LAUSR

We read with great interest the study by Sparrelid et al. about assessment of volume (CT based) and function (with Tcmebrofenin hepatobiliary scintigraphy (HBS) of the future remnant liver (FRL) for 9 patients with colorectal liver metastasis (CRLM) undergoing associating liver partition and portal vein ligation for staged hepatectomy (ALPPS). This is the third study published so far to confirm that the increase in FLR volume in ALPPS does not keep pace with liver function within the short period of time between stages of ALPPS. While the Stockholm group’s restriction performing ALPPS only in patients with colorectal liver metastases (CRLM) in face of the worse outcomes for other indications and their thorough evaluation of patients with indocyanate green (ICG), mebrofenin and LimaX test has to be applauded, there may remain concern about the heterogeneity of the study population (among the 9 patients, 6 had previously undergone PVE and/or PVL) and the high heterogenity in measurements of liver function 6 days after the procedure (from −35.7% to +83.8%, leading to a median FRL function gain of 28.2%). With evidence from now three studies, it is becoming more difficult to turn the eyes away from the fact that ALPPS with its short time period between stages may have a real problem. It is important to emphasize that, while the extent of hypertrophy induced by ALPPS remains impressive, there is no need for hurry in the treatment of non-resected colorectal liver metastases that have responded appropriately to conversion chemotherapy. Second, the potential of inducing extensive hypertrophy through less invasive means than a two-stage hepatectomy with full or partial transection of the liver are far from exhausted. Recently, we developed a new percutaneous interventional procedure called BExtended Liver Venous Deprivation^ (eLVD) technique, which combined, during the same procedure, right portal vein embolization and right and middle hepatic vein embolizations. We showed that eLVD was safe and resulted in an increase in liver volume that is comparable to ALPPS. Additionally, a functional evaluation of the FLR was performed in 3 patients with CRLM using Tc-mebrofenin scanning 7 days after the procedure, similarly to Sparrelid et al. and based on the methodology developed by the Amsterdam group. Of note, we found comparable baseline liver function in our patients as Sparrelid et al. (respectively 1.95%/min/m [1.6–2.2] compared to 1.8%/min/ m [1.4–2.9]) suggesting that we are dealing with them same patient population. In the 3 patients undergoing eLVD with Tc-mebrofenin, a significant increase in FRL volume (+53.4%) as well as function (+65.7%) was observed 7 days * Emmanuel Deshayes [email protected]