Influence of histological inflammatory activity on regenerative capacity of liver after percutaneous transhepatic portal vein embolization

Percutaneous transhepatic portal vein embolization (PTPE) produces regenerative hypertrophy in the nonembolized part of the liver, but the regenerative capacity after PTPE in patients with chronic hepatitis is unknown. We studied 34 patients with hepatocellular carcinoma and chronic hepatitis who underwent PTPE at the right portal vein. Hepatic lobular volumes were calculated by computed tomography before and 2 weeks after PTPE. The increase in left lobular volume was analyzed using a stepwise multiple regression method incorporating 11 factors: age; portal venous pressure; proportional volume of the right lobe; indocyanine green retention test; platelet count; serum levels of aspartate transaminase, alanine transaminase, total bilirubin, and albumin; and histological inflammatory grade and stage of fibrosis, according to the criteria of the International Association for the Study of the Liver recommended at their 1994 meeting. The median volume of the left lobe had increased from 405 to 554 cm³ (P < 0.0001) by 2 weeks after PTPE. Inflammatory grade was the only independent factor predicting regenerative hypertrophy (regeneration ratio (%) = 80.3 − 20.1 × grade; standard correlation coefficient = −0.566; P = 0.0014). Histological inflammatory activity was the essential factor regulating liver regeneration after PTPE in patients with chronic hepatitis. (Received May 14, 1998; accepted Aug. 28, 1998)     

Preoperative percutaneous transhepatic portal embolization with absolute ethanol in patients with hepatocellular carcinoma

Preoperative percutaneous transhepatic portal vein embolization (PTPE) has been used in recent years to decrease the amount of liver resected and to reduce the risk of postoperative liver failure in patients with hepatocellular carcinoma. Various thrombogenic agents have been employed for this purpose. We evaluated the clinical safety and efficacy of absolute ethanol for PTPE and examined the histopathologic changes that follow ethanol embolization of the liver. We studied nine patients with hepatocellular carcinoma who were not originally regarded as surgical candidates because of a high risk of postoperative liver failure. They received preoperative PTPE of the right portal vein, with an average of 22.8 ml of absolute ethanol. The right lobe showed complete obstruction of portal venous branches and massive necrosis of the liver parenchyma. Macroscopically, there was atrophy of the embolized lobes and compensatory hypertrophy of the remaining lobes. The mean volume of the nonembolized lobe increased, from 351 to 585 and 633 ml, 2 and 4 weeks after embolization, respectively. The mean regeneration rate of this lobe was 16.7 cm³/day for the first 2 weeks after embolization and 10.1 cm³/day for the first 4 weeks. Transient dynamic increases in alanine aminotransferase concentrations were seen. All patients subsequently underwent right lobectomy of the liver and survived without severe complications. Portal vein embolization with absolute ethanol makes more extensive hepatectomy possible by reducing the volume necessary to resect, and it preserves the function of the remaining liver.     

Factors affecting liver regeneration after right portal vein embolization

BACKGROUND/AIMS: The factors influencing the effect of portal vein embolization performed prior to hepatectomies are not clearly understood. METHODOLOGY: In 18 patients who underwent portal vein embolization, serum transforming growth factor-alpha levels and the nonembolized liver volume were studied after portal vein embolization. The increase in the nonembolized liver volume was compared with the change in serum transforming growth factor-alpha levels and several other clinical variables. RESULTS: The volume of the nonembolized liver significantly increased from 430+/-114 cm3 to 521+/-113 cm3. The serum transforming growth factor-alpha levels significantly increased on the 7th day after portal vein embolization and peaked on the 18th day. The percentage increase in the nonembolized liver volume 14 days after portal vein embolization was significantly correlated with the nonembolized liver volume and the increase in the portal flow velocity, and it was independently and significantly correlated with the increase in the transforming growth factor-alpha level 14 days after portal vein embolization (r2=0.674, P=0.0014 and r=0.761, P<0.0005). CONCLUSIONS: The increase in the transforming growth factor-alpha level 14 days after portal vein embolization was the only independent factor related to the hypertrophy of the nonembolized liver. Measurement of its serum level may be a useful indicator in the scheduling of subsequent extensive hepatectomies.     

Transjugular preoperative portal embolization (TJPE) a pilot study

BACKGROUND/AIMS: Because of our previous experience with transjugular intrahepatic portosystemic shunt, we decided to apply the transjugular approach to preoperative portal embolization. The aim of this pilot study was to determine the feasibility and the potential advantages and disadvantages of this new method. METHODOLOGY: Under ultrasound guidance the right or left portal branch was punctured from the right, median or left hepatic vein. Then, a catheter was placed near the portal bifurcation and used to perform right portal branch embolization with a mixture of Histoacryl and Lipiodol. Pre- and post-transjugular preoperative portal embolization duplex ultrasound and CT scan were performed to assess portal flow and liver tissue growth. Hospital stay, pain and hepatic enzymes were monitored. RESULTS: Fifteen patients underwent a transjugular preoperative portal embolization without any serious complication. Mean of hospital stay was 3.3 +/- 0.6 days. (2-5 days). Portal embolization was successful in all cases; left portal branch velocity increased from 11.8 +/- 7.5 cm/s before, to 16.5 +/- 3.5 cm/s on day one, and 14.8 +/- 3.3 cm/s on day 28 after transjugular preoperative portal embolization; volume of non-embolized segments increased by 10% within the 4 weeks after transjugular preoperative portal embolization. Right hepatectomy was possible in 12 patients CONCLUSIONS: This method is safe, painless, and can be proposed in cases of impossibility to perform the standard percutaneous transhepatic portal embolization (tumor interposition, impaired hemostasis).     

The significance of portal vein embolization in the treatment of colorectal liver metastases

The first aim of the present paper was to evaluate hypertrophy of liver parenchyma after portal vein embolization in patients after systemic chemotherapy for colorectal carcinoma metastases and planned extensive liver resections. The second aim was to study whether hypertrophy of the liver parenchyma remnant after could influence the postoperative course large liver resections in long-term chemotherapy within complex therapy of colorectal carcinoma.The prospective study comprised of 43 patients with colorectal hepatic metastases in whom liver resections of 4-5 segments were planned (Table 1). All patients underwent complex therapy of colorectal carcinoma, including chemotherapy consisting of 6-12 therapeutic cycles. Time interval between chemotherapy and liver resection was 2-24 months (mean interval of 8 months). Twenty patients whose presumed liver parenchyma remnant was less than 40% of total liver volume were indicated for portal vein embolization (mean liver parenchyma remnant of 29%). This was always embolization of the right portal branch. Twenty-three patients were primarily indicated to liver resection. RESULTS: Hypertrophy of the left liver lobe occurred in all 20 patients. After portal vein embolization, the volume of left liver increased on average from 476 ml (282-754) to 584 ml (380-892) (P < 0.05). Mean hypertrophy of left liver lobe after portal vein embolization was 28.5%. The measured parenchyma remnant after tumor resection increased from 29% up to 38% by hypertrophy. Mean values of ALT and AST in the postoperative period were significantly different in the groups in this study. The values of alkaline phosphatase (ALP) and gamma glutamyl transpeptidase (GMT) were lower in patients after portal vein embolization (P < 0.05). Significant differences were in postoperative level of serum bilirubin, bilirubin levels in patients after portal vein embolization were 2-3 times lower than in the group of patients after immediate surgery (P < 0.05). he values of prothrombin time were also significantly lower in patients who underwent surgery without previous portal vein embolization (P < 0.05).     

Complete necrosis of a giant tumor in liver by transcatheter arterial embolization and percutaneous transhepatic portal embolization before liver resection

A 67-year-old man admitted for abdominal pain. Abdominal CT showed a liver tumor 14 cm in diameter in the right lobe, and a low density area spreading along the left branch of the Glisson's sheath. Serum protein induced by vitamin K absence or antagonist-II (PIVKA-II) level was found extremely high. Transcatheter arterial embolization (TAE) was performed three times, resulting the lesion reduced to 7cm in diameter. As the last TAE showed little effectiveness, we planed to percutaneous transhepatic portal embolization (PTPE) followed by extended right hepatectomy. After PTPE, PIVKA-II was normalized. Histologically, complete necrosis of the tumor lesions was observed in the resected liver.     

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.     

Experimental and clinical studies on liver regeneration following transcatheter portal embolization

BACKGROUND/AIMS: We studied compensatory hypertrophy following transcatheter portal embolization experimentally in dogs and clinically under the condition of cholestasis. METHODOLOGY: Experimental study: Sixteen dogs were used for this study. Transcatheter portal embolization was performed in the left lobes (70% of the total liver) using Gelfoam powder in dogs with 2-week obstructive jaundice. Liver weight, liver blood flow and the intracellular adenosine triphosphate content of isolated hepatocytes were measured after transcatheter portal embolization. Clinical Study: transcatheter portal embolization of the right portal branch was performed in 13 patients with cancer of the biliary tract and 3 patients with hepatocellular carcinoma before (extended) right lobectomy, using Gelfoam powder and thrombin. Six patients who had a total bilirubin level > 5 mg/dLunderwent a percutaneous transhepatic biliary drainage before transcatheter portal embolization. Liver function tests, a volumetric study with computed tomography and immunohistochemical staining for profilerating cell nuclear antigen and apoptosis in the resected livers were performed. RESULTS: Experimental study: The weight ratio of the non-embolized lobes to the total liver, 2 weeks after transcatheter portal embolization in the dogs with jaundice, was significantly lower than that of the normal dogs with transcatheter portal embolization (40.5 +/- 4.5% vs. 47.6 +/- 3.2%), but significantly larger than that of the dogs without transcatheter portal embolization. The cellular adenosine triphosphate content and tissue blood flow in the embolized lobes were significantly lower than those in the nonembolized lobes in the normal and cholestatic livers. Clinical study: The postoperative course in all patients was uneventful, with no serious complication or liver dysfunction. Extended right lobectomy with caudate lobectomy was equivalent to 65% before transcatheter portal embolization and to 56% after, transcatheter portal embolization owing to compensatory hypertrophy of the left lobe. However, there was no significant difference in liver volume in the patients with or without obstructive jaundice. Apoptosis was observed in the embolized lobe. CONCLUSIONS: Preoperative transcatheter portal embolization with percutaneous transhepatic biliary drainage for the purpose of liver regeneration would be useful for treating extended hepatectomy with obstructive jaundice.     

Heat shock protein 70 induction in hepatocytes after right portal vein embolization

BACKGROUND/AIMS: Preoperative right portal vein embolization enhances remnant liver function following massive hepatectomy. Several studies have reported an increase in the volume of the left hepatic lobe after right portal vein embolization, but little information exists regarding heat shock protein induction in hepatocytes after right portal vein embolization. The objective of this study is to determine whether heat shock protein is induced in hepatocytes after right portal vein embolization in patients who underwent extended right hepatic lobectomy. METHODOLOGY: Four patients with gallbladder cancer and one patient with intrahepatic cholangiocellular carcinoma who underwent extended right hepatic lobectomy combined with caudate lobectomy and resection of the extrahepatic bile duct after right portal vein embolization were enrolled in this study. Operation was performed 21-36 days after right portal vein embolization. At operation, small liver specimens were taken immediately after laparotomy from both the right anterior segment (embolized lobe) and lower part of the left medial segment (non-embolized lobe) and heat shock protein 70 was induction in these specimens was measured by Western blotting. RESULTS: Heat shock protein 70 was induced in the left lobe relative to the right lobe in four patients, three of whom had an uneventful postoperative course. CONCLUSIONS: This paper is the first report to show the induction of heat shock protein 70 in the non-embolized hepatic lobe after right portal vein embolization in the clinical cases.     

Liver regeneration and recanalization time course following reversible portal vein embolization

BACKGROUND/AIMS: Permanent portal vein embolization (PVE) is a widely practised technique. The use of an absorbable material would be safer in clinical situations in which the embolized liver is not resected. We evaluated the efficiency of reversible PVE in terms of liver regeneration and analyzed the precise time course of portal recanalization. METHODS: Nine monkeys underwent PVE of the left and right anterior portal branches using powdered absorbable material. Repeated portograms were carried out until complete revascularization of the embolized liver. Hepatocyte proliferation rates were assessed by BrdU incorporation. Liver segment volumes were determined by CT scans performed before embolization, then 1month and 1year after embolization. RESULTS: Reversible PVE induced significant hepatocyte proliferation in the non-embolized segments (13.5+/-1.0%, 10.5+/-0.8% and 9.1+/-2.0% of cells on days 3, 5 and 7, respectively). One month after the embolization, the non-embolized liver volume had increased from 38.4+/-1.3% to 54.8+/-0.5% of total liver volume. Proximal and complete revascularization occurred 6-8 and 12-16days, respectively. CONCLUSIONS: Reversible PVE efficiently induces liver regeneration. The use of absorbable material avoids long-term liver scarring. Such material may be suitable for several clinical indications, including cell transplantation.     

Physical hemodynamic interaction between portal venous and hepatic arterial blood flow in humans.

OBJECTIVE: The hepatic arterial end-diastolic velocity (HAEDV) is normally equal to portal vein peak velocity (PVPV). However, there is no report of quantitative measurement that HAEDV was equal to PVPV. We investigated the interaction in PVPV and HAEDV in both chronic and acute hepatic hemodynamic changes. METHODS: One hundred and nineteen patients (54 with cirrhosis, 23 with chronic hepatitis, and 42 with no diffuse liver disorder) were enrolled. We investigated the differences in PVPV and HAEDV among the patients with and without liver disorder. In addition, we measured the intraindividual changes in HAEDV when PVPV was mechanically changed by percutaneous isolated hepatic perfusion in six patients and by percutaneous transhepatic portal embolization (PTPE) in six more. RESULTS: HAEDV was nearly equal to PVPV not only in patients with both normal and hepatitis but also in those with cirrhosis (PVPV-HAEDV = 3.0 +/- 5.2, 2.2 +/- 5.4, 2.3 +/- 6.5 cm/s, respectively). In the intraindividual study, both PVPV and HAEDV decreased during hepatic mechanical perfusion and HAEDV was equal to PVPV (8.2 +/- 2.8, 10.5 +/- 1.5 cm/s, respectively). After PTPE, PVPV was increased and hepatic arterial peak systolic velocity was reciprocally decreased. However, HAEDV was nearly equal to PVPV 7 days after PTPE (PVPV-HAEDV = 5.9 +/- 5.1 cm/s). CONCLUSIONS: Since arterial end-diastolic velocity depends on the downstream vascular resistance, lower HAEDV in patients with cirrhosis was considered to reflect a high outflow resistance. If there is no collateral pathway, we consider that HAEDV may actually reflect sinusoidal resistance to the same degree as PVPV.     

Combination of preoperative embolization of the right portal vein and hepatic artery prior to major hepatectomy in high-risk patients: a preliminary report

BACKGROUND/AIMS: Preoperative transhepatic portal vein embolization may not always be sufficient to achieve the desired changes in contralateral hepatic volume and function. The beneficial role of additional transcatheter arterial embolization performed after inadequate response to preoperative transhepatic portal vein embolization is described. METHODOLOGY: Four patients underwent both preoperative transhepatic portal vein embolization and transcatheter arterial embolization, and 6 control patients underwent preoperative transhepatic portal vein embolization only. Changes in right liver lobe volume fraction, residual left lobe volume fraction, and prediction score (low-risk, < 45; borderline, 45-55; high-risk > 55); were evaluated. RESULTS: 1) The change in right liver lobe volume after both preoperative transhepatic portal vein embolization and transcatheter arterial embolization (volume after/before) was 0.75 times that of the original level whereas after preoperative transhepatic portal vein embolization, they were only 0.81 times that of the original level. 2) The change in residual left liver volume after both preoperative transhepatic portal vein embolization and transcatheter arterial embolization (volume after/before) was 1.40 times that of the original level whereas after preoperative transhepatic portal vein embolization they were only 1.30 times than the original level. The changes in left liver volume after preoperative transhepatic portal vein embolization/transcatheter arterial embolization was more favorable than those after preoperative transhepatic portal vein embolization only. 3) The change in prediction score after both preoperative transhepatic portal vein embolization and transcatheter arterial embolization (after/before) was 0.81 times that of the original level. All prediction score in high-risk patients recovered to the borderline or safety zone. Change after preoperative transhepatic portal vein embolization only (before/after) was 0.87 times that of the original level. 4) All 4 patients who underwent both preoperative transhepatic portal vein embolization and transcatheter arterial embolization received right hepatic lobectomy successfully and returned to their normal life style. CONCLUSIONS: Preoperative occlusion of right hepatic inflow vessels increased the volume and function of the contralateral lobe where high-risk patients recovered to the borderline zone for major hepatic resection.     

Preoperative selective portal vein embolization (PSPVE) before major hepatic resection. Effectiveness of Doppler estimation of hepatic blood flow to predict the hypertrophy rate of non-embolized liver segments

Hepatocellular carcinoma may be unresectable for volumetric reasons. The future remaining liver after hepatectomy might be too small to ensure survival. Preoperative selective portal vein embolization of the tumorous lobe can induce hypertrophy of the future remaining liver and enable safer surgery. A 76-year-old patient with hepatocellular carcinoma needed right lobectomy however, the future remaining liver was judged insufficient to ensure an uneventful postoperative course. The left lobe to whole liver volumetric ratio was to small (29.7%) and a preoperative selective portal vein embolization of the right portal branch via a percutaneous, transhepatic, contralateral approach was performed without side effects. A Doppler estimation of left branch portal blood flow and velocity was carried out before and after preoperative selective portal vein embolization. After 21 days the left lobe volume increased by about 44.2% with a safe left lobe/whole liver ratio of 40.8%. The portal blood flow and portal blood flow velocity showed an increase of 253% and 122%, respectively. A right lobectomy was performed without complications. Three months later, computed tomography scan showed no hepatocellular carcinoma recurrence. Preoperative selective portal vein embolization is a safe technique which can enable major hepatectomy to be performed in situations otherwise judged unresectable for a life-threatening volumetric insufficiency. The portal blood flow and portal blood flow velocity evaluations can easily predict the hypertrophy rate of non-embolized liver segments.     

Changes in clinicopathological findings after portal vein embolization

BACKGROUND/AIMS: Portal vein embolization is becoming more common as a method of preventing hepatic failure after an extended hepatectomy but its mechanism is not well understood. This clinicopathological study focused on its mechanism. METHODOLOGY: Thirty patients who underwent extended hepatectomy after portal vein embolization were evaluated. Liver volume was measured before and after portal vein embolization, and histological studies were performed to examine morphological changes, morphometric parameters and apoptosis of hepatocytes. RESULTS: The mean volume of the non-embolized lobe grew significantly from 392 to 462 mL after portal vein embolization (P < 0.0001). The hypertrophy ratio of the non-embolized lobe (100 x volume change during portal vein embolization/volume before portal vein embolization, %) was correlated closely with the volume of the non-embolized lobe before portal vein embolization (r = -0.65, P < 0.0001). Histological study showed the embolized lobe hepatocytes to be atrophic, partly necrotic and apoptotic. In the non-embolized lobe, the mean hepatocyte volume was 8686 micron 3 (control: 6544 micron 3) and the mean hepatocyte count was 109 x 10(6)/mL (control: 122 x 10(6)/mL). CONCLUSIONS: The enlargement of the non-embolized lobe was caused by hypertrophy rather than hyperplasia suggesting hyperfunction. The resection of the atrophic embolized lobe, leaving the hypertrophic non-embolized lobe was thought to be less surgically stressful than hepatectomy without portal vein embolization.     

Repeat hepatectomy for colonic liver metastasis presenting intrabiliary growth--application of percutaneous transhepatic portal vein embolization for impaired liver

A 77-year-old man, whose past history included hepatitis C viral infection, transverse colectomy for transverse colon carcinoma, and right hepatectomy for colonic liver metastasis with intrabiliary growth, demonstrated left lateral sectional bile duct dilatation by computed tomography (CT). Percutaneous transhepatic cholangioscopy following percutaneous transhepatic biliary drainage demonstrated a papillary tumor compatible with recurrent liver metastasis presenting with intrabiliary growth. The recurrent tumor extended both into the left lateral inferior (B2) and superior (B3) bile duct branches. Percutaneous transhepatic portal vein embolization (PTPE) of the left lateral sectional branches was performed selectively to enhance the safety of hepatectomy in patients with impaired liver. Expected liver resection volume decreased from 48% to 36% by CT volumetry before and 5 weeks after PTPE. Left lateral sectionectomy was performed without serious postoperative complications. Resected specimen showed a solid tumor measuring 30x25mm and intraluminal tumor extension in B3 and B2. All surgical margins including the bile duct stump were free from carcinoma invasion. The patient survived for 4 years and 5 months postoperatively and died of other causes. An aggressive surgical strategy and PTPE provided significant palliation in this selected patient.     

Comparison of percutaneous transhepatic portal vein embolization and unilateral portal vein ligation

AIM: To compare the effect of percutaneous transhepatic portal vein embolization (PTPE) and unilateral portal vein ligation (PVL) on hepatic hemodynamics and right hepatic lobe (RHL) atrophy.METHODS: Between March 2005 and March 2009, 13 cases were selected for PTPE (n = 9) and PVL (n = 4) in the RHL. The PTPE group included hilar bile duct carcinoma (n = 2), intrahepatic cholangiocarcinoma (n = 2), hepatocellular carcinoma (n = 2) and liver metastasis (n = 3). The PVL group included hepatocellular carcinoma (n = 2) and liver metastasis (n = 2). In addition, observation of postoperative hepatic hemodynamics obtained from computed tomography and Doppler ultrasonography was compared between the two groups.RESULTS: Mean ages in the two groups were 58.9 ± 2.9 years (PVL group) vs 69.7 ± 3.2 years (PTPE group), which was a significant difference (P = 0.0002). Among the indicators of liver function, including serum albumin, serum bilirubin, aspartate aminotransferase, alanine aminotransferase, platelets and indocyanine green retention rate at 15 min, no significant differences were observed between the two groups. Preoperative RHL volumes in the PTPE and PVL groups were estimated to be 804.9 ± 181.1 mL and 813.3 ± 129.7 mL, respectively, with volume rates of 68.9% ± 2.8% and 69.2% ± 4.2%, respectively. There were no significant differences in RHL volumes (P = 0.83) and RHL volume rates (P = 0.94), respectively. At 1 mo after PTPE or PVL, postoperative RHL volumes in the PTPE and PVL groups were estimated to be 638.4 ± 153.6 mL and 749.8 ± 121.9 mL, respectively, with no significant difference (P = 0.14). Postoperative RHL volume rates in the PTPE and PVL groups were estimated to be 54.6% ± 4.2% and 63.7% ± 3.9%, respectively, which was a significant difference (P = 0.0056). At 1 mo after the operation, the liver volume atrophy rate was 14.3% ± 2.3% in the PTPE group and 5.4% ± 1.6% in the PVL group, which was a significant difference (P = 0.0061).CONCLUSION: PTPE is a more effective procedure than PVL because PTPE is able to occlude completely the portal branch throughout the right peripheral vein.     

Role of preoperative selective portal vein embolization in two-step curative hepatectomy for hepatocellular carcinoma

AIM: To determine the feasibility and role of ultrasound-guided preoperative selective portal vein embolization (POSPVE) in the two-step hepatectomy of patients with advanced primary hepatocellular carcinoma (HCC). METHODS: Fifty patients with advanced HCC who were not suitable for curative hepatectomy were treated by ultrasound-guided percutaneous transhepatic POSPVE with fine needles. The successful rate, side effects and complications of POSPVE, changes of hepatic lobe volume and two-step curative hepatectomy rate after POSPVE were observed. RESULTS: POSPVE was successfully performed in 47 (94.0 %) patients. In patients whose right portal vein branches were embolized, their right hepatic volume decreased and left hepatic volume increased gradually. The ratio of right hepatic volume to total hepatic volume decreased from 62.4 % before POSPVE to 60.5 %, 57.2 % and 52.8 % after 1, 2 and 3 weeks respectively. The side effects included different degree of pain in liver area (38 cases), slight fever (27 cases), nausea and vomiting (9 cases). The level of aspartate alanine transaminase (AST), alanine transaminase (ALT) and total bilirubin (TBIL) increased after POSPVE, but returned to preoperative level in 1 week. After 2-4 weeks, two-step curative hepatectomy for HCC was successfully performed on 23 (52.3 %) patients. There were no such severe complications as ectopic embolization, local hemorrhage and bile leakage. CONCLUSION: Ultrasound-guided percutaneous transhepatic POSPVE with fine needles is feasible and safe. It can extend the indications of curative hepatectomy of HCC, and increase the safety of hepatectomy.     

A new technique to acquire additional liver volume for left lobe graft in living donor liver transplantation

BACKGROUND/AIMS: Left lobe graft is an ideal option to minimize potential risk for the donor in adult living-donor liver transplantation (LDLT). However, its use is restricted due to size limitations. The purpose of this study was to determine the impact of a new technique for the acquisition of additional liver volume for left lobe graft. METHODOLOGY: Three donors underwent left hepatic lobectomy by exploiting a new technique as follows: a demarcation line was marked by clamping the right first Glisson's pedicle. A parenchymal transection plane was located 1 cm right side from the demarcation line and just on the left side of the right anterior Glisson's pedicle. A part of the anterior segment added to the left lobe graft by this procedure belonged to right anterior segment by preoperative CT. The preoperative volumetry of the liver was performed using the 3D-CT software, which was able to calculate total liver volume and the volume of each vessel's territories. Additional liver volume was calculated by preoperative CT scan and defined as part of the perfusion area by the right anterior portal branch. Blood perfusion of the additional liver area was postoperatively assessed by dynamic CT, and graft outcome was also evaluated. RESULTS: An additional gain ranged from 40 mL to 51 mL (mean 41.8 mL). GV/SLV was 35.7, 60.0, and 41.0%. The rate of additional volume in GV/SLV ranged from 7.2-8.4% (mean 7.6%). All grafts functioned well. The CT scan performed on early postoperative period confirmed excellent blood perfusion the additional segment. No complication attributable to small-for-size graft was noted. CONCLUSIONS: This new technique for left lobe graft harvesting proved a promising approach to gain additional volume, thereby avoiding small-for-size graft in adult LDLT.     

Compensatory hepatic hypertrophy after occlusion of branches of the portal vein or bile duct

The effect on the liver of portal or bile duct branch occlusion was examined in rabbits by measuring hepatic tissue blood flow and cellular kinetics, using the bromodeoxyuridine labeling index. The portal branch bile duct branch, or both, to the main lobe and caudate lobe (80.4% of total liver weight) were ligated or embolized just above the right posterior lobe (19.6%), resulting in compensatory hypertrophy of the right posterior lobe and atrophy of the main and caudate lobes. Twenty-four days after ligation, the degree of compensatory hypertrophy in the different groups was comparable. There were significant differences in the pattern of the development of hypertrophy. Ligation of both a portal branch and the corresponding bile duct resulted in more rapid hypertrophy and atrophy than ligation of a portal branch alone. Ligation of a branch of the bile duct resulted in slow development of hypertrophy and atrophy. In the embolization group, the increase in the right posterior lobe stopped 6 days after the operation, resulting that it was about 40% thereafter. Histological findings showed that the fibrin clot had contracted and was floating in the portal branch to the main lobe. These results suggested that portal blood flow to the main lobe had resumed and was gradually increasing as the clot contracted. Portal branch ligation gave results superior to those with portal branch embolization with regard to application to preoperative procedure in extended hepatobiliary surgery.     

Selective hypertrophy of the lobus caudatus as a novel approach enabling extended right hepatectomy in the presence of a non-perfused left lateral liver lobe

Introduction

Portal vein embolization (PVE) is a well-established technique to enhance functional hepatic reserves of segments II and III before curative extended right hepatectomy for tumors of the right liver lobe. However, an adequate hepatopetal flow of the left lateral portal vein branches is required for a sufficient PVE-associated hypertrophy.

Case report

Here, we report a 65-year old patient suffering from a locally advanced intrahepatic cholangiocarcinoma in the right liver lobe and segment IV. A curative extended right hepatectomy after preoperative PVE of liver segments IV–VIII was initially impossible because of partial thrombosis of the left lateral portal vein branches resulting in an ischemic-type atrophy of segments II and III. However, due to a massive hypertrophy of the caudate lobe following PVE of liver segments IV–VIII, subsequent extended right hepatectomy with intraoperative thrombectomy of segments II and III was made possible.

Conclusions

To our knowledge this is the first case in which an extended right hepatectomy for a liver malignancy, in the presence of atrophic left lateral section, was made possible by a massive PVE-associated hypertrophy of the caudate lobe.