Preoperative Portal Vein Embolization Group Research Articles

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.

Preoperative Left Portal Vein Embolization for Left Liver Resection in High-Risk Hepatobiliary Malignancy Patients.

Preoperative portal vein embolization (PVE) is performed for right liver (RL) and sometimes left liver (LL) resection to prevent postoperative surgical complications. We retrospectively reviewed 10 patients who underwent preoperative left PVE before LL resection for hepatobiliary malignancies along with 3 propensity score-matched control groups (n=40 each). Mean patient age was 68.6±6.9years. Diagnoses included intrahepatic cholangiocarcinoma (n=4), perihilar cholangiocarcinoma (n=3), neuroendocrine carcinoma (n=1), recurrent cholangiocarcinoma (n=1), and inflammatory liver mass (n=1). The reason for left PVE was a large LL>40% of the total liver volume (TLV) with a major comorbidity or age>70years with a poor overall condition. All patients underwent preplanned operations, including LL resection at 1-3weeks post PVE. The LL volume proportion of the TLV was 44.9±1.7 and 40.7±2.3% before and after PVE; thus, 1-2weeks post PVE, the kinetic shrinkage rate of the LL was 9.4±3.3%, and the kinetic growth rate of the RL was 7.6±2.7%. The overall surgical complication rates were 40, 50, and 39.2% in the left PVE, large LL control, and all three control groups, respectively (p≥0.727). In contrast, the adjusted rates of major complications were 0% in the left PVE group versus 36.8% (p=0.040), 25.6% (p=0.123), and 15.8% (p=0.295) in the large-, medium-, and small-sized LL control groups, respectively. Our experience indicates that left PVE is safe and induces atrophy of the LL effectively. We suggest that it can be a useful option to reduce the risk of postoperative complications in elderly high-risk patients.

Clinical effectiveness of preoperative portal vein embolization in the treatment of colorectal cancer liver metastases:a meta-analysis

Objective To investigate the clinical effectiveness of preoperative portal vein embolization(PVE) in the treatment of colorectal cancer liver metastases(CRLM). Methods All eligible casecontrol studies comparing the clinical effectiveness of preoperative PVE or without PVE before hepatectomy were searched out from Pub Med, EMBASE and CBM database.Data on the rate of postoperative complications, liver failure and mortality and the 5-year overall survival rate were metaanalyzed. Results A total of 8 studies comprising 676 patients were included, including 253 patients in the PVE group and 423 patients in the no PVE group.The rate of postoperative complications was higher in the PVE group than in the no PVE group, and there were no significant differences in the rate of postoperative liver failure and mortality and the 5-year overall survival rate between the two groups. Conclusion Patients with unresectable liver metastases because of insufficient future liver remnant and high risk of surgery could get a chance of relative safe resection, and the long-term results were comparable to the patients with initially resectable liver metastases which didn't need PVE. Key words: Colorectal liver metastases; Portal vein embolization; Future liver remnant; Hepatectomy; Prognosis

Predictors of Posthepatectomy Ascites with or without Previous Portal Vein Embolization

Aim: To identify predictors of postoperative ascites after liver resection for patients with or without preoperative portal vein embolization (PVE). Methods: Patients undergoing PVE prior to hepatectomy (PVE group; n = 37) were compared with patients who underwent liver resection without PVE (n = 503). Ascites was defined as postoperative daily drainage of clear ascitic fluid exceeding 200 ml/day. Pre-, intra-, and postoperative variables were retrospectively analyzed using uni- and multivariate analyses. Results: Postoperative ascites was present in 13.5% (5/37) of patients who underwent PVE before hepatectomy, compared to 5.8% (29/503) in the group undergoing liver resection without PVE (p = 0.061). In all patients, cirrhosis (OR 54.505, p < 0.001), operation time (OR 1.004, p = 0.014), and the use of the Pringle maneuver (OR 2.336, p = 0.041) were independent risk predictors for ascites in multivariate analysis. In PVE patients, cirrhosis (OR 0.156, p < 0.001) was the only independent significant predictor of ascites after resection. In patients undergoing liver resection without PVE, independent risk factors with multivariate analysis were operation time (OR 1.005, = 0.001) and cirrhosis (OR 26.609, p < 0.001). Conclusion: Operation time and the use of the Pringle maneuver were significant predictors of ascites after hepatectomy. Cirrhosis was a significant risk factor associated with postoperative ascites.

Preoperative portal vein embolization (PVE) for patients with hepatocellular carcinoma can improve resectability and may improve disease‐free survival

The aim of this study is to identify the efficacy of portal vein embolization (PVE) before right hepatectomy in patients with hepatocellular carcinoma (HCC) with regard to hepatic function, surgical stress, and survival benefit. Fifty-five patients with HCC underwent right hepatectomy between 1999 and 2009. Preoperative PVE was performed in 19 patients (PVE group) and was not applied in 36 patients (non-PVE group). Changes in liver function and volume were investigated in PVE group. Short and long clinical outcomes after the surgeries were compared between the two groups. The percentage of future liver remnant (%FLR) before PVE was significantly lower (37.8%) in PVE group than in non-PVE group (58.1%) but increased remarkably after PVE (from 37.8% to 55.0%, P < 0.0001). Cumulative disease-free survival and overall survival rates in PVE group were significantly superior to those in non-PVE group (P = 0.010 and 0.049, respectively). Although surgical stress estimated by E-PASS scores and CRP value was not different between the groups, the postoperative value of PT on postoperative day 3 in PVE group was significantly better than in non-PVE group. Preoperative PVE improves resectability and may improve disease-free survival for patients with HCC requiring right hepatectomy.

Major hepatic resection for hepatocellular carcinoma with or without portal vein embolization: Perioperative outcome and survival

Preoperative portal vein embolization (PVE) is performed to minimize perioperative risks of major hepatic resection for hepatocellular carcinoma (HCC), but its effects on tumor growth are ill defined. Perioperative outcome and survival after major hepatic resection for HCC, with and without PVE, were investigated. Patients that underwent major hepatic resection (> or =3 segments) for HCC between January 1998 and May 2007 were analyzed retrospectively. Preoperative PVE was performed when the remnant liver volume was predicted to be insufficient. A total of 54 patients underwent major hepatic resection for HCC: 21 patients with PVE before resection (PVE group) and 33 patients without PVE (non-PVE group). PVE and non-PVE groups had similar rates of fibrosis or cirrhosis, hepatitis C virus, hepatitis B virus, American Joint Committee on Cancer stage, preoperative transarterial chemoembolization, overall postoperative complications, and positive margin (P = nonsignificant for all rates). There were no perioperative deaths in the PVE group and 6 (18%) deaths in the non-PVE group (P = .038). Median follow-up was 21 months. Excluding perioperative deaths, overall survival rates at 1, 3, and 5 years were 94%, 82%, and 72%, respectively, in the PVE group and 93%, 63%, and 54%, respectively, in the non-PVE group (P = .35). Similarly, disease-free survival (DFS) rates were not significantly different between the groups, with 1-, 3-, and 5-year DFS rates of 84%, 56%, and 56%, respectively, in the PVE group and 66%, 49%, and 49%, respectively, in the non-PVE group (P = .38). PVE before major hepatic resection for HCC is associated with improved perioperative outcome. Excluding perioperative mortality, overall survival and DFS rates were similar between patients with and without preoperative PVE.

The efficacy of preoperative portal vein embolization for extended hepatectomy: a meta-analysis

To investigate the clinical value of preoperative portal vein embolization (PVE) for extended hepatectomy. A comprehensive Pubmed, Medline and Ovid database search to identify all registered literature on portal vein embolization. Meta-analysis was performed to assess the result of PVE. A total of 9 literatures provided data sufficiently enough for analysis involving in 494 patients. The results showed that postoperative liver failure was higher in the non-PVE group than the PVE group, but there was no difference in postoperative mortality between the PVE and non-PVE group; in sub-category analysis of hepatocellular carcinoma and liver metastasis of colorectal cancer, there was no difference in postoperative 1, 3 and 5-year survival rate between the PVE group and non-PVE group; 1 literature about liver metastasis of colorectal cancer show there was significant difference in postoperative metastasis between the PVE and non-PVE group; several patients after PVE didn't performed hepatectomy due to disease progress. PVE is a safe and effective procedure to prevent postresection liver failure due to insufficient liver remnant, but surgeon should be cautious to choose the patient for PVE.

Preoperative Portal Vein Embolization and Surgical Resection in Patients with Hepatocellular Carcinoma and Small Future Liver Remnant Volume: Comparison with Transarterial Chemoembolization

Preoperative portal vein embolization (PVE) increases the future liver remnant (FLR) volume, thus enabling surgical resection in patients with small FLR volume. It is unclear, however, if this approach can enhance survival in patients with hepatocellular carcinoma (HCC). We therefore compared the outcomes of preoperative PVE and surgical resection with transarterial chemoembolization (TACE). Changes in FLR volumes were analyzed in 32 HCC patients who underwent preoperative PVE and surgical resection. Long-term outcomes were compared with 64 TACE-treated patients matched for gender, Child-Turcotte-Pugh class, tumor size and number, serum alpha-fetoprotein levels, and UICC stage. In the PVE group, the baseline ratio of FLR/total estimated liver volumes (TELV) was 27.6 +/- 7.2%. Following PVE, FLR volume increased 34% (336.5 vs 449.4 mL, P < .001) and the ratio of FLR/TELV increased from 27.6 +/- 7.2 to 36.9 +/- 8.1% (P < .001). There was no mortality associated with PVE or surgical resection. The 5-year survival rate was significantly higher in the PVE group than in the TACE group (71.9% vs 45.6%, P = .03). Multivariate analysis showed that treatment modality was an independent predictive factor for survival (odds ratio 2.05, 95% confidence interval 1.01-4.16, P = .046). Preoperative PVE enables surgical resection in HCC patients with small FLR volume and improves patient survival compared with TACE.

Increased Safety by Two-Stage Hepatectomy with Preoperative Portal Vein Embolization in Rats

We evaluated the usefulness of preoperative portal vein embolization (PVE) in rats for increasing the safety of liver resection. During PVE, portal vein branches that perfused the central and left lobes of the liver were embolized. Liver weight, the elimination of indocyanine green, and the number of Kupffer cells were examined 7 days after PVE and in intact rats. Then we examined rats that had undergone PVE (PVE group), rats in which the embolized part of the liver was resected 7 days after PVE (PVE-Hx group), rats without PVE in which the same lobes of the liver were resected (Hx group), and rats that had undergone a sham operation (sham-operation group) for liver weight, the mitotic index of the hepatocytes, serum alanine aminotransferase activity, total bilirubin, and antithrombin III activity. Some rats in the four groups received an intravenous injection of 0.5 or 2.5 mg/kg endotoxin 48 hr after the operation (the second operation, if done), and the 24-hr survival rate was calculated. Some rats given 0.5 mg/kg endotoxin were killed 6 hr after the injection, and the extent of liver injury was examined biochemically and histologically. Seven days after PVE, the nonembolized part of the liver was about twice the weight of the corresponding lobes in the intact rats, the density of Kupffer cells was doubled, and the hepatic function per unit weight was about the same as that in these controls. Hepatic dysfunction and the endotoxin-induced liver injury were significantly slighter in the PVE and PVE-Hx groups than in the Hx group. Preoperative PVE could make hepatectomy safer.