Comparing Liver Venous Deprivation and Portal Vein Embolization for Perihilar Cholangiocarcinoma: Is It Time to Shift the Focus to Hepatic Functional Reserve Rather than Hypertrophy?

SIMPLE SUMMARY: Liver venous deprivation (LVD) has emerged as a promising technique in the pursuit of improving surgical outcomes for perihilar cholangiocarcinoma (PHC) patients. This procedure, which combines portal inflow and hepatic outflow abrogation, has generated significant clinical interest. However, its specific role in optimizing the future liver remnant (FLR) before liver resection, especially when compared to portal vein embolization (PVE), remains unclear. Between 2013 and 2022, all patients with PHC undergoing preoperative FLR enhancement were evaluated. FLR volume assessments were conducted at two time points to evaluate early and late efficacy indicators. While both LVD and PVE cohorts experienced similar post-procedural complications, LVD demonstrated superior FLR function and growth rates at both assessment points. This suggests faster recovery and improved remnant liver functionality. Although FLR volumes remained comparable between the techniques, LVD emerged as an effective method for optimizing FLR in PHC, potentially enhancing liver function and reducing post-hepatectomy liver failure rates, thus improving overall surgical outcomes. ABSTRACT: Purpose: Among liver hypertrophy technics, liver venous deprivation (LVD) has been recently introduced as an effective procedure to combine simultaneous portal inflow and hepatic outflow abrogation, raising growing clinical interest. The aim of this study is to investigate the role of LVD for preoperative optimization of future liver remnant (FLR) in perihilar cholangiocarcinoma (PHC), especially when compared with portal vein embolization (PVE). Methods: Between January 2013 and July 2022, all patients diagnosed with PHC and scheduled for preoperative optimization of FTR, through radiological hypertrophy techniques, prior to liver resection, were included. FTR volumetric assessment was evaluated at two distinct timepoints to track the progression of both early (T(1), 10 days post-procedural) and late (T(2), 21 days post-procedural) efficacy indicators. Post-procedural outcomes, including functional and volumetric analyses, were compared between the LVD and the PVE cohorts. Results: A total of 12 patients underwent LVD while 19 underwent PVE. No significant differences in either post-procedural or post-operative complications were found. Post-procedural FLR function, calculated with (99m) Tc-Mebrofenin hepatobiliary scintigraphy, and kinetic growth rate, at both timepoints, were greater in the LVD cohort (3.12 ± 0.55%/min/m(2) vs. 2.46 ± 0.64%/min/m(2), p = 0.041; 27.32 ± 16.86%/week (T(1)) vs. 15.71 ± 9.82%/week (T(1)) p < 0.001; 17.19 ± 9.88%/week (T(2)) vs. 9.89 ± 14.62%/week (T(2)) p = 0.034) when compared with the PVE cohort. Post-procedural FTR volumes were similar for both hypertrophy techniques. Conclusions: LVD is an effective procedure to effectively optimize FLR before liver resection for PHC. The faster growth rate combined with the improved FLR function, when compared to PVE alone, could maximize surgical outcomes by lowering post-hepatectomy liver failure rates.