Close relation between the inferior vena cava ligament and the caudate lobe in the human liver

Background/Purpose

This study was conducted to clarify the real relation between the inferior vena cava (IVC) ligament and the caudate lobe in the human liver and also to elucidate their surgical importance in liver surgery.

Methods

Specimens obtained from 20 adult cadaveric livers were submitted for the study. Histological structures of the IVC ligament and its relationship to the caudate lobe and the IVC were microscopically investigated.

Results

The IVC ligament was a broad membranous connective tissue bridging the left and right side edges of the caval groove in which the IVC was embedded. At both edges of the caval groove, the IVC ligament was continuously transformed from the Glisson's capsules of the caudate and right lobes. The component of the portal triad, which originated from that of caudate lobe, and lymphatics were distributed in the IVC ligament without exception and ectopic hepatocytes existed in it in 4 of the 20 cases.

Conclusions

A close relation between the IVC ligament and the caudate lobe was confirmed. The findings suggested that the IVC ligament is a kind of degenerated hepatic tissue. When dissecting it, surgeons should manipulate it carefully to prevent unexpected bleeding and bile leakage.

     

Morphometric analysis of caudate veins for advanced liver surgery

Background

Accurate knowledge of the surgical anatomy of the caudate lobe is indispensable in the performance of liver surgery. Although previous cast studies have provided much useful overall information about the locations of the caudate veins, little is known about how to establish the exact locations of the caudate and short hepatic veins prior to surgery.

Objectives

This study was conducted as a practical morphometric analysis of the caudate veins using preoperative enhanced computed tomography (CT) and intraoperative ultrasound (IOUS).

Methods

From July 2003 to October 2005, 116 donor hepatectomies were performed for adult living donor liver transplantation. The numbers and locations of visible caudate veins were examined pre- and intraoperatively using CT and IOUS.

Results

In the 116 patients, a total of 152 caudate veins were detected, which were classified as being of either typical (n = 135) or non-typical (n = 17) type. One caudate vein was detectable in 83 patients (72%), two in 30 patients (26%) and three in three patients (3%). A total of 67% of caudate veins detected by IOUS and 70% detected by CT were located on the ventral 60 ° of the inferior vena cava (IVC). The remaining veins were scattered on both lateral sides.

Conclusions

Preoperative CT and IOUS were useful in providing morphometric information of sizable caudate veins. Precise information on these veins is essential for the safe dissection of the caudate lobe from the IVC in advanced liver surgery.     

Hepatic artery reconstruction first for the treatment of hilar cholangiocarcinoma bismuth type IIIB with contralateral arterial invasion: a novel technical strategy

Background

En-bloc liver resection with the extrahepatic bile duct is mandatory to obtain tumour-free surgical margins and better long-term outcomes in hilar cholangiocarcinoma (CC). One of the most important criteria for irresectability is local extensive invasion to major vessels. As hilar CC Bismuth type IIIB often requires a major left hepatic resection, the invasion of the right hepatic artery (RHA) usually contraindicates this procedure.

Methods

The authors describe a novel technique that allowed an oncological resection in two patients with hilar CC Bismuth type IIIB and contralateral arterial invasion. Arterial reconstruction between the posterior branch of the RHA and the left hepatic artery (LHA) was performed as the first surgical step. Once arterial vascular flow was restored, a left trisectionectomy with caudate lobe resection and portal vein reconstruction was performed.

Results

In both patients an R0 resection was achieved. Both patients made a full recovery and were discharged within 14 days of surgery. Both patients remain free of disease at 18 months.

Conclusions

This new technique allows a R0 resection to be achieved in patients with Bismuth type IIIB hilar CC with contralateral arterial involvement.     

The use of biological grafts for reconstruction of the inferior vena cava is a safe and valid alternative: results in 32 patients in a single institution

Background

Resection and reconstruction of the inferior vena cava (IVC) is occasionally required in the surgical treatment of intra-abdominal tumours. IVC reconstruction can be performed with biological or synthetic graft material, with most centres preferring synthetic grafts. In spite of the potential advantages of biological grafts in terms of handling characteristics, and safety, very limited data are available about their use in patients requiring an IVC resection.

Methods

Medical records of 32 patients who underwent an IVC resection and reconstruction from 1990 and 2011 with autogenous peritoneo-fascial (N = 22) and bovine pericardial (N = 10) grafts were reviewed.

Results

A tangential resection with patch repair was performed in 10 patients, whereas in the remaining 22 it was necessary to resect and replace a segment or all of the retrohepatic IVC. A concomitant liver resection was performed in 14 patients, nephrectomy in 10 and pancreaticoduodenectomy in 2 patients. There were no acute or late complications related to graft thrombosis or infection. Three patients died as a consequence of multi-organ failure. Overall survival at 1 and 5 years was 78% and 48%, respectively.

Conclusions

The preferential use of synthetic grafts in IVC replacement is not evidence based. Selection of an appropriate prosthetic graft for IVC reconstruction should be based on the safety and its handling features. The use of biological grafts for IVC repair is a valid alternative to current synthetic materials and may in fact be superior in terms of biocompatability, ease of handling, reduced rate of infection and improved long-term patency without permanent anticoagulation.     

Feasibility of bloodless liver resection using Lumagel, a reverse thermoplastic polymer, to produce temporary, targeted hepatic blood flow interruption

Background

Lumagel, a reverse thermosensitive polymer (RTP), provides targeted flow interruption to the kidney by reversibly plugging segmental branches of the renal artery, allowing blood-free partial nephrectomy. Extending this technology to the liver requires the development of techniques for temporary occlusion of the hepatic artery and selected portal vein branches.

Methods

A three-phased, 15 swine study was performed to determine feasibility, techniques and survival implications of using Lumagel for occlusion of inflow vessels to targeted portions of the liver. Lumagel was delivered using angiographic techniques to sites determined by pre-operative 3-D vascular reconstructions of arterial and venous branches. During resection, the targeted liver mass was resected without vascular clamping. Three survival swine were sacrificed at 3 weeks; the remainder at 6 weeks for pathological studies.

Results

Six animals (100%) survived, with normal growth, blood tests and no adverse events. Three left lateral lobe resections encountered no bleeding during resection; one right median resection bled; two control animals bled significantly. Pre-terminal angiography and autopsy showed no local pathology and no remote organ damage.

Conclusions

Targeted flow interruption to the left lateral lobe of the swine liver is feasible and allows resection without bleeding, toxicity or pathological sequelae. Targeting the remaining liver will require more elaborate plug deposition owing to the extensive collateral venous network.     

Aggressive combined resection of hepatic inferior vena cava, with replacement by a ringed expanded polytetrafluoroethylene graft, in living-donor liver transplantation for hepatocellular carcinoma beyond the Milan criteria

Background/purpose

We present the cases of two patients with hepatocellular carcinoma (HCC) beyond the Milan criteria (MC) who underwent living-donor liver transplantation (LDLT) combined with aggressive hepatic venacaval resection and replacement of the hepatic inferior vena cava (IVC) by an artificial vascular graft. The aim of the resection and replacement of the hepatic IVC was to resect completely a latent cancer adjacent to the hepatic IVC and to avoid micrometastasis via the hepatic veins during increased manipulation of the native liver with HCC.

Methods

First, the hepatic hilus was dissected and the infrahepatic IVC was encircled. After minimum mobilization of the liver, the common orifice of the middle and left hepatic veins and suprahepatic IVC was encircled. Venovenous bypass (VVB) was started to stabilize systemic hemodynamics. After cross-clamping of the infrahepatic and suprahepatic IVC, the IVC was divided at the site just below the confluence of the common orifice of the middle and left hepatic veins and its infrahepatic site. Then, all retroperitoneal attachments of the right lobe were dissected and the native liver was resected with the retrohepatic IVC. The IVC was replaced by a ringed expanded polytetrafluoroethylene (e-PTFE) graft. Infrahepatic venous recirculation ended the VVB. An extended left-lobe graft was implanted. The e-PTFE grafts were covered with the greater omentum to avoid infection.

Results

The operations were completed safely. The postoperative courses were free of complications related to the reconstruction of the hepatic IVC. One patient developed recurrence in the left adrenal gland.

Conclusion

LDLT combined with hepatic venacaval resection and replacement by an e-PTFE graft for HCC beyond the MC could be safe and feasible under VVB. Further studies are needed to confirm to what extent this procedure could prevent post-transplant recurrence in HCC beyond the MC.     

Systematic review and meta-analysis of the role of vascular resection in the treatment of hilar cholangiocarcinoma

Background

The management of hilar cholangiocarcinoma has evolved over time and extended liver resection, including the caudate lobe, and major vascular resection and extended lymphadenectomy have become established practice. The benefit of vascular resection has not been investigated.

Methods

A systematic search of the MEDLINE and EMBASE databases was used to identify studies. A systematic review and a meta-analysis of the available studies were conducted according to PRISMA guidelines. Odds ratios were calculated using the Mantel–Haenszel method. Primary outcome variables assessed included morbidity, mortality, vascular complications and the effect of vascular resection on longterm survival.

Results

Of 411 search results, only 24 studies reported the results of vascular resection in hilar cholangiocarcinoma. Meta-analysis showed increased morbidity and mortality with hepatic artery resection. Portal vein resection was achievable with no impact on postoperative mortality. Vascular resection did not improve negative margin rates and had no impact on longterm survival.

Conclusions

Portal vein resection does not preclude curative resection; however, it is not routinely recommended unless there is suspicion of tumour invasion. There was no proven survival advantage with portal vein resection. Arterial resection results in higher morbidity and mortality with no proven benefit.     

Anatomic hepatectomy as a definitive treatment for hepatolithiasis: a cohort study

Background

Treatment requirements in hepatolithiasis may vary and may involve a multidisciplinary approach. Surgical resection has been proposed as a definitive treatment.

Objectives

This study aimed to evaluate the clinical results of anatomic liver resection among Chilean patients with hepatolithiasis.

Methods

An historical cohort study was conducted. Patients who underwent hepatectomy as a definitive treatment for hepatolithiasis from January 1990 to December 2010 were included. Patients with a preoperative diagnosis of cholangiocarcinoma were excluded. Preoperative, operative and postoperative variables were evaluated.

Results

A total of 52 patients underwent hepatectomy for hepatolithiasis. The mean ± standard deviation patient age was 49.8 ± 11.8 years (range: 24–78 years); 65.4% of study subjects were female. A total of 75.0% of subjects had a history of previous cholecystectomy. The main presenting symptom was abdominal pain (82.7%). Hepatic involvement was noted in the left lobe in 57.7%, the right lobe in 34.6% and bilaterally in 7.7% of subjects. The rate of postoperative clearance of the biliary tree was 90.4%. Postoperative morbidity was 30.8% and there were no postoperative deaths. Three patients had recurrence of hepatolithiasis, which was associated with Caroli''s disease in two of them. Overall 5-year survival was 94.5%.

Conclusions

Anatomic liver resection is an effective treatment in selected patients with hepatolithiasis and is associated with low morbidity and no mortality. At longterm follow-up, anatomic hepatectomy in these patients was associated with a lower rate of recurrence.     

Hepatic resection for metastatic endometrioid carcinoma

Background:

The role of hepatic resection for gynaecological tumours is not well defined as evidence on the subject is lacking. This article describes a tertiary hepatopancreatobiliary unit''s experience with hepatic resection for liver metastases from endometrioid primaries.

Methods:

Five women in whom liver metastases developed at 11 months to 10 years post-primary resection are presented. These patients subsequently underwent hepatic resection with disease-free survival of 8–66 months post-resection.

Results:

Outcomes in this patient series support hepatic resection in the face of isolated liver metastasis.

Conclusions:

The authors advocate that patients with hepatic deposits should be referred to specialist hepatobiliary units with a view towards hepatic resection and a subsequent good outcome.     

Hepatocellular adenoma: an excellent indication for laparoscopic liver resection

Objectives

Laparoscopic resection for benign liver disease has gained wide acceptance in recent years and hepatocellular adenoma (HA) seems to be an appropriate indication. This study aimed to discuss diagnosis and treatment strategies, and to assess the feasibility, safety and outcomes of pure laparoscopic liver resection (LLR) in a large series of patients with HA.

Methods

Of 88 patients who underwent pure LLR, 31 were identified as having HA. Diagnosis was based on radiological evaluation and resections were performed for lesions measuring >5.0 cm.

Results

The sample included 29 female and two male patients. Their mean age was 33.2 years. A total of 27 patients had a single lesion, one patient had two and one had four lesions. The two remaining patients had liver adenomatosis. Mean tumour size was 7.5 cm. Three right hepatectomies, 17 left lateral sectionectomies and 11 wedge resections or segmentectomies were performed. There was no need for blood transfusion or conversion to open surgery. Postoperative complications occurred in two patients. Mean hospital stay was 3.8 days.

Conclusions

Hepatocellular adenoma should be regarded as an excellent indication for pure LLR. Pure LLR is safe and feasible and should be considered the standard of care for the treatment of HA when performed by surgeons with experience in liver and laparoscopic surgery.     

Is Endoscopic Mucosal Resection a Sufficient Treatment for Low-Grade Gastric Epithelial Dysplasia?

Background/Aims

The rate of diagnosis of gastric adenoma has increased because esophagogastroduodenoscopy is being performed at an increasingly greater frequency. However, there are no treatment guidelines for low-grade dysplasia (LGD). To determine the appropriate treatment for LGD, we evaluated the risk factors associated with the categorical upgrade from LGD to high grade dysplasia (HGD)/early gastric cancer (EGC) and the risk factors for recurrence after endoscopic treatment.

Methods

We compared the complication rates, recurrence rates, and remnant lesions in 196 and 56 patients treated with endoscopic submucosal dissection (ESD) and endoscopic mucosal resection (EMR), respectively, by histologically confi rming low-grade gastric epithelial dysplasia.

Results

The en bloc resection rate was significantly lower in the EMR group (31.1%) compared with the ESD group (75.0%) (p<0.001). However, no significant difference was observed in the prevalence of remnant lesions or recurrence rate (p=0.911) of gastric adenoma. The progression of LGD to HGD or EGC caused an increase in the incidence of tumor lesions >1 cm with surface redness and depressions.

Conclusions

For the treatment of LGD, EMR resulted in a higher incidence of uncertain resection margins and a lower en bloc resection rate than ESD. However, there was no signifi cant difference in recurrence rate.     

Results of chest wall resection and reconstruction in 162 patients with benign and malignant chest wall disease

Background

Chest wall resection is a complicated treatment modality with significant morbidity. The purpose of this study is to report our experience with chest wall resections and reconstructions.

Methods

The records of all patients undergoing chest wall resection and reconstruction were reviewed. Diagnostic procedures, surgical indications, the location and size of the chest wall defect, performance of lung resection, the type of prosthesis, and postoperative complications were recorded.

Results

From 1997 to 2008, 162 patients underwent chest wall resection.113 (70%) of patients were male. Age of patients was 14 to 69 years. The most common indications for surgery were primary chest wall tumors. The most common localized chest wall mass has been seen in the anterior chest wall. Sternal resection was required in 22 patients, Lung resection in 15 patients, Rigid prosthetic reconstruction has been used in 20 patients and nonrigid prolene mesh and Marlex mesh in 40 patients. Mean intensive care unit stay was 8 days. In-hospital mortality was 3.7 % (six patients).

Conclusions

Chest wall resection and reconstruction with Bone cement sandwich with mesh can be performed as a safe and effective surgical procedure for major chest wall defects and respiratory failure is lower in prosthetic reconstruction patients than previously reported (6).     

Randomized clinical trial of local infiltration plus patient-controlled opiate analgesia vs. epidural analgesia following liver resection surgery

Objectives

Epidural analgesia is recommended for the provision of analgesia following major abdominal surgery. Continuous local anaesthetic wound infiltration may be an effective alternative. A prospective randomized trial was undertaken to compare these two methods following open liver resection. The primary outcome was length of time required to fulfil criteria for discharge from hospital.

Methods

Patients undergoing open liver resection were randomized to receive either epidural (EP group) or local anaesthetic wound infiltration plus patient-controlled opiate analgesia (WI group) for the first 2 days postoperatively. All other care followed a standardized enhanced recovery protocol. Time to fulfil discharge criteria, pain scores, physical activity measurements and complications were recorded.

Results

Between August 2009 and July 2010, 65 patients were randomized to EP (n= 32) or WI (n= 33). The mean time required to fulfil discharge criteria was 4.5 days (range: 2.5–63.5 days) in the WI group and 6.0 days (range: 3.0–42.5 days) in the EP group (P= 0.044). During the first 48 h following surgery, pain scores were significantly lower in the EP group both at rest and on movement. Resting pain scores within both groups were rated as mild (range: 0–3). There was no significant difference between the groups in time to first mobilization or overall complication rate (48.5% in the WI group vs. 58.1% in the EP group; P= 0.443).

Conclusions

Local anaesthetic wound infiltration combined with patient-controlled opiate analgesia reduces the length of time required to fulfil criteria for discharge from hospital compared with epidural analgesia following open liver resection. Epidural analgesia provides superior analgesia, but does not confer benefits in terms of faster mobilization or recovery.     

Resection of hilar cholangiocarcinoma with left hepatectomy after pre-operative embolization of the proper hepatic artery

Background:

Right or right-extended hepatectomy including the caudate lobe is the most common treatment for hilar cholangiocarcinoma (HC). A 5-year survival of up to 60% can be achieved using this procedure if R0-resection is obtained. However, for some patients a left-sided liver resection is necessary to obtain radical resection. The close relationship between the right hepatic artery and the HC in these patients frequently limits the ability to achieve a radial R0-resection without difficult vascular reconstruction. The aim of the present study was to describe the outcome of patients who underwent pre-operative embolization of the proper hepatic artery in an effort to induce development of arterial collaterals thus allowing the resection of the proper and right hepatic artery without vascular reconstruction.

Methods:

In patients presenting with HC who were considered to require a left hepatic lobectomy and in whom pre-operative work up revealed possible tumour invasion of the right hepatic artery, transcatheter arterial embolization (TAE) of the proper hepatic artery or the left and right hepatic arteries was performed. Three weeks later, a left-sided hepatectomy with resection of all portal structures except the portal vein was performed.

Results:

In six patients, pre-operative embolization of the proper hepatic artery was performed. Almost instantaneously in all six patients arterial flow signals could be detected in the liver using Doppler ultrasonography. No patient died peri-operatively. In all six patients an R0 radial resection was achieved and in three an R0 proximal transection margin was obtained. All post-operative complications were managed successfully using percutaneous drainage procedures. No patient developed local recurrence and two patients remain disease free more than 7 years after surgery.

Summary:

After pre-operative embolization of the proper hepatic artery, resection of the HC with left hepatectomy is a promising new approach for these technically demanding patients, giving them the chance of a cure.     

Hepatic resection for non-colorectal, non-neuroendocrine, non-sarcoma metastasis: a single-centre experience

Background

The aim of the present study was to analyse the outcome after hepatic resection for non-colorectal, non-neuroendocrine, non-sarcomatous (NCNNNS) metastatic tumours and to identify the factors predicting survival.

Methods

All patients who underwent hepatic resection for NCNNNS metastatic tumours between September 1996 and June 2009 were included. Patients'' demographics, clinical and histopathological parameters, overall survival and the factors predicting survival were analysed.

Results

In all, 65 patients underwent hepatic resection for metastasis. The most common site of a primary tumour was the kidney (24 patients). Fifteen patients had synchronous tumours. Fifty patients had major liver resections and 22 patients had bilobar disease. The median number of liver lesions resected was 1 and the median maximum diameter of the metastasis was 6 cm. A R0 resection was performed in 51 patients. The 1-, 3- and 5-year overall survival from the time of metastasectomy was 72.9%, 47.9% and 25.6%, respectively, with a median survival of 19 months. The presence of a tumour of greater than 6 cm (P = 0.048) and a positive resection margin (P = 0.04) were associated with poor survival.

Conclusion

Hepatic resection for metastasis from NCNNNS tumours can offer acceptable long-term survival in selected patients. To offer a chance of a cure a R0 resection must be performed.     

The measurement of liver resection margins

Background

All tissue shrinks to some degree when placed in formalin fixative solution. The degree of shrinkage of liver tissue has particular relevance to the measurement of resection margins, as the current recommendation is that the surgeon should aim to achieve a resection margin of at least 1 cm. We were unable to find any published data concerning shrinkage of liver tissue in formalin. The aim of this study was therefore to quantify the shrinkage of liver specimens in the fixation process.

Methods

Distances of 10, 30 and 50 mm were measured and marked on 18 fresh liver specimens. The specimens were then fixed in 10% formalin solution for 24 h, and the distances were re-measured to assess shrinkage.

Results

The observed shrinkage at all three distances was <10% after 24 h in formalin. The degree of shrinkage was statistically significant.

Conclusion

Although the degree of shrinkage is small, it may be important when considering resection margins of the order of 1 cm and should therefore be taken into account.     

Role of quantification of hepatic steatosis and future remnant volume in predicting hepatic dysfunction and complications after liver resection for colorectal metastases: a pilot study

Objectives

Accurate prediction of safe remnant liver volume to minimize complications following liver resection remains challenging. The aim of this study was to assess whether quantification of steatosis improved the predictive value of preoperative volumetric analysis.

Methods

Thirty patients undergoing planned right or extended right hemi-hepatectomy for colorectal metastases were recruited prospectively. Magnetic resonance imaging was used to assess the level of hepatic steatosis and future remnant liver volume. These data were correlated with data on postoperative hepatic insufficiency, complications and hospital stay. Correlations of remnant percentage, remnant mass to patient mass and remnant mass to body surface area with and without steatosis measurements were assessed.

Results

In 10 of the 30 patients the planned liver resection was altered. Moderate–severe postoperative hepatic dysfunction was seen in 17 patients. Complications arose in 14 patients. The median level of steatosis was 3.8% (range: 1.2–17.6%), but was higher in patients (n= 10) who received preoperative chemotherapy (P= 0.124), in whom the median level was 4.8% (range: 1.5–17.6%). The strongest correlation was that of remnant liver mass to patient mass (r= 0.77, P < 0.001). However, the addition of steatosis quantification did not improve this correlation (r= 0.76, P < 0.001).

Conclusions

This is the first study to combine volumetric with steatosis quantifications. No significant benefit was seen in this small pilot. However, these techniques may be useful in operative planning, particularly in patients receiving preoperative chemotherapy.     

Tumour growth after portal vein embolization with pre-procedural chemotherapy for colorectal liver metastases

Background

For resection of colorectal cancer (CRC) liver metastases, pre-operative portal vein embolization (PVE) is used to increase the size of the future liver remnant (FLR) prior to advanced liver resection when indicated. PVE is speculated to cause tumour progression, but only a limited number of studies have analysed tumour growth after PVE in the context of pre-procedural chemotherapy, which was the aim of this retrospective study.

Methods

Patients treated with stabilizing chemotherapy and PVE before liver resection for CRC metastases were included. Tumour progression according to RECIST guidelines and a change in tumour volume was analysed on computed tomography (CT) scans prior to chemotherapy, before PVE and after PVE, respectively.

Results

Thirty-four patients were included, of whom 23 had bilobar disease. Of tumours in the embolized lobe, 3/34 showed progression after PVE as compared with 3/23 in the non-embolized lobe (P = 0.677). A decrease in tumour volume of 16% and 11% was noted in the embolized and non-embolized lobe, respectively (P = 0.368). Patients were off chemotherapy in a median of 16 days before PVE. There was a linear correlation between the growth of tumours and time between the end of chemotherapy and PVE (r = 0.25, P = 0.0005).

Conclusion

The rate of progression of CRC liver metastases after PVE and pre-procedural chemotherapy was lower in the present study as compared with previous reports. This applies to tumours in both the embolized and non-embolized lobes and is associated with keeping the time between the end of chemotherapy and PVE short.     

Safety and efficacy of preoperative right portal vein embolization in patients at risk for postoperative liver failure following major right hepatectomy

Background

Right portal vein embolization (RPVE) has been utilized with or without segment IV (RPVE + IV) prior to hepatectomy to induce hypertrophy and prevent liver insufficiency in patients with a predicted future liver remnant (FLR) of ≤30% or cirrhosis.

Methods

Records of patients who underwent RPVE during 2006–2010 were retrospectively reviewed. Patient demographics, operative outcomes and complications were analysed. Computed tomography-based volumetrics were performed to determine FLR volume and degree of hypertrophy. Patients were stratified by segment IV embolization. Short-term outcomes following RPVE and liver resection are reported.

Results

A total of 23 patients were identified. Ten patients underwent RPVE and 13 underwent RPVE + IV. The RPVE procedure resulted in a 38% increase in FLR volume. Liver volumes, hypertrophy rates and outcomes were similar in both groups. Rates of operative complications in the RPVE and RPVE + IV groups were similar at 50% and 54%, respectively, and most complications were minor. Complication rates as a result of embolization were 30% in the RPVE group and 31% in the RPVE + IV group. One patient underwent modified operative resection as a result of a complication of RPVE.

Conclusions

Right portal vein embolization (±segment IV) is a safe and effective modality to increase FLR volume. Post-embolization complications and short-term outcomes after resection are acceptable and are similar in both RPVE and RPVE + IV.     

Portal vein embolization stimulates tumour growth in patients with colorectal cancer liver metastases

Objectives

Portal vein embolization (PVE) can facilitate the resection of previously unresectable colorectal cancer (CRC) liver metastases. Bevacizumab is being used increasingly in the treatment of metastatic CRC, although data regarding its effect on post-embolization liver regeneration and tumour growth are conflicting. The objective of this observational study was to assess the impact of pre-embolization bevacizumab on liver hypertrophy and tumour growth.

Methods

Computed tomography scans before and 4 weeks after PVE were evaluated in patients who received perioperative chemotherapy with or without bevacizumab. Scans were compared with scans obtained in a control group in which no PVE was administered. Future liver remnant (FLR), total liver volume (TLV) and total tumour volume (TTV) were measured. Bevacizumab was discontinued ≥ 4 weeks before PVE.

Results

A total of 109 patients and 11 control patients were included. Portal vein embolization induced a significant increase in TTV: the right lobe increased by 33.4% in PVE subjects but decreased by 34.8% in control subjects (P < 0.001), and the left lobe increased by 49.9% in PVE subjects and decreased by 33.2% in controls (P = 0.022). A total of 52.8% of the study group received bevacizumab and 47.2% did not. There was no statistical difference between the two chemotherapy groups in terms of tumour growth. Median FLR after PVE was similar in both groups (28.8% vs. 28.7%; P = 0.825).

Conclusions

Adequate liver regeneration was achieved in patients who underwent PVE. However, significant tumour progression was also observed post-embolization.