Right Portal Vein Ligation is as Efficient as Portal Vein Embolization to Induce Hypertrophy of the Left Liver Remnant

Background Aim of this retrospective study was to compare induction of left liver hypertrophy after right portal vein ligation (PVL) and right portal vein embolization (PVE) before right hepatectomy for liver metastases. Materials and Methods Between 1998 and 2005, 18 patients underwent a PVE, whereas 17 patients underwent a PVL during a first stage laparotomy. Results There was no complication related to PVE or PVL. After a similar interval time (7 ± 3 vs 8 ± 3 weeks), the increase of the left liver volume was similar between the two groups (35 ± 38 vs 38 ± 26%). After PVE and PVL, right hepatectomy was performed in 12 and 14 patients, respectively. Technical difficulties during the right hepatectomy were similar according to duration of procedure (6.4 ± 1 vs 6.7 ± 1 h, p = 0.7) and transfusion rates (33 vs 28%, p = 0.7). Mortality was nil in both groups, and morbidity rates were respectively 58% for the PVE group and 36% for the PVL group (p = 0.6). Conclusion Right PVL and PVE result in a comparable hypertrophy of the left liver. During the first laparotomy of a two-step liver resection, PVL can be efficiently and safely performed.     

Laparoscopic Right Hepatectomy Extended to Middle Hepatic Vein After Right Portal Vein Embolization

Background

Laparoscopic right hepatectomy (LRH) is a complex but feasible procedure. Preoperative portal vein embolization (PVE) can add difficulties that warrant particular technical modifications. A LRH extended to middle hepatic vein after PVE is presented, with special attention paid to specific operative findings and to useful technical modifications.

Methods

A 62-year-old female patient with a body mass index of 30.5 kg/m² was diagnosed with a 3-cm unresectable centrally located intrahepatic cholangiocarcinoma with infiltration of the retrohepatic vena cava, segment VII portal branch, and adjacent to the middle hepatic vein and portal bifurcation. After four cycles of GEMOX, partial response was observed, disappearing vascular infiltration. PVE was required to perform an extended LRH. Consequently, during pedicle dissection, significant inflammation was found in the vicinity of the right portal vein. Thus, the section of the portal and biliary elements was delayed until the transection of the parenchyma reached the hilum. The opening of the parenchyma improved exposure, allowing the safe management of these structures individually.

Results

The total operative time was 438 min. Three periods of 15-min pedicle occlusion resulted in <100 ml bleeding. Hospital stay was 4 days. Pathological examination revealed residual cholangiocarcinoma with intense posttreatment changes (pT1) and tumor-free margins. After an 18-month follow-up, the patient was alive and free of disease.

Conclusions

LRH is feasible and safe, even after PVE. Nevertheless, periportal inflammation can hinder hilar dissection. In this setting, delaying section of portal and biliary elements until parenchymal transection reaches the hilar region may result in a useful and safe strategy.     

Predictive Factors for Hypertrophy of the Future Remnant Liver After Selective Portal Vein Embolization

Background  

To analyze predictive factors of hypertrophy of the nonembolized future remnant liver (FRL) after transhepatic preoperative portal vein embolization (PVE) of the liver to be resected.     

Portal Vein Embolization Using a Histoacryl/Lipiodol Mixture before Right Liver Resection

Purpose: The purpose of this retrospective study was to evaluate the efficacy and safety of percutaneous transhepatic portal vein embolization (PVE) of the right liver lobe using Histoacryl/Lipiodol mixture to induce contralateral liver hypertrophy before right-sided (or extended right-sided) hepatectomy in patients with primarily unresectable liver tumors. Methods: Twenty-one patients (9 females and 12 males) underwent PVE due to an insufficient future liver remnant; 17 showed liver metastases and 4 suffered from biliary cancer. Imaging was performed prior to and 4 weeks after PVE. Surgery was scheduled for 1 week after a CT or MRI control. The primary study end point was technical success, defined as complete angiographical occlusion of the portal vein. The secondary study end point was evaluation of liver hypertrophy by CT and MRI volumetry and transfer to operability. Results: In all the patients, PVE could be performed with a Histoacryl/Lipiodol mixture (n = 20) or a Histoacryl/Lipiodol mixture with microcoils (n = 1). No procedure-related complications occurred. The volume of the left liver lobe increased significantly (p < 0.0001) by 28% from a mean of 549 ml to 709 ml. Eighteen of twenty-one patients (85.7%) could be transferred to surgery, and the intended resection could be performed as planned in 13/18 (72.3%) patients. Conclusion: Preoperative right-sided PVE using a Histoacryl/Lipiodol mixture is a safe technique and achieves a sufficient hypertrophy of the future liver remnant in the left liver lobe.     

Increase in the Serum Bile Acid Level Predicts the Effective Hypertrophy of the Nonembolized Hepatic Lobe After Right Portal Vein Embolization

Background  The purpose of the present study was to investigate the clinical association between serum bile acid level changes and liver hypertrophy in portal vein embolization (PVE). Methods  In 31 patients, the serum total bile acid level was prospectively measured before and 1, 3, 5, 7, and 14 days after right PVE. Computed tomographic volumetry was performed before and 25.0 ± 3.6 days after PVE. Results  Portal vein embolization induced the liver hypertrophy with a median increase in the left lobe volume (ILV) of 165 cm³ and a median percentage ILV (%ILV) of 29%. Compared with the pretreatment level, the serum bile acid levels significantly increased on day 3 and day 14 after PVE (p = 0.017 and p = 0.003, respectively). In patients with greater hypertrophy after PVE (ILV > 165 cm³ and %ILV > 30%), the increases in the bile acid level on day 3 were larger than that in those with lesser hypertrophy (p = 0.008 and p = 0.002, respectively). The increase on day 3 positively correlated with the ILV and %ILV (p = 0.003 and p = 0.004, respectively). The serum bile acid levels on day 3, 5, and 7 after PVE increased in patients with %ILV > 30% but not in those with %ILV ≤ 30%. Conclusions  Portal vein embolization increases the serum bile acid level in patients with effective liver hypertrophy in the nonembolized lobe. The increase on day 3 is a useful predictor of effective hypertrophy of the nonembolized lobe. Thus, bile acid signaling may be important for liver regeneration post-PVE.     

Volumetric and Functional Recovery of the Remnant Liver After Major Liver Resection with Prior Portal Vein Embolization

Introduction  Portal vein embolization is an accepted method to increase the future remnant liver preoperatively. The aim of this study was to assess the effect of preoperative portal vein embolization on liver volume and function 3 months after major liver resection. Materials and methods  This is a retrospective case-control study. Data were collected of patients who underwent portal vein embolization prior to (extended) right hemihepatectomy and of control patients who underwent the same type of resection without prior portal vein embolization. Liver volumes were measured by computed tomography volumetry before portal vein embolization, before liver resection, and 3 months after liver resection. Liver function was assessed by hepatobiliary scintigraphy before and 3 months after liver resection. Results  Ten patients were included in the embolization group and 13 in the control group. Groups were comparable for gender, age, and number of patients with a compromised liver. The mean future remnant liver volume was 33.0 ± 8.0% prior to portal vein embolization in the embolization group and 45.6 ± 9.1% in the control group (p < 0.01). Prior to surgery, there were no significant differences in future remnant liver volume and function between the groups. Three months postoperatively, the mean remnant liver volume was 81.9 ± 8.9% of the initial total liver volume in the embolization group and 79.4 ± 11.0% in the control group (p > 0.05). Remnant liver function increased up to 88.1 ± 17.4% and 83.3 ± 14% respectively of the original total liver function (p > 0.05). Conclusion  Preoperative portal vein embolization does not negatively influence postoperative liver regeneration assessed 3 months after major liver resection. No grant support. Paper presented at the SSAT, Chicago, June 1, 2009.     

Percentage of Future Liver Remnant Volume Before Portal Vein Embolization Influences the Degree of Liver Regeneration After Hepatectomy

Background

Clinical determinants of liver regeneration induced by portal vein embolization (PVE) and hepatectomy remain unclear. The aims of this study were to investigate how liver regeneration occurs after PVE followed by hepatectomy and to determine which factors strongly promote liver regeneration.

Methods

Thirty-six patients who underwent both preoperative PVE and major hepatectomy were enrolled in this study. Percentage of future liver remnant volume before PVE (%FLR-pre) was compared with the remnant liver volume after PVE (%FLR-post-PVE) and on postoperative day 7 after hepatic resection (%FLR-post-HR). Clinical indicators contributing to liver regeneration induced by both PVE and hepatectomy were examined by logistic regression analysis.

Results

PVE and hepatectomy caused a two-step regeneration. FLR-pre, FLR-post-PVE, and FLR-post-HR were 448, 579, and 761 cm³, respectively. The %FLR-pre was significantly associated with liver regeneration induced by both PVE and hepatectomy (r?=?0.63, p?<?0.0001). Multiple regression analysis showed that only %FLR-pre was independently correlated with posthepatectomy liver regeneration (p?=?0.027, odds ratio?=?13.8).

Conclusion

After PVE and the subsequent hepatectomy, liver regeneration was accomplished in a two-step manner. Liver regeneration was strongly influenced by the %FLR-pre.     

Impact of Biomarkers Expression Before and After Portal Vein Embolization on Recurrence After Two-Stage Hepatectomy for Colorectal Liver Metastases

Background  

The adverse oncological effect of portal vein embolization (PVE) in patients with colorectal liver metastases (CLM) remains controversial. This study was designed to evaluate the effect of PVE on change of tumor characteristics using tumor specimens obtained from sequential hepatectomy before and after PVE.     

Colorectal Liver Metastases Growth in the Embolized and Non-Embolized Liver After Portal Vein Embolization: Influence of Initial Response to Induction Chemotherapy

Purpose

To compare tumor progression in both embolized and non-embolized liver lobes after portal vein embolization (PVE) in patients with bilobar colorectal liver metastases (CLM), according to the initial response to induction chemotherapy.

Methods

From 2002 to 2012, a total of 42 consecutive patients with bilobar CLM initially treated using induction chemotherapy underwent right PVE to achieve adequate future liver remnant volume. Tumoral and liver parenchyma volumes, as well as their volume variations, were measured on computed tomography before and after PVE in both embolized and non-embolized. Patients were classified as fast (≤6 cycles of induction chemotherapy) and slow (>6 cycles) responders.

Results

Overall, 432 metastases were analyzed in 42 patients. Patients were slow responders in 29 (69 %) cases. Tumoral volume increased in 29 (69 %) cases in the embolized liver (+48 %; p < 0.0001), and in 28 (66 %) cases in the non-embolized liver (+31 %; p < 0.0001). Fast responders had a tumoral volume decrease in both embolized (?4 %) and non-embolized (?9 %) lobes. On the opposite side, slow responders had tumoral volume increase in both embolized (+79 %) and non-embolized (+32 %) lobes. On multivariate analysis, a ‘slow’ response to induction chemotherapy was the only factor associated with tumoral progression in both embolized (p = 0.0012) and non-embolized (p = 0.001) lobes.

Conclusion

Tumor growth after PVE is observed in both embolized and non-embolized liver lobes in most patients but is significantly associated with slow response to induction chemotherapy.     

One-Stage Hepatectomy Following Portal Vein Embolization for Colorectal Liver Metastasis

Background

Although portal vein embolization (PVE) has been applied for surgical resection of colorectal liver metastases (CLM), the clinical usefulness of liver surgery following PVE for CLM remains unknown.

Methods

A total of 115 patients were evaluated retrospectively. Among them, 49 underwent one-stage hepatectomy following PVE (PVE group). The remaining 66 patients underwent at least hemihepatectomy without PVE (non-PVE group). This analysis compared the short- and long-term outcomes between the PVE and non-PVE groups.

Results

There were no deaths in either group. Using the Clavien–Dindo classification, the rates of postoperative morbidity ≥ grade 1 were 34.7 % in the PVE group and 25.0 % in the non-PVE group (p = 0.26). The 3-year overall survival rates were 54.6 and 64.5 % in the PVE and non-PVE groups, respectively (p = 0.89). The multivariate analysis the variable performance/nonperformance of PVE was not detected as an independent predictor of poor survival.

Conclusions

Our one-stage hepatectomy policy of using PVE provides acceptable morbidity and favorable long-term outcomes.     

Chemotherapy With Bevacizumab Does Not Affect Liver Regeneration After Portal Vein Embolization in the Treatment of Colorectal Liver Metastases

Background  Blockage of vascular endothelial growth factor (VEGF) in murine models has been shown to impair liver regeneration after partial hepatectomy. The aim of this study was to evaluate the effects of chemotherapy with or without bevacizumab (monoclonal antibody anti-VEGF) on liver regeneration after portal vein embolization (PVE) in the treatment of colorectal liver metastases and its possible effect on postoperative outcome after major liver resection. Methods  Records of 65 consecutive patients treated with or without preoperative chemotherapy (with or without bevacizumab) and PVE for colorectal liver metastases from September 1995 to February 2007 were reviewed from a prospective database. Future liver remnant (FLR) volume, degree of FLR hypertrophy after PVE, morbidity, mortality, and survival were analyzed. Results  Preoperative PVE was performed after chemotherapy in 43 patients and without chemotherapy in 22 patients. Among the 43 patients treated with chemotherapy, 26 received concurrent bevacizumab. After a median of 4 weeks after PVE, there was no difference in FLR volume increase among patients treated with or without chemotherapy. Similarly, there was no statistically significant difference in degree of FLR hypertrophy among patients treated without (mean, 10.1%) or with chemotherapy, with or without bevacizumab (8.8% and 6.8%) (P = .11). Forty-eight (74%) of 65 patients underwent extended right or right hepatectomy after PVE. No differences in morbidity and mortality were observed among patients treated with or without preoperative chemotherapy (with or without bevacizumab). Conclusion  Preoperative chemotherapy with bevacizumab does not impair liver regeneration after PVE. Liver resection can be performed safely in patients treated with bevacizumab before PVE. Presented at The Society of Surgical Oncology, 61st Annual Cancer Symposium, Chicago, IL, March 13–16, 2008.     

A Nomogram to Predict Major Complications After Hip and Knee Arthroplasty

We aimed to develop a nomogram for risk stratification of major postoperative complications in hip and knee arthroplasty based on preoperative and intraoperative variables, and assessed whether this tool would have better predictive performance compared to the Surgical Apgar Score (SAS). Logistic regression analysis was performed to develop a nomogram. Discrimination and calibration were assessed. Net reclassification improvement (NRI) was used to compare to the SAS. All variables were found to be statistically significant predictors of post-operative complications except race and lowest heart rate. The concordance index was 0.76 with good calibration. Compared to the SAS, the NRI was 71.5% overall. We developed a clinical prediction tool, the Morbidity and Mortality Acute Predictor for arthroplasty (arthro-MAP) that might be useful for postoperative risk stratification.     

A Nomogram to Predict Disease-Free Survival After Surgical Resection of GIST

Background

Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors of the gastrointestinal tract. Adjuvant imatinib therapy has resulted in improved disease-free survival (DFS) following resection of primary GIST. The aim of our study was to create a nomogram to predict DFS following resection of GIST.

Method

Using a multi-institutional cohort of patients who underwent surgery for primary GIST at 7 academic hospitals in the USA and Canada between January 1998 and December 2012, a multivariable Cox proportional hazards model predicting DFS was created using backward stepwise selection. A nomogram to predict DFS following surgical resection of GIST was constructed with the variables selected in the multivariable model. We tested nomogram discrimination by calculating the C-statistic and compared the nomogram to four existing GIST prognostic stratification systems.

Results

A total of 365 patients who underwent surgery for primary GIST was included in the study. Using backward stepwise selection, sex, tumor size, tumor site, and mitotic rate were selected for incorporation into the nomogram. The nomogram demonstrated superior discrimination compared to the NIH criteria, modified NIH criteria, and Memorial Sloan-Kettering Nomogram and had similar discrimination to the Miettinen criteria (C-statistic 0.77 vs 0.73, 0.71, 0.71, and 0.78, respectively).

Conclusion

Four independent predictors of recurrence following surgery for primary GIST were used to create a nomogram to predict DFS. The nomogram stratified patients into prognostic groups and performed well on internal validation.     

Liver Transplantation After Acute Portal Vein Thrombosis: Case Report

BackgroundPortal vein thrombosis is a relatively frequent complication in patients with liver cirrhosis. Its detection and management are essential to avoid worsening portal hypertension or liver function complications. This complication can also negatively impact or even preclude liver transplant.Case presentationWe report the case of a patient who presented with acute portal vein thrombosis, which allowed the diagnosis of liver cirrhosis and hepatocarcinoma within the Milan criteria. Chemical thrombolysis was performed with a mechanical aspiration of the thrombus, and in a second moment, the patient was submitted to a liver transplant.ConclusionsAdvances in the therapeutic approach to portal vein thrombosis and surgical techniques have allowed the condition to no longer be an absolute contraindication to liver transplantation. Diagnosis in the acute phase is associated with greater therapeutic success, aiming to avoid the extension of thrombosis and achieve portal vein recanalization.     

Intrahepatic Segmental Portal Vein Thrombosis After Living-Related Donor Liver Transplantation

Background

Intrahepatic segmental portal vein thrombosis after living-related liver transplantation (LRLT) is uncommon. The cause remains unclear.

Methods

After providing written informed consent, 25 recipients receiving LRLT at our institution from January 2011 to September 2013 were enrolled in this study. We performed triphase computerized tomographic (CT) study of the liver graft of each recipient 1 month after LRLT. The patencies of hepatic artery, portal vein, and hepatic vein were evaluated in detail. The triphase CT scans of the liver of each donor before transplantation also were reviewed. Thrombosis of the intrahepatic segmental portal vein was defined as the occlusion site of the portal vein being intrahepatic. Extrahepatic portal vein thrombosis was excluded in this study.

Results

Among the 25 patients, 2 (8%) developed thrombosis of intrahepatic segmental portal vein. One 47-year-old man received LRLT for hepatitis B viral infection–related liver cirrhosis (Child-Pugh class C) with 3 hepatocellular carcinomas (total tumor volume <8 cm). Another 53-year-old man received LRLT for alcoholic liver cirrhosis (Child-Pugh class C). Both had developed progressive jaundice and cholangitis 1 month after surgery. Intrahepatic biliary stricture was found on the follow-up magnetic resonance images. However, liver triphase CT study demonstrated occlusion of intrahepatic portal vein of segment 8 in each patient. Radiologic interventions and balloon dilatation therapy via percutaneous transhepatic biliary drainage route improved the symptoms and signs of cholangitis and obstructive jaundice for both.

Conclusions

Thrombosis of intrahepatic segmental portal vein is not common but is usually associated with complications of intrahepatic bile duct. Early detection is important, and follow-up CT study of liver is suggested.     

Intraportal Stent Placement Combined with Right Portal Vein Embolization Against Advanced Gallbladder Carcinoma

(Received for publication on Mar. 24, 1997; accepted on Nov. 6, 1997)