Left Portal Vein Embolization Research Articles

ALPPS for Left Trisectionectomy with Reconstruction of the Hepato-caval Junction Using a Peritoneal Patch Under Total Vascular Exclusion.

Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) may rescue remnant liver hypertrophy after failure of portal vein embolization (PVE).1 Venous reconstruction is unusual during the first step of ALPPS.2 We report herein an ALPPS for colorectal liver metastases with reconstruction of the hepato-caval junction during the first step. After failure of left PVE, a total ALPPS procedure was performed to achieve left trisectionectomy. A complete transection of the parenchyma was done to avoid extensive dissection during the second step in the context of the venous reconstruction. Total vascular exclusion (TVE) was applied selectively during venous reconstruction using a peritoneal patch.3 RESULTS: The first step lasted 285 min with 200 ml of blood loss, and 29 min of TVE. On postoperative day (POD) 5 there was a good recovery of liver function [prothrombin time 75%; bilirubin 25 µmol/L]. On POD 14, imaging showed an increase of the future remnant liver volume and function to 50% and 48%, respectively. The second step of ALPPS lasted 120 min, with transfusion of one unit of blood, allowing resection of seven liver metastases. Postoperative course experienced a biliary fistula, the patient was discharged on POD 31 and received adjuvant chemotherapy. There was recurrence of one liver metastasis, treated by percutaneous ablation before later resection of the primary. The patient was free of recurrence 12 months after ALPPS. Hepato-caval junction reconstruction can be performed during the first step of an ALPPS procedure, facilitated by the availability of a peritoneum patch.

Sequential preoperative hepatic vein embolization after portal vein embolization for extended left hepatectomy in colorectal liver metastases

BackgroundThe role of portal vein embolization to increase future liver remnant (FLR) is well-established in the treatment of colorectal liver metastases. However, the role of hepatic vein embolization is unclear.Case reportA patient with colorectal liver metastases received neoadjuvant chemotherapy prior to attempted resection. At the time of resection his tumor appeared to invade the left and middle hepatic vein, requiring an extended left hepatectomy including segments five and eight. Post-operatively, he underwent sequential left portal vein embolization followed by left hepatic vein embolization and finally, middle hepatic vein embolization. Hepatic vein embolization was performed to increase the FLR as well as to allow collateral drainage of the FLR to develop. A left trisectionectomy was then performed and no evidence of postoperative liver congestion or morbidity was found.ConclusionSequential portal vein embolization and hepatic vein embolization for extended left hepatectomy may be considered to increase FLR and may prevent right hepatic congestion after sacrificing the middle vein.

Liver hypertrophy and accelerated growth of implanted tumors in nonembolized liver of rabbit after left portal vein embolization

BackgroundPortal vein embolization (PVE) has become a standard preoperative procedure to promote hypertrophy of the future remnant liver to reduce postoperative liver failure. Whether PVE accelerates tumor growth is still controversial. We developed a left PVE procedure and investigated its effect on liver hypertrophy and tumor growth in a rabbit liver tumor model. Materials and methodsVX2 tumors were implanted in both the external left and right middle lobe (the bilateral group) or in the external left lobe only (the unilateral group) of rabbit liver. Both groups were further divided into a PVE or a sham/control group. Tumor volume and tumor growth rate as volume relative increase were determined by ultrasound. Liver volume–to–body weight index, an index for liver volume, was compared. Serum HGF was measured by ELISA. ResultsIn the bilateral PVE group, tumor volume and relative increase value in the nonembolized lobe were significantly (71% and 65%, respectively) greater than those in the control group at 5 d post-PVE. In the unilateral PVE group, liver volume–to–body weight index of the nonembolized lobes was significantly increased by 17%. Increase of serum HGF level after PVE was correlated well with both tumor growth and liver hypertrophy. ConclusionsLeft PVE promoted both the growth of implanted tumors and liver hypertrophy in the nonembolized liver, in which serum HGF might play an important role.

Selective Portal Vein Embolization and Colorectal Liver Metastases in Rat: A New Experimental Model for Tumor Growth Study

Portal vein embolization (PVE) has been proposed to induce hypertrophy of liver before major resection. Because there are some concerns about the effect on tumor growth, experimental research is needed, requiring reliable small animal model. The aim was to assess technical feasibility of PVE model in rat and to report colorectal liver metastases (LM) tumor growth. LM were induced in 40 rats by injecting DHDK12 cells into the left liver lobe. At d 7, a portography was performed through a laparotomy in 20 rats allowing the left PVE. Twenty rats without PVE served as control. All rats were sacrificed at d 30. Liver and tumor volume were calculated. Mortality rate was 20% (n=8). PVE was successful in 15/19 rats (79%). Compared with control rats, the left PVE induced both significant atrophy of the left lobe (3.5±0.8 versus 7.4±0.9 mm3, P<0.0001) and contralateral hypertrophy (5.8±1.1 versus 3.6±0.7 mm3, P<0.0001). LM tumor volume in the left liver was significantly decreased in PVE group compared to control, 124.4±95.7 mm3versus 231.1±90.1 mm3, P=0.008. PVE is feasible in rats with a 79% success rate. Significant hypertrophy of the remnant liver and atrophy of the embolized liver were noted suggesting the efficacy of PVE. LM tumor growth decreased significantly in the embolized lobe. Our model can be used for experimental studies evaluating tumor growth and effects of new drugs against LM in a situation that mimics the human situation before partial hepatectomy.

Portal vein embolization induces compensatory hypertrophy of remnant liver

To evaluate the effectiveness and safety of different portal vein branch embolization agents in inducing compensatory hypertrophy of the remnant liver and to offer a theoretic basis for clinical portal vein branch embolization. Forty-one adult dogs were included in the experiment and divided into four groups. Five dogs served as a control group, 12 as a gelfoam group, 12 as a coil-gelfoam group and 12 as an absolute ethanol group. Left portal vein embolization was performed in each group. The results from the embolization in each group using different embolic agents were compared. The safety of portal vein embolization (PVE) was evaluated by liver function test, computed tomography (CT) and digital subtraction angiography (DSA) of liver and portal veins. Statistical test of variance was performed to analyze the results. Gelfoam used for PVE was inefficient in recanalization of portal vein branch 4 wk after the procedure. The liver volume in groups of coil-gelfoam and absolute ethanol increased 25.1% and 33.18%, respectively. There was no evidence of recanalization of embolized portal vein, hepatic dysfunction, and portal hypertension in coil-gelfoam group and absolute ethanol group. Portal vein branch embolization using absolute ethanol and coil-gelfoam could induce atrophy of the embolized lobes and compensatory hypertrophy of the remnant liver. Gelfoam is an inefficient agent.

Safety and Efficacy of Preoperative Portal Vein Embolization with Polyvinyl Alcohol in 58 Patients with Liver Metastases

The objective of our study was to evaluate the safety and efficacy of transhepatic lobar portal vein embolization (PVE) using polyvinyl alcohol (PVA) particles to induce contralateral lobar hypertrophy in patients with liver-only metastases and normal underlying liver function. Fifty-eight consecutive patients with small predicted future liver remnants (FLRs) underwent PVE with PVA particles to induce hypertrophy of the contralateral hemi-liver before surgical resection of liver metastases. Total liver, right hemi-liver, and left hemi-liver volumes were calculated before and after embolization using a 3D workstation. Eight patients underwent left PVE; 47, right PVE; and three, right and segment IV PVE. There were no major complications of the procedure. The mean increases in the ratio of the FLR to the total estimated liver volume after right, right and segment IV, and left PVE were 9%, 10%, and 3%, respectively; the corresponding mean hypertrophy ratios were 24.3%, 31.9%, and 1.5%, respectively. Right PVE using PVA particles alone as the embolic agent is safe and effective in achieving left hemi-liver hypertrophy. In contrast, left PVE did not induce significant right hemi-liver hypertrophy in this patient population.