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.     

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.     

Changes in hepatic lobe volume in hepatocellular carcinoma after transcatheter arterial and percutaneous transhepatic portal embolization

BACKGROUND/AIMS: Determining changes in liver volume after preoperative percutaneous transhepatic portal embolization (PTPE) for hepatocellular carcinoma (HCC) is essential in managing the operation safely. We evaluated the alterations in liver volume by means of ultrasonography (US) and computed tomography (CT). METHODOLOGY: We studied 12 patients scheduled for hepatectomy with HCC. Transcatheter arterial embolization (TAE) and PTPE of the right portal vein were performed preoperatively. Liver volume was evaluated before and after PTPE. RESULTS: The volume of the right lobe measured by CT significantly decreased from 709+/-266 cm3 before PTPE to 589+/-209 cm3 18 days after PTPE (P=0.0021). The volume of the left lobe significantly increased from 382+/-97 cm3 to 477+/-84 cm3 (P=0.0008). US volume measurement of the left lateral segment revealed a temporary volume increase 2 days after PTPE and a significant linear correlation between the hypertrophy ratios from 2 to 18 days after PTPE (r=0.946, P<0.0001). CONCLUSIONS: Preoperative PTPE allowed a compensatory volume increase in the remnant liver. A sonographic estimation is useful in confirming the dynamic alteration of liver hypertrophy. Care must be taken for appropriate timing of a CT scan for volume measurements, considering the drawbacks associated with irradiation.     

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)     

Limitation of portal vein embolization for extension of hepatectomy indication in patients with hepatocellular carcinoma

BACKGROUND/AIMS: Although percutaneous trans-hepatic portal vein embolization (PTPE) expands the candidate pool for hepatectomy in patients with hepatobiliary malignancies, the role of PTPE in patients with active hepatitis or cirrhosis has yet to be determined. METHODOLOGY: Records of patients who underwent PTPE of the right portal vein between 1984 and April 2001 were reviewed retrospectively. To determine the indication for PTPE and subsequent hepatectomy, clinical variables, including serum concentrations of hyaluronic acid (HA), procollagen type III peptide (P-III-P), and the 7S domain of type IV collagen (7S-IV), were compared between patients who underwent right hepatectomy (group A; n=44) and the other patients (group B; n=17). RESULTS: The scores for prediction of postoperative liver failure (prediction score) and serum HA and P-III-P concentrations were different in the two groups. Thirteen of 30 patients (43%) whose prediction score was more than 50, the limit of the hepatectomy without PTPE, successfully underwent right hepatectomy following PTPE. The resectability ratios increased to 75% and 100%, when the HA concentration was < or = 100mg/L and the P-III-P concentration < or = 0.7/mL. CONCLUSIONS: Serum HA and P-III-P concentrations are useful guidelines for identifying candidates for right hepatectomy following PTPE.     

Human erythrocyte polyamine levels after portal vein embolization

BACKGROUND/AIMS: Polyamine levels in erythrocytes are related to liver regeneration and could be used as an index of liver regeneration after partial hepatectomy. We investigated liver regeneration after portal vein embolization according to the changes of erythrocyte polyamine levels. METHODOLOGY: Levels of polyamines (putrescine, spermidine, and spermine) in erythrocytes were assayed by high-pressure liquid chromatography for 13 patients with hepatocellular carcinoma after portal vein embolization and 16 patients (8 from group reported earlier) after right bisegmentectomy of the liver for hepatocellular carcinoma. In the first group, embolization preceded surgery by 3 weeks. RESULTS: The mean total polyamine level in erythrocytes and the levels of spermidine and spermine were significantly higher at day 7 after embolization, decreasing later. Spermidine and spermine increased by day 7 after partial hepatectomy, decreasing later. Their mean increase was smaller and more gradual when embolization was done before resection than without embolization. CONCLUSIONS: Embolization causes regeneration of the non-embolized portion of the liver, and embolization before liver resection allows regenerative activities of the liver remaining after resection to be lower than without the embolization.     

A new approach to percutaneous transhepatic portal embolization using ethanolamine oleate iopamidol

Purpose

We aimed to examine the therapeutic efficacy of ethanolamine oleate iopamidol (EOI) as an embolic material for percutaneous transhepatic portal embolization (PTPE).

Methods

Eighty-two patients with liver tumors were treated with PTPE. Fifty-eight patients had hepatocellular carcinomas, 11 had liver metastases, and 13 had other liver tumors. A total of 55 patients (group E) were treated with 5% ethanolamine oleate after gelatin sponge administration. As a control, we evaluated 27 patients (group F) who were treated with fibrin glue and iodized oil. PTPE was mainly indicated before hepatic resection, for patients with high nontumorous volumetric resection ratios (the nontumorous volumetric resection ratio was estimated to be greater than 65% in patients with an indocyanine green retention ratio of 15 min (ICG R15) of 10% or less, and the nontumorous volumetric resection ratio was estimated to be greater than 40% in the patients with an ICG R15 of 10–20%).

Results

All patients were successfully treated percutaneously under local anesthesia. Balloon-occluded and ipsilateral approaches were used in 81 patients (99%) and 62 (75%) patients, respectively. The rate of insufficient embolization or recanalization was significantly lower in group E (7.3%) in comparison to group F (25.9%; p < 0.05). The volumetric resection ratios, before and after PTPE, decreased from 60 to 45% in group E and from 63 to 55% in group F. The post-PTPE resection ratio was significantly decreased in group E. Before and after PTPE, average ICG R15 values changed from 17 to 27% in group E and from 18 to 26% in group F. The complication rates in groups E and F were similar (7.3 vs. 7.4%).

Conclusion

EOI is a safe embolic material that can be used to induce greater liver hypertrophy, in comparison to fibrin glue, in PTPE for liver tumors.     

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.     

Evaluation of liver function for the application of preoperative portal vein embolization on major hepatic resection

BACKGROUND/AIMS: Although preoperative portal vein embolization has been employed for hepatectomy to increase the safety of the surgery, patient selection criteria for hepatectomy following portal vein embolization have still not been established. In this study liver functional tests before and after portal vein embolization were evaluated in order to determine their influence on the outcome of subsequent hepatectomy and the prognostic potential of this approach. METHODOLOGY: Forty-five patients, who had undergone major hepatic resection after embolizing the right portal branch, were divided into the following 3 groups according to their postoperative course: complication(-), complication(+), and liver failure group. Clinical, analytical, and hemodynamic parameters obtained before and after portal vein embolization were compared between the three groups. RESULTS: Significant differences were found between the complication(-) group and the liver failure group for 8 factors, and statistically significant cut-off points distinguishing the liver failure group could be determined. Based upon values measured before PVE these were: 1) portal pressure > 16 cmH2O; 2) pre-PVE serum cholinesterase < 160 U/L; 3) pre-PVE serum hyaluronate > 130 ng/mL. Based on values measured after PVE they were: 1) a hypertrophic ratio of the left lobe < 1.21; 2) post-PVE ICGR15 (%) > 16%; 3) a portal pressure measured immediately after PVE > 25 cmH2O; 4) post-PVE serum cholinesterase < 160 U/L; 5) post-PVE serum hyaluronate > 160 ng/mL. Discriminant function analysis in a stepwise manner showed that the portal pressure and serum levels of hyaluronate measured before and after portal vein embolization were the most useful in prediction of the outcome of the following hepatectomy. CONCLUSIONS: Patients whose data match the above criteria before portal vein embolization should be excluded as candidates for major hepatic resection with portal vein embolization. Even after portal vein embolization in patients whose data match post-portal vein embolization criteria major hepatic resection may have to be abandoned, or the extent of the hepatic resection reconsidered.     

Usefulness of measuring hepatic functional volume using Technetium-99m galactosyl serum albumin scintigraphy in bile duct carcinoma: report of two cases

We report the usefulness of measuring functional liver volume in two patients undergoing hepatectomy. Case 1 involved a 47-year-old man with hepatitis B virus infection. The indocyanine green test retention rate at 15 min (ICGR15) was 14%. Liver uptake ratio (LHL15) by technetium-99 m galactosyl human serum albumin (^99mTc-GSA) liver scintigraphy was 0.91. The patient displayed hilar bile duct carcinoma necessitating right hepatectomy. After preoperative portal vein embolization (PVE), future remnant liver volume became 54% and functional volume by ^99mTc-GSA became 79%. Although the permitted resected liver volume was lower than the liver volume, scheduled hepatectomy was performed following the results of functional liver volume. Case 2 involved a 75-year-old man with diabetes. ICGR15 was 27.4% and LHL15 was 0.87. The patient displayed bile duct carcinoma located in the upper bile duct with biliary obstruction in the right lateral sector. The right hepatectomy was scheduled. After PVE, future remnant volume became 68% and functional volume became 88%. Although ICGR15 was worse as 31%, planned hepatectomy was performed due to the results of functional volume. In the liver with biliary obstruction or portal embolization, functional liver volume is decreased more than morphological volume. Measurement of functional volume provides useful information for deciding operative indication.     

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.     

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.     

Hepatic clearance measured with 99mTc-GSA single-photon emission computed tomography to estimate liver fibrosis

AIM: To evaluate the clinical utility of hepatic clearance(HC) measured with technetium-99m-diethylenetriaminepenta-acetic acid-galactosyl human serum albumin(99mTc-GSA) single-photon emission computed tomography(SPECT) to estimate the degree of liver fibrosis.METHODS:Seventy-eight consecutive patients who underwent initial hepatectomy due to hepatocellular carcinoma were enrolled in this study.Indocyanine green clearance(ICG R15),quantitative indices estimated by 99mTc-GSA[the receptor index(LHL15 and HH15)and HC via SPECT analysis],and conventional liver function tests were performed before hepatectomy.Correlations among the quantitative indices for liver functional reserve,conventional liver function tests,andthe degree of liver fibrosis were evaluated.RESULTS:The degree of liver fibrosis was correlated with ICG R15,HH15,LHL15,and HC.HC showed the best correlation with conventional liver function tests.According to multivariate analysis,HC and LHL15 were significant independent predictors of severe fibrosis.HC was the most valuable index for predicting severe fibrosis.CONCLUSION:HC measured with 99mTc-GSA SPECT is a reliable index for assessing liver fibrosis before hepatectomy.     

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.     

Mechanism of liver regeneration after liver resection and portal vein embolization (ligation) is different?

Whether or not liver regeneration after portal branch embolization (PE) (ligation, PVL) in the non-embolized (ligated) lobe is by the same mechanism as regeneration in the remnant lobe after liver resection has been reviewed. Portal vein branch embolization and heat shock protein are then discussed. Tumor growth accelerated in the remnant liver after hepatectomy. In contrast, PE or PVL resulted in marked contralateral hepatic hypertrophy and significant reduction of tumor growth in the non-embolized (non-ligated) lobes. Follistatin administration significantly increased liver regeneration after hepatectomy in rats. In contrast, regeneration of non-ligated lobes after PVL was not accelerated by exogenous follistatin. Tumor growth also was not accelerated. The liver regeneration rate peaked at 48–72 h in the nonligated lobe after PVL, a delay of 24 h compared with the remnant liver after hepatectomy. In the postoperative early stage, the expression of activin βA, βC, and βE mRNAs was stronger in PVL than in hepatectomy. At 72 h the expression of activin receptor type IIA mRNA reached a peak in hepatectomy, but was significantly lower in PVL. Thus, regulation of activin signaling through receptors is one of the factors determining liver regeneration after hepatectomy and PVL. These serial experimental results imply that the mechanism of liver regeneration after portal branch ligation (embolization) is different from that after hepatectomy. Heat shock protein was induced in the liver experimentally by intermittent ischemic preconditioning and could play some beneficial role in the recovery of liver function after hepatectomy, even in cirrhotic patients. When heat shock protein following right portal vein embolization in both the embolized and non-embolized hepatic lobes was investigated in clinical cases, a two to fourfold increase in HSP70 was induced in the non-embolized lobe compared with the embolized lobe. Oral administration of geranylgeranylacetone (a non-toxic HSP inducer) suppressed inflammatory responses and improved survival after 95% hepatectomy by induction of HSP70 in rats.     

Effects of portal vein embolization before major hepatectomy

BACKGROUND/AIMS: Major hepatectomy can now be successfully performed after portal vein embolization, but the effects of portal vein embolization have not been clearly delineated. Our objective is to examine whether portal vein embolization really contributes to the success of major hepatectomy. METHODOLOGY: Thirty-eight patients underwent portal vein embolization and hepatectomy of two subsegments or more. They all belonged to a high-risk group according to a prognostic score. We selected 9 of 38 patients with liver metastases (PE-meta group) and 32 patients who had undergone hepatectomy without portal vein embolization (non-PE-meta group) during the study period to compare the serum levels of total bilirubin after hepatectomy. Fifteen of 38 patients had the levels of polymorphonuclear leukocyte elastase and thrombin-antithrombin complex examined after hepatectomy (PE group) and so did 20 patients without portal vein embolization (non-PE group). RESULTS: The maximum levels of total bilirubin in non-PE-meta group correlated with the percentage of hepatic parenchyma to be resected. In the patients receiving portal vein embolization, the pre-PE and post-PE levels were both below the regression. Similar shifts were seen in the graphs of polymorphonuclear leukocyte elastase and thrombin-antithrombin complex. CONCLUSIONS: The effects of preoperative portal vein embolization on safety in major hepatectomy were proved by its suppression of rise in total bilirubin, polymorphonuclear leukocyte elastase and thrombin-antithrombin complex after hepatectomy.     

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.     

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.     

Morphological and functional changes after portal vein occlusion in rats

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

Portal embolization in various types of liver: novel variables to predict hypertrophy

BACKGROUND/AIMS: The aim of this study was to investigate the hypertrophic effect of portal embolization in various types of liver and clarify useful variables, for predicting efficacy of portal embolization. METHODOLOGY: Portal embolization was performed for 46 patients with hepatocellular carcinoma (n = 30), biliary tract cancer (n = 9), or metastatic liver tumors (n = 7). The hypertrophic effect of portal embolization in relation to diseases, clinical liver conditions, histological fibrosis, and liver function were examined. RESULTS: The hypertrophic effect of portal embolization was impaired in the patients with hepatocellular carcinoma, chronic hepatitis/cirrhotic liver, and advanced liver fibrosis. ICGR15 (indocyanine green dye retention rate at 15 minutes) was revealed to be an independent adverse predicting factor. Especially in hepatocellular carcinoma patients, platelet count was significantly correlated with the hypertrophy ratio. In patients who underwent major hepatectomy for hepatocellular carcinoma, not only the incidences of posthepatectomy liver failure but also survival rate were similar between patients with and without portal embolization, although patients with portal embolization originally had a limited liver function. CONCLUSIONS: Preoperative portal embolization made major hepatectomy possible in hepatocellular carcinoma patients, although portal embolization was less effective compared with other diseases. ICGR15 and platelet count may be novel variables to predict the hypertrophic effect of portal embolization in all and hepatocellular carcinoma patients, respectively.