Evaluating surgeon attitudes towards the safety and efficacy of portal vein occlusion and associating liver partition and portal vein ligation: a report of the MALINSA survey

Background: Various techniques, including portal vein embolization (PVE), contralateral portal vein ligation (PVL) and associating liver partition and portal vein ligation (ALPPS), are being used to augment the future liver remnant (FLR) volume in preparation for a major hepatectomy. The present study aims to survey and document the availability, variation, utilization and attitudes toward these techniques across centres in North and South America. Methods: A descriptive, 20-question survey was developed and internally validated with expert review. The survey was distributed to 115 centres in North and South America. Results: Of the 115 centres, 54 institutions (47%) returned the surveys. Regarding the question of which modality was most likely to produce adequate hypertrophy, the respondents were equally distributed (ALPPS, 37%; PVE, 35%; equal, 22%). The procedure that respondents judged the safest to achieve liver hypertrophy was PVE (82%). Institutions with capability to extended PVE to segment IV rated the likelihood of PVE technical success (6.2 versus 8.5, P = 0.012) and likelihood of subsequent hypertrophy (5.6 versus 7.8, P = 0.011) higher than institutions without this capability. Although the use of modern embolic materials was associated with a likelihood of successful PVE (P = 0.032), only 49% of respondents who performed PVE used embolic microspheres. Conclusions: There exists significant variability in utilization of and attitudes towards the available techniques for FLR volume augmentation. Penetration of best practice techniques for PVE is lacking, and may be contributing towards disappointment with PVE efficacy, potentially motivating the utilization of the riskier ALPPS procedure.