Abstract
Purpose: Hepatic and/or portal vein embolization are performed before hepatectomy for patients with insufficient future liver remnant and usually achieved with a trans-hepatic approach. The aim of the present study is to describe a modified trans-venous liver venous deprivation technique (mLVD), avoiding the potential risks and limitations of a percutaneous approach to hepatic vein embolization, and to assess the safety, efficacy, and surgical outcome after mLVD. Materials and Methods: Retrospective single-center institutional review board-approved study. From March 2016 to June 2019, consecutive oncologic patients with combined portal and hepatic vein embolization were included. CT volumetric analysis was performed before and after mLVD to assess liver hypertrophy. Complications related to mLVD and surgical outcome were obtained from medical records. Results: Thirty patients (62.7 ± 14.5 years old, 20 men) with liver metastasis (60%) or primary liver cancer (40%) underwent mLVD. Twenty-one patients (70%) had hepatic vein anatomic variants. Technical success of mLVD was 100%. Four patients had complications (three minor and one major). FLR hypertrophy was 64.2% ± 51.3% (mean ± SD). Twenty-four patients (80%) underwent the planned hepatectomy and no surgery was canceled as a consequence of mLVD complications or insufficient hypertrophy. Fifty percent of patients (12/24) had no or mild complications after surgery (Clavien-Dindo 0-II), and 45.8% (11/24) had more serious complications (Clavien-Dindo III-IV). Thirty-day mortality was 4.2% (1/24). Conclusion: mLVD is an effective method to induce FLR hypertrophy. This technique is applicable in a wide range of oncologic situations and in patients with complex right liver vein anatomy.
Highlights
Surgical resection is the principal curative option in patients with primary hepatic tumors and liver metastases
To overcome the limitations of the percutaneous technique, we developed a modified liver venous deprivation technique
In patients with Klatskin tumors and hepatocellular carcinoma, or after multiple cycles of neoadjuvant chemotherapy, an insufficient future liver remnant (FLR) was defined as baseline FLR
Summary
Surgical resection is the principal curative option in patients with primary hepatic tumors and liver metastases. Resectability may be limited by volume and function of the liver remnant after surgery [known as the future liver remnant (FLR)] [1]. Against this limitation, strategies to increase FLR rapidly before surgery were developed to prevent postoperative liver insufficiency. Portal vein embolization (PVE) was the first technique developed in the late 1980s [2] and became widely used because it was highly reliable and allowed liver hypertrophy with low morbidity [3]. More invasive surgical strategies have been developed like ALPPS: Associating Liver Partition and Portal vein Ligation for Staged hepatectomy [6]. Despite excellent results for hypertrophy, complications and mortality rate were too high and some questions about the functional quality of the hypertrophied liver limited the initial enthusiasm for this approach [7]
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