Major Hepatectomy In Patients Research Articles

Impact of the future liver remnant volume before major hepatectomy

IntroductionFollowing major liver resection, posthepatectomy liver failure (PHLF) is associated with a high mortality rate. As there is no therapy for PHLF available, avoidance remains the main goal. A sufficient future liver remnant (FLR) is one of the most important factors to reduce the risk for PHLF; however, it is not known which patients benefit of volumetric assessment prior to major surgery. MethodsA retrospective, bi-institutional cohort study was conducted including all patients who underwent major hepatectomy (extended right hepatectomy, right hepatectomy, extended left hepatectomy and left hepatectomy) between 2010 and 2023. ResultsA total of 1511 major hepatectomies were included, with 29.4 % of patients undergoing FLR volume assessment preoperatively. Overall, PHLF B/C occurred in 9.8 % of cases. Multivariate analysis identified diabetes mellitus, extended right hepatectomy, perihilar cholangiocarcinoma (pCCA), gallbladder cancer (GBC) and cirrhosis as significant risk factors for PHLF B/C. High-risk patients (with one or more risk factors) had a 15 % overall incidence of PHLF, increasing to 32 % with a FLR <30 %, and 13 % with an FLR of 30–40 %. Low-risk patients with a FLR <30 % had a PHLF rate of 21 %, which decreased to 8 % and 5 % for FLRs of 30–40 % and >40 %, respectively. For right hepatectomy, the PHLF rate was 23 % in low-risk and 38 % in high-risk patients with FLR <30 %. ConclusionPatients scheduled for right hepatectomy and extended right hepatectomy should undergo volumetric assessment of the FLR. Volumetry should always be considered before major hepatectomy in patients with risk factors such as diabetes, cirrhosis, GBC and pCCA. In high-risk patients, a FLR cut-off of 30 % may be insufficient to prevent PHLF, and additional liver function assessment should be considered.

Is hepatectomy feasible for hepatocellular carcinoma patients with clinically significant portal hypertension and beyond the Milan criteria?

BackgroundHepatocellular carcinoma (HCC) patients with clinically significant portal hypertension (CSPH) and beyond the Milan criteria undergoing hepatectomy were previously considered to be at high risk and to have a poor prognosis, especially for major hepatectomy. The aim of this study was to investigate the safety and efficacy of hepatectomy in those patients. MethodsData were collected on HCC patients with CSPH treated at a single centre from January 2010 to October 2021. Propensity score-matched (PSM) analysis was used to balance the bias between groups. ResultsOf the included patients, 556 underwent hepatectomy and 172 underwent transcatheter arterial chemoembolization (TACE). Comparison of patients beyond the Milan criteria and those with Milan criteria underwent hepatectomy, the 90-day mortality and complication rates were similar in the two groups. However, the overall survival (OS) and recurrence-free survival (RFS) of patients within the Milan criteria were significantly better than those beyond the Milan criteria (p < 0.001). In HCC patients beyond the Milan criteria, OS of performing hepatectomy was significantly longer than TACE (p < 0.001). Within HCC patients beyond the Milan criteria underwent hepatectomy, there was no significant difference in 90-day mortality and complications between minor and major hepatectomy in patients beyond the Milan criteria and no significant difference in RFS and OS after PSM. ConclusionsHepatectomy for HCC patients with CSPH and beyond the Milan criteria is safe and feasible, with an acceptable prognosis and no significant difference between minor and major hepatectomy.

Prevention of post-hepatectomy liver failure after major resection of colorectal liver metastases: is hepato-biliary scintigraphy the optimal tool?

Liver failure is the most threatening complication after hepatectomy for colorectal liver metastases. Recent studies indicate that liver functional evaluation by hepatobiliary scintigraphy (HBS) could be more sensitive than volumetry to predict the risk of post-hepatectomy liver failure (PHLF). The aim of this study was to evaluate the performance of 99mTc-mebrofenin HBS, when used as the main preoperative assessment before major hepatectomy in patients with liver metastases from colorectal cancer. This retrospective study reviewed data from all patients with colorectal liver metastases treated at Montpellier Cancer Institute between 2013 and 2020. Only patients who underwent HBS before surgery were included. The primary aim was to evaluate how the use of this functional imaging modifies the surgical management of patients with colorectal liver metastases. Among the 80 patients included, 26 (32.5%) underwent two-stage hepatectomy and 13 (16.3%) repeated hepatectomies. Severe postoperative complications occurred in 16 patients (20%) and all-grade liver failure occurred in 13 patients (16.3%). Seventeen patients (21.3%) underwent major liver surgery based on sufficient mebrofenin uptake, although the retrospectively evaluated future liver remnant (FLR) volume was insufficient (<30% of total liver). None of these patients had PHLF. This study showed the reliability of HBS for the preoperative functional assessment of patients with colorectal liver metastases. Indeed, it allowed performing major hepatectomy safely in 20% more patients who would not have been considered for surgery on the basis of volumetric assessment.

Adverse Effects of Sarcopenic Obesity on Postoperative Complications after Major Hepatectomy in Patients with Hilar Cholangiocarcinoma.

Sarcopenic obesity (SO), which is defined as a high ratio of visceral adipose tissue to skeletal muscle, is a well-known risk factor for post-hepatectomy outcomes in patients with hepatocellular carcinoma. However, few studies have evaluated the effect of SO on postoperative outcomes in patients with hilar cholangiocarcinoma (CCC). This retrospective study aimed to evaluate the effect of preoperative SO on postoperative outcomes in patients with hilar CCC following major hepatectomy. Preoperative SO was assessed in 328 patients undergoing hepatectomy for hilar CCC at three institutions between 2006 and 2016. SO was calculated from cross-sectional visceral fat and muscle area displayed on preoperative CT imaging. Preoperative SO was present in 98 patients (29.9%). The major complication rate in patients with SO was higher than in those without SO (54.1% vs. 37.0%, p = 0.004). Additionally, postoperative hospital stays were prolonged in patients with SO (18.5 vs. 16.5 days, p = 0.038). After multivariable analysis, SO was identified as an independent risk factor for major complications after hepatectomy in hilar CCC patients (OR = 0.866, 95% CI: 1.148–3.034, p = 0.012). Careful postoperative management is needed after major hepatectomy in hilar CCC patients with SO.

Right hepatectomy with preservation of the entire caudate lobe in patients with metastatic liver tumors: a case of a new hepatectomy technique and treatment strategy for patients with marginal liver function

BackgroundPerforming major hepatectomy for patients with marginal hepatic function is challenging. In some cases, the procedure is contraindicated owing to the threat of postoperative liver failure. In this case report, we present the first case of marginal liver function (indocyanine green clearance retention rate at 15 min [ICGR15]: 28%) successfully treated with right hepatectomy, resulting in total caudate lobe preservation.Case presentationA 71-year-old man was diagnosed with sigmoid colon cancer with three liver metastases (S5, S7, and S8). All of metastatic lesions shrunk after chemotherapy, but his ICGR15 and indocyanine green clearance rate (ICGK) were 21% and 0.12, respectively. Moreover, the remnant liver volume was only 39%. Therefore, portal venous embolism (PVE) of the right portal vein was suggested. Portography showed divergence of the considerably preserved right caudate lobe branch (PV1R) from the root of the right portal vein. The liver function was reevaluated 18 days after PVE was suggested. During this time, the ICGR15 (21–28%) and ICGK rate (0.12–0.10) deteriorated. The right caudate lobe was significantly enlarged; thus, a total caudate lobe-preserving hepatectomy (TCPRx) was performed. Patients eligible for TCPRx included those with (1) hepatocellular carcinoma or metastatic liver cancer, (2) no tumor in the caudate lobe, (3) marginal liver function (ICG Krem greater than 0.05 if TCPRx was adapted; otherwise, less than 0.05) and Child–Pugh classification category A, and (4) preserved PV1R and right caudate bile duct branch. The procedure was performed through (A) precise estimation of the remnant liver volume preoperatively, (B) repeated intraoperative cholangiography to confirm the biliary branch of the right caudate lobe (B1R) conservation, and (C) stapler division of posterior and anterior Glisson’s pedicles laterally to avoid injuries to the PV1R and B1R.ConclusionsRight hepatectomy with total caudate lobe preservation, following PVE, was a safe and viable surgical technique for patients with marginal liver function.

Rescue Partial ALPPS for Left Hemihepatectomy with Reconstruction of the Middle Hepatic Vein

Major hepatectomy in patients with insufficient future liver remnant (FLR) volume and impaired liver functional reserve has considerable risks for posthepatectomy liver failure (PHLF). The patient was a male in his 70s with an intrahepatic cholangiocarcinoma in left hemiliver, involving the middle hepatic vein (MHV). Although FLR volume after left hemihepatectomy was estimated to be 64.4% of the total liver volume, an indocyanine green retention rate at 15 min (ICG-R15) value was 24.2%, thus the patient underwent left portal vein embolization. The FLR volume increased to 71.3%; however, the noncongestive FLR volume was re-estimated as 45.8% after resection of the MHV, the ICG-R15 value was 29.0%, and ICG-Krem was calculated as 0.037. We performed partial rescue Associating Liver Partition and Portal vein occlusion for Staged hepatectomy (ALPPS) for left hemihepatectomy with the MHV reconstruction. On the first stage, partial liver partition was done along Rex-Cantlie’s line, preserving the MHV and sacrificing the remaining branches to segment 8. The FLR volume increased to 77.4% on day 14. The ICG-R15 value was 29.6%, but ICG-Krem after MHV reconstruction was estimated to be 0.059. The second-stage operation on day 21 was left hemihepatectomy with the MHV reconstruction using the left superficial femoral vein graft. The usage of rescue partial ALPPS may contribute to preventing PHLF by introducing occlusion of the portal and/or venous branches in the left hemiliver before curative hepatectomy.

Muscularity Defined by the Combination of Muscle Quantity and Quality is Closely Related to Both Liver Hypertrophy and Postoperative Outcomes Following Portal Vein Embolization in Cancer Patients

Portal vein embolization (PVE) is a common procedure for preventing hepatic insufficiency after major hepatectomy. While evaluating the body composition of surgical patients is common, the impact of muscularity defined by both muscle quantity and quality on liver hypertrophy after PVE and associated outcomes after major hepatectomy in patients with hepatobiliary cancer remain unclear. This retrospective review included 126 patients who had undergone hepatobiliary cancer resection after PVE. Muscularity was measured on preoperative computed tomography images by combining the skeletal mass index and intramuscular adipose content. Various factors including the degree of hypertrophy (DH) of the future liver remnant and post-hepatectomy outcomes were compared according to muscularity. DH did not differ by malignancy type. Patients with high muscularity had better DH after PVE (P = 0.028), and low muscularity was an independent predictor for poor liver hypertrophy after PVE [odds ratio (OR), 3.418; 95% confidence interval (CI), 1.129-10.352; P = 0.030]. In subgroup analyses in which patients were stratified into groups based on primary hepatobiliary tumors and metastases, low muscularity was associated with higher incidence of post-hepatectomy liver failure (PHLF) ≥ grade B (P = 0.018) and was identified as an independent predictor for high-grade PHLF (OR 3.931; 95% CI 1.113-13.885; P = 0.034) among the primary tumor group. In contrast, muscularity did not affect surgical outcomes in patients with metastases. Low muscularity leads to poor liver hypertrophy after PVE and is also a predictor of PHLF, particularly in primary hepatobiliary cancer.

Functional transition: Inconsistently parallel to the increase in future liver remnant volume after preoperative portal vein embolization.

BACKGROUNDPreoperative portal vein embolization (PVE) is a widely used strategy to enable major hepatectomy in patients with insufficient liver remnant. PVE induces hypertrophy of the future liver remnant (FLR) and a shift of the functional reserve to the FLR. However, whether the increase of the FLR volume (FLRV) corresponds to the functional transition after PVE remains unclear.AIMTo investigate the sequential relationship between the increase in FLRV and functional transition after preoperative PVE using 3-dimensional (3D) computed tomography (CT) and 99mTc-galactosyl-human serum albumin (99mTc-GSA) single-photon emission computed tomography (SPECT) fusion images. METHODSThirty-three patients who underwent major hepatectomy following PVE at the Department of Gastroenterological Surgery I, Hokkaido University Hospital between October 2013 and March 2018 were enrolled. Three-phase dynamic multidetector CT and 99mTc-GSA SPECT scintigraphy were performed at pre-PVE, and at 1 and 2 wk after PVE; 3D 99mTc-GSA SPECT CT-fused images were constructed from the Digital Imaging and Communications in Medicine data using 3D image analysis system. Functional FLRV (FFLRV) was defined as the total liver volume × (FLR volume counts/total liver volume counts) on the 3D 99mTc-GSA SPECT CT-fused images. The calculated FFLRV was compared with FLRV.RESULTSFFLRV increased by a significantly larger extent than FLRV at 1 and 2 wk after PVE (P < 0.01). The increase in FFLRV and FLRV was 55.1% ± 41.6% and 26.7% ± 17.8% (P < 0.001), respectively, at 1 wk after PVE, and 64.2% ± 33.3% and 36.8% ± 18.9% (P < 0.001), respectively, at 2 wk after PVE. In 3 of the 33 patients, FFLRV levels decreased below FLRV at 2 wk. One of the three patients showed rapidly progressive fatty changes in FLR. The biopsy at 4 wk after PVE showed macro- and micro-vesicular steatosis of more than 40%, which improved to 10%. Radical resection was performed at 13 wk after PVE. The patient recovered uneventfully without any symptoms of pos-toperative liver failure.CONCLUSIONThe functional transition lagged behind the increase in FLRV after PVE in some cases. Evaluating both volume and function is needed to determine the optimal timing of hepatectomy after PVE.

Regional liver function analysis with gadoxetic acid-enhanced MRI and virtual hepatectomy: prediction of postoperative short-term outcomes for HCC.

To explore the role of quantitative regional liver function assessed by preoperative gadoxetic acid-enhanced MRI with computer-aided virtual hepatectomy to predict short-term outcomes after major hepatectomy for HCC. We retrospectively reviewed the records of 133 consecutive patients with HCC who underwent preoperative gadoxetic acid-enhanced MRI and indocyanine green (ICG) test. Forty-five patients received open major hepatectomy. Liver function reserve and the future liver remnant were evaluated by computer-aided virtual hepatectomy. Global liver functional parameters included the T1 relaxation time reduction rate (T1ratio) and functional liver volume (FV), whereas regional parameters included the rT1pos, rT1ratio, remnant FV (rFV), and remnant FV ratio (rFVratio) of the remnant liver. The functional parameters of the MRI and ICG were used to predict the short-term outcomes (liver failure and major complications) after major hepatectomy. The T1ratio and FV were correlated with the ICG test (rho = - 0.304 and - 0.449, p < 0.05). FV < 682.8 ml indicated preoperative ICG-R15 ≥ 14% with 0.765 value of the area under the curve (AUC). No patient who underwent major resection with good liver functional reserve (ICG < 14%) and enough future remnant volume (> 30% standard LV) developed liver failure. Low rT1ratio (< 66.5%) and high rT1pos (> 217.5 ms) may predict major complications (AUC = 0.831 and 0.756, respectively; p < 0.05). The rT1ratio was an independent risk factor for postoperative major complications (odds ratio [OR] = 0.845, 95% CI, 0.736-0.966; p < 0.05). Preoperative gadoxetic acid-enhanced MRI with computer-aided virtual hepatectomy may facilitate optimal assessment of regional liver functional reserve to predict short-term outcomes after major hepatectomy for HCC. • Preoperative gadoxetic acid-enhanced MRI with virtual hepatectomy and volumetric analysis can provide precise liver volume and regional functional assessment. • Quantitative regional liver function assessed by gadoxetic acid-enhanced MRI can predict the short-term outcomes after major hepatectomy in patients with HCC. • The regional liver function assessed by gadoxetic acid-enhanced MRI is an independent risk factor for postoperative major complications.

Safety and Feasibility of Laparoscopic Major Hepatectomy after Portal Vein Embolization

Background and Aim: The operative safety and feasibility of laparoscopic major hepatectomy in patients after portal vein embolization is unknown, prompting our investigation of its safety and feasibility in patients at our center. Methods: Fifteen patients (male=13, female=2, with median age of 58 years), underwent laparoscopic major hepatectomy after portal vein embolization. Ten patients had hepatocellular carcinoma, two had combined hepatocellular carcinoma and cholangiocarcinoma, and 2 colorectal liver metastases, and 1 cholangiocarcinoma. Results: All patients were Child-Turcotte-Pugh score, 10 had liver fibrosis, and 10 had viral hepatitis. The median interval between portal vein embolization and laparoscopic major hepatectomy was 21 days. The median operative time was 324 min, estimated blood loss was 100 mL. White (2.5 mm) and blue (3.5 mm) cartridges were used in one patient each and Tri-Staple tan (2–3 mm) in 11 patients, and two patients required a combination of tan and purple cartridges (3–4 mm). There was one biliary leak and stricture after using a white cartridge, one transient hepatic insufficiency, and three minor complications. One patient died from a stroke on postoperative day 37. The mortality rate was 6.6% (1/15), and the morbidity rate was 33% (5/15). Conclusions: Laparoscopic major hepatectomy after portal vein embolization seems relatively safe and feasible. We advise against using a white cartridge and recommend a thicker cartridge for a more secure staple line.

Adverse Effect of Sarcopenic Obesity on Postoperative Complications after Major Hepatectomy in Patients with Hilar Cholangiocarcinoma

Recently, it is well known that sarcopenia is one of the risk factors on post-hepatectomy outcomes in patients with hepatocellular carcinoma. However, there were seldom reports for effect of sarcopenia or sarcopenic obesity (SO) on postoperative outcomes in patients with perihilar cholangiocarcinoma (CCC). The purpose of this study is to evaluate the effect of preoperative sarcopenia or SO on postoperative outcomes in patients with hilar CCC following major heptectomy.

Central hepatectomy for hepatocellular carcinoma in a patient with anti-Gerbich antibody

BackgroundAnti-Gerbich (Ge) alloantibody against high-frequency erythrocyte antigen is extremely rare. Owing to incomplete evidence regarding the degree and severity of adverse events induced by hemolytic transfusion reactions, the transfusion management often remains cumbersome in these patients. We report an anti-Ge alloantibody positive patient with hepatocellular carcinoma (HCC) who underwent central hepatectomy (CH) without the need for an allogeneic blood transfusion.Case presentationA 76-year-old Japanese woman was diagnosed with HCC measuring 9.5 × 8.0 cm in segments 4, 5, and 8 of the liver. This patient with anti-Ge alloantibody had a history of two pregnancies without transfusion. CH was planned, and based on the suggestion from the multidisciplinary team meeting, preoperative autologous donation (PAD) and acute normovolemic hemodilution (ANH) were performed. CH was successfully performed by using CUSA and Thunderbeat® with Pringle maneuver and infra-hepatic inferior vena cava clamping without perioperative need for an allogeneic blood transfusion. She has been alive without recurrence after a follow-up period of 45 months.ConclusionTo our knowledge, this is the first case report of hepatectomy in a patient with anti-Ge alloantibody. A multidisciplinary team approach, PAD and ANH, and bloodless liver surgical techniques appear to be useful for major hepatectomy in patients with extremely rare blood type.

Liver venous deprivation compared to portal vein embolization to induce hypertrophy of the future liver remnant before major hepatectomy: A single center experience

BackgroundTo assess the safety and efficacy of liver venous deprivation (simultaneous hepatic vein embolization with portal vein embolization) compared with portal vein embolization alone before major hepatectomy in patients with small future liver remnant. MethodsWe assessed all consecutive patients who underwent ipsilateral liver venous deprivation before major hepatectomy (>4 Couinaud’s segments) at the University Hospital Lausanne from 2016 to 2018. Postembolization, volumetric analysis after liver venous deprivation and postoperative outcomes were compared with patients who underwent portal vein embolization alone (portal vein embolization group) from 2010 to 2016. ResultsDuring the study period, 21 patients underwent liver venous deprivation and 39 portal vein embolization alone. In the liver venous deprivation versus portal vein embolization groups, dropout rate owing to disease progression was 1 of 21 vs 9 of 39 (P = .053). There were no per procedural complications after liver venous deprivation and no difference in the postoperative outcomes. Future liver remnant hypertrophy was greater in the liver venous deprivation group (median 135%, interquartile range: 123%–154%) than in the portal vein embolization group (median 124%, interquartile range: 107%–140%) at a median time of 22 days after liver venous deprivation vs 26 days after portal vein embolization (P = .034). The median kinetic growth rate was also greater (2.9%/week, interquartile range: 1.9–4.3% vs 1.4%/week, interquartile range: 0.7–2.1%; P < .001). ConclusionIpsilateral liver venous deprivation before major hepatectomy is safe and seems to induce a greater and faster future liver remnant hypertrophy than after portal vein embolization alone. More data are needed to analyze the impact of liver venous deprivation on tumor growth.

Liver venous deprivation is superior to portal vein embolization to induce future remnant liver hypertrophy before major hepatectomy: A single center experience.

Background: To assess the safety and efficacy of liver venous deprivation (simultaneous hepatic vein embolization (HVE) with portal vein embolization (PVE)) compared to PVE only before major hepatectomy in patients with too small future remnant liver (FRL). Material & Methods: All consecutive patients who underwent ipsilateral liver venous deprivation (LVD) before major hepatectomy (>4 Couinauds' segments) at the University Hospital CHUV from 2016 to 2018 were assessed. In order to analyse the safety and efficacy of LVD, post embolization, postoperative outcomes and volumetric analysis were compared with patients who underwent PVE alone (PVE group) from 2010 to 2016. FRL hypertrophy was calculated by two validated formulas and liver volumetry was performed by 2 different observers (1 surgeon and 1 radiologist). Results: During the study period, 18 patients underwent LVD and 50 PVE. In the PVE vs. LVD groups, dropout rate was 40% vs. 0% due to disease progression, respectively. Median time from embolization to surgery was 36 days (range: 23-109 days) after LVD vs. 35 days (range: 20-181 days) after PVE (p=0.924).There was no significant difference in the operative time, estimated blood loss, morbidity rate, median length of hospital stay and mortalitybetween the two groups. FRL hypertrophy was significantly higher in the LVD group (median; 135%, range: 112%-232%) than in the PVE group (median; 124%, range: 98%-203%) (p=0.039) in a median of 25 days (23 days after LVD, 26 days after PVE) after embolization. FRL hypertrophy analysis less than 21 days after embolization showed that degree of hypertrophy was significantly higher in the LVD group (n=7, median; 136%, range: 112%-168%) than in the PVE group (n=10, median; 112%, range: 98%-148%) (p=0.011). Conclusions Ipsilateral liver venous deprivation before major hepatectomy is safe and induces a higher and faster FRL hypertrophy than after PVE only.

Risk of liver failure after major hepatectomy for patients with hepatocellular carcinoma

Risk of liver failure after major hepatectomy for patients with hepatocellular carcinoma

Sequential transcatheter arterial chemoembolization and portal vein embolization versus portal vein embolization alone before major hepatectomy for patients with large hepatocellular carcinoma: An intent-to-treat analysis

BackgroundLittle is known about the value of sequential transcatheter arterial chemoembolization and portal vein embolization compared with portal vein embolization alone before major hepatectomy for large hepatocellular carcinoma. We aimed to compare early and long-term outcomes of these two strategies. MethodsWe included all consecutive patients with large hepatocellular carcinoma (≥50 mm) scheduled for sequential transcatheter arterial chemoembolization and portal vein embolization or portal vein embolization alone before major hepatectomy from January 2005 to December 2015. Comparisons were made on an intent-to-treat basis. ResultsA total of 55 patients were included as follows: sequential transcatheter arterial chemoembolization and portal vein embolization (n = 27) and portal vein embolization alone (n = 28). Baseline patient and tumor characteristics were similar in the 2 groups. Downstaging after transcatheter arterial chemoembolization changed the initial strategy in 4 patients who finally underwent liver transplant (n = 1) and limited hepatectomy (n = 3). Overall survival and progression-free survival were better in the transcatheter arterial chemoembolization group compared with the portal vein embolization alone group (3-year overall survival of 60% vs 20%; P = .01 and 3-year progression-free survival of 35% vs 0%; P < .001). The proportion of patients who finally underwent hepatectomy after transcatheter arterial chemoembolization plus portal vein embolization was 91% vs 68% after portal vein embolization alone (P = .08). Hypertrophy of the future remnant liver after portal vein embolization was greater after transcatheter arterial chemoembolization (43% vs 31%, P = 0.03). After resection, the group that received transcatheter arterial chemoembolization and portal vein embolization experienced better progression-free survival compared with portal vein embolization alone (3-year progression-free survival of 28% vs 0%; P = .03). ConclusionOur results suggest that transcatheter arterial chemoembolization before portal vein embolization increases the degree of hypertrophy of the future remnant liver after portal vein embolization and yields improved oncologic outcomes in patients with large hepatocellular carcinomas planned for major hepatectomy.

Sequential transarterial chemoembolization and portal vein embolization versus portal vein embolization alone before major hepatectomy for patients with large hepatocellular carcinoma

Sequential transarterial chemoembolization and portal vein embolization versus portal vein embolization alone before major hepatectomy for patients with large hepatocellular carcinoma

Mortality and morbidity after hepatic resection in patients undergoing hemodialysis: analysis of a national inpatient database in Japan

BackgroundWhether patients undergoing hemodialysis have greater risks of mortality and morbidity after hepatic resection remains unclear. MethodsWe used the Diagnosis Procedure Combination database, a national inpatient database in Japan, to identify patients who underwent hepatic resection from July 2010 to March 2014. Propensity scorematching analysis was performed to compare morbidity and mortality between patients with and without hemodialysis. ResultsOf 53,651 eligible patients, 498 (0.93%) underwent hemodialysis. Propensity score-matching analysis indicated greater in-hospital mortality in patients with than without hemodialysis (8.6% vs 2.0%; P < .001). Patients undergoing hemodialysis had more postoperative major complications than did patients not undergoing hemodialysis (18.1% vs 7.4%; P < .001). In the subgroup analyses for in-hospital mortality, the odds ratio of hemodialysis was 2.36 (95% confidence interval, 0.78–6.59; P = .067) in limited resection, 4.61 (95% confidence interval, 1.90–11.2; P < .001) in segmentectomy or sectoriectomy, and 5.58 (95% confidence interval, 3.40–14.9; P < .001) in bisectoriectomy or trisectoriectomy. In the age subgroup analyses, the odds ratio of hemodialysis was 4.38 (95% confidence interval, 2.66–7.21; P < .001) in patients aged <80 years and 7.20 (95% confidence interval, 1.55–36.7; P = .0011) in those aged ≥80 years. ConclusionPatients undergoing hemodialysis had a substantially increased risk of mortality and morbidity after hepatic resection. Surgical indications for major hepatectomy in patients undergoing hemodialysis who are ≥80 years of age may be limited and require careful scrutiny.

Portal Vein Embolization: History and Current Indications

Portal vein embolization (PVE) was first adapted for patients undergoing major hepatectomy for hepatocellular carcinoma (HCC). In these patients, PVE caused hypertrophy of the unaffected liver and increased the volumetric ratio of future liver remnant (FLR) to total liver volume. ^99mTechnetium-galactosyl human serum albumin (^99mTc-GSA) scintigraphy revealed that PVE also induced a shift in hepatic function from the embolized part to the nonembolized part of the liver. Various hepatobiliary malignancies can be treated using PVE, and PVE is increasingly being used to expand the indication for major hepatectomy in patients with initially insufficient FLR volume or function. The indication for PVE is determined by the underlying liver function and standardized FLR volume. In patients with chronic hepatitis, the histologic inflammatory activity was negatively correlated with the increase in FLR volume, and PVE is not suitable for patients with high serum 7s collagen concentrations (>8 ng/ml). This finding may predict the efficacy of PVE. PVE before major hepatectomy can act as a tolerance test to avoid postoperative hepatic failure. PVE also improved long-term survival after liver resection in patients with HCC. Presently, PVE is a safe and useful treatment for patients undergoing major hepatectomy.

Portal Vein Embolization via Percutaneous Transsplenic Access prior to Major Hepatectomy for Patients with Insufficient Future Liver Remnant

PurposeTo evaluate the feasibility and safety of percutaneous transsplenic portal vein embolization (PVE) before major hepatectomy for patients with insufficient future liver remnant. Materials and MethodsFrom May 2014 to June 2015, 27 transsplenic PVEs were attempted in 26 patients. In 16 patients, transsplenic PVE was indicated because of huge or multiple tumors in the trajectory of the puncture (n = 15) or a high-positioned liver (n = 1), which prevented safe ipsilateral transhepatic access. In the remaining 10 patients, transsplenic access was planned. A perihilar splenic vein was punctured using a 21-gauge Chiba needle under ultrasound and fluoroscopic guidance. Embolization of portal venous branches was performed using gelatin sponge particles followed by application of coils, an AMPLATZER Vascular Plug (AGA Medical Corporation, Golden Valley, Minnesota), or glue to prevent recanalization. Embolization of transsplenic routes was performed using coils followed by glue. ResultsTranssplenic PVE was successful in 24 (88.9%) of 27 sessions; 3 procedures failed because of splenic vein dissection (n = 1) and failed splenic vein puncture (n = 2). Major complications occurred in 1 patient (3.8%) with splenic vein dissection. Minor complications occurred in 2 patients: a small amount of fluid collection in the splenic hilar area in 1 patient and glue migration along the splenic vein in 1 patient. Planned liver resection was performed in 24 of 26 patients at 4.9 weeks ± 3.5 after PVE. ConclusionsTranssplenic PVE is safe and feasible and can be an effective alternative treatment for patients with a challenging ipsilateral, transhepatic route.