Efficacy of preoperative portal vein embolization prior to major hepatectomy for patients with impaired liver function: A retrospective study

Hepatocellular carcinoma (HCC) is often associated with chronic liver disease, such as hepatitis or cirrhosis, and this association may limit the use of surgery as a therapy, and if surgery is pursued, may give rise to postoperative hepatic failure. We evaluated the outcome in patients with HCC given preoperative portal vein embolization (PVE) before they underwent major hepatectomy. After PVE, portal pressure increased significantly. Two weeks after PVE, both the volume of the non-embolized lobe and the 15-min indocyamine green retention rate (ICG R15) were significantly increased. The prognostic score, calculated on the basis of age, ICG R15, and the resection rate, was significantly decreased. The operative mortality rate was significantly lower in patients who underwent PVE before surgery than in patients who did not receive PVE. The cumulative survival rate of the PVE patients, even those with cirrhosis of the liver, was significantly higher. Prior PVE appears to allow more extensive major hepatectomy and to lessen the risk of this invasive surgery. However, patients in whom the portal pressure immediately after PVE was more than 30cm H₂O and/or whose prognostic score exceeded 50 points developed postoperative hepatic failure. These features should be kept in mind when it is decided whether surgery is indicated. Nevertheless, preoperative PVE appears to be a beneficial procedure for patients undergoing major hepatectomy, particularly those with chronic liver disease.     

Portal vein embolization vs. portal vein ligation for induction of hypertrophy of the future liver remnant

The objective of this study was to assess the efficacy of right portal vein embolization (PVE) vs. right portal vein ligation (PVL) for induction of hypertrophy of the left lateral liver lobe before extended right hepatectomy. Thirty-four patients with primary or secondary liver tumors and estimated remnant functional liver parenchyma of less than 0.5% of body weight underwent either right PVE (transcutaneous, n= 10; transileocolic, n =7) or right PVL (n=17). Liver volume was assessed by CT scan before occlusion of the right portal vein and prior to resection. There were no deaths. The morbidity rate in each group was 5.8% (PVE, 1 abscess; PVL, 1 bile leak). The increase in liver volume was significantly higher after PVE compared with PVL (188±81 ml vs. 123±58 ml) (P= 0.012). Postoperative hospital stay was significantly shorter after PVE in comparison to PVL (4±2.9 days vs. 8.1±5.1 days;P<0.01). Curative liver resection was performed in 10 of 17 patients after PVE and 11 of 17 patients after PVL. PVE and PVL were found to be feasible and safe methods of increasing the remnant functional liver volume and achieving resectability for extended liver tumors. PVE results in a significantly more efficient increase in liver volume and a shorter hospital stay. Presented at the Forty-Third Annual Meeting of The Society for Surgery of the Alimentary Tract, San Francisco, California, May 19–22, 2002 (oral presentation).     

Preoperative transhepatic portal vein embolization for impaired residual hepatic function in patients with obstructive jaundice

Fifty patients with obstructive jaundice with biliary tract carcinoma who underwent percutaneous transhepatic portal vein embolization (PTPE) were studied to evaluate the clinical utility of PTPE in preparation for extensive liver resection. PTPE was performed 2–3 weeks before surgery, via the standard contralateral approach in the first seven patients and via the ipsilateral approach, devised by the authors, in the last 43 patients. The following portal branches in which embolization was planned were all successfully embolized: the right portal vein in 35 patients; the right portal vein plus the left medial portal branch in 6; the left portal vein and the right anterior portal branch in 3; the left portal vein in 2; the right anterior portal branch in 3; and the right posterior portal branch in 1. There were no procedure-related complications. Helical computed tomography demonstrated compensatory hypertrophy of the non-embolized segments. After PTPE, 35 of the 50 subjects underwent major hepatectomy with or without portal vein resection and/or pancreatoduodenectomy; the remaining 15 were found to have peritoneal dissemination or liver metastasis, and no resection was performed. Of the 35 hepatectomized patients, 3 died of posthepatectomy liver failure, and 1 patient died of pneumonia with pulmonary lymphangitis carcinomatosis; the other 31 patients were discharged in good condition. The hospital death rate was 11.8% (4/35), and mortality directly related to the surgery was 8.6% (3/35). PTPE appears to have the potential to increase the safety of extensive liver resection for patients with obstructive jaundice.     

门静脉栓塞术在肝脏肿瘤二期切除中的应用

目的 探讨门静脉栓塞术在肝脏肿瘤二期切除过程中的作用与安全性。方法 分析总结5例难以一期切除肝脏肿瘤,先行门静脉栓塞术后再行二期肿瘤切除患者的临床资料。所有患者均采用B超及DSA引导下经皮肝门静脉左支穿刺法对门静脉右支进行栓塞。检测门静脉栓塞术后肝功能及肝叶体积变化,总结门静脉栓塞与肿瘤二期切除手术成功率。结果 5例患者均成功实施PVE术,术后出现一过性的肝功能减退,经保肝治疗短期恢复,未栓塞侧肝脏体积代偿性增大明显,达到预期效果;所有病例均顺利完成二期肝叶切除术,术后肝功能良好。结论 门静脉栓塞术成功率高、安全可行,对侧肝脏代偿性增大明显,达到预期目的,使得难以一期切除的肝脏肿瘤可以切除,从而提高肝脏肿瘤的切除率。     

Associating liver partition and portal vein ligation for staged hepatectomy versus sequential transarterial chemoembolization and portal vein embolization in staged hepatectomy for HBV-related hepatocellular carcinoma: a randomized comparative study

BackgroundBoth portal vein embolization (PVE) and associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) have merits and demerits when used in patients with unresectable liver cancers due to insufficient volumes in future liver remnant (FLR).MethodsThis study was a single-center, prospective randomized comparative study. Patients with the diagnosis of hepatitis B related hepatocellular carcinoma (HCC) were randomly assigned in a 1:1 ratio to the 2 groups. The primary endpoints were tumor resection and three-year overall survival (OS) rates.ResultsBetween November 2014 to June 2016, 76 patients with unresectable HBV-related HCC due to inadequate volume of FLR were randomly assigned to ALPPS groups (n=38) and TACE + PVE groups (n=38). Thirty-seven patients (97.4%) in the ALPPS group compared with 25 patients (65.8%) in the TACE + PVE group were able to undergo staged hepatectomy (risk ratio 1.48, 95% CI: 1.17–1.87, P<0.001). The three-year OS rate of the ALPPS group (65.8%) (95% CI: 50.7–80.9) was significantly better than the TACE + PVE group (42.1%) (95% CI: 26.4–57.8) (HR 0.50, 95% CI: 0.26–0.98, two-sided P=0.036). However, no significant difference in the OS rates between patients who underwent tumor resection in the 2 groups of patients was found (HR 0.80, 95% CI: 0.35–1.83, two-sided P=0.595). Major postoperative complications rates after the stage-2 hepatectomy were 54.1% in the ALPPS group and 20.0% in the TACE + PVE group (risk ratio 2.70, 95% CI: 1.17–6.25, P=0.007).ConclusionsALPPS resulted in significantly better intermediate-term OS outcomes, at the expenses of a significantly higher perioperative morbidity rate compared with TACE + PVE in patients who had initially unresectable HBV-related HCC.     

Functional transition: Inconsistently parallel to the increase in future liver remnant volume after preoperative portal vein embolization

BACKGROUNDPreoperative portal vein embolization (PVE) is a widely used strategy to enable major hepatectomy in patients with insufficient liver remnant. PVE induces hypertrophy of the future liver remnant (FLR) and a shift of the functional reserve to the FLR. However, whether the increase of the FLR volume (FLRV) corresponds to the functional transition after PVE remains unclear.AIMTo investigate the sequential relationship between the increase in FLRV and functional transition after preoperative PVE using 3-dimensional (3D) computed tomography (CT) and ^99mTc-galactosyl-human serum albumin (^99mTc-GSA) single-photon emission computed tomography (SPECT) fusion images. METHODSThirty-three patients who underwent major hepatectomy following PVE at the Department of Gastroenterological Surgery I, Hokkaido University Hospital between October 2013 and March 2018 were enrolled. Three-phase dynamic multidetector CT and ^99mTc-GSA SPECT scintigraphy were performed at pre-PVE, and at 1 and 2 wk after PVE; 3D ^99mTc-GSA SPECT CT-fused images were constructed from the Digital Imaging and Communications in Medicine data using 3D image analysis system. Functional FLRV (FFLRV) was defined as the total liver volume × (FLR volume counts/total liver volume counts) on the 3D ^99mTc-GSA SPECT CT-fused images. The calculated FFLRV was compared with FLRV.RESULTSFFLRV increased by a significantly larger extent than FLRV at 1 and 2 wk after PVE (P < 0.01). The increase in FFLRV and FLRV was 55.1% ± 41.6% and 26.7% ± 17.8% (P < 0.001), respectively, at 1 wk after PVE, and 64.2% ± 33.3% and 36.8% ± 18.9% (P < 0.001), respectively, at 2 wk after PVE. In 3 of the 33 patients, FFLRV levels decreased below FLRV at 2 wk. One of the three patients showed rapidly progressive fatty changes in FLR. The biopsy at 4 wk after PVE showed macro- and micro-vesicular steatosis of more than 40%, which improved to 10%. Radical resection was performed at 13 wk after PVE. The patient recovered uneventfully without any symptoms of pos-toperative liver failure.CONCLUSIONThe functional transition lagged behind the increase in FLRV after PVE in some cases. Evaluating both volume and function is needed to determine the optimal timing of hepatectomy after PVE.     

Morphological and functional changes after portal vein occlusion in rats

We investigated morphological and functional changes after portal vein occlusion in rats. Portal branches for the median and left lateral lobes were ligated, after which the lobes were examined micromorphologically. After embolization of the same branches, regenerative capacity was evaluated in normal livers and in livers with CCl₄-induced cirrhosis. Indocyanine green elimination, antithrombin III activity, and Kupffer cell density were also investigated. In another set of rats, the embolized lobes were resected 0, 2, 4, or 7 days after portal vein embolization (PVE), and endotoxin was injected intravenously 48h after each hepatectomy. In the ligated lobes, apoptotic hepatocytes were detected mainly around a widespread necrotic area on day 2, and among normal hepatocytes on day 7. In the nonembolized livers of control rats, increases were noted in liver weight, ornithine decarboxylase (ODC) activity, DNA synthesis, and mitosis of hepatocytes. In the cirrhotic livers, ODC activity was stimulated in a fashion similar to that seen in control liver, but DNA synthesis and weight change was delayed, although not significantly. On days 2, 4, 7, and 14 PVE, Kupffer cell density was about twice that seen in rats before PVE. Endotoxin-induced liver injury was slight if the rats had received PVE 4-7 days before the hepatectomy.     

超声引导下选择性门静脉栓塞在肝癌二期切除中的应用

目的　探讨超声引导下经皮经肝细针穿刺术前选择性门静脉栓塞 (POSPVE)后对不宜手术切除的肝细胞性肝癌 (HCC)二期切除的可能性。　方法　 32例不宜手术切除的HCC患者行超声引导下经皮经肝细针穿刺POSPVE ,观察手术成功率及术后不良反应、各肝叶体积及预计肝切除率的动态变化、二期手术切除率等指标。　结果　手术成功 30例 (93.8% ) ,右侧门静脉支栓塞后右肝体积逐步减少 ,左肝体积逐步增大 ,术前、术后 1w、2w、3w时的预计肝切除率分别为 6 6 .6 %、6 5 .5 %、6 2 .9%、6 0 6 %。术后 2 6例出现不同程度的肝区隐痛 (2 6例 )、低热 (19例 )、恶心呕吐 (7例 )。有程度不同的肝功能减退 ,AST由术前 (44 .6± 5 .3)IU/L ,至术后 1d (5 6 .2± 7.6 )IU/L ,术后 3d (5 1.4± 5 .5 )IU/L ;ALT由术前(5 8.4± 7.4 )IU/L ,至术后 1d (6 2 .8± 9.6 )IU/L ,术后 3d (6 0 .2± 8.5 )IU/L ;TBIL由术前 (14 .6± 5 .3) μmol/L至术后 1d (19.1± 8.6 ) μmol/L ,术后 3d (17.4± 7.7) μmol/L ;PT由术前 (82 .6± 6 .3) % ,至术后 1d (78.6±8.2 ) % ,术后 3d (75 .3± 6 .4 ) %。术后 2w - 4w ,14例 (43.8% )完成了肝癌二期肝切除手术。　结论　超声引导下经皮经肝细针穿刺POSPVE简便易行 ,可扩大肝癌肝切除手术     

经皮微波或射频消融肝实质分隔联合门静脉栓塞计划性肝切除术治疗余肝体积不足肝癌及胆管癌3例报告

目的 探讨经皮微波或射频消融肝实质分隔联合门静脉栓塞计划性肝切除术（percutaneous microwave/radiofrequency ablation liver partition and portal vein embolization for planned hepatectomy,PAPEP）替代联合肝脏分隔和门静脉结扎的二步肝切除术（associating liver partition and portal vein ligation for staged hepatectomy, ALPPS）治疗剩余肝体积（future liver remnant,FLR）不足肝癌和胆管癌的可行性和安全性。方法 回顾性分析2015年7-9月浙江省人民医院肝胆胰外科应用PAPEP治疗FLR不足的2例原发性肝癌和1例肝门部胆管癌的临床资料。先超声引导下经皮微波消融分隔预留侧和切除侧肝实质（percutaneous microwave ablation liver partition,PMA）,PMA后1~3 d行门静脉栓塞术（portal vein embolization,PVE）,PVE后10~13 d测量FLR,术前系统评估后限期肝切除术：2例肝癌分别行肝右三叶和右尾叶切除术、扩大右半肝切除术,1例肝门部胆管癌行肝右三叶和尾叶切除、肝肠内引流术。结果 PMA前3例标准全肝体积（standard liver volume,SLV）分别为1231.2mL、1202.9mL、1217.1mL,FLR分别为355.6 mL、383.4 mL、385.0 mL,FLR/SLV分别为28.9%、31.9%、31.6%。PMA时间118~132 min, PVE时间158~180 min,PMA或PVE术后病人低热经对症处理好转,肝功能无明显变化。PMA+PVE后10~13 d FLR分别为502.1 mL、527.4 mL、476.3 mL,较术前分别增大41.2%、37.6%、23.7%。肝切除术时间230~440 min,术中出血120~1800 mL。肝门部胆管癌术后并发膈下脓肿,经穿刺后治愈;1例肝癌术后并发腹水、黄疸,经内科治疗后治愈,术后住院时间15~40 d。 结论 PAPEP有望代替ALPPS治疗剩余肝体积不足的肝癌或肝门部胆管癌。     

Arguments for a selective approach of preoperative portal vein embolization before major hepatic resection

Preoperative PVE can induce hypertrophy of the future liver remnant volume resulting in a decrease of surgical risk after major hepatic resection. However, the number of patients with normal liver at risk is small and there is no arguments for inducing hypertrophy before standard right hepatectomy. Therefore, in patients with normal liver PVE is indicated in patients in whom very extended liver resection or associated major gastro-intestinal surgery is planned. In patients with chronic liver disease and in those with injuried liver (chemotherapy, major steatosis, cholestasis), PVE is indicated before major liver resection.     

先天性门静脉部分缺如伴肝脏重塑

先天性门静脉缺如是临床上十分罕见的门静脉先天性胚胎发育异常,由于该疾病缺乏特征性临床表现,容易造成误诊、漏诊。2013年2月宁波市第一医院收治了1例先天性门静脉部分缺如伴肝脏重塑患者,总结其增强CT检查表现,探讨影像学检查对该疾病的诊断价值,以提高临床医师对该疾病的认识。     

Chemotherapy does not impair hypertrophy of the left liver after right portal vein obstruction

In patients with multiple colorectal liver metastases, the technical limits of curative surgery can be overcome by both reducing tumor volume with preoperative chemotherapy and by increasing the future remnant liver with portal vein embolization. Chemotherapy is generally discontinued before the embolization because it is alleged to impair hypertrophy of the future remnant liver. We have tested this assumption by comparing two groups of patients who had undergone right portal vein obstruction: 10 patients in whom chemotherapy was maintained until surgery and 10 patients in whom it was interrupted at least 1 month prior to portal obstruction. The two groups, with and without chemotherapy, were comparable for patient’s age (60 ± 9 versus 61 ± 9 years), number of metastases (7.7 ± 3 versus 6.2 ± 3), and future remnant liver volume (25 ± 9% versus 23 ± 5% of the total liver). After right portal vein obstruction, the increase of the future remnant liver was comparable in the two groups (33 ± 26% versus 25 ± 7%). Liver resection was performed in 14 patients (7 in each group) with a similar morbidity rate (57% in each group). In conclusion, continuing chemotherapy while portal vein obstruction is performed did not impair the hypertrophy of the future remnant volume nor the postoperative course after liver resection. Therefore, chemotherapy can be safely continued until liver surgery, when portal vein obstruction is indicated.     

Evaluation of the effect of portal vein embolization on liver function by (99m)tc-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 (99m)Tc-galactosyl human serum albumin (GSA) causes specific binding to viable hepatocytes and serves as an index of liver function. MATERIALS AND METHODS: (99m)Tc-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 (> or =30 cm H(2)O) 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: (99m)Tc-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 (99m)Tc-GSA uptake following PTPE may predict the response to liver resection.     

肝门部胆管癌术前门静脉栓塞的血流动力学与肝再生的关系

目的 研究肝门部胆管癌术前门静脉栓塞(PVE)前后血流动力学的变化,并分析其与非栓塞肝叶增生速度的关系.方法 回顾性分析2008年4月至2009年12月第二军医大学东方肝胆外科医院收治的21例肝门部胆管癌患者的临床资料.在手术治疗前进行钢圈PVE治疗,在该治疗前和治疗后第3、7、14天采用彩色多普勒超声对门静脉的血流动...     

Risk factors of posthepatectomy liver failure after portal vein embolization

Background/Purpose. Major hepatectomy has been successfully performed after portal vein embolization (PE). However, posthepatectomy liver failure following hyperbilirubinemia (HB) sometimes occurs even after PE. Our objective was to determine what factors affected post-hepatectomy HB and liver failure. Methods. Forty-two patients underwent PE before major hepatectomy or repeat hepatic resection after partial hepatectomy. Having a prognostic score over 40, they all belonged to a high-risk group. They were classified into two groups according to posthepatectomy levels of total bilirubin: normal group and HB group. The HB group was further divided into two subgroups: recovered subgroup and fatal subgroup. We investigated the differences between the two groups and the two subgroups. Results. Ten of 14 cases (71%) in the HB group were biliary tract disease with jaundice before PE. The indocyanine green retention rate (ICGR15) before PE, skeletonization of the hepatoduodenal ligament (HDL), and portal venous pressure after PE were significantly different between the two groups as shown by multivariate analysis. Postoperative complication was the only factor significantly different between the two subgroups by univariate analysis. Conclusions. When the patients underwent major hepatectomy combined with skeletonization of the HDL for biliary tract disease with jaundice, they were subject to posthepatectomy HB even after PE. If they had postoperative complications, fatal hepatic failure must have occurred.     

原发性肝癌切除术后门静脉血栓相关性肝坏死的临床分析

目的 探讨原发性肝癌切除术后门静脉血栓相关性肝坏死的临床表现及诊疗方法 .方法 回顾性分析上海东方肝胆外科医院2018年11月至2019年10月8例原发性肝癌切除术后门静脉血栓相关性肝坏死患者的临床资料,包括患者的人口统计学特征、临床表现、手术方式、实验室检查及影像学检查结果 、临床诊疗及预后等.结果 原发性肝癌切除术...