Optimizing future remnant liver prior to major hepatectomies: increasing volume while decreasing morbidity and mortality

Post hepatectomy liver failure (PHLF) remains the most dreaded complication in major hepatectomies. Adequate future remnant liver (FRL) plays a pivotal role in prevention of PHLF. Pre-operative portal vein embolization (PVE) has become standard of care for increasing the FRL in preparation for major hepatectomies. Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) has also been used, though has demonstrated a substantial risk of morbidity and mortality. However, there are many situations in which PVE achieves an inadequate extent of hypertrophy, potential increasing the risk of PHLF.