Hepatic inflow modulation with a portocaval shunt stabilizes hepatic hemodynamics and enhances liver regeneration after extended hepatectomy in a porcine model

Abstract Posthepatectomy liver failure due to small-for-size and flow (SFSF) syndrome is linked to high morbidity and mortality, with hepatic inflow modulation potentially promoting liver regeneration and mitigating SFSF-induced damage. This study evaluated the effect of hepatic inflow modulation using a portocaval shunt (PCS) following extended hepatectomy in a porcine model. Sixteen female landrace pigs were assigned to two groups: a control group undergoing left extended hepatectomy and a PCS group undergoing the same procedure with PCS. Hepatic artery flow (HAF), portal vein flow (PVF), and portal vein pressure (PVP) were measured pre- and post-surgery and on postoperative day (POD) 7. Liver volume was assessed via contrast-enhanced computed tomography before surgery and euthanasia. On POD 7, relative HAF was significantly higher, and relative PVF significantly lower in the PCS group. PVP was higher in the control group post-resection but normalized by POD 7. The final remnant liver volume was approximately 20% larger in the PCS group (791.9 vs. 659.5 mL; p = 0.002). By reducing PVF while preserving HAF, PCS stabilized hepatic hemodynamics and was associated with enhanced liver hypertrophy and regeneration, likely reflecting reduced parenchymal injury and improved hepatocyte oxygenation. These findings support PCS as a promising strategy to stabilize hepatic hemodynamics and enhance liver regeneration after extended hepatectomy.