Simultaneous ipsilateral dual (DSM-TACE and PVE) embolization (SIDE Technique) for preoperative augmentation of future liver remnant (FLR)

Abstract

Purpose: Portal Vein Embolization(PVE) is a gold standard strategy to increase FLR at level of Kinetic Growth Rate (KGR) about 2.3 cc/day and to prevent posthepatectomy liver failure (PHLF). Up to 30% of patient with liver malignance still couldn't underwent surgery after PVE due to tumor progression and/or insufficient FLR regeneration during waiting period. Currently there are no methods that resolves both mentioned issues. Our aim was to develop new method that potentially will increase number of the patients with insufficient FLR that will succeed to underwent liver surgery. Results also were compared with currently developed methods of FLR augmentation such as extended liver venous deprivation (eLVD) and ALPPS. Method: 9 initially unresectable, due to small FLR, patients with colorectal liver metastases (CRLM) having more than three criteria of Fong Clinical Risk Score for CRLM, in close proximity to FLR critical structures ), were approved by Ethical Committee for Simultaneous PVE and Transarterial Chemoembolization with Degradable Starch Microspheres (DSM-TACE). Simultaneously, immediately after standard PVE, was performed oxaliplatin based DSM-TACE with short-term embolic material of the whole tumor bearing liver to be resected that safely allowed to achieve I) postembolic infarction II) pharmacologically induced hepatic Veno-Occlusive Disease(VOD(Fig 2d)) in liver to be removed, as a trigger of increased FLR regeneration(Fig.1), without biliary tree damage(Fig. 2 a,c) and what distinguishes it advantageously III) local tumor control. Results: Unprecedented FLR regeneration with KGR 23.5 cc/day(range from 17.6 to 57.25 cc/day) was observed. The latter allow us to achieve safe FLR volume to perform extended hepatectomies within recommended 2-3 weeks period to avoid chemotherapy related neutropenic window in all 9 patients even so there were no myelosuppression observed. This allows us safely shortening time to resection to 15 days in 5 last consecutive patients. In all CRLM about 60% (range from 40% to 90%) necrosis was achieved(Fig. 2 a). All patients have successfully underwent major liver resection with 0% dropout. There was no severe morbidity and mortality. Conclusion: We propose safe method of preoperative FLR adaptation which is not only second to none in the achieving liver regeneration rate but also is the only one that allows local tumor control and/or downsize borderline resectable tumors.