Extended hepatectomy in patients with hepatobiliary malignancies with and without preoperative portal vein embolization

HYPOTHESIS: Preoperative portal vein embolization (PVE) allows potentially curative hepatic resection without additional morbidity or mortality in patients with hepatobiliary malignancies who are marginal candidates for resection based on small liver remnant size. DESIGN: A retrospective review of a consecutive series of patients in a multi-institutional database who underwent extended hepatectomy. SETTING: University-based referral centers. PATIENTS: Forty-two patients underwent preoperative determination of the future liver remnant (FLR) volume before extended hepatectomy (> or = 5 segments) for hepatobiliary malignancy without chronic underlying liver disease. Patients were stratified by treatment with or without preoperative PVE. INTERVENTION: Preoperative percutaneous PVE. MAIN OUTCOME MEASURES: Clinical characteristics, FLR volume, operative morbidity, and survival. RESULTS: There was no difference between the groups that did and did not undergo PVE for the number of tumors, tumor size, estimated blood loss, duration of the operation, complexity of resection, or surgical margins. The FLR at presentation was significantly smaller in patients who underwent PVE than in patients who did not undergo PVE (18% vs 23%; P<.001). After PVE, FLR volumes increased significantly (P =.003); preoperative FLR volumes were similar in both groups (patients who underwent PVE, 25%; and patients who did not undergo PVE, 23%). There was no perioperative mortality and no statistical difference in the incidence of perioperative complications between those who did and those who did not undergo PVE (5 [28%] of 18 patients vs 5 [21%] of 24 patients). The overall 3-year survival was 65% and the median survival duration was equivalent in the 2 groups (40 vs 52 months for those who did vs those who did not undergo PVE). CONCLUSION: Portal vein embolization enables safe and potentially curative extended hepatectomy in a subset of patients who would otherwise be marginal candidates for resection based on a small liver remnant size.     

Extension of right portal vein embolization to segment IV portal branches

HYPOTHESIS: Routine embolization of segment IV, combined with right portal vein embolization (PVE), has been suggested in patients who are candidates for right trisegmentectomy to induce higher and faster hypertrophy of segments II-III. Our objective was to compare hypertrophy of segments II-III induced by PVE with and without extension to segment IV in patients undergoing major hepatectomy. METHODS: Twenty-six consecutive patients were prospectively evaluated; the future remnant liver volume was calculated using the portal phase of spiral computed tomographic scans before and 3 to 4 weeks after right PVE (group R, n = 13), which was extended to segment IV branches in 13 patients (group L). RESULTS: Twenty patients (76.9%) underwent the scheduled hepatic resection. Of the 6 patients who did not undergo the planned operation, 5 showed disease progression; in 1 patient (group L), there was an insufficient increase of the future remnant liver volume due to the presence of embolizing material in the left lobe. The mean +/- SD time between PVE and volume measurements was 31.8 +/- 9.3 days. The overall mean +/- SD future remnant liver volume increase was 53.1% +/- 24.8%; the increase for segment IV was significantly higher in group R than group L. The mean +/- SD post-PVE volumes of segments II-III and the rate of volume increase were similar in the 2 groups: group R, 348.4 +/- 83.1 cm3 and 67.8% +/- 30.8%, respectively, vs group L, 391.2 +/- 78.05 cm3 and 56.1% +/- 35.1%, respectively (P = .20 and P = .40). CONCLUSION: Extension of embolization to segment IV portal branches should not be routinely used because a similar volume increase of segments II-III can be simply achieved by right PVE.     

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.     

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).     

Two hundred forty consecutive portal vein embolizations before extended hepatectomy for biliary cancer: surgical outcome and long-term follow-up

OBJECTIVE: To assess clinical benefit of portal vein embolization (PVE) before extended, complex hepatectomy for biliary cancer. SUMMARY BACKGROUND DATA: Many investigators have addressed clinical utility of PVE before simple hepatectomy for metastatic liver cancer or hepatocellular carcinoma, but few have reported PVE before hepatectomy for biliary cancer due to the limited number of surgical cases. METHODS: This study involved 240 consecutive patients with biliary cancer (150 cholangiocarcinomas and 90 gallbladder cancers) who underwent PVE before an extended hepatectomy (right or left trisectionectomy or right hepatectomy). All PVEs were performed by the "ipsilateral approach" 2 to 3 weeks before surgery. Hepatic volume and function changes after PVE were analyzed, and the outcome also was reviewed. RESULTS: There were no procedure-related complications requiring blood transfusion or interventions. Of the 240 patients, 47 (19.6%) did not undergo subsequent hepatectomy. The incidence of unresectability was higher in gallbladder cancer than in cholangiocarcinoma (32.2% versus 12.0%, P < 0.005). The remaining 193 patients (132 cholangiocarcinomas and 61 gallbladder cancers) underwent hepatectomy with resection of the caudate lobe and extrahepatic bile duct (n = 187), pancreatoduodenectomy (n = 42), and/or portal vein resection (n = 63). Seventeen (8.8%) patients died of postoperative complications: mortality was higher in gallbladder cancer than in cholangiocarcinoma (18.0% versus 4.5%, P < 0.05); and it was also higher in patients whose indocyanine green clearance (KICG) of the future liver remnant after PVE was <0.05 than those whose index was >or=0.05 (28.6% versus 5.5%, P < 0.001). The 3- and 5-year survival after hepatectomy was 41.7% and 26.8% in cholangiocarcinoma and 25.3% and 17.1% in gallbladder cancer, respectively (P = 0.011). In 136 other patients with cholangiocarcinoma who underwent a less than 50% resection of the liver without PVE, a mortality of 3.7% and a 5-year survival of 27.6% were observed, which was similar to the 132 patients with cholangiocarcinoma who underwent extended hepatectomy after PVE. CONCLUSIONS: PVE has the potential benefit for patients with advanced biliary cancer who are to undergo extended, complex hepatectomy. Along with the use of PVE, further improvements in surgical techniques and refinements in perioperative management are necessary to make difficult hepatobiliary resections safer.     

Preoperative portal vein embolization for extended hepatectomy

OBJECTIVE: To examine the authors' experience with preoperative ipsilateral portal vein embolization (PVE) and assess its role in extended hepatectomy. SUMMARY BACKGROUND DATA: Extended hepatectomy (five or more liver segments) has been associated with higher complication rates and increased postoperative liver dysfunction than have standard hepatic resections involving lesser volumes. Recently, PVE has been used in patients who have a predicted (postresection) future liver remnant (FLR) volume less than 25% of total liver volume in an attempt to increase the FLR and reduce complications. METHODS: Sixty patients from 1996 to 2002 were reviewed. Thirty-nine patients had PVE preoperatively. Eight patients who had PVE were not resected either due to the discovery of additional unresectable disease after embolization but before surgery (n = 5) or due to unresectable disease at surgery (n = 3). Therefore, 31 patients who had PVE subsequently underwent extended hepatic lobectomy. A comparable cohort of 21 patients who had an extended hepatectomy without PVE were selected on the basis of demographic, tumor, and liver volume characteristics. Patients had colorectal liver metastases (n = 30), hepatocellular carcinoma (n = 15), Klatskin tumors (n = 9), peripheral cholangiocarcinoma (n = 3), and other tumors (n = 3). The 52 resections performed included 42 extended right hepatectomies, 6 extended left hepatectomies, and 4 right hepatectomies extended to include the middle hepatic vein and the caudate lobe but preserving the majority of segment 4. Concomitant vascular reconstruction of either the inferior vena cava or hepatic veins was performed in five patients. RESULTS: There were no differences between PVE and non-PVE groups in terms of tumor number, tumor size, tumor type, surgical margin status, complexity of operation, or perioperative red cell transfusion requirements. The predicted FLR was similar between PVE and non-PVE groups at presentation. After PVE the FLR was higher than in the non-PVE group. No complications were observed after PVE before resection. There was no difference in postoperative mortality, with one death from liver failure in the non-PVE group and no operative mortality in the PVE group. Postoperative peak bilirubin was higher in the non-PVE than the PVE group, as were postoperative fresh-frozen plasma requirements. Liver failure (defined as the development of encephalopathy, ascites requiring sustained diuretics or paracentesis, or coagulopathy unresponsive to vitamin K requiring fresh-frozen plasma after the first 24 hours postresection) was higher in the non-PVE patients than the PVE patients. The hospital stay was longer in the non-PVE than the PVE group. CONCLUSIONS: Preoperative PVE is a safe and effective method of increasing the remnant liver volume before extended hepatectomy. Increasing the remnant liver volume in patients with estimated postresection volumes of less than 25% appears to reduce postoperative liver dysfunction.     

Resection of nonresectable liver metastases from colorectal cancer after percutaneous portal vein embolization

OBJECTIVE: To assess the influence of preoperative portal vein embolization (PVE) on the long-term outcome of liver resection for colorectal metastases. SUMMARY BACKGROUND DATA: Preoperative PVE of the liver induces hypertrophy of the remnant liver and increases the safety of hepatectomy. METHODS: Thirty patients underwent preoperative PVE and 88 patients did not before resection of four or more liver segments. PVE was performed when the estimated rate of remnant functional liver parenchyma (ERRFLP) assessed by CT scan volumetry was less than 40%. RESULTS: PVE was feasible in all patients. There were no deaths. The complication rate was 3%. The post-PVE ERRFLP was significantly increased compared with the pre-PVE value. Liver resection was performed after PVE in 19 patients (63%), with surgical death and complication rates of 4% and 7% respectively. PVE increased the number of resections of more than four segments by 19% (17/88). Actuarial survival rates after hepatectomy with or without previous PVE were comparable: 81%, 67%, and 40% versus 88%, 61%, and 38% at 1, 3, and 5 years respectively. CONCLUSIONS: PVE allows more patients with previously unresectable liver tumors to benefit from resection. Long-term survival is comparable to that after resection without PVE.     

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.     

Sequential Preoperative Ipsilateral Portal and Arterial Embolization in Patients with Colorectal Liver Metastases

Background Preoperative portal vein embolization (PVE) induces ipsilateral atrophy of the hepatic parenchyma to be resected, as well as contralateral compensatory hypertrophy of the residual liver. However, there are two potential problems with this technique: inadequate contralateral hypertrophy and tumor progression while waiting for the non-embolized liver to hypertrophy. We devised a strategy to deal with these two problems by performing an ipsilateral hepatic artery embolization 6 weeks after an unsatisfactory PVE in an effort to accelerate the hypertrophy of the remnant liver. Materials and Methods Two patients with colorectal liver metastases underwent to this sequential preoperative treatment in order to achieve resectability of their metastatic disease. Results Both patients successfully underwent major hepatic resection. Conclusions In our experience sequential ipsilateral portal vein and hepatic artery embolization extended the indications for liver resection for metastatic colorectal cancer.     

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??Preoperative portal vein embolization for hilar cholangiocarcinoma: a report of 16 cases YI Bin*, XU Ai-min, QÜ Zeng-qiang, et al. *First Department of Biliary ract Diseases, Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, Shanghai 200438,China
Corresponding author: JIANG Xiao-Qing, E-mail:jxq1225@sina.com
Abstract Objective To evaluate whether portal vein embolization (PVE) is safe and efficacious in patients with hilar cholangiocarcinoma who are estimated to have inadequate/marginal future liver remnant (FLR). Methods Between January 2007 and March 2009 at Eastern Hepatobiliary Surgery Hospital of the Second Military Medical University, 16 cases of FLR ratio <50% requiring major hepatectomy underwent PVE with multiple steel coils. Results Sixteen cases (PVE group) were performed PVE resulted from hepatic function injury and FLR ratio <50%. Thirty-three cases (nonPVE group) were performed extended hepatectomy en bloc with the tumor resulted from FLR ratio >50%. PVE complications including bile leak (1/16) and coil displacement (2/16) did not delay hepatectomies. Deficiency of FLR hypertrophy appeared in one case with underlying cirrhosis and prevented him away from surgery. Local tumor progression and peritoneal dissemination precluded hepatectomy in 2 cases. The other 13 cases (81.3%) underwent extended hepatectomy en bloc with the tumor. The PVE hepatectomy group (n=13) had similar complication and mortality rates compared with the non-PVE hepatectomy group (FLR ratio > 50%, n=33) (complication rate, 69.2% vs. 63.6%, P=1.000; mortality rate, 0 vs. 9.1%, P=0.548). Conclusion PVE is a safe and efficacious procedure in inducing adequate hypertrophy of the FLR before major hepatic resection for hilar cholangiocarcinoma.     

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.     

Selective versus total biliary drainage for obstructive jaundice caused by a hepatobiliary malignancy

BACKGROUND: Controversy exists regarding which approach is preferable among types of biliary drainage for obstructive jaundice before major hepatectomy: selective biliary drainage (SBD) only on the future remnant liver (FRL) or total biliary drainage (TBD). METHODS: There were 42 consecutive patients who underwent SBD (n = 15) or TBD (n = 27) for obstructive jaundice caused by a hepatobiliary malignancy, and subsequent portal vein embolization (PVE) before extended hemihepatectomy. The hypertrophy ratio, defined as the ratio of the FRL volume after PVE to that before PVE, was evaluated. The bilirubin clearance also was calculated. RESULTS: The hypertrophy ratio was higher in patients with SBD than in those with TBD (median, 128%; range, 111-152% vs median, 121%; range, 102-138%; P = .013). The bilirubin clearance of FRL with SBD was markedly improved after PVE compared with that in patients with TBD. CONCLUSIONS: SBD is superior to TBD in promoting hypertrophy of the FRL induced by PVE and in guaranteeing good liver function before major hepatectomy.     

Standardized measurement of the future liver remnant prior to extended liver resection: methodology and clinical associations

BACKGROUND: There is no agreement regarding the preoperative measurement of liver volumes and the minimal safe size of the liver remnant after extended hepatectomy. METHODS: In 20 patients with hepatobiliary malignancy and no underlying chronic liver disease, volumetric measurements of the liver remnant (segments 2 and 3 +/- 1) were obtained before extended right lobectomy (right trisegmentectomy). The ratios of future liver remnant to total liver volume were calculated by using a formula based on body surface area. In 12 patients, response to preoperative right trisectoral portal vein embolization was evaluated. In 15 patients who underwent the planned resection, preoperative volumes were correlated with biochemical and clinical outcome parameters. RESULTS: The future liver remnants increased after portal vein embolization (26% versus 36%, P < .01). Smaller size liver remnants were associated with an increase in postoperative liver function tests (P < .05) and longer lengths of hospital stay (P < .02). Preliminary data indicates an increase in major complications for liver volumes < or = 25% (P = .02). CONCLUSIONS: A simple method of measurement provides an assessment of the liver remnant before resection. It is useful in evaluating response to portal vein embolization and in predicating the outcome before extended liver resections.     

Parameters associated with changes in liver volume in patients undergoing portal vein embolization

BACKGROUND: To identify predictors of changes in hepatic volumes after portal vein embolization (PVE) before hepatectomy, we examined the relationship between clinicopathological parameters and changes in volume of embolized and nonembolized liver and regeneration of remnant liver after hepatectomy. MATERIALS AND METHODS: The subjects were 25 patients who underwent laparotomy. PVE was performed through transileocolic vein (n = 15) and percutaneous transhepatic puncture (n = 10). RESULTS: Significant atrophy and hypertrophy of the embolized and nonembolized liver were observed after PVE, respectively, and further increase of remnant liver volume was observed after hepatectomy. Background liver disease did not seem to influence the results. Alkaline phosphatase (ALP) level correlated negatively with atrophy of embolized lobe (r = -0.433). Platelet count correlated positively with hypertrophy of nonembolized lobe (r = 0.412, P < 0.05) and percent increase between lobes and (r = 0.515, P < 0.05). Seven (32%) patients developed postoperative complications, such as long-term ascites or cholestasis. Changes in embolized liver and percent increase between lobes in patients with postoperative cholestasis (-94 +/- 97 cm(3) and 9.6 +/- 5.1% gain) were significantly lower than those in patients without cholestasis (17 +/- 54 cm(3) and 6.6 +/- 1.3% gain, P < 0.05). CONCLUSION: ALP and platelet counts might be able to predict PVE effect and were related to postoperative course. Identification of more specific predictors is desirable.     

Preoperative Portal Vein Embolization and Surgical Resection in Patients with Hepatocellular Carcinoma and Small Future Liver Remnant Volume: Comparison with Transarterial Chemoembolization

BACKGROUND: 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). METHODS: 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. RESULTS: 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). CONCLUSIONS: Preoperative PVE enables surgical resection in HCC patients with small FLR volume and improves patient survival compared with TACE.     

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.     

肝门部胆管癌术前行门静脉栓塞16例分析

目的 探讨未来残余肝较小的肝门部胆管癌病人行门静脉栓塞是否安全有效。 方法 对2007年1月至2009年3月第二军医大学附属东方肝胆外科医院拟行大部肝切除、未来残余肝/全肝体积（FLR/ TLV）比<50%的16例接受钢圈门静脉栓塞（portal vein embolization,PVE）的临床资料进行分析。 结果 术前16例（PVE组）因肝功能损害、FLR/TLV < 50%者行PVE治疗,33例（非PVE组）FLR/TLV > 50%者行肿瘤联合肝切除。PVE后3例出现并发症,原因为胆漏和钢圈移位,但未推迟肝切除术日期。16例PVE中1例合并肝硬化出现非栓塞肝叶增生不全而未能接受外科治疗,2例术中发现肿瘤进展、腹膜播散未能接受肝切除术,余13例（81.3%）行联合肝切除的肿瘤切除术。PVE组和非PVE组的手术并发症发生率分别为69.2%及63.6%,手术死亡率为0及9.1%。二者相比差异无统计学意义。结论 PVE能安全、有效地诱导肝门胆管癌术前未来残余肝增生。     

Portal vein embolization before right hepatectomy: prospective clinical trial

OBJECTIVE: To assess the impact of liver hypertrophy of the future liver remnant volume (FLR) induced by preoperative portal vein embolization (PVE) on the immediate postoperative complications after a standardized major liver resection. SUMMARY BACKGROUND DATA: PVE is usually indicated when FLR is estimated to be too small for major liver resection. However, few data exist regarding the exact quantification of sufficient minimal functional hepatic volume required to avoid postoperative complications in both patients with or without chronic liver disease. METHODS: All consecutive patients in whom an elective right hepatectomy was feasible and who fulfilled the inclusion and exclusion criteria between 1998 and 2000 were assigned to have alternatively either immediate surgery or surgery after PVE. Among 55 patients (25 liver metastases, 2 cholangiocarcinoma, and 28 hepatocellular carcinoma), 28 underwent right hepatectomy after PVE and 27 underwent immediate surgery. Twenty-eight patients had chronic liver disease. FLR and estimated rate of functional future liver remnant (%FFLR) volumes were assessed by computed tomography. RESULTS: The mean increase of FLR and %FFLR 4 to 8 weeks after PVE were respectively 44 +/- 19% and 16 +/- 7% for patients with normal liver and 35 +/- 28% and 9 +/- 3% for those with chronic liver disease. All patients with normal liver and 86% with chronic liver disease experienced hypertrophy after PVE. The postoperative course of patients with normal liver who underwent PVE before right hepatectomy was similar to those with immediate surgery. In contrast, PVE in patients with chronic liver disease significantly decreased the incidence of postoperative complications as well as the intensive care unit stay and total hospital stay after right hepatectomy. CONCLUSIONS: Before elective right hepatectomy, the hypertrophy of FLR induced by PVE had no beneficial effect on the postoperative course in patients with normal liver. In contrast, in patients with chronic liver disease, the hypertrophy of the FLR induced by PVE decreased significantly the rate of postoperative complications.     

Sequential preoperative arterial and portal venous embolizations in patients with hepatocellular carcinoma

HYPOTHESIS: Hepatic resection is the only curative treatment for large hepatocellular carcinoma (HCC). Sequential, preoperative, selective transcatheter arterial chemoembolization (TACE) and portal vein embolization (PVE) allow feasible and safe major hepatic resections to be performed in HCC patients with chronic liver disease. DESIGN: Retrospective cohort study. SETTING: University hospital. PATIENTS: Seventeen HCC patients who underwent preoperative PVE following selective TACE for planned major hepatic resections were enrolled. The indications for PVE were determined using the volumetric ratio of the future remnant liver parenchyma and the indocyanine green retention ratio at 15 minutes. INTERVENTION: Preoperative TACE and PVE. MAIN OUTCOME MEASURES: Tumor characteristics and blood test results before and after TACE and PVE, changes in the volumes of the liver segments after PVE, the feasibility of major hepatic resections, and short- and long-term patient prognoses. RESULTS: The liver function test results transiently worsened after TACE and PVE but returned to baseline levels within 1 (after TACE) or 2 (after PVE) weeks. Within 2 weeks after PVE, 22% +/- 4% hypertrophy of the nonembolized segments was obtained; subsequent major hepatic resections were feasible in 16 patients. Four minor complications (25%) were experienced postoperatively; however, liver failure did not occur. The 5-year overall and disease-free survival rates after curative resection were 55.6% and 46.7%, respectively. CONCLUSIONS: Sequential TACE and PVE contribute to both the broadening of surgical indications and the safety of major hepatic resections performed in HCC patients with damaged livers. The long-term outcome of this treatment strategy is satisfactory.     

Percutaneous portal vein embolization increases the feasibility and safety of major liver resection for hepatocellular carcinoma in injured liver

OBJECTIVE: To assess the influence of preoperative portal vein embolization (PVE) on the long-term outcome of liver resection for hepatocellular carcinoma (HCC) in injured liver. SUMMARY BACKGROUND DATA: On an healthy liver, PVE of the liver to be resected induces hypertrophy of the remnant liver and increases the safety of hepatectomy. On injured liver, this effect is still debated. METHODS: During the study period, 10 patients underwent preoperative PVE and 19 patients did not before resection of three or more liver segments for HCC in injured liver (cirrhosis or fibrosis). PVE was performed when the estimated rate of remnant functional liver parenchyma (ERRFLP) assessed by computed tomographic scan volumetry was less than 40%. RESULTS: In all patients, PVE was feasible. There were no deaths or complications. The ERRFLP after PVE was significantly increased compared with the pre-PVE value. Liver resection was performed after PVE in 9 of 10 patients, with surgical death and complication rates of 0% and 45%, respectively. PVE increased the number of resections of three or more segments by 47% (9/19). Overall actuarial survival rates with or without previous PVE (89%, 67%, and 44% vs. 80%, 53%, and 53% at 1, 3 and 5 years, respectively) and disease-free actuarial survival rates (86%, 64%, and 21% vs. 55%, 17%, and 17% at 1, 3, and 5 years respectively) after hepatectomy were comparable. CONCLUSION: With the use of PVE, more patients with previously unresectable HCC in injured liver can benefit from resection. Long-term survival rates are comparable to those after resection without PVE.