Portal Embolization Research Articles

Вплив ендоваскулярної підготовки на результати хірургічного лікування поширених гемангіом печінки

Objective – to study the effectiveness of preoperative portal vein branches embolization (PVE) in patients with advanced liver hemangiomas in the complex of preparation of these patients for radical liver resection. Materials and methods. PVE was performed in 67 patients with liver hemangiomas, the volume of the future liver remnant in which was less than 20 % of intact liver parenchyma. Laboratory parameters were studied before PVE, on day 5 after the intervention and immediately before liver resection. Hypertrophy of the future liver remnant was assessed by comparing computer tomography data before PVE and before resection. Results. In patients after PVE, an increase in the future liver remnant by 57.0 % was observed, which allowed 62 (92.5 %) patients to be included in the operable group. A significant increase of aminotransferases and decrease of blood albumin and protein on day 5 after PVE and their return before resection of the liver to baseline values was observed. This indicates an increase in cytolysis processes and a decrease in the synthetic function of the liver immediately after endovascular intervention. Restoration of the hepatic tissue occurs for 3 weeks. Conclusions. In patients with advanced liver hemangiomas who are candidates for liver resection, PVE is an effective minimally invasive technique for reducing the risk of postoperative complications associated with a small liver remnant.

Liver atrophy after percutaneous transhepatic portal embolization occurs in two histological phases: Hepatocellular atrophy followed by apoptosis.

AIMTo clarify the histological changes associated with liver atrophy after percutaneous transhepatic portal embolization (PTPE) in pigs and humans.METHODSAs a preliminary study, we performed pathological examinations of liver specimens from five pigs that had undergone PTPE in a time-dependent model of liver atrophy. In specimens from embolized lobes (EMB) and nonembolized lobes (controls), we measured the portal vein to central vein distance (PV-CV), the area and number of hepatocytes per lobule, and apoptotic activity using the terminal deoxynucleotidyl transferase dUTP nick-end labeling assay. Immunohistochemical reactivities were evaluated for light chain 3 (LC3) and lysosomal-associated membrane protein 2 (LAMP2) as autophagy markers and for glutamine synthetase and cytochrome P450 2E1 (CYP2E1) as metabolic zonation markers. Samples from ten human livers taken 20-36 d after PTPE were similarly examined.RESULTSPV-CVs and lobule areas did not differ between EMB and controls at day 0, but were lower in EMB than in controls at weeks 2, 4, and 6 (P ≤ 0.001). Hepatocyte numbers were not significantly reduced in EMB at day 0 and week 2 but were reduced at weeks 4 and 6 (P ≤ 0.05). Apoptotic activity was higher in EMB than in controls at day 0 and week 4. LC3 and LAMP2 staining peaked in EMB at week 2, with no significant difference between EMB and controls at weeks 4 and 6. Glutamine synthetase and CYP2E1 zonation in EMB at weeks 2, 4, and 6 were narrower than those in controls. Human results were consistent with those of porcine specimens.CONCLUSIONThe mechanism of liver atrophy after PTPE has two histological phases: Hepatocellular atrophy is likely caused by autophagy in the first 2 wk and apoptosis thereafter.

A Rare Case of Hydrogen Peroxide-Induced Gastric Emphysema and Portal Venous Gas Embolism Treated With Hyperbaric Oxygen Therapy

A Rare Case of Hydrogen Peroxide-Induced Gastric Emphysema and Portal Venous Gas Embolism Treated With Hyperbaric Oxygen Therapy

Liver Injury and Tumor-Inhibiting Effect of Sequential Transcatheter Arterial Chemoembolization and Portal Venous Embolization on Rabbit VX2 Liver Carcinoma.

BackgroundThe concepts of sequential transcatheter arterial chemoembolization (TACE) and portal venous embolization (PVE) were proposed to prevent the detrimental tumor growth-inducing effect of PVE and to facilitate growth of further future liver remnant (FLR). This study aimed to investigate the effect of sequential TACE and PVE on liver damage and the therapeutic effect in a rabbit VX2 liver tumor model.Material/MethodsRabbits bearing VX2 liver tumors were randomly divided into TACE+PVE, TACE, PVE, and Sham groups. Plasma levels of aspartate aminotransferase (AST), alanine aminotransferase (ALT), total bilirubin (TBIL), and alkaline phosphatase (ALP) at 6 h, 24 h, 3 days, and 7 days were measured by ELISA assay. Tumor diameter on day 7 was measured and the tumor sections with cleaved caspase-3 was stained and observed.ResultsPlasma ALT, AST, and ALP levels were significantly increased at the first hours after the interventions. The TACE group had higher increases than the TACE+PVE and PVE alone groups. ALT, AST, and ALP levels decreased on day 7 and presented a trend to return to the baseline level. The TACE+PVE group showed stronger tumor-inhibiting effect than the TACE and PVE alone groups and also induced the highest level of tumor cell apoptosis.ConclusionsThe liver damage caused by TACE+PVE is mild and recoverable. TACE+PVE showed stronger tumor-inhibiting effect than in the TACE and PVE group and also induced the highest level of tumor cell apoptosis.

Rescue associating liver partition and portal vein ligation for staged hepatectomy after portal embolization: Our experience and literature review.

AIMTo report a single-center experience in rescue associating liver partition and portal vein ligation for staged hepatectomy (ALPPS), after failure of previous portal embolization. We also performed a literature review.METHODSBetween January 2014 and December 2015, every patient who underwent a rescue ALPPS procedure in Toulouse Rangueil University Hospital, France, was included. Every patient included had a project of major hepatectomy and a previous portal vein embolization (PVE) with insufficient future liver remnant to body weight ratio after the procedure. The ALPPS procedure was performed in two steps (ALPPS-1 and ALPPS-2), separated by an interval phase. ALPPS-2 was done within 7 to 9 d after ALPPS-1. To estimate the FLR, a computed tomography scan examination was performed 3 to 6 wk after the PVE procedure and 6 to 8 d after ALPPS-1. A transcystic stent was placed during ALPPS-1 and remained opened during the interval phase, in order to avoid biliary complications. Postoperative liver failure was defined using the 50-50 criteria. Postoperative complications were assessed according to the Dindo-Clavien Classification.RESULTSFrom January 2014 to December 2015, 7 patients underwent a rescue ALPPS procedure. Median FLR before PVE, ALPPS-1 and ALPPS-2 were respectively 263 cc (221-380), 450 cc (372-506), and 660 cc (575-776). Median FLR/BWR before PVE, ALPPS-1 and ALPPS-2 were respectively 0.4% (0.3-0.5), 0.6% (0.5-0.8), and 1% (0.8-1.2). Median volume growth of FLR was 69% (18-92) after PVE, and 45% (36-82) after ALPPS-1. The combination of PVE and ALPPS induced a growth of median initial FLR of +408 cc (254-513), leading to an increase of +149% (68-199). After ALPPS-2, 4 patients had stage I-II complications. Three patients had more severe complications (one stage III, one stage IV and one death due to bowel perforation). Two patients suffered from postoperative liver failure according to the 50/50 criteria. None of our patients developed any biliary complication during the ALPPS procedure.CONCLUSIONRescue ALPPS may be an alternative after unsuccessful PVE and could allow previously unresectable patients to reach surgery. Biliary drainage seems to reduce biliary complications.

HEPATOBILIARY SCINTIGRAPHY FOR RISK ASSESSMENT OF POSTHEPATECTOMY LIVER FAILURE

Aim: to assess the role of hepatobiliary scintigraphy for prognosis of hepatic failure after liver resection; to determine threshold index of hepatic uptake of radioactive agent as an indication for surgical prevention of hepatic failure. Material and Methods. The study included 2 groups of patients who underwent hepatobiliary scintigraphy. The 1st group consisted of 50 patients with diffuse liver diseases (chronic hepatitis, liver cirrhosis) in whom histological examination of liver was performed according to METAVIR. 49 patients with liver tumors underwent advanced liver resections (over segments by Couinaud). Results. The highest median of hepatic uptake (2,86) was revealed in patients with liver fibrosis F1, the lowest (2,02) – in patients with liver fibrosis F4. Threshold value of hepatic uptake was 2,4. In 18 patients with hepatic uptake index <2,4 and remnant liver <40% surgical prevention of hepatic failure was performed: portal vein ligation (1), portal embolization (12), percutaneous embolization with radiofrequency ablation along the plane of future liver dissection (5). An increase of hepatic uptake index up to 2.7 ± 0.47 was revealed in the areas of liver regeneration and hypertrophy in 14–21 days after surgery. Conclusion. Combined static and dynamic hepatobiliary scintigraphy is valuable to assess volume and function of different liver segments. Threshold hepatic uptake index of 2.4 is sensitive to predict postoperative liver failure in case of future remnant liver <40%.

Treatments for colorectal liver metastases: A new focus on a familiar concept.

A major challenge for the management of advanced-colorectal-cancer is the multidisciplinary approach required for the treatment of liver metastases. Reducing the burden of liver metastases with liver-directed therapy has an important impact on both survival and health-related quality of life. This paper debates the rationale and current liver-directed approaches for colorectal liver metastases based on the evidence of literature and new clinical trials. Surgery is the gold standard, when feasible, and it's the main treatment goal for patients with potentially-resectable disease as a means of prolonging progression-free survival. Better tumor response rates with modern systemic therapy mean that more unresectable patients are now down-staged for radical resection following conversion therapy but for other patients, additional procedures are needed. In multiple unilobar disease, when the projected remnant liver is <30% of the total liver, portal embolization or selective-internal-radiation-therapy (SIRT) can induce hypertrophy of the healthy liver, leading to resectability. In multiple bilobar disease, in situ destruction of non-resectable lesions by minimally invasive techniques may be associated with liver resection to achieve potential curative intent. Other palliative liver-directed approaches, such as SIRT or intra-hepatic chemotherapy (HAI), which are associated with higher response rates, may also have role in down-staging patients for resection. Until recently, such technologies have not been validated in prospective controlled trials. However in the light of new Phase 3 data for SIRT as well as for HAI combined with modern therapies or radiofrequency ablation in the first- and second-line setting, the clinical value of these treatments needs to be re-appraised.

Minimally Invasive Liver Preconditioning for Hepatocyte Transplantation in Rats.

In the context of cell transplantation in the liver parenchyma, preconditioning is essential to enhance cell engraftment and liver repopulation. The authors have developed a minimally invasive technique of temporary portal embolization using an absorbable material, called reversible portal vein embolization. We hereby describe the method for isolating hepatocytes from a donor rat before transplanting hepatocytes after reversible portal vein embolization in the recipient.

A case presentation of ALPPS procedure for liver resection

In patient with colorectal liver metastases only surgery is associated with a survival plateau. Main factors for resection are localizations of metastasis and functional liver remnant. To prevent liver failure after extended hepatic resection we perform two stage procedure with portal vein ligation or embolisation. In March 2012 was published first large study for new technique of two stage hepatic resection. In fisrt procedure surgeon performed in situ resection with perservation of arteries, vein and bile ducts. After one week CT was performed and if adequate hypertrophy of liver remain was observed final procedure with removal of transected liver was performed. Authors describe 100% hypertrophy of future liver remant in 1 to 2 week period. We will describe first procedure performed in Slovenia in our clinical department.

Novel rat model of repetitive portal venous embolization mimicing human non-cirrhotic idiopathic portal hypertension

Novel rat model of repetitive portal venous embolization mimicing human non-cirrhotic idiopathic portal hypertension

Parenchymal-sparing hepatectomy for deep-placed colorectal liver metastases

The feasibility of parenchymal-sparing hepatectomy has yet to be assessed based on the tumor location, which affects the choice of treatment in patients with colorectal liver metastases. Sixty-three patients underwent first curative hepatectomy for deep-placed colorectal liver metastases whose center was located >30mm from the liver surface. Operative outcomes were compared among patients who underwent parenchymal-sparing hepatectomy or major hepatectomy (≥3 segments). Parenchymal-sparing hepatectomy and major hepatectomy were performed for deep-placed colorectal liver metastases in 40 (63%) and 23 (37%) patients, respectively. Resection time was longer in the parenchymal-sparing hepatectomy than in the major hepatectomy group (57 vs 39minutes) (P=.02) and cut-surface area was wider (120 vs 86cm2)(P<.01). Resected volume was smaller in the parenchymal-sparing hepatectomy than in the major hepatectomy group (251 vs 560g)(P<.01). No differences were found between the 2 groups for total operation time (306 vs 328minutes), amount of blood loss (516 vs 400mL), rate of major complications (10% vs 13%), and positive operative margins (5% vs 4%). Overall, recurrence-free, and liver recurrence-free survivals did not differ between the 2 groups. Direct major hepatectomy without portal venous embolization could not have been performed in 40% of the parenchymal-sparing hepatectomy group (16/40) because of the small liver remnant volume. Parenchymal-sparing hepatectomy for deep-placed colorectal liver metastases was performed safely without compromising oncologic radicality. Parenchymal-sparing hepatectomy can increase the number of patients eligible for an operation by halving the resection volume and by increasing the chance of direct operative treatment in patients with ill-located colorectal liver metastases.

Embolización portal hepática preoperatoria con lipiodol y gelatina absorbible

ObjectiveTo evaluate outcomes of preoperative hepatic portal vein embolisation with lipiodol and absorbable gelatin in order to generate liver hypertrophy and enable right hepatectomy in selected patients with liver tumours and future insufficient residual liver. Materials and methodsPortal vein embolisation (PVE) with lipiodol and absorbable gelatin sponge mixed with iodine based contrast was performed in 18 patient candidates for right hepatectomy between March 2002 and April 2014. The pre-embolisation liver volume evaluations were performed by computed tomography with intravenous contrast. Patients underwent an ultrasound-guided percutaneous puncture, followed by angiography. The controls of hypertrophy and volume estimation were performed in the 4th week after portal embolisation. The patients were followed-up on an outpatient basis or by using their medical records. ResultsThe median age was 58 years, with a 1:0.8 male: female ratio. The total estimated liver volume, excluding the tumour, of all patients evaluated prior to surgery was 1587.75 cm3 (median). The previous estimated liver volume and its relation to the future remaining portion before PVE was 19.9%. The absolute median growth of future residual liver parenchyma post-PVE was 306.2 to 475.2 cm3, being an increase of 43.5%, and the mean growth of liver volume and remaining portion ratio post-PVE was 8.5% (P<.001). Complications were one haematoma and one aseptic necrosis. ConclusionThe selection of patients is of paramount importance, and PVE with lipiodol and absorbable gelatin in our environment is a safe and effective procedure.

Hepatic encephalopathy (HE) due to intrahepatic portosystemic shunt after total gastrectomy

A 67-year-old woman was admitted in the department of Neuology for investigation of recurrent episodes of mental confusion nd speech difficulty lasting 3–4 days. Between the episodes she as presenting somnolence and flapping tremor. The symptoms tarted shortly after gastrectomy followed by chemotherapy for astric non-Hodgkin’s lymphoma. Haematological profile, liver iochemistry, thyroid function and immunology tests were noral. Serum ammonia levels were 174 g/dL (normal <35 g/dL). T scan and MRI of brain were unremarkable. Electroencephaloram demonstrated polymorphic abnormal waves of type 9 and . Examination of cerebro-spinal fluid was normal. MRI angiogaphy showed a large intrahepatic shunt between a large branch f portal vein and hepatic vein in the right hepatic lobe (Fig. 1). he 3-dimensional reconstruction images confirmed angiography ndings (Fig. 2). Trans-hepatic portal venous embolization with coil lacement to intrahepatic porto-systemic shunt (IPSS) was successully performed. Throughout the 4-year post-procedural follow up eriod, the patient remained free from hepatic encephalopathy.

Portal embolization as treatment in patient with pre-operative hepatocellular carcinoma

Introduction: Liver malignancy have increased in incidence over the decades, and the liver is a common site of metastases. In recent decades, improvements in surgical techniques, increased understanding of liver anatomy and advances in perioperative care have resulted in improvements in mortality. Case report: Men, 71, complaining of abdominal discomfort. Upper abdominal CT scan that showed a mass in the right lobe of the liver, occupying segments V, VI, VII, VIII, 1 3 6 × 11.6 × 13 cm in their largest diameter, without involvement of other segments. Biopsy diagnosed with well-differentiated hepatocellular carcinoma was performed. Conducting right portal vein embolization in order to increase the residual liver volume for subsequent hepatectomy. Patient underwent embolization and portal vein chemoembolization of the right hepatic artery was discharged on POD 50. It was accompanied with rescanned after 30 days, which showed growth of 28.9% of the FFR. Hospitalized for 40 days to carry out the right hepatectomy was discharged in 110 days, and outpatient follow-up. Conclusions: The preoperative embolization portal vein yielded growth of residual liver 28.9% hepatectomy sufficient to allow safety.

Liver partition and portal vein ligation in staged hepatectomy (ALPPS) as a savage procedure after failed portal embolization in colorectal liver metastases

Liver partition and portal vein ligation in staged hepatectomy (ALPPS) as a savage procedure after failed portal embolization in colorectal liver metastases

Associating portal embolization and artery ligation (apeal): The best way to safely induce rapid liver regeneration in staged hepatectomy

Associating portal embolization and artery ligation (apeal): The best way to safely induce rapid liver regeneration in staged hepatectomy

M1 macrophage infiltrations and histological changes in the liver after portal vein embolization using fibrinogen and OK432 in the rat

The mechanism of anti-tumor effect of transarterial Immuno-Embolization (TIE) using OK-432 has not been well elucidated. In this study, we aimed to investigate the tissue injury and immune response after portal venous embolization (PVE) with/without OK-432. Embolic materials (L group: lipiodol, LF group: lipiodol+fibrinogen, LO group: lipiodol+OK-432, LFO group: lipiodol+fibrinogen+OK-432) were administered via the right portal vein in Wistar rats. The histological findings in LFO group demonstrated liver damage with severe architectural changes. The concentrations of CD68+ cells were observed in a time-dependent manner; it was significantly increased in the LO group on day 1 and in the LFO group on day 3. CD68+CD163− macrophages significantly increased in the LFO group on day 7 (P<0.05). In conclusion, PVE with fibrinogen and OK-432 markedly increased the CD68+CD163− infiltrating macrophages around the peri-portal area in the liver. This novel technique could be applied as immune-enhanced chemo-embolization of liver tumors.

Extreme liver surgery as treatment of liver tumors involving the hepatocaval confluence.

Analyze the characteristics, surgical technique, morbidity and survival of patients treated with extreme liver surgery. We present a series of consecutive patients with malignant liver tumors in hepatocaval confluence treated in a single center with extreme liver surgery (April 2008-March 2015). Data were collected prospectively and analyzed with SPSS 21.0. 12 patients were included. 50% were male and 50% were female with a mean age of 59±10years old. The median of comorbidities was 7 according to the Charlson Age Comorbidity Index. The 75% of the tumors were metastases, most of them from colorectal cancer. Most of the patients received neoadjuvant chemotherapy and in 58% preoperative portal embolization was performed. Major hepatectomies were performed (66.7% extended right hepatectomy, 33.3% left extended hepatectomy). The 83.3% of the patients needed vascular reconstruction. Postoperative morbidity was more than grade II in 50% of the patients according to Dindo-Clavien classification. There was no intraoperative mortality. The postoperative mortality rate at 90days was 33% due to hepatic failure and biliary fistula. In December 2015, 33% of the patients are still alive with a mean survival of 19months (13-23) with an ECOG Performance Status of 0. Extreme liver surgery carries a high rate of morbidity and mortality that seem to increase with age and with higher tumor volumes, according to the literature. It is a therapeutic option to consider in patients with low comorbidity suffering from malignant neoplasms that involve the hepatocaval confluence, when no other treatment with curative intention can be performed.

Patient with Large Liver Tumor, Bleeding Ulcer and Unstable Angina Treated with Coronary Stenting Followed by Portal Embolization and Major Liver Surgery with Ticagrelor and Aggrastat Prophylaxis

Background: There is very little data in the literature on how to handle Dual Antiplatelet Therapy (DAPT) and newly adapted Drug Eluting Stents (DES) in patients in need of liver surgery due to malignant disease. Case report: A man, 79 years of age, with a bleeding hepatocellular carcinoma in a normal liver, bleeding duodenal ulcer and Acute Coronary Syndrome (ACS). Coronary angiography showed significant stenoses in the left main coronary artery (LM), Left Anterior Descending (LAD), first and second diagonal branches (D1, D2), Circumflex (Cx) and Right Coronary Artery (RCA). The patient was treated with Percutaneous Coronary Intervention (PCI) including six everolimus eluting coronary stents, aspirin and ticagrelor followed by portal embolization two months after stenting and another two months later liver resection, bridging with the Glycoprotein Receptor Inhibitor (GPI) tirofiban. The portal embolization was uneventful but there were bleeding complications after liver surgery, calling for very close monitoring of the antithrombotic treatment under these complex conditions. Discussion: Close monitoring and individualization of therapy was essential to make portal embolization and liver tumor surgery possible in this patient with DES and DAPT.

Associating portal embolization and artery ligation to induce rapid liver regeneration in staged hepatectomy

Insufficient volume of the future liver remnant (FLR) is a major cause of unresectability in patients with bilobar colorectal liver metastases (CLM). The objective of this study was to evaluate the safety and efficacy of the novel associating portal embolization and artery ligation (APEAL) technique before extended right hepatectomy during a two-stage procedure for CLM. All patients who had undergone extended right hepatectomy during two-stage surgery for CLM between 2012 and 2014 were identified retrospectively from a prospectively maintained database. In the first stage, right portal vein embolization, partial right hepatic artery ligation and devascularization of segment IVb along the round ligament without parenchymal transection were associated with clearance of the FLR and/or primary tumour resection. Liver volumetry was performed using OsiriX software on postoperative day (POD) 7 and 30. Ten patients underwent the APEAL procedure. During the first stage, APEAL was combined with colorectal resection in seven patients. The median (range) interval between the two stages was 45 (31-71) days. The FLR volume increased from 327 (214-537) cm(3) before surgery to 590 (508-1072) cm(3) on POD 7 and 701 (512-1018) cm(3) on POD 30. This corresponded to a FLR regeneration rate of 104 (42-185) and 134 (53-171) per cent respectively. There were no deaths. The overall morbidity rate was 60 per cent (6 of 10) after each procedure, with severe morbidity occurring in two and three of ten patients after the first and second procedures respectively. APEAL induces fast, safe, reproducible and effective FLR growth when an extended right hepatectomy is scheduled in patients with multiple bilobar CLM.