Mean Future Liver Remnant Research Articles

Use of selective internal radiation therapy with yttrium-90 as a bridge to liver resection: a 5-year single-center experience

Selective internal radiation therapy (SIRT) with yttrium-90 (Y-90) has been historically reserved for unresectable liver malignancy. Evidence is emerging for the use of SIRT to increase future liver remnant (FLR), allowing for the resection of previously inoperable disease. This was a 5-year retrospective review of all patients undergoing SIRT with Y-90 at a tertiary institute. Patient demographics, clinicopathologic data, surgical details, and postoperative outcomes were reviewed. The primary outcome, safety of liver resection after SIRT, was evaluated with 90-day morbidity and mortality. A total of 134 SIRT procedures were performed on 113 patients. Post-SIRT complications occurred in 18 patients (15.9%), with a single 30-day mortality. In addition, 17 patients underwent SIRT with the intent to augment FLR for liver resection. After SIRT, mean hepatic mebrofenin extraction and FLR increased from 2.5%/min/m2 and 30.5% to 4.2%/min/m2 and 52.5% (P=.01 and P<.0001, respectively). Ten patients underwent resection, and there were 2 intraoperative complications. The median time from SIRT to resection was 5.2 months. The 90-day postoperative morbidity was 20% (n=2), and complications were analyzed according to the Clavien-Dindo II classification scale. There was no 30-day or 90-day postoperative mortality. Post-SIRT liver resection is a challenging procedure with low postoperative mortality and morbidity.

Clinician overconfidence in visual estimation of the posthepatectomy liver remnant volume: A proximal source of liver failure after major hepatic resection?

BackgroundPost-hepatectomy liver failure is a source of morbidity and mortality after major hepatectomy and is related to the volume of the future liver remnant. The accuracy of a clinician’s ability to visually estimate the future liver remnant without formal computed tomography liver volumetry is unknown. MethodsTwenty physicians in diagnostic radiology, interventional radiology, and hepatopancreatobiliary surgery reviewed 20 computed tomography scans of patients without underlying liver pathology who were not scheduled for liver resection. We evaluated clinician accuracy to estimate the future liver remnant for 3 hypothetical major hepatic resections: left hepatectomy, right hepatectomy, and right trisectionectomy. The percent-difference between the mean and actual computed tomography liver volumetry (mean percent difference) was tested along with specialty differences using mixed-effects regression analysis. ResultsThe actual future liver remnant (computed tomography liver volumetry) remaining after a hypothetical left hepatectomy ranged from 59% to 75% (physician estimated range: 50%–85%), 23% to 40% right hepatectomy (15%–50%), and 13% to 29% right trisectionectomy (8%–39%). For right hepatectomy, the mean future liver remnant was overestimated by 95% of clinicians with a mean percent difference of 22% (6%–45%; P < .001). For right trisectionectomy, 90% overestimated the future liver remnant by a mean percent difference of 25% (6%–50%; P < .001). Hepatopancreatobiliary surgeons overestimated the future liver remnant for proposed right hepatectomy and right trisectionectomy by a mean percent difference of 25% and 34%, respectively. Based on years of experience, providers with <10 years of experience had a greater mean percent difference than providers with 10+ years of experience for hypothetical major hepatic resections, but was only significantly higher for left hepatectomy (9% vs 6%, P = .002). ConclusionA clinician’s ability to visually estimate the future liver remnant volume is inaccurate when compared to computed tomography liver volumetry. Clinicians tend to overestimate the future liver remnant volume, especially in patients with a small future liver remnant where the risk of posthepatectomy liver failure is greatest.

Reproducibility and efficiency of liver volumetry using manual method and liver analysis software

BackgroundFor liver volumetry, manual tracing on computed tomography (CT) images is time-consuming and operator dependent. To overcome these disadvantages, several three-dimensional simulation software programs have been developed; however, their efficacy has not fully been evaluated. MethodsThree physicians performed liver volumetry on preoperative CT images on 30 patients who underwent formal right hepatectomy, using manual tracing volumetry and two simulation software programs, SYNAPSE and syngo.via. The future liver remnant (FLR) was calculated using each method of volumetry. The primary endpoint was reproducibility and secondary outcomes were calculation time and learning curve. ResultsThe mean FLR was significantly lower for manual volumetry than for SYNAPSE or syngo.via; there was no significant difference in mean FLR between the two software-based methods. Reproducibility was lower for the manual method than for the software-based methods. Mean calculation time was shortest for SYNAPSE. For the two physicians unfamiliar with the software, no obvious learning curve was observed for using SYNAPSE, whereas learning curves were observed for using syngo.via. ConclusionsLiver volumetry was more reproducible and faster with three-dimensional simulation software, especially SYNAPSE software, than with the conventional manual tracing method. Software can help even inexperienced physicians learn quickly how to perform liver volumetry.

Evidence on Indications and Techniques to Increase the Future Liver Remnant in Children Undergoing Extended Hepatectomy: A Systematic Review and Meta-Analysis of Individual Patient Data

BackgroundTechniques to increase the future liver remnant (FLR) have fundamentally changed the indications and criteria of resectability in adult liver surgery. In pediatric patients however, these procedures have rarely been applied and the potential benefit or harm as well as suited indications are unclear.MethodsA systematic literature search of MEDLINE, Web of Science, and CENTRAL was conducted. Based on a PRISMA-compliant, predefined methodology, all studies reporting pediatric patients (< 18y) undergoing liver resection with either associating liver partition and portal vein ligation for stages hepatectomy (ALPPS) or preoperative portal vein embolization or ligation (PVE/PVL) were included. Baseline data, periinterventional morbidity, increase of FLR and outcomes were analyzed.Results15 studies reporting on 21 pediatric patients with a mean age of 4 years and 7 months (range 1.8 months – 17 years) were included. 12 ALPPS procedures, 8 PVE and 1 PVL were performed. The applied criteria for performing ALPPS or PVE were heterogenous and thresholds for minimally acceptable FLR varied. Mean FLR [% of total liver volume] before the intervention was 23.6% (range 15.0 – 39.3%) in the ALPPS group and 31.4% (range 21.5 – 56.0%) in the PVE group. Mean increase of FLR before stage 2 resection was 69.4% (range 19.0 – 103.8%) for ALPPS and 62.8% (range 25.0 – 108.0%) after PVE. No postoperative death occurred, one early intrahepatic recurrence after an ALPPS procedure was reported. Overall postoperative morbidity was 23.8%.ConclusionValidated criteria for minimal FLR in pediatric liver resection are lacking and so are clear indications for ALPPS or PVE. In special cases, ALPPS and PVE can be valuable techniques to achieve complete resection of pediatric liver tumors. However, more data are needed, and future studies should focus on a definition and validation of posthepatectomy liver failure as well as the minimally needed FLR in pediatric patients undergoing extended hepatectomy.Systematic Review Registration[www.clinicaltrials.gov], identifier [PROSPERO 2021 CRD42021274848].

Clinician Overconfidence in the Visual Estimation of the Post-Hepatectomy Liver Remnant Volume: A Proximal Source of Liver Failure after Major Hepatic Resection?

Introduction: Post-hepatectomy liver failure (PHLF) remains a significant source of morbidity and mortality in patients undergoing major hepatic resections. The accuracy of visually estimating the future liver remnant (FLR) without formal CT liver volumetry (CTLV) is unknown. Methods: Twenty physicians in diagnostic radiology, interventional radiology, and hepatopancreatobiliary surgery reviewed 20 CT scans of patients without underlying liver pathology. We evaluated clinician accuracy to estimate the FLR for three proposed major hepatic resections: left hepatectomy (LH), right hepatectomy (RH), and right trisectionectomy (RT). The percent-difference between the mean and actual CTLV volume was tested along with specialty differences using mixed effects regression analysis. Results: The actual FLR (based on CTLV) remaining after LH ranged from 59-75% (physician estimated range: 50-85%), 23-40% for RH (estimated range: 15-50%), and 13-29% for RT (estimated range: 8-39%). For LH, the mean FLR was visually underestimated by 95% of physicians (MPD FLR: 8%; range: 2-16%; P < 0.0001). For RH, the mean FLR was overestimated by 95% with a MPD of 22% (range: 6-45%; P < 0.0001). For RT, 90% overestimated the FLR by a MPD of 25% (range: 6-50%; P < 0.0001)(Figure). HPB surgeons overestimated the FLR for proposed RH and RT by a MPD of 25% and 34%, respectively. Conclusion: Visual estimation alone of the FLR is potentially dangerously inaccurate as compared to CT liver volumetry. Overestimation is most apparent in a small FLR where the risk of PHLF is greatest.

Portal vein embolization with n-butyl-cyanoacrylate before hepatectomy: a single-center retrospective analysis of 46 consecutive patients.

Preoperative portal vein embolization (PVE) is performed to induce hypertrophy of the future liver remnant enabling major liver resection in patients with various types of liver tumors. To evaluate safety and effectiveness of PVE with n-butyl-cyanoacrylate (NBCA). All consecutive patients referred to our hospital for PVE between July 2006 and July 2017 were retrospectively reviewed. Volumetry was performed on computed tomography images before and after PVE, segmenting the total liver volume and the future liver remnant (FLR), i.e. liver segments I-III. PVE was performed in 46 patients (18 women, 28 men; mean age = 61 years) using local anesthesia. The ipsilateral technique was used in 45 patients. Adverse events were rare. The mean FLR volume increase was 56%, the degree of hypertrophy was 9.7%, and the kinetic growth rate was 2.1%/week. The median ± SD period between PVE and liver surgery was 7 ± 3 weeks. Forty-two patients (91%) had surgery; liver resection was performed in 37 (80%) patients. Three patients (7%) developed transient liver failure after surgery. There was no 90-day post-PVE or postoperative mortality. PVE using NBCA through the ipsilateral approach in local anesthesia is safe and effective in inducing hypertrophy of the future liver remnant enabling surgery, and thereby increasing survival in patients with liver tumors.

Hepaticopancreaticoduodenectomy for advanced gall bladder carcinoma: Is it worthwhile?

Presenter: Vikas Gupta| PGIMER Chandigarh Background: Hepatico-pancreaticoduodenectomy(HPD) is curative option for locally advanced carcinoma gall bladder however its wide acceptance is debated due to concerns over high morbidity and mortality Methods: Twenty-four patients undergoing HPD for locally advanced carcinoma gall bladder were analyzed retrospectively. Patient and tumour characteristics, preoperative treatment and survival out comes were analyzed. Pancreatoduodenectomy component of HPD was done in standard fashion while hepatic component was tailored as per the extent of bile duct and liver involvement. Either bi-segmentectomy or modified right extended hepatectomy with segment 4apreserving was done Results: Median age was 54 years with male to female ratio 1:4. Twenty patients required preoperative biliary drainage and none required portal vein embolization . Mean future liver remnant was 41.2±4.67. Major hepatic resections were performed in 18 and bisegmentectomy was done in six. Vascular resection was performed in 10 (41.7%) patients when macroscopic vascular invasion was confirmed during surgery; combined resection/reconstruction of the portal vein and hepatic artery was carried out in 33.4% and 8.3% patients respectively. Direct invasion of the pancreas was observed in 19 (79%). R0 resection was achieved in 18 (75%). T3 disease was seen in 16 (66.7%) and T4 in 8 (33.3%). Node positivity was seen in 12 (50%). Grade B & C liver failure was seen in 2 and 3 patients respectively. Pancreatic fistula grade B was seen in 8 patients and grade C in none. Grade 3 or more complications were observed in 8 (33.33%)patients. Three (12.5%) patients died post operatively. Overall 1, 2 and 3 years survival rate was 72.7%, 45.5% and 9.1%, with a median survival time of 24 months. 1, 2 and 3 years survival rate was 90%, 60%, 10% respectively in node negative patients and 70%, 40%, 10% respectively in node positive disease.1, 2 and 3 years survival rate was 69.23%, 30.7%, 0% respectively without vascular resection and 77.77%, 66.66%, 22.22% respectively with vascular resection. Conclusion: HPD with vascular resection can be done safely in selected group of patients with advanced gall bladder cancer as it remains only option for long term cure.

Safety and outcomes of pre-operative portal vein embolization using N-butyl cyanoacrylate (Glue) in hepatobiliary malignancies: A single center retrospective analysis.

Aims and Objectives:To evaluate the outcome of preoperative portal vein embolization (PVE) using N-butyl cyanoacrylate (NBCA) for change in future liver remnant (FLR) volume, biochemical changes, and procedure-related complications. The factors affecting FLR hypertrophy and the rate of resection was also evaluated for this cohort.Materials and Methods:From 2012 to 2017, PVE utilizing NBCA mixed with lipiodol (1:4) was performed using percutaneous approach in 28 patients with hepatobiliary malignancies with low FLR. All patients underwent volumetric computed tomography (CT) assessment before and at 3–5 weeks after PVE and total liver volume (TLV), FLR volume, and FLR/TLV ratio, changes in portal vein diameter and factors affecting FLR were evaluated. Complications and the resectability rate were recorded and analyzed.Result:PVE was successful in all 28 patients. The mean FLR increased by 52% ± 32% after PVE (P < 0.0001). The FLR/TLV ratio was increased by 14.2% ± 2.8% (P < 0.001). Two major complications were encountered without any impact on surgery. There was no significant change seen in liver function test and complete blood counts after PVE. Eighteen patients (64.28%) underwent hepatic resection without any liver failure, and only three patients developed major complication after surgery. Remaining ten patients did not undergo surgery because of extrahepatic metastasis detected either on follow-up imaging or staging laparotomy. Patients with diabetes showed a lower rate of hypertrophy (P < 0.05).Conclusion:Preoperative PVE with NBCA is safe and effective for increasing FLR volume in patients of all age group and even in patients with an underlying liver parenchymal disease with hepatobiliary malignancy. Lesser hypertrophy was noted in patients with diabetes. A reasonable resectability was achieved despite having a high rejection in gall bladder cancer subgroup due to rapid disease progression.

The technical aspects of a feasible new technique for ipsilateral percutaneous transhepatic portal vein embolization.

To devise a simple new technique wherein absolute ethanol is injected via a sheath under proximal balloon occlusion of the right portal vein using a single-balloon catheter and to examine its feasibility and safety for ipsilateral portal vein embolization (PVE). Between 2010 and 2016, PVE was performed in 19 patients prior to undergoing extended right hepatectomy. PVE was performed via a percutaneous transhepatic ipsilateral approach, the right portal branch was embolized under ultrasound guidance, and a balloon catheter was placed in the proximal site of the main right portal branch. Absolute ethanol was injected through a sheath under proximal balloon occlusion of the right portal vein using a double-lumen catheter. We evaluated its technical success and complications following PVE and changes in liver enzyme levels. Furthermore, we calculated changes in future liver remnant (FLR) and FLR/total functional liver volume (TFLV) ratio and assessed complications following hepatic resection. PVE was successfully performed in all patients. Mean FLR and FLR/TFLV significantly increased following PVE (p < 0.01). The change in the FLR and FLR/TFLV ratio was 39.6 ± 16.2%. One patient (6.5%) developed procedure-related complications following PVE (perihepatic hematoma). The new technique for ipsilateral right PVE is safe, effective, and convenient. This is the first study to investigate the efficacy of injecting ethanol via a sheath under proximal balloon occlusion of the right portal vein using a single-balloon catheter.

Efficacy of percutaneous transhepatic portal vein embolization using gelatin sponge particles and metal coils.

BackgroundPercutaneous transhepatic portal vein embolization (PTPE) can increase the future liver remnant (FLR) volume before extended liver resection; however, there is no current consensus regarding the best embolic material for PTPE.PurposeTo evaluate the efficacy of PTPE using gelatin sponge particles and coils.Material and MethodsThe medical records of 136 patients who underwent PTPE using gelatin sponge particles and metal coils were retrospectively reviewed. We evaluated the procedural details, liver volume on CT, and clinical status before and after PTPE.ResultsThe mean FLR volume increased significantly from 390 ± 147 cm3 to 508 ± 141 cm3 (P < 0.001). A mean of 22.1 ± 9.4 days after PTPE, the mean increase in the ratio of FLR volume to total liver volume was 9.4 ± 6.5%. Complications related to PTPE occurred in five patients, including arterial damage (n = 4) and biloma (n = 1). The white blood cell count and C-reactive protein level increased significantly and then returned to baseline within seven days. Aspartate aminotransferase and alanine aminotransferase showed no significant changes. Fever (defined by the Common Terminology Criteria for Adverse Events v4.0) was reported in 74 patients (54%), but it was generally mild (Grade 1/2; n = 72). None of the patients experienced severe complications that required cancellation of surgery.ConclusionPTPE with gelatin sponge particles and coils may impose low physical stress on patients and is a safe method of inducing a significant increase of FLR.

Combined Preoperative Portal and Hepatic Vein Embolization (Biembolization) to Improve Liver Regeneration Before Major Liver Resection: A Preliminary Report.

Insufficient volume of the future liver remnant (FLR) is a major cause of non-resectable disease in patients presenting with primary or metastatic liver tumours. The objective of this study was to evaluate the safety and efficacy of the combined preoperative portal and hepatic vein embolization (biembolization) before extended right liver resections. This retrospective study was performed in a tertiary centre between 2014 and 2015. Combined right portal and hepatic vein embolization (biembolization) was proposed, as an alternative to ALPPS procedure, for all patients with primary or metastatic liver tumour, before right extended hepatectomy. CT scan liver volumetry was assessed before biembolization, three weeks after biembolization and one week after surgery. Seven patients underwent biembolization. All patients had right portal vein embolization (PVE) combined with right hepatic vein embolization (HVE, n=4), median HVE (n=2) and right+median HVE (n=1). Three patients had preoperative liver disease and two received preoperative chemotherapy. No biembolization procedure-related complications occurred. The mean FLR regeneration rate was 52.6% (range: 18.2-187.9) after the biembolization. One patient with gallbladder carcinoma was not operated because of peritoneal carcinomatosis diagnosed after the biembolization. The remnant six patients did not develop postoperative liver failure. Biembolization seems to induce safe, reproducible and effective FLR growth before extended right hepatectomy, in patients with primary or metastatic liver tumour.

Associating Liver Partition and Portal vein ligation for Staged hepatectomy after pre-operative chemotherapy.

Recently a procedure termed 'Associating Liver Partition and Portal vein ligation for Staged hepatectomy' (ALPPS) was developed to increase the resectability of marginally resectable or locally unresectable liver tumours. This study focused on the application of ALPPS in patients with advanced colorectal liver metastases (CRLM) and pre-operative chemotherapy, with the aim to investigate whether the latter still allows for sufficient hypertrophy of the future liver remnant (FLR) following the first step of ALPPS. Retrospective analysis was performed on six patients suffering from advanced CRLM. Analyses comprised demographical and basic clinical data, the perioperative courses as well as short- and long-term outcomes. All patients presented with bilobular CRLM and pre-operative chemotherapy of at least 6 months. Extended right hemihepatectomy was performed in all cases, four patients additionally received atypical resections in segments II/III. Mean FLR prior to step 1 of ALPPS was 397.9 cm3 (121-753 cm3 ), on average representing 20.9% of the total liver volume (13.2-27.1%). A mean hypertrophy of the FLR of 67.9% (32.5-94.1%) was achieved. Overall, severe morbidity (Dindo Clavien >3a) occurred in two patients. Following completion of ALPPS, mean post-operative disease-free survival was 5.7 months (2.6-8.9 months). Despite pre-operative chemotherapy, ALPPS seems to result in adequate liver hypertrophy, preventing post-operative small-for-size syndrome. However, there might be a high risk of tumour recurrence in patients with an aggressive tumour biology.

Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) in colorectal liver metastasis: the radiologist's perspective.

Hepatic resection is the only potentially curative treatment for patients with colorectal liver metastasis (CRLM). Many multidisciplinary approaches, including the associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) procedure, have been proposed to increase the resectability rate in these patients. ALPPS is the most recently described staged liver resection technique, representing an advantageous strategy to induce a rapid and marked increase in the future liver remnant (FLR) volume. The aim of this article is to describe the radiological evaluation of this procedure and its variation. This retrospective study included 9 patients with CRLM who underwent the ALPPS procedure. Abdominal imaging studies were reviewed, with an emphasis on a rational radiological approach. The number of liver metastases, the FLR volume (pre- and postportal vein ligation), anatomical variations, potential pitfalls related to disease progression, and postoperative complications were evaluated. The types of hepatic resection included 4 classical ALPPS cases, 3 right ALPPS variations, and 2 left ALPPS variations. The mean FLR volume calculated in the initial evaluation was 453mL (213-790mL). Following the first surgery, the mean FLR volume increased to 634mL (410-957mL), which indicated a mean volume increase of 181.1mL (95% CI 149.7-212.5mL; p<0.001) and a mean absolute volume increase of 48% (19%-88%). The ALPPS procedure is an emerging form of two-stage hepatectomy. In this context, radiologists should provide crucial preoperative and perioperative information that may change surgical planning and contribute to an improvement in the oncologic outcome.

Inverting the ALPPS paradigm by minimizing first stage impact: the Mini-ALPPS technique.

The current associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) approach is represented by an aggressive first surgical procedure followed by a shorter and less aggressive second procedure. This paradigm has been associated with high morbidity and mortality. Inverting the aggressiveness of the surgical stages might be beneficial in order to facilitate patient recovery during interval period. We propose a new technical paradigm for the ALPPS approach. During the first stage, partial parenchymal transection combined with intraoperative portal vein embolization (PVE) was performed. Liver mobilization was kept at minimum while hilar plate or hilum dissection was strictly avoided. The completion surgery by means of the anterior approach was carried out once sufficient future liver remnant (FLR) hypertrophy and function were certified. We applied this technique in four patients (hepatocellular carcinoma in a cirrhotic liver = 1 and colorectal liver metastases = 3). The mean FLR hypertrophy was 62.6% (range 49-79). All the four patients underwent the completion surgery with R0 margins, and neither one developed liver failure nor major complications. The technique proposed inverts the current ALPPS strategy, minimizing the first stage impact to promote rapid patient recovery and leaving the main surgical procedure for the second stage. The combination of evidence-based facts such as partial parenchymal transection, intraoperative PVE, and "non-touch" oncological rules was feasible and safe, allowing complete tumor resection in highly selected candidates with extensive liver disease.

Is “small for size syndrome” a relatively new complication after the ALPPS procedure?

Aim of this study is to assess the incidence and outcome of small for size syndrome after ALPPS procedure. This novel procedure is claimed to induce accelerated and increased growth of future liver remnant after major hepatectomies. We prospectively collected data on nine consecutive patients undergoing ALPPS procedure at our center. Main patients' characteristics, outcome and postoperative complications, including small for size syndrome were analyzed. Main interval between two stages of ALPPS was 15.1 days. Mean future liver remnant hypertrophy was 93.2%. Severe complications occurred in 44.4% of patients and mortality occurred in two cases (22.2%). Small for size syndrome occurred in two cases (22.2%). The first one was detected intraoperatively during first stage. It was successfully managed by spleno-renal venous shunt. Second case was not promptly detected and died on postoperative day 64. This case series provides evidence that SFFS can be an important complication after ALPPS procedure. If it is not promptly detected and properly managed it can be a cause of death as occurred in our case.

Preresection transarterial chemoembolization for hepatocellular carcinoma: an experience with 23 patients.

The routine use of transarterial chemoembolization (TACE) prior to resection for hepatocellular carcinoma (HCC) is not recommended, although its use in the transplant setting is gaining popularity. In the absence of other effective neoadjuvant or adjuvant treatment options, TACE may benefit selected patients. The aim was to evaluate the feasibility and outcomes of preoperative TACE for selected patients with HCC. From November 2010 to October 2012, 23 patients of HCC were selected by a multidisciplinary team to undergo TACE prior to resection. TACE was successful in all patients with no intraprocedural complications. TACE reduced the mean maximum tumor diameter from 9.2 to 8.2 cm and increased the mean future liver remnant (FLR) from 37.7 % to 49.1 %. Nineteen resections were completed with negative margins, of which only three patients (15.8 %) had cirrhosis. Two patients (10.5 %) experienced postoperative bile leaks and six patients (31.5 %) developed postoperative liver failure, two (10.5 %) of which succumbed to grade C liver failure. From the date of surgery, the median follow up time was 17.1 months. Four patients (17 %) did not undergo curative resection due to disease progression in three patients and severe TACE toxicity in one patient. None of the resected patients developed disease recurrence and the overall survival was 21 months. Encouraging outcomes in terms of disease recurrence and overall survival need to be balanced with the risk of surgical drop out and perioperative complications when selecting patients for TACE prior to resection.

Portal Vein Embolization before Right Hepatectomy or Extended Right Hepatectomy Using Sodium Tetradecyl Sulfate Foam: Technique and Initial Results

PurposeTo evaluate the safety and efficacy of portal vein embolization (PVE) with sodium tetradecyl sulfate (STS) foam. Materials and MethodsA single-center retrospective review of 35 patients (27 men and 8 women; mean age, 61 y) who underwent PVE with STS foam was performed. The technical success rate, rate of PVE at producing adequate future liver remnant (FLR) hypertrophy, and rate of disease progression precluding resection after PVE were analyzed. Complications of PVE and liver resection after PVE were recorded. ResultsPVE was performed on 35 patients before right hepatic resection for both primary and secondary hepatic malignancies (22 hepatocellular carcinoma, 10 metastasis, 2 cholangiocarcinoma, 1 invasive gallbladder carcinoma). Technical success was achieved in 97.1% (34 of 35) of patients. Mean FLR of the total estimated liver volume increased from 24.5% (SD, 7.7%) to 36.5% (SD, 14.5%), a mean percentage increase of 48.8% (SD, 34.3%). PVE produced adequate FLR hypertrophy in 31 of 35 patients (88.6%). Proposed right hepatectomy was subsequently performed in 27 patients (77.1%). One patient remains scheduled for surgery, two had peritoneal spread at surgery and resection was aborted, two had disease progression on imaging after PVE, and three had inadequate FLR hypertrophy with no surgery. One major complication was observed related to PVE that involved nontarget embolization to segment III, which was managed conservatively. ConclusionsPreoperative PVE with STS foam is a safe and effective method to induce hypertrophy of the FLR.

Efficacy and Safety of Portal Vein Embolization for Two-Stage Hepatectomy in Patients with Colorectal Liver Metastasis

PurposeTo examine the efficacy and safety of portal vein embolization (PVE) when used during two-stage hepatectomy for bilobar colorectal liver metastases (CLM). Materials and MethodsPVE was performed as an adjunct to two-stage hepatectomy in 56 patients with CLM. Absolute future liver remnant (FLR) volumes, standardized FLR ratios, degree of hypertrophy (DH), and complications were analyzed. Segment II and III volumes and DH were also measured separately. All volumetric measurements were compared with a cohort of 96 patients (n = 37 right portal vein embolization [RPVE], n = 59 right portal vein embolization extended to segment IV portal veins [RPVE+4]) in whom PVE was performed before single-stage hepatectomy. ResultsFor patients who completed RPVE during two-stage hepatectomy (n = 17 of 17), mean absolute FLR volume increased from 272.1 cm3 to 427.0 cm3 (P < .0001), mean standardized FLR ratio increased from 0.17 to 0.26 (P < .0001), and mean DH was 0.094. For patients who completed RPVE+4 during two-stage hepatectomy (n = 38 of 39), mean FLR volume increased from 288.7 cm3 to 424.8 cm3 (P < .0001), mean standardized FLR increased from 0.18 to 0.26 (P < .0001), and mean DH was 0.083. DH of the FLR was not significantly different between two-stage hepatectomy and single-stage hepatectomy. Complications after PVE occurred in five (8.9%) patients undergoing two-stage hepatectomy. ConclusionsPVE effectively and safely induced a significant DH in the FLR during two-stage hepatectomy in patients with CLM.

Preoperative portal vein embolization with a combination of trisacryl microspheres, gelfoam and coils

To evaluate the safety and efficiency of preoperative portal vein embolization (PVE) with a combination of trisacryl microspheres, gelfoam and coils for inducing lobar hypertrophy in hepatobiliary malignancy patients. PVE was performed by a percutaneous left approach in 63 patients with hepatic malignancy (hepatocarcinoma=38, colorectal metastasis=14, cholangiocarcinoma=11). The indication of PVE and surgery was evaluated by hepatic tumor board take into consideration to the tumor extension and the hepatic volume on initial and post-embolization CT-scans. The total functional liver volume (TELV) and future liver remnant (FLR) volume were measured before and 24±5days after PVE to assess FLR, TELV and FLR/TELV ratios. Efficiency evaluation was based on FLR increase, the ability to perform the hepatectomy and the hepatic function after surgery. Safety evaluation was determined by clinical and biological follow-up after embolization and surgery. PVE was successful in all the patients. The mean FLR volume increases by 57±56% after embolization (449±180cm(3) to 663±254cm(3)) (P<0.0001). The FLR/TELV ratio increases by 11% after PVE (25±8% to 36±12%). Three minors' complications were registered without impact on surgery, and four patients developed portal hypertension. Forty-nine patients underwent hepatectomy; none of them developed liver failure. Surgery was not performed in 14 patients due to tumor progression (n=9), inadequate hypertrophy of FLR (n=1) and portal hypertension (n=4). Preoperative PVE with a combination of trisacryl microspheres, gelfoam and coils is a safe and effective method for inducing contralateral hypertrophy before right hepatectomy in patients with advanced hepatobiliary malignancy.

Does Preoperative Portal Vein Embolization Have Any Impact on the Outcome of Right-Side Hepatectomy for Klatskin Tumor?

Background and AimThe clinical usefulness of portal vein embolization (PVE) for Klatskin tumor is not well established. The authors explored the change in liver volume and function before and after major hepatectomy and evaluated the effect of PVE. MethodsThirty-three consecutive patients who underwent right hepatectomy with an initial future liver remnant (FLR) ≤ 30 % for Klatskin tumors at Seoul National University Hospital were included. ResultsEleven patients underwent PVE, and eight patients received right trisectionectomy. PVE induced a mean FLR increase of 19.3 % after a mean of 15.8 days. At postoperative month 1, liver volume and liver hypertrophy ratio was comparable between PVE and no-PVE group. For patients with an initial FLR ≤ 20 %, postoperative liver hypertrophy rate of PVE group was comparable to no-PVE group. Liver function tests were not affected by PVE or the initial FLR. Postoperative liver hypertrophy ratio was negatively correlated with the initial FLR (hypertrophy ratio (%) = 326.7–0.4×initial FLR (ml), P = 0.001). There was no severe PVE-related morbidity, and postoperative morbidity rate was comparable in PVE and no-PVE group. ConclusionThe postoperative liver hypertrophy ratio, final liver volume, or liver function tests were not affected by PVE. Postoperative liver hypertrophy was related to the initial FLR.