Efficacy and perioperative safety of different future liver remnant modulation techniques: a systematic review and network meta-analysis

Background: In daily clinical practice, different future liver remnant (FLR) modulation techniques are increasingly used to allow a liver resection in patients with insufficient FLR volume. This systematic review and network meta-analysis aims to compare the efficacy and perioperative safety of portal vein ligation (PVL), portal vein embolization (PVE), liver venous deprivation (LVD) and associating liver partition and portal vein ligation for staged hepatectomy (ALPPS). Methods: A literature search for studies comparing liver resections following different FLR modulation techniques was performed in MEDLINE, Embase and Cochrane Central, and pairwise and network meta-analyses were conducted. Results: Overall, 23 studies comprising 1557 patients were included. LVD achieved the greatest increase in FLR (17.32 %, 95% CI 2.49–32.15), while ALPPS was most effective in preventing dropout before the completion hepatectomy (OR 0.29, 95% CI 0.15–0.55). PVL tended to be associated with a longer time to completion hepatectomy (MD 5.78 days, 95% CI -0.67–12.23). Liver failure occurred less frequently after LVD, compared to PVE (OR 0.35, 95% CI 0.14–0.87) and ALPPS (OR 0.28, 95% CI 0.09–0.85). Discussion: ALPPS and LVD seem superior to PVE and PVL in terms of achieved FLR increase and subsequent treatment completion. LVD was associated with lower rates of post hepatectomy liver failure, compared to both PVE and ALPPS. A summary of the protocol has been prospectively registered in the PROSPERO database (CRD42022321474).