Portal Embolization Research Articles

Two stage hepatectomy (TSH) or Associating liver partition and portal vein ligation for staged hepatectomy (ALLPS) for bilobar multiple colorectal liver metastasis

Of patients with colorectal cancer, 30% to 50% present with liver metastasis at the time of diagnosis or develop metastasis later. Hepatectomy is the primary curative treatment option for patients with colorectal liver metastases (CRLMs). Patients with bilateral, multiple CRLMs and a small estimated tumor free future liver remnant (FLR) present a treatment challenge. These patients may need a two-stage hepatectomy (TSH) in which portal venous ligation (PVL) or portal venous embolization (PVE) is included in the first stage to stimulate hypertrophy of the FLR before final resection. This method generates a 27% to 39% increase in FLR volume in 4 to 8 weeks. The risks in this method are tumor progression during the waiting period and insufficient hypertrophy, making resection impossible in 25% to 38% of the patients preparing to undergo TSH. To increase liver growth rate and volume, which renders more patients resectable in a shorter time, a novel concept of liver resection, associating liver partition and portal vein ligation for staged hepatectomy (ALPPS), was described in 2011. However, in the early study 68% of the patients experienced complications and the surgical mortality rate was 12%. A recent, the only multicenter randomized controlled trial (RCT) revealed that compared with the use of TSH, the use of ALPPS for patients with CRLM resulted in a higher resection rate (92%) without a higher 90-day mortality rate (8.3%), a higher rate of severe complication rate (43%) or a lower rate of negative surgical margins in the liver. A previous meta-analysis including 9 retrospective studies showed that TSH for CRLM exhibited lower perioperative morbidity and mortality rates than ALPPS, suggesting the superiority of TSH. On the other hand, in a recent meta-analysis in 2020 including 7 retrospective studies and 1 RCT, compared with TSH, ALPPS for advanced CRLM resulted in superior surgical efficacy with comparable perioperative mortality rate and short-term oncological outcomes, while this was at the cost of increased perioperative minor complications. From a clinical perspective, traditional TSH has been frequently regarded as a preferred treatment modality in earlier studies, and ALPPS was reserved as an alternative, typically after failed PVE or PVL. At present, this paradigm may have changed, as there is growing evidence indicating that the surgical benefits given by ALPPS are at least not inferior to those given by TSH according to recent studies. ALPPS may be feasible for bilobar multiple colorectal liver metastasis. Still, long-term outcomes remain to be elucidated and therefore the role of ALPPS regarding oncological outcome remains uncertain.

Therapeutic plasma exchange as an effective salvage measure for post-hepatectomy hepatic failure: A case report

Major hepatectomy can result in post-hepatectomy hepatic failure (PHHF) and therapeutic plasma exchange (TPE) can be used as a salvage procedure for liver support. We herein present a case of 69-year-old male patient with perihilar cholangiocarcinoma who was successfully managed with salvage TPE. Preoperative portal embolization was performed to reduce the parenchymal resection rate. The extent of surgery was right hepatectomy with partial excision of the ventral portion of the segment IV, caudate lobectomy, bile duct resection and extensive lymph node dissection. No noticeable surgical complications occurred after the operation, but serum total bilirubin level increased gradually and reached 10 mg/dL at 1 month after the operation. At postoperative day 38, total bilirubin level raised to 19.8 mg/dL and prothrombin time deteriorated significantly, thus salvage TPE was started. TPE was performed three times per week for 2 weeks; consequently, the total bilirubin level was maintained below 10 mg/dL. A few days later, a rebound of total bilirubin occurred; accordingly, 2 sessions of TPE were performed additionally. Overall, a total of 8 sessions of TPE were performed. The patient was discharged at 84 days after operation. The total bilirubin level returned to normal at 5 months after operation. This patient is doing well for past 9 months. In Korea, TPE for liver support has been approved by the social health insurance since August 2020. In conclusion, salvage TPE is an effective liver support measure for PHHF, thus we suggest starting TPE if serum total bilirubin level reaches 10 mg/dL after hepatectomy.

Prompt intervention can avert catastrophic outcome of portal venous air embolism during ERCP

Prompt intervention can avert catastrophic outcome of portal venous air embolism during ERCP

Ipsilateral access portal venous embolization (PVE) for preoperative hypertrophy exhibits low complication rates in Clavien-Dindo and CIRSE scales

BackgroundPortal venous embolization (PVE) is a minimal invasive preoperative strategy that aims to increase future liver remnant (FLR) in order to facilitate extended hemihepatectomy. We analyzed our data retrospectively regarding complications and degree of hypertrophy (DH).Methods: 88 patients received PVE either by particles / coils (n = 77) or by glue / oil (n = 11), supported by 7 right hepatic vein embolizations (HVE) by coils or occluders. All complications were categorized by the Clavien- Dindo (CD) and the CIRSE classification.ResultsIn 88 patients (median age 68 years) there was one intervention with a biliary leak and subsequent drainage (complication grade 3 CD, CIRSE 3), two with prolonged hospital stay (grade 2 CD, grade 3 CIRSE) and 13 complications grade 1 CD, but no complications of grade 4 or higher neither in Clavien- Dindo nor in CIRSE classification. The median relative increase in FLR was 47% (SD 35%). The mean pre-intervention standardized FLR rose from 23% (SD 10%) to a post-intervention standardized FLR of 32% (SD 12%). The degree of hypertrophy (DH) was 9,3% (SD 5,2%) and the kinetic growth rate (KGR) per week was 2,06 (SD 1,84).ConclusionPVE and, if necessary, additional sequential HVE were safe procedures with a low rate of complications and facilitated sufficient preoperative hypertrophy of the future liver remnant.

Intraoperative Ultrasound and Liver Metastasis: Diagnostic Value

Introduction: The preoperative diagnosis of liver metastases has improved in recent years with CT and MRI. Intraoperative ultrasound can identify metastases that had gone unnoticed. Objective: Compare the number of metastases identified in preoperative radiological tests, intraoperative ultrasound findings and their histological correlation. Material and Methods: From May 2009 to September 2020, 145 cases previously evaluated in the Digestive Tumors Committee were operated. The diagnostic study was based on abdominal CT and +/- resonance. The preoperative radiological diagnosis was complemented in the surgical intervention with manual palpation and systematic intraoperative ultrasound performed in our unit by the liver surgeon. Results: During the study period, 145 cases were operated on, and 133 resections were performed in 111 patients. Eight cases with portal embolization were excluded from the study due to the difficulty of evaluating them correctly. After performing an exploration of the abdominal cavity and intraoperative ultrasound detailing the number of lesions and their location, 12 patients (8%) were not resectable. The comparative results between radiological tests, intraoperative ultrasound, and histological analysis (Table 1) found that in 14 cases (11%) the ultrasound identified more metastases than the tests performed in the preoperative study. Conclusions: Intraoperative ultrasound in MH metastasis surgery must be performed thoroughly and systematically. In our experience, intraoperative ultrasound identifies 11% of liver metastases not described in preoperative imaging tests, all of them with subsequent histological confirmation.

Contralateral liver tumor behavior after portal embolization: are two-stage hepatectomies always justified?

Contralateral liver tumor behavior after portal embolization: are two-stage hepatectomies always justified?

3D laparoscopic anatomical segment 8 resection for colorectal liver metastasis recurrence after previous left hemi-hepatectomy

Purpose: Patients suffering from colorectal liver metastasis (CRLM) often have recurrent disease and many patients will undergo multiple surgical procedures during the course of their disease. Redo hepatic surgery can be notoriously difficult. In this video we will show a case of 3d laparoscopic anatomical segment 8 resection after previous left hemi-hepatectomy for CRLM. Method: This 75 year old patient had a local recurrence of a metastasis of her colon cancer (pT2N0, 2014) at the previous resection plane after left hemi-hepatectomy (2019, R1). The recurrence was in contact with the right anterior pedicle. The patient had stable disease after 10 cycles of chemotherapy (Folfox- Bevacizumab) and was considered for surgery. Preoperative calculation of FLR for segment 5/8 resection showed a 34% FLR. Extensive chemotherapy was administered preoperatively suggesting chemotherapy induced liver injury. A pre-operative portal embolization of P8 was performed to induce hypertrophy of the FLR. CT scan 6 weeks after embolization showed no apparent hypertrophy in S6/7. Results: A 3D laparoscopic anatomical S8 resection was performed. Segment 5 could be preserved by selective transection of S8 pedicle. Operation and peri-operative course were uneventful. Operative time of 3hours, estimated blood loss of 250ml. No postoperative liver insufficiency. TOSGS 0, patient went home POD 3. Conclusion: Laparoscopic redo hepatic surgery after previous major hepatectomy is technically challenging, but can safely be performed with low morbidity and good oncological outcomes.

Hybrid transileocecal portal vein embolization associated with staging laparoscopy for planned major hepatectomy in advanced hepatobiliary cancers.

Portal vein embolization (PVE) is widely used to promote the hypertrophy of a future liver remnant (FLR) and reduce posthepatectomy liver failure. The aim of this study was to evaluate the efficacy of transileocecal portal embolization (TIPE) associated with staging laparoscopy (hybrid lap-TIPE) for a planned hepatectomy in advanced hepatobiliary cancers. The hybrid lap-TIPE procedure consisted of staging laparoscopy for complete screening of the abdominal cavity with cytoreductive surgery and subsequent TIPE. Data on hybrid lap-TIPE, performed between March 2013 and February 2020, were collected retrospectively. Hybrid lap-TIPE was conducted for 52 patients, and a subsequent TIPE was accomplished in 42 patients (80.8%), since staging laparoscopy detected latent or unresectable factors in 13 patients (25.0%), among which 2 patients with hepatocellular carcinoma and 1 with colorectal liver metastasis received laparoscopic cytoreductive surgery for latent lesions in the FLR. Finally, radical hepatectomy was completed in 36 patients (69.2%), including 3 patients who underwent cytoreductive surgery. The most common operation was an extended right hepatectomy (50.0%), followed by right hepatectomy (30.6%), including 3 hepatopancreatoduodenectomies. The overall morbidity associated with hybrid lap-TIPE and hepatectomy was 7.1% and 41.7%, respectively. The mortality associated with hybrid lap-TIPE and hepatectomy was 0% and 5.6%, respectively. The rates of 2-year survival and 2-year disease-free survival were 64.8% and 61.9%, respectively, after hepatectomy. Hybrid lap-TIPE is safe and could be a useful treatment option for patients with advanced hepatobiliary cancer because it can help to identify optimal candidates for PVE followed by a planned hepatectomy.

Extended liver resection including hypertrophy concept with portal venous embolisation for giant haemangioma. Too much surgery?

Haemangiomas of the liver are benign tumours, which are often diagnosed randomly. With an increase in size haemangiomas could become symptomatic. In this case therapeutic options, surgical or interventional, have to be weighted to a conservative approach. We present a case of a 36-year old woman with a symptomatic giant haemangioma of the right liver lobe. Because of the size of the tumor and the small future liver remnant we decided to perform a major liver resection after hypertrophy induction with a preoperative portal vein embolization; an option mainly used for major hepatectomies in malignant tumors of the liver. But however, this case shows, that using a hypertrophy concept also for benign liver tumours is the safer approach, if an extended resection is necessary and the future liver remnant is critical.

Expression of MMP-2 in residual VX2 liver tumor after transcatheter arterial embolization combined with portal venous embolization in an animal model

ObjectiveThis study aimed to analyze the effects of transcatheter arterial embolization (TAE) combined with portal venous embolization (PVE) on the expression of MMP-2 in residual VX2 liver tumor tissues, liver function and non-embolic lobe regeneration. MethodsA total of 72 rabbits were randomly divided into Sham, TAE, PVE and TAE ​+ ​PVE groups (n ​= ​18/group). The tissue samples from each group were taken at 6 ​h, 3 days and 7 days after interventional operation, respectively. MMP-2 expression was detected by immunohistochemistry, Real-time PCR, and Western-blotting. The main indicators (such as AST, ATL, and TBIL) of liver function and the volume of non-embolized hepatic lobes were measured in each group after operation. One-way ANOVA and Kruskal-wallis method were used for statistical analysis. ResultsThe expression of MMP-2 mRNA and protein remained the highest in the Sham group, and the expression of MMP-2 mRNA and protein in TAE, PVE and TAE ​+ ​PVE groups were successively increased, and the expression of MMP-2 in TAE ​+ ​PVE group was always significantly higher than TAE group. The AST and ALT levels in each group on day 7 after operation showed a significant declination, and all groups have recovered to the preoperative baseline level and TBIL has a slight fluctuation in each group after operation with no statistical difference. On day 7 after operation, the increasing volume of non-embolized liver lobes in TAE ​+ ​PVE group showed a more significant effect than those in PVE group, but there was no statistical significance (37.62 ​± ​1.54 ​ml VS 36.18 ​± ​1.15 ​ml, P ​= ​0.881), and its volume was significantly higher than those in the sham group (27.03 ​± ​1.11 ​ml). ConclusionTAE ​+ ​PVE is considered to be an efficient and safe approach for treating rabbit VX2 liver transplantation tumor, but the expression of MMP-2 increased fastest after TAE ​+ ​PVE, which might promote tumor cell invasion and metastasis.

Transient venous air embolism after ERCP: worrisome or not?

The paper describes the occurrence of a rare complication – portal and systemic venous air embolism – after endoscopic retrograde cholangiopancreatography, related to the endoscopic procedure. It can be associated with the more frequently encountered post-endoscopic retrograde cholangiopancreatography complications pancreatitis or cholangitis. However, it can also be noted with perforation. The presented case suggests that in the clinical context an early abdominal ultrasound examination confirming hepatic portal venous gas and/or systemic venous air embolism could be useful for the diagnosis of post-endoscopic retrograde cholangiopancreatography retroduodenal perforation, and thus highlights the need for a high index of suspicion should this occurrence be noted post-procedurally, in order to ensure the best care of patients.

Sequential Portal Vein Embolization: a Technical Option for Hepatic Metastasis Resection

We present the clinical case of a patient who, having been referred for surgery on two-stage hepatectomy, could not have a conventional portal embolization performed as an intermediate step in order to be able to resection the whole of the hepatic illness she was suffering. During right portal embolization (PE), the portography revealed minimal flow in the left portal vein, without thrombosis or stenosis. Given the risk of serious hepatic insufficiency, the embolization procedure was ruled out. Our option was to perform a portal embolization in two stages: initial PE of the right posterior branch, and subsequently, right anterior branch PE. After that, the liver resection could be completed.

The aura of malignant tumor: Clinical analysis of malignant tumor-related pyogenic liver abscess.

The global incidence of pyogenic liver abscess (PLA) is increasing, but related reports of malignant tumor-related PLA are infrequent. Potential malignant tumors of PLA have been reported, but there is no relevant predictive model for this subsection of patients.To explore the risk factors of malignant tumor-related PLA.A retrospective analysis about a total of 881 patients who had been diagnosed with PLA from January 2005 to May 2018 was performed. The incidence of malignant tumor-related PLA in the study was 9.99% (88/881) out of all PLA cases. And that of potential malignant tumors with PLA was 4.65% (41/881). There were 62 patients with malignant tumor-related PLA in the observation group, while 146 cases without malignant tumor-related PLA were considered as control group. The data from 52 cases of malignant tumor and nonmalignant tumor-related PLA was verified.The malignant tumor type was mainly hepatobiliary malignant tumor, which occupies 72.3% (45/62) in all malignant tumor related PLA cases used to the model. Compared with nonmalignant tumor group, the rate of ineffective and mortality was higher in the malignant tumor group [19.4%(12/62) vs 7.5%(11/148), P = .01]. Multivariate analysis suggested that hepatobiliary interventional therapy or surgery, hepatitis B virus infection, multiple abscesses, portal embolism, and bile duct dilatation were independent risk factors for potential malignant tumors within the patients who combined with PLA.PLA could be considered as an early warning sign of potential malignant tumors. Malignant tumor-related PLA had a poor prognosis. Patients with PLA who have more than one independent risk factor or logit(P) > −1.694 may be considered as the high risk group for potential hepatobiliary or colorectal malignant tumors.

Clinical impact of liver venous deprivation (LVD) compared to portal venous embolization (PVE) in patients undergoing right hepatectomy

Clinical impact of liver venous deprivation (LVD) compared to portal venous embolization (PVE) in patients undergoing right hepatectomy

Anatomical liver resections for intrahepatic cholangiocarcinomas: Perioperative results and survival

Presenter: Gabriela Ochoa MD | Pontificia Universidad Católica de Chile Background: Intrahepatic cholangiocarcinma (ICC) is an infrequent neoplasm, whose incidence is increasing with a poor prognosis. The only curative management is surgery, however, despite the correct selection of the cases, only 1/3 of patients achieve negative margins. We aimed to describe the experience and results in resected cases from Catholic University Hospital in Chile. Methods: Retrospective cohort analysis of the resected ICC cases with curative intention, between 2006 to 2019. The information was obtained from electronical clinical reports. The analysis was made with descriptive statistics. Results: Out of 17 patients operated for ICC. 10 were males and 7 women, between 48 and 84 years-old, 2 with risk factors (chronic liver disease, iatrogenic bile duct injury). 5 patients received neoadjuvant therapy and in 1 case portal embolization was made beforehand. 13 cases were performed open and 4 laparoscopic. There were 4 extended right hepatectomies, 3 right hepatectomies, 4 extended left hepatectomies, 3 left hepatectomies, 2 bisegmentectomies (IV, V) 1 left lateral sectionectomy. Mean operative time was 263 minutes and hospital stay average was 14,2 days. There was no 30-day mortality. The global morbidity was 41,2% (7 patients), and Clavien Dindo >IIIB complications were 17,6% (3 patients). Reoperations were performed in 2 cases, one for hemoperitoneum and the other for bile leak. The oncologic classification was Ia (1), Ib (1), II (4), IIIa (2), IIIb (8) y IV (1). There were positive lymph nodes in 8 cases and 1 patient with peritoneal metastases. 8 patients resulted R1 (47,1%). 14 patients received adjuvant treatment. The global survival was 82,4% at 6 months, 46,7% at 1 year and 40% at 2 years, with a mean follow-up of 24,3 months. Conclusion: The surgical treatment of ICC normally requires large anatomical liver resections, despite which, the incidence of R1 positive margins is high and could result in the poor prognosis of long-term disease.

Right trisectionectomy with portal reconstruction for klatskin tumor

Abstract Background: Many techniques of right hepatic trisectionectomy (extended right hepatectomy) are now standardized in patients with hepatocellular carcinoma or metastatic tumors, but in case of hilar cholangiocarcinoma are not yet. Materials: We present a 66 years old male, under preoperative diagnosis of hilar cholangiocarcinoma, a patient underwent right hepatic trisectionectomy with previous portal embolization and hepaticojejunostomy. During the procedure a part of portal vein was resected for infiltration and embolization at the first stage. Limph nodes were resected too. Results: In the second stage the extended right hepatectomy was successfully performed, and the patient was discharged from the hospital in good condition. Histologically was diagnosed as having cholangiocarcinoma. The resection margins, proximal and distal, were negative. The lymph nodes were neoplasia-negatives. Conclusions: Extended right hepatectomy with portal vein reconstruction can be used for a longer proximal resection and can offer a better chance of long-term survival in selected patients with locally advanced hilar cholangiocarcinoma.

CD133 + cell infusion in patients with colorectal liver metastases going to be submitted to a major liver resection (CELLCOL): A randomized open label clinical trial

BackgroundTreatment of liver metastases of colorectal carcinoma is surgical resection. However, only 10–15% of the patients in this context will be candidate for curative resection arising other 10–13% after response to neoadyuvant chemotherapy. In order to perform the liver metastases surgery, it is necessary to have a sufficient remnant liver volume (RLV) which allows maintaining an optimal liver function after resection.Studies on liver regeneration have determined that CD133 + stem cells are involved in liver hypertrophy developed after an hepatectomy with encouraging results. As presented in previous studies, CD133 + stem cells can be selected from peripheral blood after stimulation with G-CSF, being able to obtain a large number of them. We propose to treat patients who do not meet criteria for liver metastases surgery because of insufficient RLV (<40%) with CD133 + cells together with portal embolization, in order to achieve enough liver volume which avoids liver failure. Methods/Design: The aim of this study is to evaluate the effectiveness of preoperative PVE plus the administration of CD133 + mobilized from peripheral blood with G-CSF compared to PVE only. Secondary aims areto compare the grade of hypertrophy, speed and changes in liver function, anatomopathological study of hypertrophied liver, to determine the safety of the treatment and analysis of postoperative morbidity and surveillance. Study designProspective randomized longitudinal phase IIb clinical trial, open, to evaluate the efficacy of portal embolization (PVE) together with the administration of CD133 + cells obtained from peripheral blood versus PVE alone, in patients with hepatic metastasis of colorectal carcinoma (CCRHM). DiscussionThe number of CD133 + obtained from peripheral blood after G –CSF stimulation will be far greater than the number obtained with direct puncture of bone marrow. This will allow a greater intrahepatic infusion, which could have a direct impact on achieving a larger and quicker hypertrophy. Consequently, it will permit the treatment of a larger number of patients with an increase on their survival. Trial registrationClinicalTrials.gov, ID NCT03803241.

A case of complete necrosis of a huge hepatocellular carcinoma after percutaneous transhepatic portal embolization

A case of complete necrosis of a huge hepatocellular carcinoma after percutaneous transhepatic portal embolization

Two-Stage Hepatectomy with Portal Embolization to Treat Bilateral Hepatic Adenomas

Two-Stage Hepatectomy with Portal Embolization to Treat Bilateral Hepatic Adenomas

Perioperative impact of liver venous deprivation compared with portal venous embolization in patients undergoing right hepatectomy: preliminary results from the pioneer center.

Preoperative portal vein embolization (PVE) is currently the standard technique used routinely to increase the size of the future remnant liver (FRL) before major hepatectomies. The degree of hypertrophy (DH) is approximatively 10% and requires on average six weeks. ALPPS is faster and achieves a good DH but with a higher morbidity and mortality. One method recently proposed to increase the FRL is liver venous deprivation (LVD), but its clinical and operative impact is still unknown. The aim of this study is to compare intra- and postoperative morbidity/mortality and the histological evaluation of the liver parenchyma between PVE and LVD in patients undergoing anatomic right hepatectomy. Fifty-three consecutive patients undergoing PVE and LVD before a major hepatectomy were retrospectively analysed between 2015 and 2017. In order to reduce the bias, only potential standard right hepatectomies were selected. Surgical resections and the radiologic procedures were performed by the same Institution. Intra-operative parameters (transfusions, perfusions, bleeding, operative time), postoperative complications (Clavien-Dindo and ISGLS criteria), and histological findings were compared. To induce FRL growth 16 patients underwent PVE and 13 LVD. One patient of the PVE group was not resected due to peritoneal metastases. Surgery was performed for hepatocellular carcinoma (PVE =9, LVD =3), metastases (PVE =5, LVD =10), or others diseases (PVE =2, LVD =0). Per- and post-operative morbidity/mortality rates after PVE and LVD procedures were null. No differences between the two groups were found in terms of intraoperative bleeding (median: 550 vs. 1,200 mL; P=0.36), hepatic pedicle clamping (5 vs. 3 patients; P=0.69), intraoperative red blood cells transfusions (median: 622 vs. 594; P=0.42) and operative time (median: 270 vs. 330 min; P=0.34). Post-operative course was similar when comparing both medical and surgical complications in the two arms (PVE n=7, LVD n=10, P=0.1). Major complications (Clavien-Dindo ≥ IIIa) occurred in 3 patients undergoing PVE and in 1 patient of the LVD group (P=0.6). No difference in biliary leak (P=0.1), haemorrhage (P=0.2) and liver failure (P=0.64) was found. One cirrhotic patient in the group of PVE died of post-operative liver failure due to left portal vein thrombosis. Although we experienced a more marked liver damage when assessing on neoplastic liver parenchyma, no statistical difference was observed in terms of atrophy (P=0.19), necrosis (P=0.5), hemorrhage (P=0.42) and sinusoidal dilatation (P=0.69). Despite the limitations of our study, to our knowledge this is the first report to compare the two techniques LVD is a promising and safe procedure to induce a fast FRL hypertrophy, showing similar mortality/morbidity rates during and after surgery compared to PVE.