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Liver Regeneration after two-stage liver transplantation is more effective than after other preconditioning procedures in colorectal liver metastases.

INTRODUCTION
Induction of liver regeneration represents an option to expand the resectability in patients with expected small future liver remnant (FLR). The aim of this cohort-study is to compare the liver regeneration between different surgical procedures, including novel procedures such as two-stage living donor liver transplantation using a small for size grafts.


METHODS
Forty-three patients with colorectal liver metastases were included between 2004 and 2020. These underwent one of the following three procedures: portal vein embolization (PVE), associated liver partition with portal vein ligation for staged hepatectomy (ALPPS), and living donor two-stage liver transplantation (LT). The volume gain of the future liver remnant was analyzed in comparison between the three mentioned procedures.


RESULTS
The type of surgery performed had a significant correlation with liver regeneration with a strong effect to the benefit of ALPPS and liver transplantation, respectively (r = 0.6, P = 0.00003). The type of surgery was the only independent co-factor in the multiple regression, which showed a significant influence on FLR-increase favouring two-stage transplantation compared to the other two related procedures (ß = 0.12, T = 3.9, P = 0.0004). The histological and immunohistochemical studies also showed a clear advantage of proliferation to the benefits of two-stage liver transplantation compared with ALPPS.


CONCLUSION
Two-stage liver transplantation using small for size grafts induces better FLR-increase than portal vein embolization or ALPPS in patients with colorectal liver metastases.