Percutaneous Portal Vein Embolization Research Articles

Hypertrophy responses after portal vein embolization, complete and partial ALPPS in patients undergoing major liver resection

Background: Portal vein embolization (PVE) is the standard technique to induce hypertrophy of a small future remnant liver (FRL). ALPPS offers a more rapid hypertrophy response. The first stage (ALPPS1) can be performed with complete or partial (laparoscopic) transection of the liver parenchyma. The aim of this study was to investigate the increases in volume, function and postoperative outcomes among these procedures. Material & Methods: 72 patients with insufficient FRL were included in this retrospective analysis and were divided into three groups: 51 underwent PVE, 12 complete-ALPPS1 (open) and 9 partial-ALLPS1. All patients underwent CT-volumetry and functional assessment using 99mTc-mebrofenin hepatobiliary scintigraphy before and after VPE or ALPPS1. The increase in FRL function and volume were compared between the groups. Severe complications (Clavien-Dindo=3A) and 90-day mortality were evaluated after final liver resection. Results: The median increase in FRL function in the PVE, complete-ALPPS1 and partial-ALPPS1 group was 1.5, 1.7 and 1.3 fold higher, respectively, than the increase in volume; this was however not significant in the partial-ALPPS1 group (P<0.01, P<0.01 and P=0.44). The volumetric hypertrophy response did not differ between the three groups, but was reached earlier in both ALPPS1 groups (8 and 10 days, respectively) compared to the PVE group (23 days). Of all groups, 37 (73%), 10 (83%) and 6 (67%), respectively, proceeded with liver resection. All resected patients after partial-ALPPS1 had laparoscopic stage 1 in combination with percutaneous PVE. Of the resected patients, 18%, 30% and 17% had severe postoperative complications and the 90-day mortality was 2%, 25% and 0%, respectively. Conclusion: Increase of FRL function exceeded increase of volume after both PVE and ALPPS1. The target hypertrophy response was reached earlier in ALPPS. Complete and partial-ALPPS1 showed comparable functional and volumetric hypertrophy responses. Laparoscopic partial-ALPPS1 is preferred considering lower morbidity and mortality rates after resection.

Clinical efficacy and safety of injection of lobaplatin via hepatic artery puncture combined with percutaneous portal venipuncture in the treatment of middle and late primary liver cancer

Objective To explore the clinical efficacy and safety of injecting lobaplatin through hepatic artery puncture combined with percutaneous catheter selective portal vein embolization(SPVCE) in the treatment of primary liver cancer. Methods A total of 118 patients with advanced primary liver cancer admitted to Binzhou Central Hospital of Shandong Province from August 2015 to January 2017 were selected as in the study, and randomly divided into two groups according to the digital table, namely TACE(hepatic carcinoma arterial perfusion chemoembolization)+ SPVCE group and TACE group, with 59 cases in each group.In the TACE+ SPVCE group, injection lobaplatin was administered with gelatin sponge as the drug-borne embolic agent, superselective hepatic artery chemoembolization(TACE) combined with SPVCE was performed, regional embolization was performed for liver cancer, and only TACE was administered in the TACE group.The curative effect and adverse reactions of the two groups were observed and compared. Results The short-term objective(CR+ PR) efficiency of the TACE+ SPVCE group was 74.57%(44/59), which was significantly higher than that of the TACE group [54.23% (32/59)], the difference was statistically significant(χ2=5.323, P=0.021). The differences were statistically significant in the main indicators, such as the decrease of tumor lesion volume, the increase of liver volume without cancer, and the decrease of FAP(all P<0.05). The long-term objective efficiency of the TACE+ SPVCE group was 45.76%(27/59), which was also significantly higher than that of the TACE group[32.2%(19/59)], but the difference was no statistically significant(χ2=2.280, P=0.131). The TACE+ SPVCE group extended the median survival time by 3.5 months compared to the TACE group, there was statistically significant difference in median survival between the two groups(t=3.211, P=0.000). Major adverse reactions were compared between the two groups, the patients with decreased albumin in the TACE + SPVCE group was less than the TACE group, but there was no statistically significant difference(χ2=1.156, P=0.282), the patients with bone marrow inhibition in the TACE + SPVCE group decreased significantly compared with the TACE group, the difference was statistically significant(χ2=4.882, P=0.027), patients with severe gastrointestinal tract decreased compared with conventional TACE group, but there was no statistically significant difference(χ2=1.035, P=0.308). Conclusion Injection for drug carrier with lobaplatin with gelatin sponge embolism agent, percutaneous puncture catheter super choice hepatic artery hepatic artery embolism chemotherapy combined with percutaneous puncture catheter SPVCE for primary liver cancer lines of regional embolization, is safe and effective, and can improve the curative effect of conventional TACE, and prolong survival, has important clinical value for advanced liver cancer patients that cannot be surgically removed. Key words: Liver neoplasms; Percutaneous catheter selective portal vein embolism; Hyperselective hepatic artery chemoembolization; Los platinum; Medicated embolism; Regional embolization of liver cancer; Clinical efficacy; Security

Retrospective Comparative Study of Absolute Ethanol with N-Butyl-2-Cyanoacrylate in Percutaneous Portal Vein Embolization

PurposeThis study compared the efficacy of absolute ethanol with that of N-butyl-2-cyanoacrylate (NBCA) in portal vein embolization (PVE) before partial hepatectomy. Materials and MethodsBetween January 2012 and February 2016, 61 patients (43 men, 18 women; median; 69 years of age) underwent PVE using absolute ethanol (January 2012 to January 2014; n = 27) or NBCA (February 2014 to February 2016; n = 34). The primary endpoint was increase in the nonembolized liver volume (NELV)-to-total functional liver volume (TFLV) ratio, and the secondary endpoints were changes in embolized liver volume (ELV) and NELV, changes in laboratory data, and adverse events. ResultsThe increase in the NELV/TFLV ratio was significantly higher in the ethanol group than in the NBCA group (13.0% vs. 9.5%, respectively; P = 0.003). The decrease in ELV was significantly greater in the ethanol group (−191.9 vs. −99.2 mL, respectively; P = 0.001). The increase in NELV did not differ significantly (129.4 vs. 116.0 mL, respectively; P = 0.316). In the ethanol group, grade 3–4 transient elevation of aspartate aminotransferase and alanine aminotransferase occurred in 22 patients (81.5%) and 22 patients (81.5%) patients, respectively, whereas it occurred in 1 patient (3.0%) and 1 patient (3.0%), respectively, in the NBCA group. One patient in the ethanol group (3.7%) showed grade 2 hepatic necrosis, and 2 patients with grade 3 subcapsular biloma (5.9%) and 1 with grade 3 liver abscess (2.9%) occurred in the NBCA group (P = 0.696). ConclusionsPVE with ethanol conferred greater increase in the NELV/TFLV ratio than NBCA due to its severe atrophic effect in ELV, but no significant differences in NELV increase were found.

Percutaneous Portal Vein Embolization Using a Simplified Sheathless 18-Gauge Trocar Needle Approach: Review of Efficacy and Safety

PurposePortal vein (PV) embolization (PVE) is traditionally performed via a PV sheath with selective embolization of PV branches. Here, the efficacy and safety of PVE with the use of only an 18-gauge needle is reported. Materials and MethodsConsecutive patients who underwent PVE from 2009 through 2017 were retrospectively reviewed. Forty-five patients (mean age, 60 y ± 7.6; 38 men) underwent 45 PVE procedures. Hepatocellular carcinoma, cholangiocarcinoma, and metastases accounted for 26 (58%), 13 (29%), and 6 (13%) patients, respectively. PVE was performed by puncturing a branch of right PV with an 18-gauge needle under US guidance. Via the same needle, direct portography was performed, followed by PVE with an N-butyl cyanoacrylate/Lipiodol mixture. Percentage increase of future liver remnant (FLR) volume and increase in ratio of FLR to total liver volume were estimated as measures of efficacy. Complications were reported according to Society of Interventional Radiology classification. Fluoroscopy time, procedure time, and dose–area product (DAP) were recorded. ResultsTechnical success rate was 100%. The median DAP, fluoroscopy time, and procedure time were 74,387 mGy·cm2 (IQR, 90,349 mGy·cm2), 3.5 min (IQR, 2.10 min), and 24 min (IQR, 10.5 min). Among the 23 patients with complete CT volumetry data, mean increase in the ratio of FLR to total liver volume and percentage increase of FLR volume were 12.5% ± 7.7 and 50% ± 33, respectively. There were 3 minor complications (asymptomatic nonocclusive emboli in FLR) and 3 major complications (1 hepatic vein emboli, 1 subphrenic collection, and 1 hepatic infarct). ConclusionsPVE via a sheathless 18-gauge needle approach is feasible, with satisfactory FLR hypertrophy.

PERCUTANEOUS RADIOFREQUENCY ASSISTED LIVER PARTITION WITH PORTAL VEIN EMBOLIZATION FOR STAGED HEPATECTOMY (PRALPPS).

ABSTRACTBackground: When a major hepatic resection is necessary, sometimes the future liver remnant is not enough to maintain sufficient liver function and patients are more likely to develop liver failure after surgery. Aim: To test the hypothesis that performing a percutaneous radiofrecuency liver partition plus percutaneous portal vein embolization (PRALPPS) for stage hepatectomy in pigs is feasible. Methods: Four pigs (Sus scrofa domesticus) both sexes with weights between 25 to 35 kg underwent percutaneous portal vein embolization with coils of the left portal vein. By contrasted CT, the difference between the liver parenchyma corresponding to the embolized zone and the normal one was identified. Immediately, using the fusion of images between ultrasound and CT as a guide, radiofrequency needles were placed percutaneouslyand then ablated until the liver partition was complete. Finally, hepatectomy was completed with a laparoscopic approach. Results: All animals have survived the procedures, with no reported complications. The successful portal embolization process was confirmed both by portography and CT. In the macroscopic analysis of the pieces, the depth of the ablation was analyzed. The hepatic hilum was respected. On the other hand, the correct position of the embolization material on the left portal vein could be also observed. Conclusion: “Percutaneous radiofrequency assisted liver partition with portal vein embolization” (PRALLPS) is a feasible procedure.

Role of interventional radiology in managing pediatric liver tumors : Part 2: percutaneous interventions.

Hepatoblastoma and hepatocellular carcinoma (HCC) are the most common pediatric liver malignancies, with hepatoblastoma occurring more commonly in younger children and HCC occurring more commonly in older children and adolescents. Although surgical resection (including transplant when necessary) and systemic chemotherapy have improved overall survival rate for hepatoblastoma to approximately 80% from 30%, a number of children with this tumor type are not eligible for operative treatment. In contradistinction, pediatric HCC continues to carry a dismal prognosis with an overall 5-year survival rate of 30%. The Paediatric Hepatic International Tumour Trial (PHITT) is an international trial aimed at evaluating both existing and emerging oncologic therapies for primary pediatric liver tumors. Interventional radiology offers a number of minimally invasive procedures that aid in diagnosis and therapy of pediatric liver tumors. For diagnosis, the PHITT biopsy guidelines emphasize and recommend percutaneous image-guided tumor biopsy. Additionally, both percutaneous and endovascular procedures provide therapeutic alternatives that have been, to this point, only minimally utilized in the pediatric population. Specifically, percutaneous ablation offers a number of cytotoxic technologies that can potentially eradicate disease or downstage children with unresectable disease. Percutaneous portal vein embolization is an additional minimally invasive procedure that might be useful to induce remnant liver hypertrophy prior to extended liver resection in the setting of a primary liver tumor. PHITT offers an opportunity to collect data from children treated with these emerging therapeutic options across the world. The purpose of this manuscript is to describe the potential role of minimally invasive percutaneous transhepatic procedures, as well as review the existing data largely stemming from the adult HCC experience.

Portal Vein Embolization in the Setting of Staged Hepatectomy with Preservation of Segment IV ± I Only for Bilobar Colorectal Liver Metastases: Safety, Efficacy, and Clinical Outcomes

PurposeTo assess frequency of adverse events, efficacy, and clinical outcomes of percutaneous portal vein embolization (PVE) in patients with bilobar colorectal liver metastases undergoing staged hepatectomy with preservation of segment IV ± I only. Materials and MethodsRetrospective analysis was performed of 40 consecutive patients who underwent right PVE after successful left lobectomy between 2005 and 2013. Rates of adverse events, future liver remnant (FLR) > 30% compared with baseline liver volume, clinical success (completion of staged hepatectomy with clearance of liver metastases), and overall survival were analyzed. ResultsPVE was performed using polyvinyl alcohol particles (n = 7; 17.5%), particles plus coils (n = 23; 57.5%), and N-butyl cyanoacrylate glue plus ethiodized oil (n = 10; 25%). Technical success was 100%. After PVE, 20% (n = 8) of patients exhibited portal venous thrombosis, ranging from isolated intrahepatic portal branch thrombosis to massive thrombosis of the main portal vein (n = 3) and responsible for periportal cavernoma and portal hypertension in 5 patients. Of patients, 23 (57.5%) had FLR ≥ 30%, and 21 (52.5%) had clinical success. Six patients had significant stenosis or occlusion of the left portal vein or biliary system after original left lobectomy, which was independently associated with FLR < 30% (R2 = 0.24). Clinical success was the only independent variable associated with survival (R2 = 0.25). ConclusionsPVE for staged hepatectomy with preservation of segment IV ± I only is technically feasible, leading to adequate hypertrophy and clinical success rates in these patients with poor oncologic prognosis. Portal venous thrombosis is greater after the procedure than in the setting of standard PVE.

Percutaneous Microwave Ablation Liver Partition and Portal Vein Embolization for Rapid Liver Regeneration: A Minimally Invasive First Step of ALPPS for Hepatocellular Carcinoma.

Percutaneous Microwave Ablation Liver Partition and Portal Vein Embolization for Rapid Liver Regeneration: A Minimally Invasive First Step of ALPPS for Hepatocellular Carcinoma.

Oncological Outcomes of Major Liver Resection Following Portal Vein Embolization: A Systematic Review and Meta-analysis.

Preoperative portal vein occlusion with either percutaneous portal vein embolization (PVE) or portal vein ligation is routinely used to induce liver hypertrophy prior to major liver resection in patients with hepatic malignancy. While this increases the future liver remnant, and hence the number of patients suitable for resection, recent evidence suggests that induction of liver hypertrophy preoperatively may promote tumor growth and increase recurrence rates. The aims of this current study were to evaluate the impact of PVE on hepatic recurrence rate and survival in patients with colorectal liver metastases (CRLM). The MEDLINE, EMBASE and Web of Science databases were searched to identify studies assessing the oncological outcomes of patients undergoing major liver resection for CRLM following PVE. Studies comparing patients undergoing one-stage liver resection with or without preoperative PVE were included. The primary outcome was postoperative hepatic recurrence (PHR), while secondary outcomes were 3- and 5-year overall survival (OS). Of the 2131 studies identified, six non-randomized studies (n=668) met the eligibility criteria, comparing outcomes of patients undergoing major liver resection with or without PVE (n=182 and n=486, respectively). No significant difference was observed in PHR (odds ratio [OR] 0.78; 95% confidence interval [CI] 0.42-1.44), 3-year OS (OR 0.80; 95% CI 0.56-1.14) or 5-year OS (OR 1.12; 95% CI 0.40-3.11). PVE does not have any adverse effect on PHR or OS in patients undergoing major liver resection for CRLM. Further studies based on individual patient data are needed to provide definitive answers.

Comparison of the efficacy of percutaneous portal vein embolization (pve) prior to major liver resection and alpps (associating liver partition and portal vein ligation for staged hepatectomy), single center experience

Comparison of the efficacy of percutaneous portal vein embolization (pve) prior to major liver resection and alpps (associating liver partition and portal vein ligation for staged hepatectomy), single center experience

Impact of 3D Rotational Angiography on Liver Embolization Procedures: Review of Technique and Applications

In the last years, the interest into interventional applications of C-arm cone-beam CT (CBCT) progressively raised, widening its clinical application from the original field of interventional neuroradiology to the field of peripheral procedures. Liver embolization procedures, due to their complexity and potential treatment-related life-threatening complications, represent one of the main clinical applications of this novel angiographic technique. CBCT has been demonstrated to render procedures safer and technically easier, and to predict outcome as well as to avoid major complications in different treatment scenarios (trans-arterial embolization, trans-arterial chemoembolization, selective internal radiation therapy, percutaneous portal vein embolization). This review summarizes all technical, dosimetric and procedural aspects of CBCT techniques, underlying all its potential clinical advantages in the field of liver embolization procedures. Moreover, the paper provides all the instructions to obtain the best diagnostic performance out of this novel angiographic technique.

Bismuth classification is associated with the requirement for multiple biliary drainage in preoperative patients with malignant perihilar biliary stricture.

Single preoperative biliary drainage for malignant perihilar biliary stricture occasionally fails to control jaundice and cholangitis. Multiple biliary drainage is required in such cases, but their clinical background is unclear. We determined the clinical characteristics associated with the requirement for multiple biliary drainage. The consecutive 122 patients with malignant perihilar biliary stricture were enrolled in a single-center retrospective study. Preoperative biliary drainage was initially performed on the future remnant hepatic lobe. Additional drainage was performed if jaundice failed to improve or cholangitis developed in undrained hepatic lobes. Detailed clinical characteristics and the number of preoperative biliary drainage procedures required before operation were analyzed. Thirty-one patients (25.4%) initially underwent multiple biliary drainage. However, 69 (56.7%) required multiple biliary drainage by the time of the operation. In the univariate analysis, the initial serum bilirubin level, cholangitis, percutaneous portal vein embolization, history of inserted endoscopic biliary stenting, length of preoperative period, operative procedure, and Bismuth classification were significant factors. In the multivariate analysis using these factors, Bismuth classification was independently associated with the requirement for multiple biliary drainage. The number of patients who required multiple biliary drainage was higher in those with Bismuth-II (91.9%), Bismuth-IIIa (65.7%), and Bismuth-IV (92.9%) than in those with Bismuth-I (22.2%) and Bismuth-IIIb (18.2%). Patients with Bismuth-II, Bismuth-IIIa, and Bismuth-IV are at higher risk for multiple biliary drainage. A strategy based on the Bismuth classification for performing preoperative biliary drainage is important for patients with malignant perihilar biliary stricture.

How can we safely climb the ALPPS?

R0 resection with zero mortality is the ultimate goal for hepatobiliary surgeons, especially for the treatment of extensive hepatobiliary malignancies. The safety of liver resection is dependent on the function of the future liver remnant (FLR), and an inadequate FLR volume is related to a significant increase in postoperative mortality and morbidity. Therefore, various criteria for the FLR volume have been proposed to secure the safety of major hepatectomies according to the extent of underlying injury in the liver [1–5]. However, these criteria for FLR volume often cause clinical dilemmas for surgeons in determining the surgical indications for patients with small FLR volumes because the safety of surgery and oncological radicality are, by nature, conflicting factors. In the history of hepatobiliary surgery, there have been two outstanding approaches for the safe management of patients with very small FLR volumes. The first was the development of techniques that manipulate the portal blood flow to induce hypertrophy of the FLR. Initially achieved using portal vein ligation (PVL) [6–8], these techniques have evolved toward percutaneous portal vein embolization (PVE) [9–12]. Increasing evidence has suggested that hypertrophy of the FLR induced by portal flow modulation is associated with an improved safety of major hepatectomies [3, 10, 13]. In addition, dynamic volume parameters, such as the degree of hypertrophy [13] or the kinetic growth rate [14], are also very informative for estimating the histologic quality and functional reserve of the underlying liver. The second noteworthy approach was the ‘‘twostage surgery’’ for the resection of multiple bilobar hepatic lesions. This sequential procedure was initially proposed by surgeons at the Hopital Paul Brousse in Paris, France, with the expectation of allowing interim liver regeneration between the two sequential hepatic resections [15]. An oncological advantage of the two-stage approach has been reported in patients with extensive colorectal liver metastases [16], and this procedure used in conjunction with or without PVE has been adopted by numerous hepatobiliary centers. These two evolutional approaches have expanded the indications for surgery, and many patients with extensive liver tumors have benefited from surgery using these approaches. However, a remaining issue is that these approaches require at least several weeks to complete the entire clearance of the tumor burden within the liver. Some authors have suggested a risk of tumor progression during the waiting time after PVE [17, 18]. Therefore, the time lag between the preoperative intervention and resection can be critical, especially for the treatment of patients with borderline resectable tumors and/or oncologically highly aggressive tumors. A recent notable paper in the field of hepatobiliary surgery was a case series introducing a new surgical procedure known as ‘‘ALPPS’’ (Associating Liver Partition with Portal vein ligation for Staged hepatectomy) that enables the rapid growth of the FLR [19]. The first stage of this procedure includes a right PVL and the in situ splitting of the liver along the umbilical fissure or the main portal fissure. Schnitzbauer et al. [19] reported that a 74 % volume increase was observed in the FLR at a median of 9 days after the first procedure. Immediately after its publication, this article triggered a large number of reactions from all over the world. Although the clinical outcomes demonstrated in this paper were very impressive and all the patients were able to proceed to a right N. Kokudo (&) J. Shindoh Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan e-mail: KOKUDO-2SU@h.u-tokyo.ac.jp

Analysis of the Efficacy of Portal Vein Embolization for Patients with Extensive Liver Malignancy and Very Low Future Liver Remnant Volume, Including a Comparison with the Associating Liver Partition with Portal Vein Ligation for Staged Hepatectomy Approach

The primary reported indication for the associating liver partition with portal vein ligation for staged hepatectomy (ALPPS) technique is in patients with very low future liver remnant volumes. Given the elevated incidence of major morbidity (40%) and liver-related mortality (12%) with ALPPS, we sought to determine the safety and efficacy of percutaneous portal vein embolization (PVE) in a similar patient population. Tumor resectability and morbidity and mortality rates were reviewed for 144 consecutive liver tumor patients with future liver remnant to body weight ratios (LR/BW) less than 0.5%. All patients were referred for preoperative percutaneous right plus segment IV PVE using embolic microspheres, with planned reassessment of the LR/BW 30 days after PVE. Post-PVE outcomes were compared with reported outcomes for ALPPS. Percutaneous PVE was successfully performed in 141 of the 144 study patients (97.9%). Adequate regeneration was observed in 139 patients (98.5%) with median post-PVE LR/BW rising from 0.33% to 0.52% (p < 0.0001), representing a per-patient median regeneration rate of 62% (range 0.3% to 379%). In total, 104 patients underwent extended right hepatectomy (n= 102) or right hepatectomy (n= 2). The remaining 40 patients (27.8%) were not resectable due to short-interval disease progression (27 patients, 18.5%), insufficient liver regeneration (5 patients, 3.5%), and medical comorbidities (8 patients, 5.6%). After resection, the following outcomes were observed: major morbidity: 33.0% (34 of 104), liver insufficiency: 12.5% (13 of 104), and 90-day liver-related mortality: 5.8% (6 of 104). These oncologic and technical results compare favorably with those of ALPPS. Based on its ability to select oncologically resectable patients and superior safety and efficacy profiles, percutaneous right+ segment IV PVE and interval surgery remains the standard of care for patients with very low future liver remnant volumes.

Percutaneous ipsilateral portal vein embolization using histoacryl glue: changing LR, resectibility rate and complications

Background: Liver resection has been the main strategy for treating either primary or secondary liver cancer. However, major liver resection may lead to postoperative liver failure. Portal vein embolization (PVE) is a procedure to induce hypertrophy of a liver remnant (LR) before major resection surgery. There are many variations in procedural techniques, with different advantages and disadvantages. Objective: We studied change in liver remnant volume, resectibility rate, and complications after percutaneous ipsilateral portal vein embolization (PVE) using histoacryl glue. Methods: Clinical data of 25 patients who underwent ipsilateral PVE were reviewed. Eighteen patients who had pre- and post- CT studies had total liver volumes (TLV) and LR volumes determined before and after the procedure using MDCT volumetry. Complications and respectability rates were recorded. Results: All 18 patients who had pre-CT and post-CT studies had increased LR volumes. The mean of LR volumes before and after ipsilateral PVE were calculated at about 449 ml and 586 ml, which were statistically significant (p Conclusion: Percutaneous transhepatic ipsilateral PVE could increase the LR volumes before major hepatic resection. There were no significant complications in our study group. Keywords: Histoacryl glue, ipsilateral approach, liver cancer treatment, liver remnant, portal vein embolization

Hepatic parenchymal atrophy induction for intractable segmental bile duct injury after liver resection.

Liver resection can result in various types of bile duct injuries but their treatment is usually difficult and often leads to intractable clinical course. We present an unusual case of hepatic segment III duct (B3) injury, which occurred after left medial sectionectomy for large hepatocellular carcinoma and was incidentally detected 1 week later due to bile leak. Since the pattern of this B3 injury was not adequate for operative biliary reconstruction, atrophy induction of the involved hepatic parenchyma was attempted. This treatment consisted of embolization of the segment III portal branch to inhibit bile production, induction of heavy adhesion at the bile leak site and clamping of the percutaneous transhepatic biliary drainage (PTBD) tube to accelerate segment III atrophy. This entire procedure, from liver resection to PTBD tube removal took 4 months. This patient has shown no other complication or tumor recurrence for 4 years to date. These findings suggest that percutaneous segmental portal vein embolization, followed by intentional clamping of external biliary drainage, can effectively control intractable bile leak from segmental bile duct injury.

Liver Hypertrophy After Percutaneous Portal Vein Embolization: Comparison of N-Butyl-2-Cyanocrylate Versus Sodium Acrylate–Vinyl Alcohol Copolymer Particles in a Swine Model

Percutaneous portal vein embolization (PPVE) induces hypertrophy of the future liver remnant before hepatic resection. The ideal embolic material has not yet been determined. We compared N-butyl-2-cyanocrylate (NBCA) with sodium acrylate-vinyl alcohol copolymer particles using a swine model. Twelve pigs underwent PPVE. Six pigs (group A) were embolized with NBCA, and 6 pigs (group B) were embolized with sodium acrylate-vinyl alcohol copolymer particles. Computed tomographic volumetry of the embolized lobe (EL) and the nonembolized lobe (NEL), along with liver function tests, was performed before and at 14 and 28days after embolization. Tissue samples from both lobes were taken 14 and 28days after PPVE. NEL-volume and NEL-ratio increases were significantly higher in group A at 14 and 28days after PPVE (78 and 52% and 91 and 66%, respectively) than in group B (32 and 12% and 28 and 10%, respectively) (p<0.05). Percent change of the EL-volume was significantly higher for group A at 28days after PPVE. No statistically significant difference was found between the groups regarding hepatocyte proliferation on the NEL and apoptosis on the EL at both time intervals. PPVE using NBCA is more efficient and causes more NEL hypertrophy than microspheres.

Percutaneous Transumbilical Portal Vein Embolization in a Patient with a Ruptured Hepatocellular Carcinoma Supplied by the Portal Vein

We describe a case of a ruptured hepatocellular carcinoma supplied by the portal vein that was successfully treated with portal vein embolization via a percutaneous transumbilical approach. A contrast material-enhanced computed tomographic (CT) scan showed the presence of a large hypervascular tumor on portal venous phase as well as right hepatic vein thrombosis and hemoperitoneum that prevented portal vein embolization by the use of the percutaneous and transjugular transhepatic approach. The use of percutaneous transumbilical portal vein embolization can be an alternative option in this situation.

Portal vein embolization: rationale, outcomes, controversies and future directions

Portal vein embolization (PVE) is now considered the standard of care to improve safety for patients undergoing extensive hepatectomy with an anticipated small future liver remnant (FLR). PVE is used to induce contralateral liver hypertrophy in preparation for major liver resection. Optimal patient selection is essential to maximize the clinical benefits of PVE. Computed tomography volumetry is used to calculate a standardized FLR and determine the need for preoperative PVE. Percutaneous PVE can be performed via the transhepatic ipsilateral or contralateral approaches, depending on operator preference. Several different embolic agents are available to the interventional radiologist, all with similar effectiveness in inducing hypertrophy. When an extended hepatectomy is planned, right PVE should include segment 4, in order to maximize FLR hypertrophy. Multiple studies have demonstrated the beneficial outcomes of PVE in both patients with healthy livers and with underlying liver diseases. Novel improvements to PVE should expand its scope to patients who were previously not candidates for the procedure.

Combined first-stage hepatectomy and colorectal resection in a two-stage hepatectomy strategy for bilobar synchronous liver metastases

This study assessed the feasibility and outcomes of combined colorectal and hepatic resection as the first step of two-stage hepatectomy in patients with bilobar synchronous colorectal liver metastases. All patients with bilobar synchronous colorectal liver metastases who were considered for two-stage hepatectomy, combining resection of the primary tumour with the first stage of hepatectomy, between 2000 and 2008 were selected from a prospectively collected database at two institutions. Data were analysed retrospectively on an intention-to-treat basis. Thirty-three patients were studied. Twenty patients received neoadjuvant chemotherapy. Combined colorectal resection and clearance of left-sided liver metastases was the first-stage procedure in all but one patient, in whom right clearance was performed. In 17 patients right portal vein ligation was undertaken at the same time. No patient died. Two patients had anastomotic leakage. Interval chemotherapy was given to 25 patients, five of whom also had percutaneous portal vein embolization. Twenty-five patients had the second-stage hepatectomy, but not eight patients with disease progression. There was one postoperative death after the second stage, and eight patients experienced morbidity. Median follow-up from the first stage was 28.7 months. Overall and disease-free survival rates for patients who completed the procedure were 80 and 44 per cent respectively at 3 years, and 48 and 22 per cent at 5 years. In patients with bilobar synchronous colorectal liver metastases who are candidates for two-stage hepatectomy, combined resection of the primary tumour and first-stage hepatectomy reduces the number of procedures, optimizes chemotherapy administration and may improve outcome.