Selective portal vein occlusion with hepatic artery preservation reduces post-hepatectomy liver failure: a retrospective cohort study

Background: Current hepatic inflow occlusion techniques have limitations in effectively preventing post-hepatectomy liver failure (PHLF) from ischemia-reperfusion injury. Innovations in occlusion methods remain a critical area for advancement. This study investigated a hepatic inflow occlusion approach using selective portal vein occlusion (SPO) while maintaining hepatic arterial flow, aiming to evaluate its perioperative effects. Methods: Clinical data from consecutive patients who underwent hepatectomy between 2014 and 2024 were retrospectively collected. Postoperative outcomes were compared after a 1:1 ratio using propensity score matching (PSM) based on sex, age, body mass index, and Child-Pugh score using a fixed random seed. Univariate and multivariate logistic regression analyses were performed to identify risk factors for PHLF. Subgroup analyses were conducted to investigate the association between vascular occlusion strategies and the incidence of PHLF. Results: A total of 574 patients (192 SPO and 382 Pringle) were included. After PSM, 384 patients (192 SPO and 192 Pringle) were compared. PHLF was observed in 26 patients (6.8%). Hepatectomy with SPO was associated with a lower incidence of PHLF (3.1% vs. 10.4%, P = 0.026). No statistically significant difference was found in postoperative Clavien-Dindo grade III-IV complication rates between two occlusion groups (7.3% vs. 13.0%, P = 0.165). The optimal cut-off value of ICG-R15 for predicting PHLF was identified as 6.9% based on receiver operating characteristic (ROC) analysis, with an area under the curve (AUC) of 0.830 (95% CI: 0.735-0.922), a sensitivity of 88.5%, and a specificity of 66.5%. In multivariate logistic regression analysis, blood loss (p = 0.019), ICG-R15 > 0.069 (p<0.001), undergoing>hemihepatectomy (p<0.001) were identified as independent risk factors for PHLF. SPO was found to be an independent protective factor (p = 0.005). Subgroup analysis identified populations that benefit more from SPO, showing a significantly lower incidence of PHLF in patients aged <60 years (OR = 5.42, P = 0.019), males (OR = 5.06, P = 0.010), those with BMI≥23 (OR = 3.81, P = 0.049), without cirrhosis (OR = 4.9, P = 0.003), with benign disease (OR = 5.07, P = 0.031), and undergoing≤hemihepatectomy (OR = 5.16, P = 0.005). Conclusion: The occlusion approach of SPO while preserving hepatic arterial flow can significantly reduce the incidence of PHLF.