Preoperative Preoperative Portal Vein Embolization Research Articles

Indocyanine green plasma clearance rate and 99mTc-galactosyl human serum albumin single-photon emission computed tomography evaluated preoperative remnant liver.

BACKGROUNDPreoperative evaluation of future remnant liver reserves is important for safe hepatectomy. If the remnant is small, preoperative portal vein embolization (PVE) is useful. Liver volume analysis has been the primary method of preoperative evaluation, although functional examination may be more accurate. We have used the functional evaluation liver using the indocyanine green plasma clearance rate (KICG) and 99mTc-galactosyl human serum albumin single-photon emission computed tomography (99mTc-GSA SPECT) for safe hepatectomy.AIMTo analyze the safety of our institution’s system for evaluating the remnant liver reserve.METHODSWe retrospectively reviewed the records of 23 patients who underwent preoperative PVE. Two types of remnant liver KICG were defined as follows: Anatomical volume remnant KICG (a-rem-KICG), determined as the remnant liver anatomical volume rate × KICG; and functional volume remnant KICG (f-rem-KICG), determined as the remnant liver functional volume rate based on 99mTc-GSA SPECT × KICG. If either of the remnant liver KICGs were > 0.05, a hepatectomy was performed. Perioperative factors were analyzed. We defined the marginal group as patients with a-rem-KICG of < 0.05 and a f-rem-KICG of > 0.05 and compared the postoperative outcomes between the marginal and not marginal (both a-rem-KICG and f-rem-KICG > 0.05) groups.RESULTSAll 23 patients underwent planned hepatectomies. Right hepatectomy, right trisectionectomy and left trisectionectomy were in 16, 6 and 1 cases, respectively. The mean of blood loss and operative time were 576 mL and 474 min, respectively. The increased amount of f-rem-KICG was significantly larger than that of a-rem-KICG after PVE (0.034 vs 0.012, P = 0.0273). The not marginal and marginal groups had 17 (73.9%) and 6 (26.1%) patients, respectively. The complications of Clavian-Dindo classification grade II or higher and post-hepatectomy liver failure were observed in six (26.1%) and one (grade A, 4.3%) patient, respectively. The 90-d mortality was zero. The marginal group had no significant difference in postoperative outcomes (prothrombin time/international normalised ratio, total bilirubin, complication, post-hepatectomy liver failure, hospital stay, 90-d, and mortality) compared with the not-marginal group.CONCLUSIONFunctional evaluation of the remnant liver enabled safe hepatectomy and may extend the indication for hepatectomy after PVE treatment.

Preoperative portal vein embolization: a comparison of ethanol and coils versus ethanol alone

Purpose To compare the efficacy and safety of preoperative portal vein embolization (PVE) with ethanol and coils versus ethanol alone. Material and methods Between April 2014 and May 2019, 45 patients underwent right preoperative PVE with ethanol and coils (n = 19; EthCo group) or ethanol alone (n = 26; Eth group). Results The change in % future liver remnant (FLR) was not significantly different between the EthCo and Eth groups (11.2 ± 4.3% versus 11.3 ± 4.1%, p = .98). Less ethanol was used in the EthCo group (9.7 ± 3.5 mL versus 11.9 ± 4.4 mL, p = .02). Recanalization was observed in eight patients only in the Eth group (p < .01). There were no differences in the pre-/post-PVE laboratory data between the two groups, except for post-PVE albumin. The volume of ethanol used was positively correlated with the post-PVE total bilirubin (p = .01), aspartate aminotransferase (AST) (p < .01) and alanine aminotransferase (ALT) (p < .01) levels. Conclusion The efficacy of PVE did not differ between the EthCo and Eth groups. The use of ethanol and coils was associated with less recanalization and liver damage compared with ethanol alone.

Quantitative assessment of liver function using hepatobiliary scintigraphy: the effect of microcirculatory alterations after portal vein embolization.

Hepatobiliary scintigraphy using technetium-99m mebrofenin has been validated as a quantitative liver function test. Preoperative portal vein embolization (PVE) is performed in patients to increase future remnant liver function and volume. Changes in hepatic microcirculation after PVE remain largely unknown and may influence the uptake of mebrofenin. The aim was to evaluate microcirculatory changes after PVE to examine differences in perfusion that might influence the uptake of mebrofenin, and consequently, assessment of function. Patients undergoing liver resection with or without preoperative PVE were included. Future remnant liver volume and function were measured before and after PVE. Hepatic microcirculation was measured in the embolized and the nonembolized lobes during resection. Microcirculatory flow index, perfused vessel density, sinusoidal diameter and red blood cell velocity were assessed. A total of 16 patients, eight with preoperative PVE and eight control patients without PVE, were included. After PVE, both function and volume of the nonembolized lobe were significantly increased, and the functional increase exceeded the increase in volume. Perfused vessel density and sinusoidal diameter were significantly higher in the nonembolized liver lobe (P<0.002 and <0.04). No significant differences between both lobes were found concerning microcirculatory flow index or red blood cell velocity. After PVE, the nonembolized lobe had a significantly higher (functional) microvascular density compared with the embolized lobe, without differences in microvascular flow. These findings indicate that the measured functional increase using hepatobiliary scintigraphy, which exceeded the volumetric increase, was not the consequence of an increase in hepatic perfusion, therefore, providing adequate representation of the liver function.

Safety and outcomes of pre-operative portal vein embolization using N-butyl cyanoacrylate (Glue) in hepatobiliary malignancies: A single center retrospective analysis.

Aims and Objectives:To evaluate the outcome of preoperative portal vein embolization (PVE) using N-butyl cyanoacrylate (NBCA) for change in future liver remnant (FLR) volume, biochemical changes, and procedure-related complications. The factors affecting FLR hypertrophy and the rate of resection was also evaluated for this cohort.Materials and Methods:From 2012 to 2017, PVE utilizing NBCA mixed with lipiodol (1:4) was performed using percutaneous approach in 28 patients with hepatobiliary malignancies with low FLR. All patients underwent volumetric computed tomography (CT) assessment before and at 3–5 weeks after PVE and total liver volume (TLV), FLR volume, and FLR/TLV ratio, changes in portal vein diameter and factors affecting FLR were evaluated. Complications and the resectability rate were recorded and analyzed.Result:PVE was successful in all 28 patients. The mean FLR increased by 52% ± 32% after PVE (P < 0.0001). The FLR/TLV ratio was increased by 14.2% ± 2.8% (P < 0.001). Two major complications were encountered without any impact on surgery. There was no significant change seen in liver function test and complete blood counts after PVE. Eighteen patients (64.28%) underwent hepatic resection without any liver failure, and only three patients developed major complication after surgery. Remaining ten patients did not undergo surgery because of extrahepatic metastasis detected either on follow-up imaging or staging laparotomy. Patients with diabetes showed a lower rate of hypertrophy (P < 0.05).Conclusion:Preoperative PVE with NBCA is safe and effective for increasing FLR volume in patients of all age group and even in patients with an underlying liver parenchymal disease with hepatobiliary malignancy. Lesser hypertrophy was noted in patients with diabetes. A reasonable resectability was achieved despite having a high rejection in gall bladder cancer subgroup due to rapid disease progression.

A Study of the sequential relationship between the increase of the future remnant liver volume and the functional transition after preoperative portal vein embolization

Background: Preoperative portal vein embolization (PVE) is a widely used strategy to enable major hepatectomy with insufficient liver remnant. PVE induces hypertrophy of the future remnant liver (FRL) and shift of the functional reserve to FRL. In this study, we investigated the sequential relationship between the increase of the FRL volume and the functional transition after preoperative PVE using 3D fused image of CT and 99mTc-galactosyl-human serum albumin (99mTc-GSA) single-photon emission computed tomography (SPECT). Methods: Thirteen patients who underwent major hepatectomy following PVE were enrolled. CT and 99mTc-GSA SPECT scintigraphy were performed at pre-PVE, one week and two weeks after PVE. Functional Volume (FV) of FRL was defined as total liver volume× (FRL volume counts/ total liver volume counts) of 99mTc-GSA SPECT from 3D fused image with CT. Results: The average increase rate of the volume of FRL and FV of FRL at one week after PVE were 31.7 (16.6) % and 41.2 (31.0) % (mean (SD)) respectively. Those of the volume of FRL and FV of FRL at two weeks after PVE were 43.5 (20.4) % and 52.4 (26.7) % respectively. In three of 13 cases, the FVs were especially lower than CT volumes of FRL at two weeks after PVE. One of the three cases progressed microsteatosis more than 30% by biopsy, and this steatosis improved to 10% 13 weeks after PVE. Conclusions: The functional transition lagged behind the increase of the FRL volume after PVE because of progressing steatosis.

Assessment of hepatic microvascular flow and density in patients undergoing preoperative portal vein embolization

BackgroundThe microvascular effects occurring after unilateral preoperative portal vein embolization (PVE) are poorly understood. The aim of this study was to assess the microvascular changes in the embolized and the non-embolized lobes after right PVE. MethodsVideos of the hepatic microcirculation in patients undergoing right hemihepatectomy following PVE were recorded using a handheld vital microscope (Cytocam) based on incident dark field imaging. Hepatic microcirculation was measured in the embolized and the non-embolized lobes at laparotomy, 3–6 weeks after PVE. The following microcirculatory parameters were assessed: total vessel density (TVD), microcirculatory flow index (MFI), proportion of perfused vessel (PPV), perfused vessel density (PVD), sinusoidal diameter (SinD) and the absolute red blood cell velocity (RBCv). Results16 patients after major liver resection were included, 8 with and 8 without preoperative PVE. Microvascular density parameters were higher in the non-embolized lobes when compared to the embolized lobes (TVD: 40.3 ± 8.9 vs. 26.8 ± 4.6 mm/mm2 (p < 0.003), PVD: 40.3 ± 8.8 vs. 26.7 ± 4.7 mm/mm2 (p < 0.002), SinD: 9.2 ± 1.7 vs. 6.3 ± 0.8 μm (p < 0.040)). RBCv, PPV and the MFI were not significantly different. ConclusionThe non-embolized lobe has a significantly higher microvascular density, however without differences in microvascular flow. These findings indicate increased angiogenesis in the hypertrophic lobe.

Analysis of Preoperative Portal Vein Embolization Outcomes in Patients with Hepatocellular Carcinoma: A Single-Center Experience

PurposeTo analyze outcomes of patients with hepatocellular carcinoma (HCC) undergoing preoperative portal vein embolization (PVE). Materials and MethodsA retrospective analysis of survival, recurrence, and complications was performed in 82 patients with HCC undergoing preoperative PVE and surgical treatment with curative intention from June 2006 to December 2014. ResultsRate of major adverse events after PVE was 11% with no mortality. Twenty-eight (34.1%) patients showed radiologic progression of HCC after PVE; 72 patients (87.8%) eventually were accepted as surgical candidates. Median interval between PVE and surgery was 37 days, and 69 patients (84.1%) ultimately underwent surgical resection. At 1 and 3 years, disease-free survival rates were 81.3% and 53.1%, respectively, and overall patient survival rates were 77.5% and 63.1%. Compared with patients accepted as surgical candidates, patients who did not undergo surgery had a higher median number of HCC tumors (1 [range, 1–5] vs 2 [range, 1–4], P = .031). At 1 and 3 years, patients with disease progression after PVE but who still underwent surgical resection showed similar recurrence-free (90% vs 79.6% and 75% vs 48.6%) and overall (72.2% vs 78.4% and 57.8% vs 64%) survival rates as the rest of the patients who underwent resection. ConclusionsPVE is a safe technique with good outcomes that potentially increases the number of patients with initially unresectable HCC who can be offered resection. Radiologic progression after PVE should not be seen as a contraindication to offer resection if it is still deemed possible.

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

Preoperative portal vein embolization with a combination of trisacryl microspheres, gelfoam and coils

To evaluate the safety and efficiency of preoperative portal vein embolization (PVE) with a combination of trisacryl microspheres, gelfoam and coils for inducing lobar hypertrophy in hepatobiliary malignancy patients. PVE was performed by a percutaneous left approach in 63 patients with hepatic malignancy (hepatocarcinoma=38, colorectal metastasis=14, cholangiocarcinoma=11). The indication of PVE and surgery was evaluated by hepatic tumor board take into consideration to the tumor extension and the hepatic volume on initial and post-embolization CT-scans. The total functional liver volume (TELV) and future liver remnant (FLR) volume were measured before and 24±5days after PVE to assess FLR, TELV and FLR/TELV ratios. Efficiency evaluation was based on FLR increase, the ability to perform the hepatectomy and the hepatic function after surgery. Safety evaluation was determined by clinical and biological follow-up after embolization and surgery. PVE was successful in all the patients. The mean FLR volume increases by 57±56% after embolization (449±180cm(3) to 663±254cm(3)) (P<0.0001). The FLR/TELV ratio increases by 11% after PVE (25±8% to 36±12%). Three minors' complications were registered without impact on surgery, and four patients developed portal hypertension. Forty-nine patients underwent hepatectomy; none of them developed liver failure. Surgery was not performed in 14 patients due to tumor progression (n=9), inadequate hypertrophy of FLR (n=1) and portal hypertension (n=4). Preoperative PVE with a combination of trisacryl microspheres, gelfoam and coils is a safe and effective method for inducing contralateral hypertrophy before right hepatectomy in patients with advanced hepatobiliary malignancy.

Mo2032 Small Cell Carcinoma of the Ampulla of Vater

[Background/Aim] An extensive hepatic resection is required in cases of malignant hepatic and biliary tract tumor. The prognosis is influenced by a shortage of functional capacity of the remnant liver. Since preoperative portal vein embolization (PVE) was first reported, this technique has become widely used in such cases. However, the indication for PVE and its outcome are unclear. In the present study, we retrospectively analyzed preoperative PVE patients. [Patients] From January 2002 to December 2011, 58 patients underwent preoperative PVE at our institute. In this study, we analyzed 46 patients (29 cases of hilar bile duct cancer [no liver damage group] and 17 colorectal liver metastatic tumor cases after chemotherapy [liver damage group]). In cases of hilar bile duct cancer or colorectal hepatic metastasis, we compared the resection rate and prognosis of these patients before and after PVE introduction. [Results] Two of 46 patients had complications caused by preoperative PVE (minimal bleeding into the biliary tract). Four cases in the group without liver damage (13.8%) could not undergo hepatectomy (3 cases, progressive disease; 1 case, no hypertrophy of the remnant liver). Five cases in the liver damage group (29.4%) could not undergo hepatectomy (1 case, severe steatohepatitis; 4 cases, no hypertrophy of the remnant liver). The median rates of hypertrophy of the remnant liver in the group without liver damage and the liver damage group were 9.4% and 7.5%, respectively (no statistical difference). The median maximum total bilirubin levels after hepatectomy in the group without liver damage and the liver damage group were 4.3 and 1.9 mg/dL, respectively (no statistical difference). In cases of hilar bile duct cancer and colorectal hepatic metastasis, the resection rate and the prognosis improved significantly after PVE introduction (resection rate: 56.7% vs. 90.2% and 30.0% vs. 58.2%, respectively; 3-year survival rate: 35.2% vs. 70.2% and 35.2% vs. 45.2%, respectively). [Conclusion] In the present study, no statistical difference was noted between the liver damage group and the group without liver damage in the rate of hypertrophy of the remnant liver after PVE and postoperative complications. However, the incidence of unresectability because of lack of hypertrophy of the remnant liver was higher in the liver damage group than in the group without liver damage. Thus, we believe that PVE has potential benefits for hilar bile duct cancer patients and colorectal liver metastasis patients because of the associated improved resection rate and prognosis.

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.

Preoperative Portal Vein Embolization: An Approach to Improve the Safety of Major Hepatic Resection

Surgery has therefore become a mainstay in the treatment of both primary and metastatic liver lesions. Unfortunately, despite these advances, extended resections yielding small volume liver remnants continue to pose risks resulting from decreased functional liver capacity, both in patients with underlying hepatic disease and in those with otherwise-healthy livers. 3,4 Preoperative portal vein embolization (PVE) has thereby emerged as a significant adjunct to major hepatic resection (more than 3 Couinaud segments), allowing for an increased volume of the future liver remnant (FLR) and resultant improved outcomes in patients with small anticipated residual liver volume. 5-10 Embolization of the portal branches in the liver to be resected results in diversion of portal bloodflow to the nonembolized segments. This rerouted portal blood, rich in hepatotropic substances, stimulates hypertrophy of the liver parenchyma. 11 PVE thus increases the mass of FLR before surgery, and in the proper patient setting, may permit safe, potentially curative resection in patients who would otherwise not be surgical candidates because of their risk of postoperative liver failure.12 The benefits of preoperative PVE are not limited to increased size of the liver remnant; however, the greater number of hepatocytes does allow improved synthetic function and avert cholestasis. Embolization of the portal vein before hepatic resection also diminishes the otherwise-abrupt increase in portal venous pressure after resection that can lead to hepatocellular injury. In addition, PVE dissociates any damage caused by increased portal pressures from the direct trauma inflicted upon the FLR during resection. 13

Foam Sclerotherapy Using Polidocanol (Aethoxysklerol) for Preoperative Portal Vein Embolization in 16 Patients

To evaluate the clinical safety and effectiveness of foam sclerotherapy using polidocanol for preoperative portal vein embolization (PVE) before hemihepatectomy of the liver. From March 2006 to October 2008, foam sclerotherapy using polidocanol was performed in 16 patients (male-to-female ratio of 12:4, age range 48-75 years [mean 62]) for PVE. Patients were diagnosed with Klatskin tumor (n = 13), gallbladder (GB) cancer (n = 2), or hepatocellular carcinoma (HCC) (n = 1). The foam was composed of a 1:2:1 ratio of 3% polidocanol (Aethoxysklerol; Kreussler Pharma, Wiesbaden, Germany), room air, and contrast media (Xenetix 350; Guerbet, Aulnay-Sous-Bois, France). The total amount of polidocanol used (2 to 8 mL [mean 4.6]) varied according to the volume of the target portal vein. We calculated the volume of future liver remnant (FLR) before and after PVE and evaluated complications associated with the use of polidocanol foam sclerotherapy for PVE. Technical success was achieved in all patients. All patients were comfortable throughout the procedure and did not experience pain during sclerotherapy. No periprocedural morbidity or mortality occurred. Patients underwent a liver dynamic computed tomography (CT) scan 2-4 weeks after PVE. FLR increased significantly after PVE using polidocanol foam from 19.3% (range 16-35%) before PVE to 27.8% (range 23-42%) after PVE (p = 0.001). All patients were operable for hemihepatectomy of the liver and achieved effective resection. Foam sclerotherapy using polidocanol is clinically safe and effective for preoperative PVE.

Percutaneous preoperative portal vein embolization using a combination of gelatin sponge and histoacryl glue

Inadequate remnant liver volume is a major cause of postoperative liver failure. Preoperative portal vein embolization (PVE) is used clinically to prevent postoperative liver insufficiency. To evaluate the efficacy and safety of preoperative portal vein embolization, by using a combination of gelatin sponge and histoacryl to induce hypertrophy of future liver remnant (FLR) in patients with a hepatobiliary malignancy. PVE using a combination of gelatin sponge and histoacryl glue was performed in 11 patients (nine men, two women; mean age 60 years, range 46-70 years). These patients were diagnosed with a hepatobiliary malignancy before surgery and their FLR volumes were judged as insufficient to allow for safe resection (FLR <25% in patients with a normal liver or FLR <40% in patients with a chronic liver disease). Liver volume changes, levels of biochemical markers, complications related to PVE, and postoperative complications were retrospectively evaluated. PVE was successful in all patients, and there were no procedural complications. The enlargement of nonembolized liver lobe was 30% (mean 118 cm3). A planned hepatectomy was cancelled in four patients due to the presence of a late-detected extrahepatic metastasis. Seven of the 11 patients underwent hepatectomy without complications. Preoperative PVE with a combination of gelatin sponge and histoacryl glue is a safe and effective procedure to induce hypertrophy of nonembolized parts of the liver.

Three hundred and one consecutive extended right hepatectomies: evaluation of outcome based on systematic liver volumetry.

This study aimed to determine the effect of preoperative liver volumetry on postoperative outcomes after extended right hepatectomy. Primary end point was to evaluate whether future liver remnant (FLR)/standardized liver volume ratio (sFLR) >20% is sufficient for a safe hepatic resection. Secondary end point was to assess whether preoperative portal vein embolization (PVE) is associated with improved outcome in patients with initial sFLR ≤ 20%. An sFLR >20% of the total liver volume has been proposed as sufficient for safe hepatic resection, but this concept has not been validated in a large series. In addition, recent reports suggest preoperative PVE is indicated for sFLR <30%. The impact of sFLR and PVE on short-term outcomes (postoperative complications, liver insufficiency, and 90-day mortality) was analyzed in 301 consecutive patients after extended right hepatectomy. Liver volumetry accounted for partial resection of segment IV. Liver insufficiency was defined as peak postoperative serum bilirubin >7 mg/dL. Predictors of liver insufficiency were identified by multivariate logistic regression. Postoperative liver insufficiency occurred in 45 patients (15%) and accounted for 61% of deaths. Among 290 patients who underwent liver volumetry, sFLR was <20% in 38 patients, 20.1% to 30% in 144, and ≥ 30% in 108. Rates of postoperative liver insufficiency and death from liver failure were similar between patients with sFLR 20.1% to 30% and sFLR ≥ 30% but higher in patients with sFLR ≤ 20% (P 0.05). Postoperative outcomes were similar between patients with increase in sFLR from ≤ 20% to >20% after PVE and patients with initial sFLR >20%. Multivariate analysis revealed that body mass index >25 kg/m2, intraoperative blood transfusion, and sFLR ≤ 20% (odds ratio = 3.18; 95% CI, 1.34-7.54) independently predicted postoperative liver insufficiency. Systematic measurement of FLR volume is important to select patients for PVE and extended right hepatectomy. A sFLR >20% is sufficient for safe hepatic resection and sFLR 20.1% to 30% is not an indication for preoperative PVE.

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.

Induction of Tumor Growth After Preoperative Portal Vein Embolization: Is It a Real Problem?

Although preoperative portal vein embolization (PVE) is an effective means to increase future remnant liver (FRL) volume, little has been published on possible adverse effects. This review discusses the clinical and experimental evidence regarding the effect of PVE on tumor growth in both embolized and nonembolized liver lobes, as well as potential strategies to control tumor progression after PVE. A literature review was performed using MEDLINE with keywords related to experimental and clinical studies concerning PVE, portal vein ligation (PVL), and tumor growth. Cross-references and references from reviews were also checked. Clinical and experimental data suggest that tumor progression can occur after preoperative PVE in embolized and nonembolized liver segments. Clinical evidence indicating possible tumor progression in patients with colorectal metastases or with primary liver tumors is based on studies with small sample size. Although multiple studies demonstrated tumor progression, evidence concerning a direct increase in tumor growth rate as a result of PVE is circumstantial. Three possible mechanisms influencing tumor growth after PVE can be recognized, namely changes in cytokines or growth factors, alteration in hepatic blood supply and an enhanced cellular host response promoting local tumor growth after PVE. Post-PVE chemotherapy and sequential transcatheter arterial chemoembolization (TACE) before PVE have been proposed to reduce tumor mass after PVE. We conclude that tumor progression can occur after PVE in patients with colorectal metastases as well as in patients with primary liver tumors. However, further research is needed in order to rate this risk of tumor progression after 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.

Portal vein embolization before major hepatectomy

To discuss the rationale, techniques and the unsolved issues regarding preoperative portal vein embolization (PVE) before major hepatectomy. After a systematic search of Pubmed, we reviewed and retrieved literature related to PVE. Preoperative PVE is an approach that is gaining increasing acceptance in the preoperative treatment of selected patients prior to major hepatic resection. Induction of selective hypertrophy of the nondiseased portion of the liver with PVE in patients with either primary or secondary hepatobiliary, malignancy with small estimated future liver remnants (FLR) may result in fewer complications and shorter hospital stays following resection. Additionally, PVE performed in patients initially considered unsuitable for resection due to lack of sufficient remaining normal parenchyma may add to the pool of candidates for surgical treatment. The results suggest that PVE is recommendable in treating the cirrhotic patients before major liver resection.