liver metastases—demonstrated that LVD is feasible and generally safe with rapid FLR hypertrophy and a high resection rate of 90%. However, the 22% rate of grade B/C PHLF underscores the need for a multidimensional approach to patient selection for hypertrophy techniques (15). Standardizing technique across centers and developing robust guidelines remain essential, and we await the results of the ongoing randomized DRAGON-2 trial comparing PVE and LVD in patients with colorectal liver metastases and small FLR volumes (16).

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, HepatoBiliary Surgery and Nutrition. The article has undergone external peer review.

Peer Review File: Available at https://hbsn.amegroups.com/article/view/10.21037/hbsn-2025-511/prf

Funding: None.

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://hbsn.amegroups.com/article/view/10.21037/hbsn-2025-511/coif). The authors have no conflicts of interest to declare.

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