Preoperative portal vein embolization: is it useful?

Background/Purpose Portal vein embolization (PVE) before hepatectomy is aimed to induce an atrophy of the embolized lobe to be resected, with a compensatory hypertrophy of the counterlobe to be preserved.Methods To answer the question Is it useful?, we reviewed the clinical outcome in 161 patients undergoing major hepatectomy after PVE for various hepatobiliary tumors.Results All the patients tolerated PVE well, and hepatic functional data returned to the baseline levels within a week. The left liver volume increased by a median of 8% (range 2%–14%) after the right PVE. The 20 patients undergoing right hepatectomy for hepatocellular carcinoma had a mean indocyanine green retention rate at 15min of 16% (SD 4%), and the 24 patients with liver metastases underwent right hepatectomy with additional left liver resection. Hepatectomy procedures comprised right or extended right hepatectomy (n = 105), left or extended left hepatectomy (n = 13), hepatopancreatoduodenectomy (n = 12), and less extensive hepatectomies (n = 31). As a whole, the operative morbidity and mortality rates were 19% and 1.2%, respectively. Hepatopancreatoduodenectomy carried no operative mortality. The cumulative 5-year survival rates were 44% in patients with hepatocellular carcinoma and 60% in patients with metastatic tumor.Conclusions PVE is useful for performing extensive hepatectomy in patients with mild hepatic dysfunction, in those with bilobar tumors, or in those undergoing hepatopancreatoduodenectomy.     

Venous resection for adenocarcinoma of head of pancreas: Does extent of portal vein resection affect outcomes?

BackgroundVenous resection with pancreaticoduodenectomy (PD) increases resectability rates in patients with adenocarcinoma of head of pancreas. The effect of extent of portal vein resection on perioperative morbidity and mortality is less clear. This retrospective cohort study compares results of PD with and without venous resection and explores the influence of extent of vein resection on perioperative morbidity and mortality.MethodsTotal 96 patients underwent standard PD (PD) and 20 patients had en bloc venous resections (VR). VR group was divided into segmental (VR-S) (6/20 patients) and tangential (VR-T) (14/20 patients) groups based on segmental or tangential type of venous resections. The groups were compared for morbidity, mortality and survival.ResultsPD and VR groups had comparable perioperative morbidity (p = 0.140) and mortality (p = 0.358) with a significantly higher operative time in VR (p < 0.001). Perioperative morbidity and mortality were similar in VR-S and VR-T groups (p = 0.690 and p = 0.157 respectively). Operative time and estimated blood loss were significantly higher in VR-S group over VR-T (p = 0.019 and p = 0.002 respectively). Median survival was similar for PD and VR (15 and 15.5 moths respectively; p = 0.278) and VR-S and VR-T groups (17 and 12.5 months respectively; p = 0.550). Expected blood loss and operative time were found to be independent predictors of morbidity.ConclusionsVenous resection with PD is associated with morbidity, mortality and overall survival comparable to that after standard resection. The extent of venous resection does not seem to affect perioperative morbidity and mortality.     

Changes in portal vein flow after adult living-donor liver transplantation: Does it influence postoperative liver function?

In adult living donor liver transplantation, using small grafts in cirrhotic patients with severe portal hypertension may have unpredictable consequences. The so-called small-for-size syndrome is present in most series worldwide. The goal of this study was to prospectively evaluate the influence of hemodynamic changes on postoperative liver function and on the percentage of liver volume increase, in the setting of living donor liver transplantation. Twenty-two consecutive adult living donor liver transplantations were performed at our institution in a 2-year period. We measured right portal flow and right hepatic arterial flow with an ultrasonic flow meter in the donor, and then in the recipient 1 hour after reperfusion. Postoperative liver function was measured by daily laboratory work. We also performed duplex ultrasounds on postoperative days 1, 2, and 7. Liver volume increase was estimated by magnetic resonance imaging graft volumetry at 2 months posttransplantation. We compared the blood flow results with the immediate liver function and its liver volume increase rate at 2 months. There was a significant increase in portal flow in the recipients compared with the donors (up to fourfold in some cases). Higher portal flow increase rates significantly correlated with faster prothrombin time normalization and faster liver volume increases. Median graft volume increase at 2 months was 44.9%. The increase in blood flow to the graft is well tolerated by the liver mass not affecting hepatocellular function as long as the graft-to body weight ratio is maintained (>0.8) and adequate outflow is provided. (Liver Transpl 2003;9:564-569.)     

Absence of the left portal vein: a difficulty for reduction of liver grafts?

BACKGROUND: Absence of the portal bifurcation is exceptional and characterized by an absent extrahepatic portal vein bifurcation, the right portal vein only being at the porta hepatis. There is no extraparenchymal left portal vein. This may represent a problem in liver splitting, reduction, and living related transplantation. METHOD: A case was encountered during reduction of a cadaveric liver allograft to a left lateral segmental graft from a 40-kg cadaveric donor to a 15-kg recipient. The portal venous inflow was reconstructed with a vein graft via a novel extrahilar approach to the left portal vein at the umbilical fissure. RESULTS: This graft was used successfully in a 3-year-old child requiring transplantation for a failed Kasai operation for extrahepatic biliary atresia. The child is now well, 1 year posttransplant, after an uneventful postoperative course with good portal flow within the graft. CONCLUSION: The situation of an absent left portal vein extrahepatic course should not preclude splitting or reduction procedures. The innovative technical solution, we propose, should add to the armamentarium of the liver transplant surgeon contemplating a left lateral segmental graft for the paediatric liver transplant recipient.     

Associating liver partition and portal vein ligation (ALPPS): A two staged procedure,in Bogotá Colombia. Case report and literature review

IntroductionFor liver tumors (primary or metastases), surgery combined with neoadjuvant, or adjuvant chemotherapy is the treatment of choice, offering long term survival time and disease-free time period (Alvarez et al., 2012) Associating liver partition and portal vein ligation, or ALPPS, it's a surgical technique that increases the future liver remnant in a short period of time, trying to avoid postoperative liver failure (PLF), and achieving R0 resections in liver malignant tumors (Alvarez et al., 2012).Presentation of the caseA 43 years old woman with colorectal liver metastases in both lobes. Colorectal surgical procedure was performed 1 year previous the liver intervention, followed by adjuvant chemotherapy. Decision of a tri-segmental hepatectomy was made to resolve the metastases. Into the surgical procedure, we evaluated the liver parenchyma, and the future liver remnant tissue was insufficient, for that reason we decided to perform ALPPS procedure.DiscussionColorectal liver metastases (CLRM) are considered the most common indication for ALPPS procedure according to the international registry. Compared with the portal vein ligation, resection rate varies from 50 to 80%, and the non-resectability disease was explained by tumor progression. Postoperative mortality rate was 5.1% in young patients (<60 years old), and 8% in general for CRLM. Oncologic outcomes represent an increased disease-free survival period and overall survival time compared with non-surgical approach.ConclusionThe ALPPS procedure it's an interesting approach to patients with not enough liver remnant tissue, with good oncologic results in terms of disease-free survival time, and overall survival. Appropriate selection of the patient, careful postoperative management, and a multidisciplinary approach are related with good postoperative outcomes.     

Hobson’s choice two-stage hepatectomy for multiple and bilobar colorectal liver metastases with portal vein embolization: report of two cases

Liver resection is recognized as the preferred treatment for patients with colorectal liver metastases (CLM) because it offers long-term survival; it is the only hope for a cure. However, in the majority of cases, liver surgery is contraindicated due to the small volume of the future remnant liver. To extend the surgical indications for CLM, a planned two-stage hepatectomy procedure with portal vein embolization (PVE) was developed specifically for patients with multiple and bilobar CLM. The rationale for performing the procedure was a concern about the possible overgrowth of intrafuture remnant liver lesions following PVE, and it was therefore recommended for all multiple bilobar CLM cases, even when one-stage hepatectomy was technically feasible. We recently performed Hobson’s choice two-stage hepatectomy in two cases for reasons different from those of the original planned two-stage hepatectomy. In the present report, we describe our Hobson’s choice two-stage hepatectomy strategy, which provided favorable short-term outcomes.     

How much liver resection is too much?

BACKGROUND: Hepatic failure occurring after liver resection carries a poor prognosis and is a complication dreaded by surgeons. Inadequate reserve in the remaining parenchyma leads to a steady decrease in liver function, inability to regenerate, and progression to liver failure. For this reason, many methods to quantify functional hepatic reserve have been developed. METHODS: This article reviews the main methods used in the assessment of hepatic reserve in patients undergoing hepatectomy and their use in operative decision making. RESULTS: A range of methods to categorically quantify the functional reserve of the liver have been developed, ranging from scoring systems (such as the Child-Pugh classification) to tests assessing complex hepatic metabolic pathways to radiological methods to assess functional reserve. However, no one method has or is ever likely to emerge as a single measure with which to dictate safe limits of resectability. CONCLUSIONS: In the future, the role of residual liver function assessment may be of most benefit in the routine stratification of risk, thus enabling both patient consent to be obtained and surgical procedure to be performed, with full information and facts regarding operative risks. However, there is no one single test that remains conclusively superior.     

Is routine abdominal drainage necessary after liver resection?

Purpose

Prophylactic abdominal drainage is performed routinely after liver resection in many centers. The aim of this study was to examine the safety and validity of liver resection without abdominal drainage and to clarify whether routine abdominal drainage after liver resection is necessary.

Methods

Patients who underwent elective liver resection without bilio-enteric anastomosis between July, 2006 and June, 2012 were divided into two groups, based on whether surgery was performed before or after, we adopted the no-drain strategy. The “former group” comprised 256 patients operated on between July, 2006 and June, 2009 and the “latter group” comprised 218 patients operated between July, 2009 and June, 2012. We compared the postoperative complications, percutaneous drainage, and postoperative hospital stay between the groups, retrospectively.

Results

There were no significant differences in the rates of postoperative bleeding, intraabdominal infection, or bile leakage between the groups. Drain insertion after liver resection did not reduce the rate of percutaneous drainage. Postoperative hospital stay was significantly shorter in the latter group.

Conclusion

Routine abdominal drainage is unnecessary after liver resection without bilio-enteric anastomosis.

     

What is the real contribution of extrahepatic cells to liver regeneration?

Extrahepatic cells, especially bone marrow (BM) cells, might contribute to liver repair, but recent published evidence suggests that they do not play a role in the normally regenerating liver. The mechanism by which extrahepatic cells express a liver-specific function in the liver, whether by transdifferentiation or by cell fusion, remains unclear. In this review, we investigate the status of findings on this controversial subject and summarize the recent research.     

Laparoscopic extended liver resection: are postoperative outcomes different?

Surgical Endoscopy - Although laparoscopic major hepatectomy (LMH) is becoming increasingly common in specialized centers, data regarding laparoscopic extended major hepatectomies (LEMH) and their...     

Influence of primary disease factors on outcome after resection of colorectal liver metastases?

The outcome after resection of hepatic metastases from colorectal cancer is influenced not only by factors of metastatic lesions but also those of primary disease. To clarify whether primary disease factors are predictive of post-resection outcome of colorectal liver metastases, 180 patients (male : female = 114 : 66; 61.1 +/-10.5 yrs; synchronous: metachronous = 95 : 85; colon: rectum = 124 : 56 who underwent surgery of colorectal liver metastases in Cancer Institute Hospital from 1995 to 2005 were recruited for analysis. Post-resection outcome of the patients with colorectal liver metastases was significantly influenced by 1) depth of invasion, 2) grade of lymph node metastasis , 3) number of metastatic lymph nodes and 4) Dukes stage of primary disease. The patients with lymph node metastases further than grade 3 showed median survival time of less than 2 years and did not survive longer than 5 years. Thus such condition seemed not warrant resective treatment for liver metastases. In case of synchronous metastatic disease, primary disease information, such as lymph node metastases, depth of invasion, and Dukes stage, were significant predictive factors after hepatectomy. Meanwhile, such factors did not show significant influence in the patients with metachronous liver metastases. In conclusion, influence of primary disease factors should be considered for deciding the indication of hepatectomy for colorectal liver metastases, especially when patients have synchronous lesions.