Deportalization, Venous Congestion, Venous Deprivation: Serial Measurements of Volumes and Functions on Morphofunctional 99mTc-Mebrofenin SPECT-CT.

Lauranne Piron,Emmanuel Deshayes,Christophe Cassinotto,Eric Assenat,Fabrizio Panaro,François Quenet,Margaux Hermida,Georges-Philippe Pageaux,Boris Guiu,Nicolas Molinari,Carole Allimant

doi:10.3390/diagnostics11010012

Abstract

The objective was to assess the changes in regional volumes and functions under venous-impaired vascular conditions following liver preparation. Twelve patients underwent right portal vein embolization (PVE) (n = 5) or extended liver venous deprivation (eLVD, i.e., portal and right and middle hepatic veins embolization) (n = 7). Volume and function measurements of deportalized liver, venous-deprived liver and congestive liver were performed before and after PVE/eLVD at days 7, 14 and 21 using 99mTc-mebrofenin hepatobiliary scintigraphy with single-photon emission computed tomography and computed tomography (99mTc-mebrofenin SPECT-CT). Volume and function progressed independently in the deportalized liver (p = 0.47) with an early decrease in function (median −18.2% (IQR, −19.4–−14.5) at day 7) followed by a decrease in volume (−19.3% (−22.6–−14.4) at day 21). Volume and function progressed independently in the venous deprived liver (p = 0.80) with a marked and early decrease in function (−41.1% (−52.0–−12.9) at day 7) but minimal changes in volume (−4.7% (−10.4–+3.9) at day 21). Volume and function progressed independently in the congestive liver (p = 0.21) with a gradual increase in volume (+43.2% (+38.3–+51.2) at day 21) that preceded a late and moderate increase in function at day 21 (+34.8% (−8.3–+46.6)), concomitantly to the disappearance of hypoattenuated congestive areas in segment IV (S4) on CT, initially observed in 6/7 patients after eLVD and represented 35.3% (22.2–46.4) of whole S4 volume. Liver volume and function progress independently whatever the vascular condition. Hepatic congestion from outflow obstruction drives volume increase but results in early impaired function.

Highlights

Extended hepatic resection with R0–R1 margins is the only way to provide a potential cure to patients with multiple liver tumors
When the future liver remnant (FLR) can be supplied by portal and arterial inflow and drained by at least one hepatic vein (HV), the patient may be eligible for surgery if there is sufficient FLR [1]
When the FLR is insufficient, preparation of the liver by portal vein embolization (PVE) leads to FLR regeneration [3,4,5] and is the standard of care to obtain an appropriate FLR before surgery [6]

Summary

Introduction

Extended hepatic resection with R0–R1 margins is the only way to provide a potential cure to patients with multiple liver tumors. When the future liver remnant (FLR) can be supplied by portal and arterial inflow and drained by at least one hepatic vein (HV), the patient may be eligible for surgery if there is sufficient FLR [1]. A combination of PVE and embolization of the right and accessory right HVs during the same intervention, called liver venous deprivation (LVD) technique, is used to optimize right PVE results [7]. The same authors described the extended liver venous deprivation (eLVD) technique including simultaneous embolization of the right portal, right and middle HVs branches, leading to a rapid increase in FLR [8]

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Conclusion