Preoperative Percutaneous Transhepatic Portal Vein Research Articles

Chylothorax after hepatectomy: a case report

BackgroundChylothorax is the accumulation of chyle within the pleural space. Chylothorax can occur as a complication after multiple different types of surgery, most frequently after thoracic surgery, albeit with an incidence rate of less than 1%. Chylothorax after abdominal surgery is extremely rare, and there are only a few case reports.Case presentationA 74-year-old Japanese woman presented with jaundice. She was diagnosed as having hilar cholangiocarcinoma and underwent right hepatectomy, caudate lobectomy, extrahepatic bile duct resection, and lymph node dissection after preoperative percutaneous transhepatic portal vein embolization. Postoperative liver function was normal. She developed chylous ascites on postoperative day 5, for which conservative treatment was initially effective. Dyspnea developed suddenly on postoperative day 42, and she had a massive right pleural effusion and a small amount of ascites. Management with pleural drainage, total parenteral nutrition, and octreotide injections decreased the chylothorax. However, the chylous effusion reaccumulated on postoperative day 57. As conservative treatments ultimately failed, lymphangiography was performed on postoperative day 62. Lymphangiography with Lipiodol (ethiodized oil) revealed extravasation into the pleural space, but the location of the leak was not identified. There was neither obstruction nor dilation of the thoracic duct. A lymphatic leak in her abdominal cavity was not demonstrated. A chest tube was placed after lymphangiography, and the chylothorax was diminished by postoperative day 71. She was discharged on postoperative day 72. Two and a half years after surgery, she is doing well with no evidence of recurrence of either chylothorax or cancer.ConclusionsChylothorax can occur after hepatectomy and pleural effusion should raise suspicion for chylothorax. Lymphangiography may be effective for both diagnosis and treatment in the case of chylothorax after hepatectomy.

Abstract No. 645 Preoperative percutaneous transhepatic portal vein embolization in biliary malignancy: hepatic hypertrophy and posthepatectomy liver failure

Abstract No. 645 Preoperative percutaneous transhepatic portal vein embolization in biliary malignancy: hepatic hypertrophy and posthepatectomy liver failure

Assessment of percutaneous transhepatic portal vein embolization with portal vein stenting for perihilar cholangiocarcinoma with severe portal vein stenosis.

The aim of the present study was to assess the clinical efficiency of portal vein (PV) stenting when performed with preoperative percutaneous transhepatic portal vein embolization (PTPVE) in patients with severe PV stenosis due to tumor invasion. Between 2007 and 2013, four consecutive patients (one male, three females; mean age, 52 years; age range, 25-73 years) with perihilar cholangiocarcinoma and PV stenosis underwent PTPVE and PV stenting. Patients were analyzed with regard to the procedure, hypertrophy of the future remnant liver (FRL), and plasma clearance rate of indocyanine green by the FRL (ICGK-F). Further, the %FRL volume increase in PTPVE was compared between the stenting group and the usual PTPVE group who have perihilar cholangiocarcinomas without PV stenosis. Preoperative PTPVE with PV stenting was successfully performed and portal flow to the FRL improved after stenting in all four patients. The %FRL volume increase was 18-60% (mean, 34%) in the stenting group and was 12-51% (mean, 21%) in the usual PTPVE group. The ICGK-F value after PTPVE exceeded 0.05 in all four patients. All patients achieved R0 resection. Preoperative PTPVE with PV stenting appears to be feasible in cases of severe PV tumor invasion and stenosis. This procedure may allow a broader indication for surgery.

Preoperative Percutaneous Transhepatic Portal Vein Embolization With Ethanol Injection

The purpose of this article is to evaluate the feasibility and efficacy of preoperative percutaneous transhepatic portal vein embolization with ethanol injection. We retrospectively evaluated 143 patients who underwent percutaneous transhepatic portal vein embolization. Hypertrophy of the future liver remnant was assessed by comparing the volumetric data obtained from CT image data before and after percutaneous transhepatic portal vein embolization. The evaluation of effectiveness was based on changes in the absolute volume of the future liver remnant and the ratio of the future liver remnant to the total estimated liver volume. Ten of 143 patients (7.0%) underwent additional embolization because of recanalization and insufficient hypertrophy of the future liver remnant. The mean increase in the ratio of the future liver remnant was 33.6% (p < 0.0001), and the mean ratio of future liver remnant to total estimated liver volume increased from 34.9% to 45.7% (p < 0.0001). Although most of the patients complained of pain after ethanol injection, they were gradually relieved of pain in a few minutes by conservative treatment. Fever (38-39°C) was reported after 47 of 151 (31.1%) percutaneous transhepatic portal vein embolization sessions and was resolved within a few days. Transient elevation of the liver transaminases was observed after the procedures and resolved within about a week. Major complications occurred in nine of 151 (6%) percutaneous transhepatic portal vein embolization sessions, but no patients developed hepatic insufficiency or severe complications precluding successful resection. One hundred twenty patients underwent hepatic resection, and two patients developed hepatic failure after surgery. Preoperative percutaneous transhepatic portal vein embolization with ethanol is a feasible and effective procedure to obtain hypertrophy of the future liver remnant for preventing hepatic failure after hepatectomy.

Preoperative estimation of remnant hepatic function using fusion images obtained by 99mTc-labelled galactosyl-human serum albumin liver scintigraphy and computed tomography

Assessment of hepatic functional reserve is important in hepatic resection. The aim of this study was to evaluate the role of hepatic asialoglycoprotein receptor (ASGP-R) analysis in the preoperative estimation of remnant liver function in liver surgery. One hundred and one patients undergoing hepatic resection for liver tumours were studied. Seventeen patients had preoperative percutaneous transhepatic portal vein embolization (PTPE). Function of the hepatic remnant was estimated before surgery using radioactivity in fusion images of both liver single-photon emission computed tomography and computed tomography scans using (99m)Tc-labelled diethylene triamine penta-acetate-galactosyl-human serum albumin. All three patients with an ASGP-R concentration below 400 nmol/l and preoperative total amount of receptor in the future remnant liver (R0-remnant) of less than 53.0 nmol per liver died. Two patients with chronic hepatitis and R0-remnant values between 53.0 and 65.0 nmol per liver and a receptor concentration lower than 600 nmol/l developed liver dysfunction. The incidence of liver failure decreased inversely with increasing R0-remnant value. A combination of receptor concentration and the amount of hepatic receptor in the future liver remnant as detected on fusion images is useful in evaluating the risk of postoperative liver failure.

Evaluation of the Effect of Portal Vein Embolization on Liver Function by 99mTc-Galactosyl Human Serum Albumin Scintigraphy

Background. Preoperative percutaneous transhepatic portal vein embolization (PTPE) increases the safety of liver resection and improves the outcome after surgery for hepatocellular carcinoma. Scintigraphy with 99mTc-galactosyl human serum albumin (GSA) causes specific binding to viable hepatocytes and serves as an index of liver function. Materials and methods. 99mTc-GSA scintigraphy was performed before and 2 weeks after PTPE of the right portal vein in 16 patients. The total receptor index, reflecting overall liver function, right receptor index (right lobe), and left receptor index (left lobe) were calculated. Results. After PTPE, the proportion of the volume of the nonembolized lobe (left lobe) increased ( P = 0.0002). The total receptor index slightly decreased after PTPE ( P = 0.090), the right receptor index decreased ( P < 0.0001), and the left receptor index increased ( P < 0.0001). The average increase rate in the left receptor index was 30% of the pre-PTPE value. In 2 patients with portal hypertension (≥30 cm H 2O) after PTPE, the left receptor index did not change. In 4 patients whose left receptor index after PTPE (including the 2 patients with portal hypertension) was <0.35, right lobectomy was not performed. Conclusions. 99mTc-GSA scintigraphy demonstrated that PTPE induces a shift in hepatic function from the embolized part to the nonembolized part of the liver. PTPE of the right portal vein increases the hepatic functional reserve of the left lobe as well as its volume. The changes in 99mTc-GSA uptake following PTPE may predict the response to liver resection.

Preoperative percutaneous transhepatic portal embolization with absolute ethanol in patients with hepatocellular carcinoma

Preoperative percutaneous transhepatic portal vein embolization (PTPE) has been used in recent years to decrease the amount of liver resected and to reduce the risk of postoperative liver failure in patients with hepatocellular carcinoma. Various thrombogenic agents have been employed for this purpose. We evaluated the clinical safety and efficacy of absolute ethanol for PTPE and examined the histopathologic changes that follow ethanol embolization of the liver. We studied nine patients with hepatocellular carcinoma who were not originally regarded as surgical candidates because of a high risk of postoperative liver failure. They received preoperative PTPE of the right portal vein, with an average of 22.8 ml of absolute ethanol. The right lobe showed complete obstruction of portal venous branches and massive necrosis of the liver parenchyma. Macroscopically, there was atrophy of the embolized lobes and compensatory hypertrophy of the remaining lobes. The mean volume of the nonembolized lobe increased, from 351 to 585 and 633 ml, 2 and 4 weeks after embolization, respectively. The mean regeneration rate of this lobe was 16.7 cm3/day for the first 2 weeks after embolization and 10.1 cm3/day for the first 4 weeks. Transient dynamic increases in alanine aminotransferase concentrations were seen. All patients subsequently underwent right lobectomy of the liver and survived without severe complications. Portal vein embolization with absolute ethanol makes more extensive hepatectomy possible by reducing the volume necessary to resect, and it preserves the function of the remaining liver.

Preoperative management of hilar cholangiocarcinoma

From both the therapeutic and diagnostic viewpoints, percutaneous transhepatic biliary drainage (PTBD) is crucial for the preoperative management of hilar cholangiocarcinoma. The direct anterior approach under fluoroscopic guidance is the most advantageous form of PTBD. Despite some advantages, endoscopic retrograde biliary drainage is contraindicated for preoperative biliary decompression. Pertinent multiple catheterizations using PTBD result in an accurate diagnosis of cancer extent, and produce effective relief of jaundice, as well as preventing the development of cholangitis. This, in turn, permits a rational surgical strategy and improved postoperative recovery. Preoperative staging of hilar cholangiocarcinoma is achieved by tube cholangiography through the PTBD catheter and by percutaneous transhepatic cholangioscopy. Angiography and percutaneous transhepatic portography are also recommended to diagneous extramural invasion of cancer. Prevention of posthepatectomy liver failure is the greatest challenge in the treatment of this disease. A multifactorial approach that combines several elements may provide sufficient data for determing the safe limits of surgery and for predicting posthepatectomy liver failure. Preoperative percutaneous transhepatic portal vein embolization (PTPE) is an effective method for preventing this intractable complication.