Pre-hepatectomy portal vein embolization: Single center experience

Aim

To evaluate the feasibility and the effectiveness of portal vein embolization (PVE) as preoperative treatment in patients scheduled to undergo right hepatectomy, when the volume of the future remnant liver (FRL) appears to be insufficient to prevent the risk of post-surgical hepatic failure.

Materials and Methods

Thirty-one consecutive patients (19 men, 12 women; age range: 54–77 years; mean age: 66.2 years) with liver malignancy (7 hepatocellular carcinoma, 13 metastases, 9 cholangiocarcinoma, and 2 gallbladder carcinoma) were selected after clinical–radiological evaluation for PVE. After the embolization changes in volume of FRL, portal pressure, liver enzymes, and complications before and after hepatectomy were assessed.

Results

PVE was successful in all patients without major complications. The mean volume of FRL, calculated before and 4 weeks after PVE, increased from 319.2 ± 45.1 to 460.2 ± 27.7 cm³ (+44.2%) in the non-cirrhotic group and from 458.4 ± 38.3 to 605.2 ± 27 cm³ (+32.1%) in the cirrhotic group. The FRL/TELV ratio increased by 9%.

Conclusion

In our experience, PVE resulted feasible, safe, with a very low rate of complications, and effective to induce liver regeneration before right hepatectomy in patients with liver malignancy.     

碘化油阿霉素肝动脉及门静脉支分期栓塞治疗原发性肝癌

Despite recent advances in hepatic surgery, management of unresectable carcinoma of the liver is still a challenging problem. From September 1988 through March 1989, 10 primary liver cancer patients were treated by hepatic artery embolization (HAE) using lipiodol-adriamycin with or without hepatic artery ligation (HAL). One of them received HAE twice in seven weeks. In two of these patients, following right HAE and HAL, right portal vein embolization (PVE) by catheterization via the ileac vein was performed. Transcatheter portal vein embolization via the ileac vein was simple, easy and safe even it was impossible to expose the hepatic hilum. All patients are alive from 7 to 12 months after operation except one who died of hepatic failure after having survived for 54 days. There was marked alleviation of symptoms and tumor shrinkage was observed in 9 out of 10 patients. HAE and PVE using lipiodol-adriamycin may have the potential of improving the therapeutic effect in patients with hepatocellular carcinoma.     

Remnant liver regeneration after two-stage hepatectomy for multiple bilobar colorectal metastases.

AIMS: Two-stage hepatectomy for multiple, bilobar liver metastases from colorectal cancer aimed to minimize liver failure risk by performing the second resection after regeneration, but impact of this strategy on volume of the future liver remnant (FLR) remained to be demonstrated. We compared two-stage hepatectomy with one stage following portal vein embolization (PVE) for multiple, bilobar liver metastases from colorectal cancer as to effects on volume of the FLR. METHODS: Forty-three patients undergoing major hepatectomy for multiple colorectal cancer metastases were divided retrospectively into patients undergoing hepatectomy following PVE (n=21) and those undergoing two-stage hepatectomy (n=22). Increases in FLR volume were compared. RESULTS: While the increase in the volume FLR averaged approximately 70 mL (302.6 mL before PVE vs. 370.9 mL after PVE) and the increase in the ratio of FLR to total liver volume averaged approximately 7.5% (30.2% to 37.5%) following PVE, first-stage hepatectomy increased FLR volume by approximately 100mL (from 259.4 to 361.4), and the ratio, by 15% (26.9% to 41.6%). The FLR hypertrophy ratio relative to pre-procedure volume estimates in the two-stage group (50.2%) was twice that in the PVE group (25.3%). CONCLUSIONS: Superiority of two-stage hepatectomy in hypertrophy of the FLR was confirmed.     

A case report of advanced huge hepatocellular carcinoma (H.C.C.) accompanied by tumor embolism to the inferior caval vein (Vv3) that was treated with surgical extended right lobectomy after multimodal therapy

We performed multimodal therapy for a huge hepatocellular carcinoma with tumor embolism (Vv3), for which excision was judged impossible. After treatment, a hepatectomy to the primary lesion was finally carried out and long-term survival was achieved. A 52-years-old man with right lateroabdominal pain had a huge occupied hepatocellular carcinoma that was detected in October 2000. A tumor embolism, which invaded the inferior vena cava, was also seen. The residual liver was judged to have insufficient capacity for a right hepatic lobectomy. A percutaneous transhepatic portal embolism (PTPE) was carried out against the right portal vein to increase in the left lobe capacity. The chemo-radiotherapy (36 Gy to the right hepatic vein and systemic administration of CDDP) and transcatheter arterial chemoembolization were added to the feeding arteries of the hepatic tumor. When a decrease in the postcaval vein tumor embolism was observed, the extended right hepatic lobectomy was performed. The postoperative course was good, and the patient was discharged from the hospital on postoperative day 41. Though lung metastasis and new lesions in left lobe were seen in a recurrence, two years and ten months since the start of the systemic chemotherapy. This case suggested that even if a huge liver cancer with vascular invasion is judged impossible to excise, multimodal therapy with the aim of surgical treatment helps retain the possibility to later chose hepatectomy for the primary lesion and improve prognosis.     

Who Benefits from Portal Vein Embolization Prior to Major Hepatectomy for Colorectal Cancer Liver Metastases?

Preoperative portal vein embolization (PVE) is used to increase the volume and function of the liver that will remain after major hepatectomy (the future liver remnant, or FLR). This report summarizes evidence supporting the use of PVE in patients with colorectal liver metastases. The safe limits of resection define the indications for PVE based on underlying liver disease—the limit in patients with normal liver is 20% of the standardized total liver volume (TLV); with diseased liver, 30% of TLV; with compensated cirrhosis, 40% of TLV. PVE can convert an inadequate FLR to an FLR sufficient to ensure safe surgery, and the degree of FLR hypertrophy after PVE predicts post-resection liver function. PVE can be safely combined with chemotherapy, including biologic agents, without significant compromise to its efficacy.     

腹腔镜辅助联合肝脏离断和门静脉结扎的二步肝切除术治疗原发性肝癌的安全性和疗效评价

目的探讨腹腔镜辅助联合肝脏离断和门静脉结扎的二步肝切除术（associating liver partition and portal vein ligation for staged hepatectomy , ALPPS ）治疗原发性肝癌的安全性和疗效。方法回顾性分析2013年12月本院收治的一例巨块型肝癌患者以腹腔镜辅助ALPPS方法切除肿瘤的临床资料。第1步在腹腔镜下结扎门静脉右支并离断左肝内外叶;第2步在第1次术后第8天,评估剩余肝脏体积能满足机体要求后行右半肝的扩大切除术,同时对患者围术期的临床指标和随访资料进行分析。结果第1次手术出血50 ml,手术时长225分钟。第2次手术出血700 ml,手术时长335分钟。切除右肝三叶大小约24．0 cm×22．0 cm×15．0 cm,重量2．7 kg,肿瘤大小约18．0 cm×16．0 cm×14．0 cm,残余肝大小约15．0 cm×13．0 cm×8．0 cm。术后病理结果为原发性肝细胞癌。术后患者出现胆漏,经保守治疗后治愈。术后随访2个月,残余肝再生体积达约1200 ml,AFP降至150 ng／ml,未发现肿瘤复发转移。术后随访至32个月,再次评估残余肝再生体积达约1300 ml,AFP 16 ng／ml,未发现肿瘤复发转移,无疾病生存期达32个月。结论腹腔镜辅助ALPPS手术可作为残肝体积不足的一些较晚期肝癌患者的治疗选择。     

Safety and Efficacy of Sequential Transcatheter Arterial Chemoembolization and Portal Vein Embolization prior to Major Hepatectomy for Patients with HCC

Objective: To evaluate the safety and efficacy of sequential transcatheter arterial chemoembolization (TACE)and portal vein embolization (PVE) before major hepatectomy for patients with hepatocellur carcinoma (HCC).Methods: In this retrospective case-control study, data were collected from patients who underwent sequentialTACE and PVE prior to major hemihepactectomy. Liver volumes were measured by computed tomographyvolumetry before TACE, and preoperation to assess degree of future remnant liver (FRL) hypertrophy and tocheck whether intro- or extrohepatic metastasis existed. Liver function was monitored by biochemistry afterTACE, prior to and after major hepatectomy. Results: Mean average FRL volume increased 32.3-71.4% (mean55.4%) compared with preoperative FRL volume. After TACE, liver enzymes were elevated, but returned tonormal in four weeks. During PVE and resection, no patient had intro- or extrohepatic metastasis. Conclusion:Sequential TACE and PVE is an effective method to improve resection opportunity, expand the scope of surgicalresection, and greatly reduce postoperative intra- and extrahepatic metastasis.     

Treatment of Rupture of a Liver Metastasis from Esophageal Leiomyosarcoma

We describe a case of rupture of a liver metastasis from esophagealleiomyosarcoma which was treated successfully by hepatic arterialembolization, thus facilitating hepatectomy. A 59-yearold womanwho had previously undergone esophagectomy for leiomyosarcomawas admitted in a state of hypovolemic shock. Ultrasonographyrevealed multiple tumors in the left lobe of the liver and massiveintraperitoneal hemorrhage, confirmed by paracentesis, possiblydue to spontaneous rupture. Subsequent hepatic angiography showedextravasation from the tumor, and embolization of the feedingleft hepatic artery was performed. After achieving hemostasis,a left hepatic lobectomy was carried out just beneath the reconstructedstomach tube. The patient made an uneventful recovery and remainswell after one year. Emergency arterial embolization followedby hepatectomy is an appropriate treatment for patients withspontaneous rupture of liver metastases.     

Comparative study of right portal vein ligation versus embolisation for induction of hypertrophy in two-stage hepatectomy for multiple bilateral colorectal liver metastases

Aim

In patients with two-stage hepatectomy (TSH) for multiple bilobar liver metastases from colorectal cancer, few clinical series compare functional remnant hypertrophy of the liver volume between right portal vein ligation (PVL) and embolisation (PVE). Our objective is to analyse the effectiveness of portal vein ligation to achieve hypertrophy of the functional remnant volume (FRV) of the liver and to compare the results with portal vein embolisation in a series of patients with multiple bilobar liver metastases from colorectal carcinoma.

Patients and methods

Between September 2001 and September 2011 we performed a TSH in 41 patients with multiple bilobar colorectal liver metastases. A right PVL was performed in 23 patients with an insufficient FRV (three patients did not complete the second stage due to tumour progression and were excluded). We prospectively compare these results with the increased remnant volume obtained in 18 patients with right PVE.

Results

The median FRV was higher in the patients with PVE, rising from 501 ml (range 309–703) to 636 ml (range 387–649), than those with PVL, rising from 510 ml (range 203–824) to 595 ml (range 313–1213) (p < 0.05). The median %FRVI was higher in the patients with PVE (median 40%; range 21–65%) than those with PVL (median 30%; range 21–60%) (p < 0.05).

Conclusions

PVL and PVE were effective in all cases for obtaining hypertrophy of the FRV before major liver resection. Right PVE obtains better results and should be used where necessary to achieve a further increase in volume.     

Extended right-sided liver resection for colorectal liver metastases—impact of percutaneous portal venous embolisation

AimTo compare the outcome after extended right liver lobe resection (ERL) for patients with liver metastases from colorectal cancer with preceding portal vein embolisation (PVE) with a non-PVE-group.MethodsNineteen patients underwent ERL (resection of segment 4–8) for colorectal liver metastases after PVE. They were compared with 21 patients that underwent an ERL without embolisation. A comparison was made with 84 patients undergoing right lobe liver resection during the same time period.Survival, post-operative morbidity and mortality were recorded and the volume of the future remnant liver (FRL) was measured with CT.ResultsThere were major complications in 1/19 patients in the PVE-group and in 6/21 in the non-PVE-group (p=0.04). No post-operative deaths were observed in the PVE-group, compared to three death in the non-PVE-group (p=0.09).The median survival in the PVE-group was 32 months, which did not differ from the non-PVE-group.In 21% of the patients that underwent PVE, progression occurred during the time between embolisation and surgery.There was no difference in survival for patients that underwent PVE followed by ERL, compared to patients that underwent standard right lobe liver resection.ConclusionThe survival of patients after ERL is comparable with patients that undergo standard right lobe resection and have less liver tumour.     

Is preoperative portal vein embolization effective in improving prognosis after major hepatic resection in patients with advanced-stage hepatocellular carcinoma?

BACKGROUND: The impact of the use of preoperative portal vein embolization (PVE) on long-term survival after surgery was evaluated by retrospective analysis of prognostic factors in patients with advanced-stage hepatocellular carcinoma (HCC) who had undergone hepatic resection with or without PVE. METHODS: The portal embolization group (Group P) consisted of 26 patients who had undergone major hepatectomy (more extensive than right hepatectomy) with PVE, and the nonembolized group (Group N) consisted of 43 patients who had undergone major hepatectomy without PVE. All patients were diagnosed with advanced HCC graded as Stage III or IV according to the International Union Against Cancer TNM classification system. Patient survival rates, recurrence rates, and recurrence sites after surgery in the two groups were evaluated and compared. RESULTS: The 1-year, 3-year, and 5-year cumulative disease specific survival rates in patients with TNM Stage III HCC, respectively, were 96.0%, 64.4%, and 52.7% in Group N and 92.9%, 57.1%, and 45.7% in Group P, whereas the corresponding values in patients with Stage IV HCC were 53.5%, 40.1%, and 26.8% in Group N and 63.5%, 50.8%, and 19.1% in Group P. There were no statistically significant differences in survival rates between Group P and Group N. Multivariate analysis showed that PVE was not a significant prognostic factor. The 1-year, 3-year, and 5-year cumulative recurrence rates for patients with both stages of disease combined were 44.1%, 80.2%, and 86.8% in Group N, respectively, and 39.9%, 72.2%, and 72.2% in Group P, respectively, with no statistically significant differences between the two groups. To date, 35 patients in Group N and 16 patients in Group P have had tumor recurrences in the liver remnant; of these, 27 patients in Group N and 12 patients in Group P had multiple recurrence foci in the liver remnant. No significant difference was seen between the two groups; however, 10 of 16 patients in Group P (62.5%) had remote organ metastasis in addition to recurrence in the liver remnant compared with only 6 of 35 patients in Group N (17.1%): This difference was significant statistically (P = 0.012). CONCLUSIONS: PVE during major hepatic resection neither improves nor worsens long-term prognosis but allows resection in a patient group that, otherwise, is considered as unresectable. Remote metastasis involving the lung, bone, or stomach was seen more frequently postoperatively in Group P compared with Group N, raising a possibly important issue regarding the use of this approach for the treatment of patients with hepatic malignancies, especially HCC.     

A pilot study of multimodality therapy for initially unresectable liver metastases from colorectal carcinoma: hepatic resection after hepatic arterial infusion chemotherapy and portal embolization

The prognosis of patients with unresectable liver metastases is poor, even if hepatic arterial infusion chemotherapy (HAI) or systemic chemotherapy is administered. A pilot study was performed to evaluate the feasibility and efficacy of multimodality therapy with hepatectomy after HAI and portal embolization for such patients. Eight patients with colorectal carcinoma and synchronous unresectable liver metastases underwent resection of the primary tumor and placement of a pump, followed by HAI with 5-fluorouracil and mitomycin C. Owing to shrinkage of the liver metastases, two patients could undergo extended right hepatic lobectomy after portal embolization, which was deemed to be essential to prevent post-operative hepatic failure. The median survival time of the eight patients was 30 months, with a response rate of 75%. Complications including sclerosing cholangitis and duodenal ulcer were observed in five patients (63%). Additional hepatectomy could be performed successfully after portal embolization without morbidity in two patients. These two patients are still alive more than 6 years after initiation of HAI and have been free of disease for more than 5 years after hepatectomy. Hepatectomy after HAI and portal embolization is feasible and may be an option to cure selected patients with initially unresectable liver metastases.      

Indications for and limitations of portal vein embolization before major hepatic resection for hepatobiliary malignancy

Portal vein embolization is a promising adjunctive tool in liver surgery; however, the understanding of liver regeneration and PVE is still in its infancy. Refinement in patient selection criteria and methods to evaluate hepatic hypertrophy and function should increase the potential indications for PVE and expand the field of major liver surgery.     

肝动脉栓寒术治疗原发性肝癌的初步报告

Twenty patients with primary hepatic carcinoma (PHC) treated by hepatic arterial embolization in our department from Dec. 1986 to Mar. 1987 are reported. There were 15 males and 5 females. The ages ranged from 34 to 75 years with an average of 50.7. Preoperative diagnosis and localization of the tumor were done by AFP, B-us, CT and angiography (right lobe 15 cases, left lobe 1 case, both lobes 4 cases). Celiac and superior mesenteric angiography was carried out by femoral artery approach and then highly selective hepatic catheterization was utilized for hepatic arterial embolization. Antitumor agent (5-Fu, adriamycin), iophendylate and foamy gel sponge were used for peripheral and proximal embolization. Manifestations were improved in most of the patients after embolization, such as relief of abdominal pain, improvement of appetite, decrease of tumor size. Total necrosis of the tumor was found in 2 patients who underwent surgery 1 month after embolization. The side effects of the posthepatic embolization such as, nausea, vomiting, abdominal pain and fever could be relieved by symptomatic treatment. No severe complications, such as gangrene of the gall bladder, hepatic failure, liver abscess, intestinal necrosis or pulmonary embolization were found except 3 patients who died of renal failure after the procedure. The liver dys-function returned to normal within 2 weeks. Hepatic arterial embolization provides an alternative treatment for the patients with PHC who has compensated liver function without severe systemic diseases, especially renal endocrine problems and severe portal hypertension. They should have patent portal system as proved by angiography. The authors considered that this therapeutic embolization with hepatic chemotherapy infusion is safe and effective in the management of PHC. It may increase the resectability and provide palliative means for the advanced and terminal cases.     

Sequential therapy of portal vein embolization and systemic chemotherapy for locally advanced perihilar biliary tract cancer

BackgroundCurative resection is the only potential treatment for cure in patients with perihilar biliary tract cancer (PBTC). However, post hepatectomy liver failure (PHLF) due to insufficient future liver remnant volume (FRLV) remains a lingering risk even after portal vein embolization (PVE). This study aimed to investigate the feasibility and efficacy of a sequential treatment strategy consisting of PVE followed by preoperative chemotherapy before surgery.MethodsBetween April 2019 and December 2021, 15 patients with locally advanced PBTC (LA-PBTC) underwent sequential treatment consisting of PVE followed by preoperative chemotherapy. The feasibility and efficacy, including resection rate, changes of FRLV, and chemotherapeutic effect, were investigated retrospectively.ResultsThirteen of 15 patients (86.6%) underwent curative resection. The median duration time between PVE and surgery was 144 days. FRLV/TLV ratio was 31.3% at prePVE, 38.4%, at two weeks after PVE, and 45.7% before surgery, respectively. There was significant increase in FRLV/TLV ratio two weeks after PVE. Additional increase in FRLV/TLV ratio was significantly achieved before surgery. PHLF occurred in 5 patients (38.4%). Pathological complete response was found in 2 of 13 patients (15.3%).ConclusionsSequential PVE and systemic chemotherapy contribute to the sufficient hypertrophy of FRLV without compromising resectability in patients with LA-PBTC.     

Salvage parenchymal liver transection for patients with insufficient volume increase after portal vein occlusion – An extension of the ALPPS approach

Background

Portal vein ligation (PVL) or embolization (PVE) are standard approaches to induce liver hypertrophy of the future liver remnant (FLR) prior to hepatectomy in primarily non-resectable liver tumors. However, this approach fails in about one third of patients. Recently, the new “ALPPS” approach has been described that combines PVL with parenchymal transection to induce rapid liver hypertrophy. This series explores whether isolated parenchymal transection boosts liver hypertrophy in scenarios of failed PVL/PVE.

Methods

A multicenter database with 170 patients undergoing portal vein manipulation to increase the size of the FLR was screened for patients undergoing isolated parenchymal transection as a salvage procedure. Three patients who underwent PVL/PVE with subsequent insufficient volume gain and subsequently underwent parenchymal liver transection as a salvage procedure were identified. Patient characteristics, volume increase, postoperative complications and outcomes were analyzed.

Results

The first patient underwent liver transection 16 weeks after failed PVL with a standardized FLR (sFLR) of 30%, which increased to 47% in 7 days. The second patient showed a sFLR of 25% 28 weeks after PVL and subsequent PVE of segment IV, which increased to 41% in 7 days after transection. The third patient underwent liver partition 8 weeks after PVE with a sFLR of 19%, which increased to 37% in six days. All patients underwent a R0 resection.

Conclusion

Failed PVE or PVL appears to represent a good indication for the isolated parenchymal liver transection according to the newly developed ALPPS approach.     

Fast-track two-stage hepatectomy by concurrent portal vein embolization at first-stage hepatectomy in hybrid interventional radiology / operating suite

ObjectivesIn two-stage hepatectomy for bilateral liver metastases, patient dropout between stages is a major issue. We recently proposed a novel approach of fast-track two-staged hepatectomy (FT-TSH), in which patients undergo concurrent first-stage hepatectomy (FSH) with portal vein embolization (PVE) in a hybrid interventional radiology surgical suite. However, its efficacy remains unclear.MethodsPatients with bilateral liver metastases scheduled for FT-TSH at MD Anderson Cancer Center between October 2017 and December 2020 were included on a prospective registry. The effectiveness and feasibility were evaluated.ResultsNineteen patients were scheduled for FT-TSH. Primary site of tumor was colon/rectum in 18 patients and ovary in one patient. Median number of tumors was 10 and median size of largest tumor before surgery was 2.4 cm. Two (11%) patients did not undergo PVE and seventeen patients (89%) completed FSH + PVE. None of the patients had a major complication (Clavien-Dindo grade ≥ III) after FSH + PVE. Median kinetic growth rate after FSH + PVE was 2.9%/week (range 0.8–5.6). Twelve patients (71%) among the seventeen who underwent FSH + PVE proceeded to second-stage hepatectomy, and ten patients (59%) finally completed second-stage hepatectomy. Median interval between stages was 5.6 weeks (4.0–20.1). One patient (10%) had a major morbidity after SSH, and there was no 90-day mortality.ConclusionsFT-TSH is safe and allows for short intervals between hepatectomy stages while achieving favorable liver hypertrophy. Further investigation is needed to evaluate the true efficacy of FT-TSH.     

经导管肝动脉和B超引导下经细针门静脉双重化疗栓塞治疗原发性肝癌

目的　研究经导管肝动脉化疗栓塞 (TACE)联合B超引导下经细针门静脉化疗栓塞(PVE)治疗原发性肝癌的疗效。方法　原发性肝癌 2 0 9例 ,其中TACE 10 4例 ,TACE +PVE 10 5例。结果　TACE组和TACE +PVE组总有效率 (CR +PR)分别为 37.5 %和 5 7.2 % ,差异有显著性 (P <0 .0 1)。门静脉癌栓消失 +缩小率分别为 2 2 .2 %和 6 8.8% ,差异有显著性 (P <0 .0 1)。 1,2 ,3年生存率TACE组分别为 6 5 .1%、36 .3%和 2 0 .5 % ;TACE +PVE组分别为 95 .6 %、5 9.6 %和 39.1% ,两组差异有显著性 (P <0 .0 5 )。结论　经导管肝动脉和B超引导下经细针门静脉双重化疗栓塞治疗原发性肝癌疗效优于单纯TACE。B超引导下经细针PVE操作简便 ,并发症少 ,值得临床推广使用。     

Two-stage hepatectomy: Who will not jump over the second hurdle?

Background

Two-stage hepatectomy uses compensatory liver regeneration after a first noncurative hepatectomy to enable a second curative resection in patients with bilobar colorectal liver metastasis (CLM).

Objective

To determine the predictive factors of failure of two-stage hepatectomy.

Method

Between 2000 and 2010, 48 patients with irresecable CLM were eligible for two-stage hepatectomy. The planned strategy was a) cleaning of the left hepatic lobe (first hepatectomy), b) right portal vein embolisation and c) right hepatectomy (second hepatectomy). Six patients had occult CLM (n = 5) or extra-hepatic disease (n = 1), which was discovered during the first hepatectomy. Thus, 42 patients completed the first hepatectomy and underwent portal vein embolisation in order to receive the second hepatectomy. Eight patients did not undergo a second hepatectomy due to disease progression.

Results

Upon univariate analysis, two factors were identified that precluded patients from having the second hepatectomy: the combined resection of a primary tumour during the first hepatectomy (p = 0.01) and administration of chemotherapy between the two hepatectomies (p = 0.03). An independent association with impairment to perform the two-stage strategy was demonstrated by multivariate analysis for only the combined resection of the primary colorectal cancer during the first hepatectomy (p = 0.04).

Conclusion

Due to the small number of patients and the absence of equivalent conclusions in other studies, we cannot recommend performance of an isolated colorectal resection prior to chemotherapy. However, resection of an asymptomatic primary tumour before chemotherapy should not be considered as an outdated procedure.     

Trans-ileocecal portal vein embolization as a preoperative treatment for right trisegmentectomy with caudate lobectomy

BACKGROUND AND OBJECTIVES: The indication of preoperative portal vein embolization (PVE) has been expanded to hepatocellular carcinoma, cholangiocellular carcinoma (CCC), hepatic metastasis, and gallbladder (GB) cancer as well as hilar cholangiocarcinoma (hCC). However, biliary cancers sometimes cause peritoneal dissemination. PATIENTS AND METHODS: We performed our preoperative trans-ileocecal-vein PVE (TIPE) method on 14 (3 GB cancer, 1 CCC, and 10 hCC), whose estimated residual liver volume was <30%. RESULTS: Out of 14 patients, peritoneal dissemination was encountered in two patients with GB cancer and one with hCC (21.4%) during our procedure. The estimated residual liver volume was 37.4 +/- 2.7% at 14 days after PVE in patients without predisposing cholangitis, while those in patients with cholangitis was 29.3 +/- 1.3% (P = 0.0002). No major complication due to the procedure was encountered in this series. CONCLUSIONS: PTPE could be the first choice for patients with hCC, hepatocellular carcinoma, and hepatic metastases. Although the TIPE proposed here has some potential disadvantages, we would recommend it especially for patients with GB cancer because of its high potential to cause cancerous peritonitis. When a patient had predisposing cholangitis, radical operation should be scheduled on >21 days after PVE rather than on 14 days.