51
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Torzilli G, Nagino M, Tzeng CWD, Kingham TP, Alatise OI, Ayandipo OO, Yamashita S, Arrington AK, Kim J, Chun YS, Vauthey JN. SSAT State-of-the-Art Conference: New Frontiers in Liver Surgery. J Gastrointest Surg 2017; 21:175-185. [PMID: 27480411 DOI: 10.1007/s11605-016-3193-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Accepted: 06/14/2016] [Indexed: 01/31/2023]
Affiliation(s)
- Guido Torzilli
- Department of Hepatobiliary and General Surgery, Humanitas Research Hospital, IRCCS, Humanitas University, Milan, Italy
| | - Masato Nagino
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Ching-Wei D Tzeng
- Department of Surgery, University of Kentucky College of Medicine, Lexington, KY, USA
| | - T Peter Kingham
- Department of Surgery, Hepatopancreatobiliary Service, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | | | | | - Suguru Yamashita
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1484, Houston, TX, 77030, USA
| | | | - Joseph Kim
- Division of Surgical Oncology, Department of Surgery, Stony Brook School of Medicine, Stony Brook, NY, USA
| | - Yun Shin Chun
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1484, Houston, TX, 77030, USA.
| | - Jean-Nicolas Vauthey
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1484, Houston, TX, 77030, USA
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52
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Sparrelid E, Jonas E, Tzortzakakis A, Dahlén U, Murquist G, Brismar T, Axelsson R, Isaksson B. Dynamic Evaluation of Liver Volume and Function in Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy. J Gastrointest Surg 2017; 21:967-974. [PMID: 28283924 PMCID: PMC5443865 DOI: 10.1007/s11605-017-3389-y] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Accepted: 02/20/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND Despite a fast and potent growth of the future liver remnant (FLR), patients operated with associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) are at risk of developing posthepatectomy liver failure. In this study, the relation between liver volume and function in ALPPS was studied using a multimodal assessment. METHODS Nine patients with colorectal liver metastases treated with neoadjuvant chemotherapy and operated with ALPPS were studied with hepatobiliary scintigraphy, computed tomography, indocyanine green clearance test, and serum liver function tests. A comparison between liver volume and function was conducted. RESULTS The preoperative FLR volume of 19.5% underestimated the preoperative FLR function of 25.3% (p = 0.011). The increase in FLR volume exceeded the increase in function at day 6 after stage 1 (FLR volume increase 56.7% versus FLR function increase 28.2%, p = 0.021), meaning that the increase in function was 50% of the increase in volume. After stage 2, functional increase exceeded the volume increase, resulting in similar values 28 days after stage 2. CONCLUSIONS In the inter-stage period of ALPPS, the high volume increase is not paralleled by a corresponding functional increase. This may in part explain the high morbidity and mortality rates associated with ALPPS. Functional assessment of the FLR is advised.
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Affiliation(s)
- Ernesto Sparrelid
- Division of Surgery, Department for Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Karolinska University Hospital, 141 86, Stockholm, Sweden.
| | - Eduard Jonas
- Division of Surgery, Department for Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Karolinska University Hospital, 141 86, Stockholm, Sweden
| | - Antonios Tzortzakakis
- Division of Radiology, Department for Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Ulrika Dahlén
- Department of Medical Physics, Karolinska University Hospital, Stockholm, Sweden
| | - Gustav Murquist
- Department of Medical Physics, Karolinska University Hospital, Stockholm, Sweden
| | - Torkel Brismar
- Division of Radiology, Department for Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Rimma Axelsson
- Division of Radiology, Department for Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Bengt Isaksson
- Division of Surgery, Department for Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Karolinska University Hospital, 141 86, Stockholm, Sweden
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53
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Eshmuminov D, Raptis DA, Linecker M, Wirsching A, Lesurtel M, Clavien PA. Meta-analysis of associating liver partition with portal vein ligation and portal vein occlusion for two-stage hepatectomy. Br J Surg 2016; 103:1768-1782. [PMID: 27633328 DOI: 10.1002/bjs.10290] [Citation(s) in RCA: 103] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Revised: 07/04/2016] [Accepted: 07/06/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND Discussion is ongoing regarding whether associating liver partition with portal vein ligation for staged hepatectomy (ALPPS) or portal vein occlusion is better in staged hepatectomy. The aim of this study was to compare available strategies using a two-stage approach in extended hepatectomy. METHODS A literature search was performed in MEDLINE, Scopus, the Cochrane Library and Embase, and additional articles were identified by hand searching. Data from the international ALPPS registry were extracted. Clinical studies reporting volumetric changes, mortality, morbidity, feasibility of the second stage and tumour-free resection margins (R0) in two-stage hepatectomy were included. RESULTS Ninety studies involving 4352 patients, including 320 from the ALPPS registry, met the inclusion criteria. Among these, nine studies (357 patients) reported on comparisons with other strategies. In the comparison of ALPPS versus portal vein embolization (PVE), ALPPS was associated with a greater increase in the future liver remnant (76 versus 37 per cent; P < 0·001) and more frequent completion of stage 2 (100 versus 77 per cent; P < 0·001). Compared with PVE, ALPPS had a trend towards higher morbidity (73 versus 59 per cent; P = 0·16) and mortality (14 versus 7 per cent; P = 0·19) after stage 2. In the non-comparative studies, complication rates were 39 per cent in the PVE group, 47 per cent in the portal vein ligation (PVL) group and 70 per cent in the ALPPS group. After stage 2, mortality rates were 5, 7 and 12 per cent respectively. CONCLUSION ALPPS is associated with greater future liver remnant hypertrophy and a higher rate of completion of stage 2, but this may be at the price of greater morbidity and mortality.
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Affiliation(s)
- D Eshmuminov
- Department of Surgery, Swiss HPB and Transplantation Centre, University Hospital Zurich, Zurich, Switzerland
| | - D A Raptis
- Department of Surgery, Swiss HPB and Transplantation Centre, University Hospital Zurich, Zurich, Switzerland
| | - M Linecker
- Department of Surgery, Swiss HPB and Transplantation Centre, University Hospital Zurich, Zurich, Switzerland
| | - A Wirsching
- Department of Surgery, Swiss HPB and Transplantation Centre, University Hospital Zurich, Zurich, Switzerland
| | - M Lesurtel
- Department of Surgery, Swiss HPB and Transplantation Centre, University Hospital Zurich, Zurich, Switzerland.,Department of General Surgery and Liver Transplantation, Croix-Rousse University Hospital, Hospices Civils de Lyon, Lyon, France
| | - P-A Clavien
- Department of Surgery, Swiss HPB and Transplantation Centre, University Hospital Zurich, Zurich, Switzerland
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54
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Ribero D, Zimmitti G, Aloia TA, Shindoh J, Fabio F, Amisano M, Passot G, Ferrero A, Vauthey JN. Preoperative Cholangitis and Future Liver Remnant Volume Determine the Risk of Liver Failure in Patients Undergoing Resection for Hilar Cholangiocarcinoma. J Am Coll Surg 2016; 223:87-97. [PMID: 27049784 PMCID: PMC4925184 DOI: 10.1016/j.jamcollsurg.2016.01.060] [Citation(s) in RCA: 94] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2015] [Revised: 01/26/2016] [Accepted: 01/27/2016] [Indexed: 12/19/2022]
Abstract
BACKGROUND The highest mortality rates after liver surgery are reported in patients who undergo resection for hilar cholangiocarcinoma (HCCA). In these patients, postoperative death usually follows the development of hepatic insufficiency. We sought to determine the factors associated with postoperative hepatic insufficiency and death due to liver failure in patients undergoing hepatectomy for HCCA. STUDY DESIGN This study included all consecutive patients who underwent hepatectomy with curative intent for HCCA at 2 centers, from 1996 through 2013. Preoperative clinical and operative data were analyzed to identify independent determinants of hepatic insufficiency and liver failure-related death. RESULTS The study included 133 patients with right or left major (n = 67) or extended (n = 66) hepatectomy. Preoperative biliary drainage was performed in 98 patients and was complicated by cholangitis in 40 cases. In all these patients, cholangitis was controlled before surgery. Major (Dindo III to IV) postoperative complications occurred in 73 patients (55%), with 29 suffering from hepatic insufficiency. Fifteen patients (11%) died within 90 days after surgery, 10 of them from liver failure. On multivariate analysis, predictors of postoperative hepatic insufficiency (all p < 0.05) were preoperative cholangitis (odds ratio [OR] 3.2), future liver remnant (FLR) volume < 30% (OR 3.5), preoperative total bilirubin level >3 mg/dL (OR 4), and albumin level < 3.5 mg/dL (OR 3.3). Only preoperative cholangitis (OR 7.5, p = 0.016) and FLR volume < 30% (OR 7.2, p = 0.019) predicted postoperative liver failure-related death. CONCLUSIONS Preoperative cholangitis and insufficient FLR volume are major determinants of hepatic insufficiency and postoperative liver failure-related death. Given the association between biliary drainage and cholangitis, the preoperative approach to patients with HCCA should be optimized to minimize the risk of cholangitis.
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Affiliation(s)
- Dario Ribero
- Department of General Surgery and Surgical Oncology, Ospedale Mauriziano Umberto I, Torino, Italy (Ribero, Zimmitti, Forchino, Amisano, Ferrero), Department of Hepatobiliary and Pancreatic Surgery, European Institute of Oncology, Milano, Italy (Ribero), Department of General Surgery, Istituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy (Zimmitti), and Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA (Aloia, Shindoh, Passot, Vauthey)
| | - Giuseppe Zimmitti
- Department of General Surgery and Surgical Oncology, Ospedale Mauriziano Umberto I, Torino, Italy (Ribero, Zimmitti, Forchino, Amisano, Ferrero), Department of Hepatobiliary and Pancreatic Surgery, European Institute of Oncology, Milano, Italy (Ribero), Department of General Surgery, Istituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy (Zimmitti), and Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA (Aloia, Shindoh, Passot, Vauthey)
| | - Thomas A Aloia
- Department of General Surgery and Surgical Oncology, Ospedale Mauriziano Umberto I, Torino, Italy (Ribero, Zimmitti, Forchino, Amisano, Ferrero), Department of Hepatobiliary and Pancreatic Surgery, European Institute of Oncology, Milano, Italy (Ribero), Department of General Surgery, Istituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy (Zimmitti), and Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA (Aloia, Shindoh, Passot, Vauthey)
| | - Junichi Shindoh
- Department of General Surgery and Surgical Oncology, Ospedale Mauriziano Umberto I, Torino, Italy (Ribero, Zimmitti, Forchino, Amisano, Ferrero), Department of Hepatobiliary and Pancreatic Surgery, European Institute of Oncology, Milano, Italy (Ribero), Department of General Surgery, Istituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy (Zimmitti), and Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA (Aloia, Shindoh, Passot, Vauthey)
| | - Forchino Fabio
- Department of General Surgery and Surgical Oncology, Ospedale Mauriziano Umberto I, Torino, Italy (Ribero, Zimmitti, Forchino, Amisano, Ferrero), Department of Hepatobiliary and Pancreatic Surgery, European Institute of Oncology, Milano, Italy (Ribero), Department of General Surgery, Istituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy (Zimmitti), and Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA (Aloia, Shindoh, Passot, Vauthey)
| | - Marco Amisano
- Department of General Surgery and Surgical Oncology, Ospedale Mauriziano Umberto I, Torino, Italy (Ribero, Zimmitti, Forchino, Amisano, Ferrero), Department of Hepatobiliary and Pancreatic Surgery, European Institute of Oncology, Milano, Italy (Ribero), Department of General Surgery, Istituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy (Zimmitti), and Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA (Aloia, Shindoh, Passot, Vauthey)
| | - Guillaume Passot
- Department of General Surgery and Surgical Oncology, Ospedale Mauriziano Umberto I, Torino, Italy (Ribero, Zimmitti, Forchino, Amisano, Ferrero), Department of Hepatobiliary and Pancreatic Surgery, European Institute of Oncology, Milano, Italy (Ribero), Department of General Surgery, Istituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy (Zimmitti), and Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA (Aloia, Shindoh, Passot, Vauthey)
| | - Alessandro Ferrero
- Department of General Surgery and Surgical Oncology, Ospedale Mauriziano Umberto I, Torino, Italy (Ribero, Zimmitti, Forchino, Amisano, Ferrero), Department of Hepatobiliary and Pancreatic Surgery, European Institute of Oncology, Milano, Italy (Ribero), Department of General Surgery, Istituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy (Zimmitti), and Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA (Aloia, Shindoh, Passot, Vauthey)
| | - Jean-Nicolas Vauthey
- Department of General Surgery and Surgical Oncology, Ospedale Mauriziano Umberto I, Torino, Italy (Ribero, Zimmitti, Forchino, Amisano, Ferrero), Department of Hepatobiliary and Pancreatic Surgery, European Institute of Oncology, Milano, Italy (Ribero), Department of General Surgery, Istituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy (Zimmitti), and Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA (Aloia, Shindoh, Passot, Vauthey)
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55
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Hwang S, Ha TY, Ko GY, Kwon DI, Song GW, Jung DH, Kim MH, Lee SK, Lee SG. Preoperative Sequential Portal and Hepatic Vein Embolization in Patients with Hepatobiliary Malignancy. World J Surg 2016; 39:2990-8. [PMID: 26304608 DOI: 10.1007/s00268-015-3194-2] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Preoperative portal vein embolization (PVE) induces shrinkage of the embolized lobe and compensatory regeneration in the non-embolized lobe, but does not always induce sufficient regeneration of the future remnant liver (FRL). We previously developed preoperative sequential PVE-hepatic vein embolization (HVE), and here we present our experience of treating 42 patients with sequential PVE-HVE. METHODS During 8-year study period, preoperative PVE-HVE was performed on 42 patients with hepatobiliary malignancies. RESULTS Primary diseases were bile duct cancers [perihilar cholangiocarcinoma (n = 33) and diffuse bile duct cancer (n = 1)], hepatocellular carcinomas (n = 4), and intrahepatic tumors [intrahepatic cholangiocarcinoma (n = 3) and gallbladder cancer liver invasion (n = 1)]. These patients demonstrated insufficient FRL regeneration following PVE, thus HVE was performed to induce further regeneration. No PVE-HVE procedure-associated complications occurred. In the bile duct cancer group, FRL volume was 33.9 ± 2.2 % before PVE, 38.4 ± 1.5 % before HVE, 43.7 ± 2.1 % at surgery, and 73.6 ± 8.3 % at 2 weeks after right hepatectomy. The degree of FRL hypertrophy was 13.3 % after PVE, 28.9 % after PHV-HVE, and 117.1 % at 2 weeks after right hepatectomy. All patients except one recovered uneventfully after surgery, and the 3-year patient survival rate was 45.1 %. In the HCC group, transarterial chemoembolization was initially performed and FRL regeneration following PVE-HVE occurred very slowly. Active FRL regeneration occurred in the liver tumor group, but rapid tumor growth was observed in 1 of 4 patients. CONCLUSION The sequential application of HVE following PVE safely and effectively induces further FRL regeneration in non-cirrhotic livers. Further validation using larger patient population and multicenter studies is needed to reliably widen the indications.
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Affiliation(s)
- Shin Hwang
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
| | - Tae-Yong Ha
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Gi-Young Ko
- Department of Diagnostic Imaging, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Dong-Il Kwon
- Department of Diagnostic Imaging, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Gi-Won Song
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Dong-Hwan Jung
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Myung-Hwan Kim
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sung-Koo Lee
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sung-Gyu Lee
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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56
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Improving the Safety of ALPPS Procedure: The Optimal Compromise Between Dropout and Mortality Risk. Comment on Schadde E et al Prediction of Mortality After ALPPS Stage-1: An Analysis of 320 Patients From the International ALPPS Registry. Ann Surg. 2015;262: 780-786. Ann Surg 2016; 266:e101-e102. [PMID: 27232259 DOI: 10.1097/sla.0000000000001800] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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57
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Simultaneous trans-hepatic portal and hepatic vein embolization before major hepatectomy: the liver venous deprivation technique. Eur Radiol 2016; 26:4259-4267. [DOI: 10.1007/s00330-016-4291-9] [Citation(s) in RCA: 125] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2015] [Revised: 02/14/2016] [Accepted: 02/17/2016] [Indexed: 02/06/2023]
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58
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Impact of Preoperative Biliary Drainage on Surgical Outcomes in Periampullary and Hilar Malignancy. Surg Laparosc Endosc Percutan Tech 2016; 26:150-5. [DOI: 10.1097/sle.0000000000000252] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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59
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Aoki T, Kubota K. Preoperative portal vein embolization for hepatocellular carcinoma: Consensus and controversy. World J Hepatol 2016; 8:439-445. [PMID: 27028706 PMCID: PMC4807305 DOI: 10.4254/wjh.v8.i9.439] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2015] [Revised: 10/29/2015] [Accepted: 03/09/2016] [Indexed: 02/06/2023] Open
Abstract
Thirty years have passed since the first report of portal vein embolization (PVE), and this procedure is widely adopted as a preoperative treatment procedure for patients with a small future liver remnant (FLR). PVE has been shown to be useful in patients with hepatocellular carcinoma (HCC) and chronic liver disease. However, special caution is needed when PVE is applied prior to subsequent major hepatic resection in cases with cirrhotic livers, and volumetric analysis of the liver segments in addition to evaluation of the liver functional reserve before PVE is mandatory in such cases. Advances in the embolic material and selection of the treatment approach, and combined use of PVE and transcatheter arterial embolization/chemoembolization have yielded improved outcomes after PVE and major hepatic resections. A novel procedure termed the associating liver partition and portal vein ligation for staged hepatectomy has been gaining attention because of the rapid hypertrophy of the FLR observed in patients undergoing this procedure, however, application of this technique in HCC patients requires special caution, as it has been shown to be associated with a high morbidity and mortality even in cases with essentially healthy livers.
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60
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Beppu T, Okabe H, Okuda K, Eguchi S, Kitahara K, Taniai N, Ueno S, Shirabe K, Ohta M, Kondo K, Nanashima A, Noritomi T, Okamoto K, Kikuchi K, Baba H, Fujioka H. Portal Vein Embolization Followed by Right-Side Hemihepatectomy for Hepatocellular Carcinoma Patients: A Japanese Multi-Institutional Study. J Am Coll Surg 2016; 222:1138-1148.e2. [PMID: 27107976 DOI: 10.1016/j.jamcollsurg.2016.03.023] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Revised: 03/09/2016] [Accepted: 03/09/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND Portal vein embolization (PVE) is useful to expand the indications of major hepatectomy; however, its oncologic effects are not fully understood. This study aimed to confirm the efficacy of preoperative PVE for hepatocellular carcinoma patients. STUDY DESIGN Between 2000 and 2012, five hundred and ten patients with hepatocellular carcinoma undergoing right-side hemihepatectomy were enrolled (PVE group, n = 162 and non-PVE group, n = 348). To equalize background factors, one-to-one propensity case-matched analysis and multivariate analysis were performed. Short- and long-term outcomes were evaluated. RESULTS Propensity score-matched patients, 148 in each group, were selected. The percentage of resected liver volume on admission was significantly greater in the PVE group (60.5% vs 48.3%; p < 0.001), but decreased considerably after PVE, from 60.5% to 50.3% (p < 0.001). The 5-year cumulative recurrence-free survival (36.4% vs 35.3%) and overall survival (58.6% vs 52.8%) rates were comparable. Extrahepatic recurrences were less common in the PVE group (18.1% vs 38.8%; p = 0.004). Independent prognostic factors for recurrence-free survival were morbidity (hazard ratio [HR] = 1.56), multiple tumors (HR = 1.97), red cell concentrate administration (HR = 1.57), older age (HR = 2.09), and massive portal invasion (HR = 2.33); and those for overall survival were morbidity (HR = 2.37), multiple tumors (HR = 1.71), and massive hepatic venous invasion (HR = 3.49). CONCLUSIONS Even though hepatocellular carcinoma patients who underwent preoperative PVE and right-side hemihepatectomy had a significantly larger resected liver volume on admission, they have a comparable long-term prognosis as patients with up front hepatectomy. In addition, PVE might decrease extrahepatic recurrences.
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Affiliation(s)
- Toru Beppu
- Department of Gastroenterological Surgery, Graduate School of Life Sciences, Kumamoto University, Kumamoto, Japan.
| | - Hirohisa Okabe
- Department of Gastroenterological Surgery, Graduate School of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Koji Okuda
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Kurume University, Kurume, Japan
| | - Susumu Eguchi
- Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Kenji Kitahara
- Department of Surgery, Saga University Faculty of Medicine, Saga, Japan
| | - Nobuhiko Taniai
- Department of Gastrointestinal and Hepato-Billiary-Pancreatic Surgery, Nippon Medical School, Tokyo, Japan
| | - Shinichi Ueno
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medicine, Kagoshima University, Kagoshima, Japan
| | - Ken Shirabe
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Masayuki Ohta
- Department of Gastroenterological and Pediatric Surgery, Oita University Faculty of Medicine, Oita, Japan
| | - Kazuhiro Kondo
- Department of Surgical Oncology and Regulation of Organ Function, Miyazaki University School of Medicine, Miyazaki, Japan
| | - Atsushi Nanashima
- Department of Surgical Oncology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Tomoaki Noritomi
- Department of Gastroenterological Surgery, Fukuoka University School of Medicine, Fukuoka, Japan
| | - Kohji Okamoto
- Department of Surgery, Gastroenterology and Hepatology Center, Kitakyushu City Yahata Hospital, Kitakyushu, Japan
| | - Ken Kikuchi
- Medical Quality Management Center, Kumamoto University, Kumamoto, Japan
| | - Hideo Baba
- Department of Gastroenterological Surgery, Graduate School of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Hikaru Fujioka
- Clinical Research Center and Department of Surgery, National Hospital Organization Nagasaki Medical Center, Nagasaki, Japan
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Marcos R, Lopes C, Malhão F, Correia-Gomes C, Fonseca S, Lima M, Gebhardt R, Rocha E. Stereological assessment of sexual dimorphism in the rat liver reveals differences in hepatocytes and Kupffer cells but not hepatic stellate cells. J Anat 2016; 228:996-1005. [PMID: 26892301 DOI: 10.1111/joa.12448] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/05/2016] [Indexed: 12/11/2022] Open
Abstract
There is long-standing evidence that male and female rat livers differ in enzyme activity. More recently, differences in gene expression profiling have also been found to exist; however, it is still unclear whether there is morphological expression of male/female differences in the normal liver. Such differences could help to explain features seen at the pathological level, such as the greater regenerative potential generally attributed to the female liver. In this paper, hepatocytes (HEP), Kupffer cells (KC) and hepatic stellate cells (HSC) of male and female rats were examined to investigate hypothesised differences in number, volume and spatial co-localisation of these cell types. Immunohistochemistry and design-based stereology were used to estimate total numbers, numbers per gram and mean cell volumes. The position of HSC within lobules (periportal vs. centrilobular) and their spatial proximity to KC was also assessed. In addition, flow cytometry was used to investigate the liver ploidy. In the case of HEP and KC, differences in the measured cell parameters were observed between male and female specimens; however, no such differences were detected for HSC. Female samples contained a higher number of HEP per gram, with more binucleate cells. The HEP nuclei were smaller in females, which was coincident with more abundant diploid particles in these animals. The female liver also had a greater number of KC per gram, with a lower percentage of KC in the vicinity of HSC compared with males. In this study, we document hitherto unknown morphological sexual dimorphism in the rat liver, namely in HEP and KC. These differences may account for the higher regenerative potential of the female liver and lend weight to the argument for considering the rat liver as a sexually dimorphic organ.
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Affiliation(s)
- Ricardo Marcos
- Laboratory of Histology and Embryology, Department of Microscopy, ICBAS - Institute of Biomedical Sciences Abel Salazar, U.Porto - University of Porto, Porto, Portugal.,Histomorphology, Physiopathology and Applied Toxicology Group, CIIMAR - Interdisciplinary Centre of Marine and Environmental Research, U.Porto - University of Porto, Porto, Portugal
| | - Célia Lopes
- Laboratory of Histology and Embryology, Department of Microscopy, ICBAS - Institute of Biomedical Sciences Abel Salazar, U.Porto - University of Porto, Porto, Portugal.,Histomorphology, Physiopathology and Applied Toxicology Group, CIIMAR - Interdisciplinary Centre of Marine and Environmental Research, U.Porto - University of Porto, Porto, Portugal
| | - Fernanda Malhão
- Laboratory of Histology and Embryology, Department of Microscopy, ICBAS - Institute of Biomedical Sciences Abel Salazar, U.Porto - University of Porto, Porto, Portugal.,Histomorphology, Physiopathology and Applied Toxicology Group, CIIMAR - Interdisciplinary Centre of Marine and Environmental Research, U.Porto - University of Porto, Porto, Portugal
| | - Carla Correia-Gomes
- Scotland's Rural College, Epidemiology Research Unit - Future Farming Systems Group, Inverness, UK
| | - Sónia Fonseca
- Laboratory of Cytometry, Department of Hematology, UMIB - Unit for Multidisciplinary Research in Biomedicine, CHP - Centro Hospitalar do Porto, ICBAS - Institute of Biomedical Sciences Abel Salazar, HSA - Hospital de Santo António, U.Porto - University of Porto, Porto, Portugal
| | - Margarida Lima
- Laboratory of Cytometry, Department of Hematology, UMIB - Unit for Multidisciplinary Research in Biomedicine, CHP - Centro Hospitalar do Porto, ICBAS - Institute of Biomedical Sciences Abel Salazar, HSA - Hospital de Santo António, U.Porto - University of Porto, Porto, Portugal
| | - Rolf Gebhardt
- Institute of Biochemistry, Faculty of Medicine, University of Leipzig, Leipzig, Germany
| | - Eduardo Rocha
- Laboratory of Histology and Embryology, Department of Microscopy, ICBAS - Institute of Biomedical Sciences Abel Salazar, U.Porto - University of Porto, Porto, Portugal.,Histomorphology, Physiopathology and Applied Toxicology Group, CIIMAR - Interdisciplinary Centre of Marine and Environmental Research, U.Porto - University of Porto, Porto, Portugal
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Esnaola NF, Meyer JE, Karachristos A, Maranki JL, Camp ER, Denlinger CS. Evaluation and management of intrahepatic and extrahepatic cholangiocarcinoma. Cancer 2016; 122:1349-69. [PMID: 26799932 DOI: 10.1002/cncr.29692] [Citation(s) in RCA: 181] [Impact Index Per Article: 22.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2015] [Revised: 08/18/2015] [Accepted: 08/19/2015] [Indexed: 12/13/2022]
Abstract
Cholangiocarcinomas are rare biliary tract tumors that are often challenging to diagnose and treat. Cholangiocarcinomas are generally categorized as intrahepatic or extrahepatic depending on their anatomic location. The majority of patients with cholangiocarcinoma do not have any of the known or suspected risk factors and present with advanced disease. The optimal evaluation and management of patients with cholangiocarcinoma requires thoughtful integration of clinical information, imaging studies, cytology and/or histology, as well as prompt multidisciplinary evaluation. The current review focuses on recent advances in the diagnosis and treatment of patients with cholangiocarcinoma and, in particular, on the role of endoscopy, surgery, transplantation, radiotherapy, systemic therapy, and liver-directed therapies in the curative or palliative treatment of these individuals. Cancer 2016;122:1349-1369. © 2016 American Cancer Society.
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Affiliation(s)
- Nestor F Esnaola
- Department of Surgery, Fox Chase Cancer Center-Temple Health, Philadelphia, Pennsylvania
| | - Joshua E Meyer
- Department of Radiation Oncology, Fox Chase Cancer Center-Temple Health, Philadelphia, Pennsylvania
| | - Andreas Karachristos
- Department of Surgery, Temple University School of Medicine, Philadelphia, Pennsylvania
| | - Jennifer L Maranki
- Department of Medicine, Temple University School of Medicine, Philadelphia, Pennsylvania
| | - E Ramsay Camp
- Department of Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - Crystal S Denlinger
- Department of Hematology/Oncology, Fox Chase Cancer Center-Temple Health, Philadelphia, Pennsylvania
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Inoue S, Ikeda O, Nakasone Y, Beppu T, Masuda T, Yokoyama K, Utsunomiya D, Baba H, Yamashita Y. Percutaneous transhepatic portal embolization using foam ethanolamine oleate and carbon dioxide (CO₂): a pilot study. Acta Radiol 2015; 56:1361-7. [PMID: 26113740 DOI: 10.1177/0284185115590285] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2014] [Accepted: 05/11/2015] [Indexed: 12/15/2022]
Abstract
BACKGROUND Percutaneous transhepatic portal embolization (PTPE) can induce atrophy of the embolized- and hypertrophy of the residual area. These effects are advantageous in patients scheduled for extended hepatectomy. PURPOSE To evaluate the clinical safety and effectiveness of foam sclerotherapy with foam ethanolamine oleate (EO) and carbon dioxide (CO2) for PTPE before hepatectomy. MATERIAL AND METHODS We performed sclerotherapy for PTPE in 15 patients with: hepatocellular carcinoma (HHC; n = 9), bile duct carcinoma (n = 5), or metastatic liver tumor from colon cancer (n = 1). The foam contained 5% EO iopamidol (EOI) and CO2 at a 1:2 ratio. We compared the percentage of the pre- and post-PTPE future liver remnant (FLR) volumes and calculated the percent FLR volume (%FLR) increase after PTPE. RESULTS The amount of EOI used (range, 14-20 mL; median, 16.8 mL) was based on the volume of the target portal vein. Technical success was achieved in 14 of 15 patients (93%); the other patient presented with computed tomography evidence of recanalization 1 week after PTPE. The FLR volume before and after portal vein embolization was 599 ± 342 and 691 ± 318 cm(3), respectively (P < 0.01); the mean %FLR volume increase was 29.5%. There was no significant difference in the mean platelet count, total bilirubin, total aspartate aminotransferase, and total creatinine before and after PTPE. One patient suffered intra-abdominal bleeding that required transcatheter arterial embolization. No other patients developed major complications higher than grade 3. CONCLUSION Sclerotherapy using foam EOI and CO2 is clinically safe and effective for PTPE before hepatectomy.
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Affiliation(s)
- Seijiro Inoue
- Department of Diagnostic Radiology, Kumamoto University Graduate School of Life Sciences, Kumamoto, Japan
| | - Osamu Ikeda
- Department of Diagnostic Radiology, Kumamoto University Graduate School of Life Sciences, Kumamoto, Japan
| | - Yutaka Nakasone
- Department of Diagnostic Radiology, Kumamoto University Graduate School of Life Sciences, Kumamoto, Japan
| | - Toru Beppu
- Department of Gastroenterological Surgery, Kumamoto University Graduate School of Life Sciences, Kumamoto, Japan
| | - Toshiro Masuda
- Department of Gastroenterological Surgery, Kumamoto University Graduate School of Life Sciences, Kumamoto, Japan
| | - Koichi Yokoyama
- Department of Diagnostic Radiology, Kumamoto University Graduate School of Life Sciences, Kumamoto, Japan
| | - Daisuke Utsunomiya
- Department of Diagnostic Radiology, Kumamoto University Graduate School of Life Sciences, Kumamoto, Japan
| | - Hideo Baba
- Department of Gastroenterological Surgery, Kumamoto University Graduate School of Life Sciences, Kumamoto, Japan
| | - Yasuyuki Yamashita
- Department of Diagnostic Radiology, Kumamoto University Graduate School of Life Sciences, Kumamoto, Japan
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She WH, Chok KSH. Strategies to increase the resectability of hepatocellular carcinoma. World J Hepatol 2015; 7:2147-2154. [PMID: 26328026 PMCID: PMC4550869 DOI: 10.4254/wjh.v7.i18.2147] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2015] [Revised: 08/10/2015] [Accepted: 08/21/2015] [Indexed: 02/06/2023] Open
Abstract
Hepatocellular carcinoma (HCC) is best treated by liver transplantation, but the applicability of transplantation is greatly limited. Tumor resection in partial hepatectomy is hence resorted to. However, in most parts of the world, only 20%-30% of HCCs are resectable. The main reason for such a low resectability is a future liver remnant too small to be sufficient for the patient. To allow more HCC patients to undergo curative hepatectomy, a variety of ways have been developed to increase the resectability of HCC, mainly ways to increase the future liver remnants in patients through hypertrophy. They include portal vein embolization, sequential transarterial chemoembolization and portal vein embolization, staged hepatectomy, two-staged hepatectomy with portal vein ligation, and Associating Liver Partition and Portal Vein Ligation in Staged Hepatectomy. Herein we review, describe and evaluate these different ways, ways that can be life-saving.
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Lim C, Mise Y, Sakamoto Y, Yamamoto S, Shindoh J, Ishizawa T, Aoki T, Hasegawa K, Sugawara Y, Makuuchi M, Kokudo N. Above 5 cm, size does not matter anymore in patients with hepatocellular carcinoma. World J Surg 2015; 38:2910-8. [PMID: 25099682 DOI: 10.1007/s00268-014-2704-y] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Solitary hepatocellular carcinoma (HCC) is a good candidate for surgical resection. However, the significance of the size of the tumor in solitary HCC remains unclear. OBJECTIVE The aim of this study was to evaluate the impact of tumor size on overall and recurrence-free survival of patients with solitary HCC. MATERIALS We retrospectively reviewed 616 patients with histologically confirmed solitary HCC who underwent curative surgical resection between 1994 and 2010. The characteristics and prognosis of patients with HCC were analyzed stratified by tumor size. RESULTS A total of 403 patients (65 %) had tumors <5 cm, 172 (28 %) had tumors between 5 and 10 cm, and 41 (7 %) had tumors >10 cm. The incidence of microvascular invasion, satellite nodules, and advanced tumor grade significantly increased with tumor size. The 5-year overall and recurrence-free survival rates of HCC <5 cm were 69.6 % and 32 %, respectively, which were significantly better than those of HCC between 5 and 10 cm (58 % and 26 %, respectively) and HCC >10 cm (53 % and 24 %, respectively). On multivariate analysis, cirrhosis (p = 0.0307), Child-Pugh B (p = 0.0159), indocyanine green retention rate at 15 min >10 % (p = 0.0071), microvascular invasion (p < 0.0001), and satellite nodules (p = 0.0009) were independent predictors of poor survival, whereas tumor size >5 cm was not. CONCLUSION Although recurrence rates are high, surgical resection for solitary HCC offers good overall survival. Tumor size was not a prognostic factor. Solitary large HCC >10 cm would be a good candidate for hepatectomy as well as solitary HCC between 5 and 10 cm.
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Affiliation(s)
- Chetana Lim
- Hepato-Biliary-Pancreatic Surgery Division, Artificial Organ and Transplantation Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Hongo 7-3-1, Bunkyo-ku, Tokyo, 1138655, Japan,
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Hypertrophy of the Left Liver in Patients with Large Tumors in the Right Liver. World J Surg 2015; 39:2031-6. [PMID: 25813823 DOI: 10.1007/s00268-015-3033-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND It has been speculated that, when right-sided major hepatectomy (RSMH) is planned for patients with large tumors in the right liver, it may not lead to a marked decrease in normally functional hepatic mass. METHODS We collected data for patients who had undergone RSMH for tumors more than 8 cm in diameter (n=50) and compared them with control patients who had undergone RSMH for tumors less than 5 cm in diameter (n=21). RESULTS The ratio of the remnant left liver volume to the nontumorous liver volume (left liver ratio) in the patients with large tumors was significantly greater than that in the control group (50.0±12.8% vs. 40.2±8.3%, p=0.002). Left liver ratio was significantly correlated with tumor volume (p<0.001). Preoperative portal vein embolization was performed in only four of the 50 patients with large tumors. None of the patients with large tumors developed postoperative liver failure. CONCLUSIONS Left liver volume in patients with large tumors in the right liver was larger than usual, perhaps reducing the risk of postoperative liver insufficiency after RSMH.
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Russolillo N, Ratti F, Viganò L, Langella S, Cipriani F, Aldrighetti L, Ferrero A. The Influence of Aging on Hepatic Regeneration and Early Outcome after Portal Vein Occlusion: A Case-Control Study. Ann Surg Oncol 2015; 22:4046-51. [PMID: 25758189 DOI: 10.1245/s10434-015-4478-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2014] [Indexed: 12/15/2022]
Abstract
BACKGROUND Portal vein occlusion (PVO) is used to increase inadequate future liver remnant volume (FLRV). Impaired liver regeneration has been reported in aged animals. This study was designed to evaluate the impact of patient age on hepatic regeneration. METHODS Sixty patients aged ≥70 years were matched 1:1 with 60 patients aged <70 years. Matching criteria were sex, diabetes, cirrhosis, pre-PVO chemotherapy and bevacizumab administration, and jaundice. RESULTS The median ages in the older and younger groups were 76 (range 70-83) years and 59 (range 20-69) years, respectively (p < 0.001). Median FLRV following PVO (33.1 ± 6.8 vs. 31.9 ± 6.0 %) and volumetric increase (0.52 ± 0.35 vs. 0.49 ± 0.34) were similar in the two groups. Of the older and younger patients, 10 % and 1.7 %, respectively, did not undergo liver surgery after PVO (p = 0.051). Mortality (5.5 vs. 6.7 %) and major morbidity (25.9.8 vs. 22 %) rates were similar. Liver failure rate was higher in older patients (35.1 vs. 16.9 %, p < 0.026), mainly due to Grade A liver failure (20.3 vs. 8.4 %, p < 0.001). Multivariate analysis showed that age ≥ 70 years [odds ratio (OR) 3.03; 95 % confidence interval (CI) 1.18-7.78; p = 0.020] and biliary cancer diagnosis (OR 4.69; 95 % CI 1.81-12.09; p = 0.001) were independent risk factors for postoperative liver failure. CONCLUSIONS Liver regeneration after PVO is not impaired by age. Nevertheless, liver resection in elderly patients is performed less often after PVO and carries a higher risk of liver failure.
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Affiliation(s)
- Nadia Russolillo
- Department of General and Oncological Surgery, Ospedale Mauriziano "Umberto I", Turin, Italy.
| | - Francesca Ratti
- Liver Unit, Department of Hepatobiliary Surgery, San Raffaele Hospital, Milan, Italy
| | - Luca Viganò
- Liver Surgery Unit, Department of Surgery, Humanitas Clinical and Research Center, Rozzano, Milan, Italy
| | - Serena Langella
- Department of General and Oncological Surgery, Ospedale Mauriziano "Umberto I", Turin, Italy
| | - Federica Cipriani
- Liver Unit, Department of Hepatobiliary Surgery, San Raffaele Hospital, Milan, Italy
| | - Luca Aldrighetti
- Liver Unit, Department of Hepatobiliary Surgery, San Raffaele Hospital, Milan, Italy
| | - Alessandro Ferrero
- Department of General and Oncological Surgery, Ospedale Mauriziano "Umberto I", Turin, Italy
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Malinowski M, Stary V, Lock JF, Schulz A, Jara M, Seehofer D, Gebauer B, Denecke T, Geisel D, Neuhaus P, Stockmann M. Factors influencing hypertrophy of the left lateral liver lobe after portal vein embolization. Langenbecks Arch Surg 2015; 400:237-46. [DOI: 10.1007/s00423-014-1266-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2014] [Accepted: 12/14/2014] [Indexed: 11/29/2022]
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Kimura N, Toyoki Y, Ishido K, Kudo D, Yakoshi Y, Tsutsumi S, Miura T, Wakiya T, Hakamada K. Perioperative blood transfusion as a poor prognostic factor after aggressive surgical resection for hilar cholangiocarcinoma. J Gastrointest Surg 2015; 19:866-79. [PMID: 25605416 PMCID: PMC4412428 DOI: 10.1007/s11605-014-2741-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2014] [Accepted: 12/27/2014] [Indexed: 01/31/2023]
Abstract
BACKGROUND Blood transfusion is linked to a negative outcome for malignant tumors. The aim of this study was to evaluate aggressive surgical resection for hilar cholangiocarcinoma (HCCA) and assess the impact of perioperative blood transfusion on long-term survival. METHODS Sixty-six consecutive major hepatectomies with en bloc resection of the caudate lobe and extrahepatic bile duct for HCCA were performed using macroscopically curative resection at our institute from 2002 to 2012. Clinicopathologic factors for recurrence and survival were retrospectively assessed. RESULTS Overall survival rates at 1, 3, and 5 years were 86.7, 47.3, and 35.7 %, respectively. In univariate analysis, perioperative blood transfusion and a histological positive margin were two of several variables found to be significant prognostic factors for recurrence or survival (P<0.05). In multivariate analysis, only perioperative blood transfusion was independently associated with recurrence (hazard ratio (HR)=2.839 (95 % confidence interval (CI), 1.370-5.884), P=0.005), while perioperative blood transfusion (HR=3.383 (95 % CI, 1.499-7.637), P=0.003) and R1 resection (HR=3.125 (95 % CI, 1.025-9.530), P=0.045) were independent risk factors for poor survival. CONCLUSIONS Perioperative blood transfusion is a strong predictor of poor survival after radical hepatectomy for HCCA. We suggest that circumvention of perioperative blood transfusion can play an important role in long-term survival for patients with HCCA.
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Affiliation(s)
- Norihisa Kimura
- Department of Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, 5 Zaifu-cho, Hirosaki City, Aomori Province 036-8562 Japan
| | - Yoshikazu Toyoki
- Department of Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, 5 Zaifu-cho, Hirosaki City, Aomori Province 036-8562 Japan
| | - Keinosuke Ishido
- Department of Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, 5 Zaifu-cho, Hirosaki City, Aomori Province 036-8562 Japan
| | - Daisuke Kudo
- Department of Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, 5 Zaifu-cho, Hirosaki City, Aomori Province 036-8562 Japan
| | - Yuta Yakoshi
- Department of Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, 5 Zaifu-cho, Hirosaki City, Aomori Province 036-8562 Japan
| | - Shinji Tsutsumi
- Department of Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, 5 Zaifu-cho, Hirosaki City, Aomori Province 036-8562 Japan
| | - Takuya Miura
- Department of Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, 5 Zaifu-cho, Hirosaki City, Aomori Province 036-8562 Japan
| | - Taiichi Wakiya
- Department of Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, 5 Zaifu-cho, Hirosaki City, Aomori Province 036-8562 Japan
| | - Kenichi Hakamada
- Department of Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, 5 Zaifu-cho, Hirosaki City, Aomori Province 036-8562 Japan
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Reply to: "ALPPS procedure for hepatocellular carcinoma with macrovascular thrombosis: a new opportunity?". J Hepatol 2015; 62:243. [PMID: 25200904 DOI: 10.1016/j.jhep.2014.09.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2014] [Accepted: 09/01/2014] [Indexed: 12/04/2022]
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Abstract
Hepatocellular carcinoma (HCC) is an epithelial tumor derived from hepatocytes; it accounts for 80% of all primary liver cancers and ranks globally as the fourth leading cause of cancer-related deaths. HCC treatment is a multidisciplinary and a multimodal task, with surgery in the form of liver resection and liver transplantation (LT) representing the only potentially curative modality. However, there are variable opinions and discussions about applying these surgical options and using other supporting treatments. This article is a narrative review that includes articles published from 1984 to 2013 located by searching scientific databases such as PubMed, SCOPUS, and Elsevier, with the main keyword of hepatocellular carcinoma in addition to other keywords such as liver transplantation, liver resection, transarterial chemoembolization, portal vein embolization, bridging therapy, and downstaging. In this review, we focus mainly on the surgical treatment options offered for HCC, in order to illustrate the current relevant data available in the literature to help in applying these surgical options and to use other supporting treatment modalities when appropriate.
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Affiliation(s)
- Ahmad A. Madkhali
- Department of Surgery, College of Medicine, King Saud University, Riyadh, Saudi Arabia,Section of Hepatopancreatobilairy and Transplant, Transplant, McGill University, Montreal, Canada
| | - Zahir T. Fadel
- Section of Hepatopancreatobilairy and Transplant, Transplant, McGill University, Montreal, Canada,Department of Surgery, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Murad M. Aljiffry
- Department of Surgery, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Mazen M. Hassanain
- Department of Surgery, College of Medicine, King Saud University, Riyadh, Saudi Arabia,Department of Oncology, McGill University, Montreal, Canada,Address for correspondence: Dr. Mazen Hassanain, Assistant Professor of Surgery and Consultant HPB and Transplant Surgery, Department of Surgery, College of Medicine, Scientific Director Liver Disease Research Centre, King Saud University, P.O.Box 25179, Riyadh, 11466, Saudi Arabia. E-mail:
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Mizuno T, Kanemoto H, Sugiura T, Okamura Y, Uesaka K. Central hepatectomy with pancreatoduodenectomy for diffusely spread bile duct cancer. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2014; 22:287-93. [PMID: 25488828 DOI: 10.1002/jhbp.197] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Major hepatectomy with concomitant pancreatoduodenectomy (major-HPD) is the only procedure that provides a curative resection for diffusely spread extrahepatic bile duct cancer (DSEBDC). We sometimes encounter patients who cannot undergo major-HPD because of a poor functional hepatic reserve. The aim of the present study was to assess the feasibility of central hepatectomy with pancreatoduodenectomy (central-HPD) for patients with DSEBDC as an alternative to major-HPD. METHODS Between 2002 and 2010, six patients with DSEBDC underwent central-HPD. The hepatectomy procedures for central-HPD included central bisectionectomy with S1 resection (S1r) and right anterior sectionectomy with S1r. RESULTS The estimated resection liver volume was decreased from 77.5% to 46.6% by the application of central-HPD. The median operative duration was 929 min, and the median blood loss was 2568 ml. Postoperative complications were observed in five patients. The proximal ductal stump was histologically positive with non-invasive cancer in three patients and positive with invasive cancer in one. The overall survival of the six patients was 62.5% at 5 years after surgery. CONCLUSIONS While central-HPD was a technically complicated procedure associated with a high morbidity rate, it offered a favorable overall survival and might be an alternative option for DSEBDC patients with a poor hepatic functional reserve.
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Affiliation(s)
- Takashi Mizuno
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center Hospital, 1007 Shimonagakubo, Nagaizumi-cho, Sunto-gun, Shizuoka, 411-8777, Japan.
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Cho A, Yamamoto H, Kainuma O, Muto Y, Yanagibashi H, Tonooka T, Masuda T. Laparoscopy in the management of hilar cholangiocarcinoma. World J Gastroenterol 2014; 20:15153-15157. [PMID: 25386064 PMCID: PMC4223249 DOI: 10.3748/wjg.v20.i41.15153] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2013] [Revised: 01/10/2014] [Accepted: 06/23/2014] [Indexed: 02/06/2023] Open
Abstract
The use of minimally invasive surgery has become widely accepted in many gastrointestinal fields, even in patients with malignancy. However, performing laparoscopic resection for the treatment of hilar cholangiocarcinoma is still not universally accepted as an alternative approach to open surgery, and only a limited number of such procedures have been reported due to the difficulty of performing oncologic resection and the lack of consensus regarding the adequacy of this approach. Laparoscopy was initially limited to staging, biopsy and palliation. Recent technological developments and improvements in endoscopic procedures have greatly expanded the applications of laparoscopic liver resection and lymphadenectomy, and some reports have described the use of laparoscopic or robot-assisted laparoscopic resection for hilar cholangiocarcinoma as being feasible and safe in highly selected cases, with the ability to obtain an adequate surgical margin. However, the benefits of major laparoscopic surgery have yet to be conclusively proven, and carefully selecting patients is essential for successfully performing this procedure.
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Miura S, Kanno A, Masamune A, Hamada S, Takikawa T, Nakano E, Yoshida N, Hongo S, Kikuta K, Kume K, Hirota M, Yoshida H, Katayose Y, Uuno M, Shimosegawa T. Bismuth classification is associated with the requirement for multiple biliary drainage in preoperative patients with malignant perihilar biliary stricture. Surg Endosc 2014; 29:1862-70. [PMID: 25277483 DOI: 10.1007/s00464-014-3878-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2014] [Accepted: 09/02/2014] [Indexed: 02/08/2023]
Abstract
BACKGROUND Single preoperative biliary drainage for malignant perihilar biliary stricture occasionally fails to control jaundice and cholangitis. Multiple biliary drainage is required in such cases, but their clinical background is unclear. We determined the clinical characteristics associated with the requirement for multiple biliary drainage. METHODS The consecutive 122 patients with malignant perihilar biliary stricture were enrolled in a single-center retrospective study. Preoperative biliary drainage was initially performed on the future remnant hepatic lobe. Additional drainage was performed if jaundice failed to improve or cholangitis developed in undrained hepatic lobes. Detailed clinical characteristics and the number of preoperative biliary drainage procedures required before operation were analyzed. RESULTS Thirty-one patients (25.4%) initially underwent multiple biliary drainage. However, 69 (56.7%) required multiple biliary drainage by the time of the operation. In the univariate analysis, the initial serum bilirubin level, cholangitis, percutaneous portal vein embolization, history of inserted endoscopic biliary stenting, length of preoperative period, operative procedure, and Bismuth classification were significant factors. In the multivariate analysis using these factors, Bismuth classification was independently associated with the requirement for multiple biliary drainage. The number of patients who required multiple biliary drainage was higher in those with Bismuth-II (91.9%), Bismuth-IIIa (65.7%), and Bismuth-IV (92.9%) than in those with Bismuth-I (22.2%) and Bismuth-IIIb (18.2%). CONCLUSIONS Patients with Bismuth-II, Bismuth-IIIa, and Bismuth-IV are at higher risk for multiple biliary drainage. A strategy based on the Bismuth classification for performing preoperative biliary drainage is important for patients with malignant perihilar biliary stricture.
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Affiliation(s)
- Shin Miura
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-Ku, Sendai, Miyagi, Japan
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Leung U, Simpson AL, Araujo RLC, Gönen M, McAuliffe C, Miga MI, Parada EP, Allen PJ, D'Angelica MI, Kingham TP, DeMatteo RP, Fong Y, Jarnagin WR. Remnant growth rate after portal vein embolization is a good early predictor of post-hepatectomy liver failure. J Am Coll Surg 2014; 219:620-30. [PMID: 25158914 DOI: 10.1016/j.jamcollsurg.2014.04.022] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2014] [Revised: 04/06/2014] [Accepted: 04/07/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND After portal vein embolization (PVE), the future liver remnant (FLR) hypertrophies for several weeks. An early marker that predicts a low risk of post-hepatectomy liver failure can reduce the delay to surgery. STUDY DESIGN Liver volumes of 153 patients who underwent a major hepatectomy (>3 segments) after PVE for primary or secondary liver malignancy between September 1999 and November 2012 were retrospectively evaluated with computerized volumetry. Pre- and post-PVE FLR volume and functional liver volume were measured. Degree of hypertrophy (DH = post-FLR/post-functional liver volume - pre-FLR/pre-functional liver volume) and growth rate (GR = DH/weeks since PVE) were calculated. Postoperative complications and liver failure were correlated with DH, measured GR, and estimated GR derived from a formula based on body surface area. RESULTS Eligible patients underwent 93 right hepatectomies, 51 extended right hepatectomies, 4 left hepatectomies, and 5 extended left hepatectomies. Major complications occurred in 44 patients (28.7%) and liver failure in 6 patients (3.9%). Nonparametric regression showed that post-embolization FLR percent correlated poorly with liver failure. Receiver operating characteristic curves showed that DH and GR were good predictors of liver failure (area under the curve [AUC] = 0.80; p = 0.011 and AUC = 0.79; p = 0.015) and modest predictors of major complications (AUC = 0.66; p = 0.002 and AUC = 0.61; p = 0.032). No patient with GR >2.66% per week had liver failure develop. The predictive value of measured GR was superior to estimated GR for liver failure (AUC = 0.79 vs 0.58; p = 0.046). CONCLUSIONS Both DH and GR after PVE are strong predictors of post-hepatectomy liver failure. Growth rate might be a better guide for the optimum timing of liver resection than static volumetric measurements. Measured volumetrics correlated with outcomes better than estimated volumetrics.
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Affiliation(s)
- Universe Leung
- Hepatopancreatobiliary Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Amber L Simpson
- Hepatopancreatobiliary Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY; Department of Biomedical Engineering, Vanderbilt University, Nashville, TN
| | - Raphael L C Araujo
- Hepatopancreatobiliary Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Mithat Gönen
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Conor McAuliffe
- Hepatopancreatobiliary Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Michael I Miga
- Department of Biomedical Engineering, Vanderbilt University, Nashville, TN
| | | | - Peter J Allen
- Hepatopancreatobiliary Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Michael I D'Angelica
- Hepatopancreatobiliary Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - T Peter Kingham
- Hepatopancreatobiliary Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Ronald P DeMatteo
- Hepatopancreatobiliary Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Yuman Fong
- Hepatopancreatobiliary Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - William R Jarnagin
- Hepatopancreatobiliary Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY.
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Sofue K, Arai Y, Shimada K, Takeuchi Y, Kobayashi T, Satake M, Sugimura K. Right portal vein embolization with absolute ethanol in major hepatic resection for hepatobiliary malignancy. Br J Surg 2014; 101:1122-8. [PMID: 24920297 DOI: 10.1002/bjs.9541] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/26/2014] [Indexed: 12/19/2022]
Abstract
BACKGROUND This study aimed to evaluate the safety and efficacy of preoperative right portal vein embolization (PVE) with absolute ethanol in patients with hepatobiliary malignancies. METHODS PVE was performed via a percutaneous transhepatic ipsilateral approach, and the right portal branch was embolized with absolute ethanol. Technical success and complications following PVE, and changes in liver enzyme levels were evaluated. Changes in future liver remnant (FLR) and FLR/total functional liver volume ratio were calculated. Complications following hepatic resection were assessed. RESULTS A total of 83 patients with hepatobiliary malignancies (53 men, 30 women; mean age 68 years) underwent right PVE. Tumour types were hilar cholangiocarcinoma (37), liver metastases (14), gallbladder cancer (13), intrahepatic cholangiocellular carcinoma (10) and hepatocellular carcinoma (HCC) (9). PVE was performed successfully in all patients. Four patients (5 per cent) developed complications following PVE (liver abscess 2, left portal vein thrombosis 1, pseudoaneurysm 1), but this did not preclude hepatic resection. Liver enzyme levels rose transiently after PVE. The mean FLR and FLR/total functional liver volume increased after PVE (from 366 to 513 cm(3) and from 31 to 43 per cent respectively; both P < 0·001). Changes in the FLR and FLR/total functional liver volume ratio were comparable between patients with HCC and those with other malignancies (42 and 44 per cent, and 12 and 12 per cent, respectively). Sixty-nine of 83 patients underwent hepatic resection at a median of 25 days after PVE, with no postoperative mortality. CONCLUSION Preoperative right PVE with absolute ethanol is safe and effective for induction of selective hepatic hypertrophy in patients with hepatobiliary malignancy.
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Affiliation(s)
- K Sofue
- Divisions of Diagnostic Radiology, National Cancer Centre Hospital, Tokyo, Japan; Department of Radiology, Kobe University, Graduate School of Medicine, Kobe, Japan
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Igami T, Ebata T, Yokoyama Y, Sugawara G, Takahashi Y, Nagino M. Portal vein embolization using absolute ethanol: evaluation of its safety and efficacy. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2014; 21:676-81. [PMID: 24816863 DOI: 10.1002/jhbp.113] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND Previously, we reported on the clinical efficacy and safety of portal vein embolization (PVE) with fibrin glue. Our embolic materials for PVE changed from fibrin glue to absolute ethanol (EOH) after 2001 due to prohibition of using fibrin glue for PVE. With introducing our technique of PVE with EOH, we evaluated its safety and efficacy with attention to the amount of EOH. METHODS The medical records of 154 patients who underwent PVE using EOH were retrospectively reviewed. RESULTS Changes with time in both the serum levels of aspartate aminotransferase (AST) and alanine aminotransferase (ALT) after PVE returned to the initial condition within 7 days after PVE. In the 96 patients who underwent CT volumerty 14 to 21 days after PVE, the volume of the embolized lobe decreased from 701 ± 165 cm(3) to 549 ± 148 cm(3) (P < 0.0001). Meanwhile, the volume of the non-embolized lobe increased from 388 ± 105 cm(3) to 481 ± 113 cm(3) (P < 0.0001). On simple linear regression, the amount of EOH was positively correlated with both the maximum of AST and that of ALT after PVE; however, it never correlated with changes in liver volume after PVE. CONCLUSIONS Portal vein embolization with EOH has a substantial effect on both hypertrophy of the non-embolized lobe and atrophy of the embolized lobe. Quick recoveries of changes with time in AST and ALT after PVE proved that PVE with EOH is a safe procedure. The amount of EOH affected the extent of liver damage but had no clinical effects on changes in liver volume after PVE.
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Affiliation(s)
- Tsuyoshi Igami
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
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Garlipp B, de Baere T, Damm R, Irmscher R, van Buskirk M, Stübs P, Deschamps F, Meyer F, Seidensticker R, Mohnike K, Pech M, Amthauer H, Lippert H, Ricke J, Seidensticker M. Left-liver hypertrophy after therapeutic right-liver radioembolization is substantial but less than after portal vein embolization. Hepatology 2014; 59:1864-73. [PMID: 24259442 DOI: 10.1002/hep.26947] [Citation(s) in RCA: 118] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2013] [Accepted: 11/17/2013] [Indexed: 12/22/2022]
Abstract
UNLABELLED In patients with liver malignancies potentially amenable to curative extended right hepatectomy but insufficient size of the future liver remnant (FLR), portal vein embolization (PVE) of the tumor-bearing liver is used to induce contralateral liver hypertrophy but leaves the tumor untreated. Radioembolization (RE) treats the tumor in the embolized lobe along with contralateral hypertrophy induction. We performed a matched-pair analysis to compare the capacity for hypertrophy induction of these two modalities. Patients with right-hepatic secondary liver malignancies with no or negligible left-hepatic tumor involvement who were treated by right-lobar PVE (n = 141) or RE (n = 35) at two centers were matched for criteria known to influence liver regeneration following PVE: 1) baseline FLR/Total liver volume ratio (<25 versus ≥ 25%); 2) prior platinum-containing systemic chemotherapy; 3) embolization of segments 5-8 versus 4-8; and 4) baseline platelet count (<200 versus ≥ 200 Gpt/L).The primary endpoint was relative change in FLR volume from baseline to follow-up. Twenty-six matched pairs were identified. FLR volume increase from baseline to follow-up (median 33 [24-56] days after PVE or 46 [27-79] days after RE) was significant in both groups but PVE produced significantly more FLR hypertrophy than RE (61.5 versus 29%, P < 0.001). Time between treatment and follow-up was not correlated with the degree of contralateral hypertrophy achieved in both groups. Although group differences in patient history and treatment setting were present and some bias cannot be excluded, this was minimized by the matched-pair design, as remaining group differences after matching were found to have no significant influence on contralateral hypertrophy development. CONCLUSION PVE induces significantly more contralateral hypertrophy than RE with therapeutic (nonlobectomy) doses. However, contralateral hypertrophy induced by RE is substantial and RE minimizes the risk of tumor progression in the treated lobe, possibly making it a suitable modality for selected patients.
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Affiliation(s)
- Benjamin Garlipp
- Universitätsklinikum Magdeburg, Klinik für Allgemein-, Viszeral- und Gefäβchirurgie, Magdeburg, Germany
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Higuchi R, Yamamoto M. Indications for portal vein embolization in perihilar cholangiocarcinoma. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2014; 21:542-9. [DOI: 10.1002/jhbp.77] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Ryota Higuchi
- Department of Surgery, Institute of Gastroenterology; Tokyo Women's Medical University; 8-1 Kawada-cho Shinjuku-ku Tokyo 162-8666 Japan
| | - Masakazu Yamamoto
- Department of Surgery, Institute of Gastroenterology; Tokyo Women's Medical University; 8-1 Kawada-cho Shinjuku-ku Tokyo 162-8666 Japan
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Miyayama S, Yamakado K, Anai H, Abo D, Minami T, Takaki H, Kodama T, Yamanaka T, Nishiofuku H, Morimoto K, Soyama T, Hasegawa Y, Nakamura K, Yamanishi T, Sato M, Nakajima Y. Guidelines on the use of gelatin sponge particles in embolotherapy. Jpn J Radiol 2014; 32:242-50. [PMID: 24510242 DOI: 10.1007/s11604-014-0292-2] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2013] [Accepted: 01/17/2014] [Indexed: 12/20/2022]
Abstract
Gelatin sponge (GS) is one of the most widely used embolic agents in interventional procedures. There are four commercially available GS products in Japan; however, the endovascular use of Gelfoam and Spongel is off-label, and Gelpart can only be used for hepatic artery embolization and Serescue can only be used for hemostasis of arterial bleeding. GS has been used for a variety of clinical indications, mainly tumor embolization and stopping massive arterial bleeding. The optimal size and preparation procedure of GS particles differs slightly for each clinical indication. In addition, there is a risk of ischemic and/or infectious complications associated with GS embolization in various situations. Therefore, radiologists should be familiar with not only the preparation and handling of GS particles, but also the disadvantages and potential risks, in order to perform GS embolization safely and effectively.
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Affiliation(s)
- Shiro Miyayama
- Department of Diagnostic Radiology, Fukuiken Saiseikai Hospital, 7-1 Wadanaka-cho, Funabashi, Fukui, 918-8503, Japan,
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81
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Portal vein embolization and ligation for extended hepatectomy. Indian J Surg Oncol 2014; 5:30-42. [PMID: 24669163 DOI: 10.1007/s13193-013-0279-y] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2013] [Accepted: 12/13/2013] [Indexed: 02/08/2023] Open
Abstract
Portal vein occlusion through embolization or ligation (PVE, PVL) offers the possibility of increasing the future liver remnant (FLR) and thus reducing the risk of hepatic failure after extended hepatectomy We reviewed the indications, scope and applicability of PVE/PVL in treatment of primary and secondary liver tumours. A thorough PubMED, Embase, Ovid and Cochrane database search was carried out for all original articles with 30 patients or more undergoing either PVE and any patient series with PVL, irrespective of number with outcome measure in at least one of the following parameters: FLR volume change, complications, length of stay, time to surgery, proportion resectable and survival data. PVE can be performed with a technical success in 98.9 % (95 % confidence interval 97-100) patients, with a mean morbidity of 3.13 % (95 % CI 1.21-5.04) and a median in-hospital stay of 2.1 (range 1-4) days (very few papers had data on length of stay following PVE). The mean increase in volume of the FLR following PVE was 39.75 % (95 % CI 30.8-48.6) facilitating extended liver resection after a mean of 37.13 days (95 % CI 28.51-45.74) with a resectability rate of 76.88 % (95 % CI 70.91-82.84). Morbidity and mortality following such extended liver resections after PVE is 26.58 % (95 % CI 19.20-33.95) and 2.59 % (95 % CI 1.34-3.83) respectively with an in-patient stay of 13.57 days (95 % CI 9.8-17.37). However following post-PVE liver hypertrophy 6.29 % (95 % CI 2.24-10.34) patients still have post-resection liver failure and up to 14.2 % (95 % CI -8.7 to 37) may have positive resection margins. Up to 4.80 % (95 % CI 2.07-7.52) have failure of hypertrophy after PVE and 17.46 % (95 % CI 11.89-23.02) may have disease progression during the interim awaiting hypertrophy and subsequent resection. PVL has a greater morbidity and duration of stay of 5.72 % (95 % CI 0-15.28) and 10.16 days (95 % CI 6.63-13.69) respectively; as compared to PVE. Duration to surgery following PVL was greater at 53.6 days (95 % CI 32.14-75.05). PVL induced FLR hypertrophy by a mean of 64.65 % (95 % CI 0-136.12) giving a resectability rate of 63.68 % (95 % CI 56.82-70.54). PVL failed to produce enough liver hypertrophy in 7.4 % of patients (95 % CI 0-16.12). Progression of disease following PVL was 29.29 (95%CI 15.69-42.88). PVE facilitates an extended hepatectomy in patients with limited or inadequate FLR, with good short and long-term outcomes. Patients need to be adequately counselled and consented for PVE and EH in light of these data. PVL would promote hypertrophy as well, but clearly PVE has advantages as compared to PVL on account of its inherent "minimally invasive" nature, fewer complications, length of stay and its feasibility to have shorter times to surgery.
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82
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Rotellar F, Pardo F, Benito A, Martí-Cruchaga P, Zozaya G, Bellver M. Laparoscopic Right Hepatectomy Extended to Middle Hepatic Vein After Right Portal Vein Embolization. Ann Surg Oncol 2014; 21:165-166. [DOI: 10.1245/s10434-013-3298-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
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Sano T, Shimizu Y, Senda Y, Kinoshita T, Nimura Y. Assessing resectability in cholangiocarcinoma. Hepat Oncol 2013; 1:39-51. [PMID: 30190940 DOI: 10.2217/hep.13.6] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Assessment of surgical resectability in cholangiocarcinoma is more complicated than other gastrointestinal malignancies and remains unestablished. According to the primary origin and tumor extent, the applied surgical procedure varies from extrahepatic bile duct resection to right or left trisectionectomy concomitant with pancreatoduodenectomy. Portal vein resection and reconstruction during hepatectomy has been feasible. Thanks to the availability of new microscopic surgical techniques, hepatic arterial resection and reconstruction have also come to be applied for locally advanced cholangiocarcinoma cases. These vascular surgical techniques can expand surgical indications for advanced cholangiocarcinoma. On the other hand, determination of the tumor extent or staging still remains difficult and imprecise. The endoscopic approach has come to play significant roles both for preoperative biliary drainage and tumor staging. Estimation of the functional reserve of future remnant liver in cholestatic patients still remains unresolved. Hepatobiliary surgeons should carefully estimate the safety of the surgical procedure in each individual patient requiring extensive hepatobiliary resection. Early establishment of the measurement methods of the functional capacity of future remnant liver is an important and urgent issue for assessing safer surgical resectablity of cholangiocarcinoma.
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Affiliation(s)
- Tsuyoshi Sano
- Hepato-Biliary & Pancreatic Surgery Division, Department of Gastroenterological Surgery, Aichi Cancer Center Hospital, 1-1 Kanokoden, Chikusa-ku, Nagoya, 464-8681, Japan
| | - Yasuhiro Shimizu
- Hepato-Biliary & Pancreatic Surgery Division, Department of Gastroenterological Surgery, Aichi Cancer Center Hospital, 1-1 Kanokoden, Chikusa-ku, Nagoya, 464-8681, Japan
| | - Yoshiki Senda
- Hepato-Biliary & Pancreatic Surgery Division, Department of Gastroenterological Surgery, Aichi Cancer Center Hospital, 1-1 Kanokoden, Chikusa-ku, Nagoya, 464-8681, Japan
| | - Taira Kinoshita
- Hepato-Biliary & Pancreatic Surgery Division, Department of Gastroenterological Surgery, Aichi Cancer Center Hospital, 1-1 Kanokoden, Chikusa-ku, Nagoya, 464-8681, Japan
| | - Yuji Nimura
- Hepato-Biliary & Pancreatic Surgery Division, Department of Gastroenterological Surgery, Aichi Cancer Center Hospital, 1-1 Kanokoden, Chikusa-ku, Nagoya, 464-8681, Japan
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Geisel D, Malinowski M, Powerski MJ, Wüstefeld J, Heller V, Denecke T, Stockmann M, Gebauer B. Improved hypertrophy of future remnant liver after portal vein embolization with plugs, coils and particles. Cardiovasc Intervent Radiol 2013; 37:1251-8. [PMID: 24310828 DOI: 10.1007/s00270-013-0810-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2013] [Accepted: 11/10/2013] [Indexed: 02/08/2023]
Abstract
PURPOSE To retrospectively analyze efficacy as measured by volume gain of future remnant liver (FRL) after right portal vein embolization (PVE) using particles only versus particles and additional central plug and/or coil (CP/C) embolization. METHODS All patients who underwent PVE between July 2011 and December 2012 were retrospectively analyzed. Right PVE was performed either with particle-only (PO) embolization or additional CP/C embolization. All enrolled patients underwent computed tomography or magnetic resonance imaging before PVE and surgery. The images were used for volumetry of the FRL. RESULTS Of 75 patients, 40 had PO and 35 CP/C embolization. Age, sex, and tumor entities did not differ significantly between the two groups. Tumor entities included cholangiocarcinoma (n = 52), metastasis from colorectal cancer (n = 14), hepatocellular carcinoma (n = 2), and others (n = 7). Time from PVE to preoperative imaging was similar in both groups. FRL volume before PVE was 329 ± 121 ml in the PO group and 333 ± 135 ml in the CP/C group, and 419 ± 135 ml and 492 ± 165 ml before operation. The average percentage volume gain was significantly higher in the CP/C group than in the PO group, with 53.3 ± 34.5 % versus 30.9 ± 28.8 % (p = 0.002). CONCLUSION Right PVE with additional CP/C embolization leads to a significantly higher gain in FRL volume than embolization with particles alone.
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Affiliation(s)
- Dominik Geisel
- Department of Diagnostic and Interventional Radiology, Charité, Campus Virchow-Klinikum, Augustenburger Platz 1, 13353, Berlin, Germany,
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Regimbeau JM, Fuks D, Chapuis-Roux E, Yzet T, Cosse C, Bartoli E, N'guyen-Khac E, Robert B, Lobjoie E. Addition of Molecular Adsorbent Recirculating System (MARS(®)) Albumin Dialysis for the Preoperative Management of Jaundiced Patients with Hilar Cholangiocarcinoma. Case Rep Gastroenterol 2013; 7:396-403. [PMID: 24163652 PMCID: PMC3806690 DOI: 10.1159/000355343] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
The preoperative management of hilar cholangiocarcinoma (HC) with jaundice focuses on decreasing the total serum bilirubin level (SBL) by performing preoperative biliary drainage (PBD). However, it takes about 6–8 weeks for the SBL to fall at a sufficient extent. The objective of this preliminary study was to evaluate the impact of Molecular Adsorbent Recirculating System (MARS®) dialysis (in association with PBD) on SBL decrease. From January 2010 to January 2011, we prospectively selected all jaundiced patients admitted to our university hospital for resectable HC and requiring PBD prior to major hepatectomy. The PBD was followed by 3 sessions of MARS dialysis over a period of 72 h. A total of 10 patients with HC were screened and two of them were included (Bismuth-Corlette stage IIIa, gender ratio 1, median age 68 years). The initial SBL in the two patients was 328 and 242 μmol/l, respectively. After three MARS dialysis sessions, the SBL had fallen by 30 and 52%, respectively. After the end of each session, there was a SBL rebound of about 10 μmol/l. The MARS decreased the serum creatinine level, the platelet count and the prothrombin index, but did not modify the serum albumin level. Pruritus disappeared after one and two sessions, respectively. MARS-related morbidity included hypotension (n = 1), tachycardia (n = 1), thrombocytopenia (n = 2) and anaemia (n = 1). When combined with PBD, MARS dialysis appears to accelerate the decrease in SBL and thus may enable earlier surgery. This hypothesis must be validated in a larger study.
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Affiliation(s)
- Jean-Marc Regimbeau
- Department of Digestive Surgery, Jules Verne University of Picardy, Amiens, France ; Department of EA4294, Jules Verne University of Picardy, Amiens, France
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Evolution of surgical treatment for perihilar cholangiocarcinoma: a single-center 34-year review of 574 consecutive resections. Ann Surg 2013; 258:129-40. [PMID: 23059502 DOI: 10.1097/sla.0b013e3182708b57] [Citation(s) in RCA: 447] [Impact Index Per Article: 40.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To review our 34-year experience with 574 consecutive resections for perihilar cholangiocarcinoma and to evaluate the progress made in surgical treatment of this disease. BACKGROUND Few studies have reported improved surgical outcomes for perihilar cholangiocarcinoma; therefore, it is still unclear whether surgical treatment of this intractable disease has progressed. METHODS Between April 1977 and December 2010, a total of 754 consecutive patients with perihilar cholangiocarcinoma were treated, of whom 574 (76.1%) underwent resection. The medical records of these resected patients were retrospectively reviewed. RESULTS The incidence of major hepatectomies has increased, and limited resections, including central hepatectomies and bile duct resections, were rarely performed. Combined vascular resection was being used more often. Operative time has become shorter, and intraoperative blood loss has also decreased significantly. Because of refinements in surgical techniques and perioperative management, morbidity decreased significantly but was still high, with a rate of 43.1% in the last 5 years. Mortality rate has also decreased significantly (P < 0.001) from 11.1% (8/72) before 1990 to 1.4% (3/218) in the last 5 years. The ratio of advanced disease defined as pStage IVA and IVB has increased significantly from 49.4% before 2000 to 61.4% after 2001. The disease-specific survival for the 574 study patients (including all deaths) was 44.3% at year 3, 32.5% at year 5, and 19.9% at year 10. The survival was significantly better in the later period of 2001 to 2010 than in the earlier period of 1977 to 2000 (38.1% vs 23.1% at year 5, P < 0.001). For pM0, R0, and pN0 patients (n = 243), the survival in the later period was good with 67.1% at year 5, which was significantly better than that of the earlier period (P < 0.001). For pM0, R0, and pN1 patients (n = 142), however, the survival in the later period was similar to that of the earlier period (22.1% vs 14.6% at year 5, P = 0.647). Multivariate analysis revealed that lymph node metastasis was the strongest prognostic indicator. CONCLUSIONS Surgical treatment of perihilar cholangiocarcinoma has been evolving steadily, with expanded surgical indication, decreased mortality, and increased survival. Survival for R0 and pN0 patients was satisfactory, whereas survival for pN1 patients was still poor, suggesting that establishment of effective adjuvant chemotherapy is needed.
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Virtual liver resection: computer-assisted operation planning using a three-dimensional liver representation. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2013; 20:157-64. [PMID: 23135735 DOI: 10.1007/s00534-012-0574-y] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
In liver surgery, understanding the complicated liver structures and a detailed evaluation of the functional liver remnant volume are essential to perform safe surgical procedures. Recent advances in imaging technology have enabled operation planning using three-dimensional (3D) image-processing software. Virtual liver resection systems provide (1) 3D imaging of liver structures, (2) detailed volumetric analyses based on portal perfusion, and (3) quantitative estimates of the venous drainage area, enabling the investigation of uncharted fields that cannot be examined using a conventional two-dimensional modality. The next step in computer-assisted liver surgery is the application of a virtual hepatectomy to real-time operations. However, the need for a precise alignment between the preoperative imaging data and the intraoperative situation remains to be adequately addressed, since the liver is subject to deformation and respiratory movements during the surgical procedures. We expect that the practical application of a navigation system for transferring the preoperative planning to real-time operations could make liver surgery safer and more standardized in the near future.
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89
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Effect of preoperative chemotherapy on postoperative liver regeneration following hepatic resection as estimated by liver volume. World J Surg Oncol 2013; 11:65. [PMID: 23497123 PMCID: PMC3621216 DOI: 10.1186/1477-7819-11-65] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2012] [Accepted: 02/15/2013] [Indexed: 01/10/2023] Open
Abstract
Background In order to analyze postoperative liver regeneration following hepatic resection after chemotherapy, we retrospectively investigated the differences in liver regeneration by comparing changes of residual liver volume in three groups: a living liver donor group and two groups of patients with colorectal liver metastases who did and did not undergo preoperative chemotherapy. Methods This study included 32 patients who had at least segmental anatomical hepatic resection. Residual liver volume, early postoperative liver volume, and late postoperative liver volume were calculated to study the changes over time. From the histopathological analysis of chemotherapy-induced liver disorders, the effect on liver regeneration according to the histopathology of noncancerous liver tissue was also compared between the two colorectal cancer groups using Kleiner’s score for steatohepatitis grading {Hepatology, 41(6):1313–1321, 2005} and sinusoidal obstruction syndrome (SOS) grading for sinusoidal obstructions {Ann Oncol, 15(3):460–466, 2004}. Results Assuming a preoperative liver volume of 100%, mean late postoperative liver volumes in the three groups (the living liver donor group and the colorectal cancer groups with or without chemotherapy) were 91.1%, 80.8%, and 81.3%, respectively, with about the same rate of liver regeneration among the three groups. Histopathological analysis revealed no correlation between either the Kleiner’s scores or the SOS grading and liver regeneration. Conclusions As estimated by liver volume, the level of liver regeneration was the same in normal livers, tumor-bearing livers, and post-chemotherapy tumor-bearing livers. Liver regeneration was not adversely affected by the extent to which steatosis or sinusoidal dilatation was induced in noncancerous tissue by chemotherapy in patients scheduled for surgery.
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90
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van Lienden KP, Hoekstra LT, Bennink RJ, van Gulik TM. Intrahepatic left to right portoportal venous collateral vascular formation in patients undergoing right portal vein ligation. Cardiovasc Intervent Radiol 2013; 36:1572-1579. [PMID: 23483283 DOI: 10.1007/s00270-013-0591-5] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2012] [Accepted: 02/10/2013] [Indexed: 01/02/2023]
Abstract
PURPOSE We investigated intrahepatic vascular changes in patients undergoing right portal vein ligation (PVL) or portal vein embolization (PVE) in conjunction with the ensuing hypertrophic response and function of the left liver lobe. METHODS Between December 2008 and October 2011, 7 patients underwent right PVL and 14 patients PVE. Computed tomographic (CT) volumetry to assess future remnant liver (FRL) and functional hepatobiliary scintigraphy were performed in all patients before and 3 weeks after portal vein occlusion. In 18 patients an intraoperative portography was performed to assess perfusion through the occluded portal branches. RESULTS In all patients after initially successful PVL, reperfused portal veins were observed on CT scan 3 weeks after portal occlusion. This was confirmed in all cases during intraoperative portography. Intrahepatic portoportal collaterals were identified in all patients in the PVL group and in one patient in the PVE group. In all other PVE patients, complete occlusion of the embolized portal branches was observed on CT scan and on intraoperative portography. The median increase of FRL volume after PVE was 41.6 % (range 10-305 %), and after PVL was only 8.1 % (range 0-102 %) (p = 0.179). There were no differences in FRL function between both groups. CONCLUSION Preoperative PVE and PVL are both methods to induce hypertrophy of the FRL in anticipation of major liver resection. Compared to PVE, PVL seems less efficient in inducing hypertrophy of the nonoccluded left lobe. This could be caused by the formation of intrahepatic portoportal neocollateral vessels, through which the ligated portal branches are reperfused within 3 weeks.
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Affiliation(s)
- K P van Lienden
- Department of Interventional Radiology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
| | - L T Hoekstra
- Department of Surgery, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - R J Bennink
- Department of Nuclear Medicine, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - T M van Gulik
- Department of Surgery, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
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91
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Mise Y, Sakamoto Y, Ishizawa T, Kaneko J, Aoki T, Hasegawa K, Sugawara Y, Kokudo N. A worldwide survey of the current daily practice in liver surgery. Liver Cancer 2013; 2:55-66. [PMID: 24159597 PMCID: PMC3747552 DOI: 10.1159/000346225] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Liver resection remains the mainstay of curative treatment for liver malignancies. A variety of preoperative assessments and surgical techniques have improved the short- and long-term outcomes of liver resection in patients with liver tumors. Recently, laparoscopic hepatectomies have been increasingly performed. The aim of the present study is to survey the current practice of liver surgery in high-volume centers in the world. METHODS A questionnaire on the preoperative assessment for liver surgery, open hepatectomy, and laparoscopic hepatectomy was sent to 94 liver centers in the world. RESULTS Forty-two centers (45%) responded to this survey (29 Asian, 9 European, and 4 North American centers). All but one of the centers evaluated the future liver remnant (FLR) volume, and 95% of them performed preoperative portal vein embolization to increase the FLR volume. In half of the centers, the required FLR volume was over 30% in patients with normal liver and 50% in patients with cirrhotic liver. To reduce the intraoperative blood loss, half of the centers routinely used Pringle's maneuver, and 85% restricted the intraoperative fluid infusion to reduce the central venous pressure. More than 10 laparoscopic hepatectomies were performed per year in 62% of the centers, and more than 30 were performed in 26%, respectively. Laparoscopic major hepatectomies were performed in 24%. Two-thirds answered that the laparoscopic approach would be feasible in donor hepatectomy. CONCLUSION The evaluation of FLR volume in patients with normal or cirrhotic liver and the usage of preoperative portal vein embolization have become essential practice in more than 90% of the centers. Reduced blood loss has been achieved using Pringle's maneuver, restriction of fluid infusion, and a variety of surgical devises. The laparoscopic approach is increasingly extended to major hepatectomy or donor hepatectomy.
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Affiliation(s)
| | | | | | | | | | | | | | - Norihiro Kokudo
- *Norihiro Kokudo, MD, PhD, Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery Graduate School of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655 (Japan), E-Mail
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92
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Farges O, Regimbeau JM, Fuks D, Le Treut YP, Cherqui D, Bachellier P, Mabrut JY, Adham M, Pruvot FR, Gigot JF. Multicentre European study of preoperative biliary drainage for hilar cholangiocarcinoma. Br J Surg 2012; 100:274-83. [PMID: 23124720 DOI: 10.1002/bjs.8950] [Citation(s) in RCA: 161] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/21/2012] [Indexed: 12/12/2022]
Abstract
BACKGROUND Indications for preoperative biliary drainage (PBD) in the context of hepatectomy for hilar malignancies are still debated. The aim of this study was to investigate current European practice regarding biliary drainage before hepatectomy for Klatskin tumours. METHODS This was a retrospective analysis of all patients who underwent formal or extended right or left hepatectomy for hilar cholangiocarcinoma between 1997 and 2008 at 11 European teaching hospitals, and for whom details of serum bilirubin levels at admission and at the time of surgery were available. PBD was performed at the physicians' discretion. The primary outcome was 90-day mortality. Secondary outcomes were morbidity and cause of death. The association of PBD and of preoperative serum bilirubin levels with postoperative mortality was assessed by logistic regression, in the entire population as well as separately in the right- and left-sided hepatectomy groups, and was adjusted for confounding factors. RESULTS A total of 366 patients were enrolled; PBD was performed in 180 patients. The overall mortality rate was 10·7 per cent and was higher after right- than left-sided hepatectomy (14·7 versus 6·6 per cent; adjusted odds ratio (OR) 3·16, 95 per cent confidence interval 1·50 to 6·65; P = 0·001). PBD did not affect overall postoperative mortality, but was associated with a decreased mortality rate after right hepatectomy (adjusted OR 0·29, 0·11 to 0·77; P = 0·013) and an increased mortality rate after left hepatectomy (adjusted OR 4·06, 1·01 to 16·30; P = 0·035). A preoperative serum bilirubin level greater than 50 µmol/l was also associated with increased mortality, but only after right hepatectomy (adjusted OR 7·02, 1·73 to 28·52; P = 0·002). CONCLUSION PBD does not affect overall mortality in jaundiced patients with hilar cholangiocarcinoma, but there may be a difference between patients undergoing right-sided versus left-sided hepatectomy.
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Affiliation(s)
- O Farges
- Department of Hepatobiliary Surgery, Hôpital Beaujon, Assistance-Publique Hôpitaux de Paris, Université Paris 7, Clichy, France.
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93
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Nagino M. Perihilar cholangiocarcinoma: a surgeon's viewpoint on current topics. J Gastroenterol 2012; 47:1165-76. [PMID: 22847554 DOI: 10.1007/s00535-012-0628-6] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2012] [Accepted: 06/09/2012] [Indexed: 02/07/2023]
Abstract
Perihilar cholangiocarcinomas are defined anatomically as "tumors that are located in the extrahepatic biliary tree proximal to the origin of the cystic duct". However, as the boundary between the extrahepatic and intrahepatic bile ducts is not well defined, perihilar cholangiocarcinomas potentially include two types of tumors: one is the "extrahepatic" type, which arises from the large hilar bile duct, and the other is the "intrahepatic" type, which has an intrahepatic component with the invasion of the hepatic hilus. The new TNM staging system published by the International Union Against Cancer (UICC) has been well revised with regard to perihilar cholangiocarcinoma, but it still lacks stratification of patient prognosis and has little applicability for assessing the feasibility of surgical treatment; therefore, further refinement is essential. Most patients with perihilar cholangiocarcinomas present with jaundice, and preoperative biliary drainage is mandatory. Previously, percutaneous transhepatic biliary drainage was used in many centers; however, it is accepted that endoscopic naso-biliary drainage is the most suitable method of preoperative drainage. Portal vein embolization is now widely used as a presurgical treatment for patients undergoing an extended hepatectomy to minimize postoperative liver dysfunction. The surgical resection of a perihilar cholangiocarcinoma is technically demanding and continues to be the most difficult challenge for hepatobiliary surgeons. Because of advances in diagnostic and surgical techniques, surgical outcomes and survival rates after resection have steadily improved. However, survival, especially for patients with lymph node metastasis, is still unsatisfactory, and the establishment of adjuvant chemotherapy is necessary. Further synergy of endoscopists, radiologists, oncologists, and surgeons is required to conquer this intractable disease.
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Affiliation(s)
- Masato Nagino
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya 466-8550, Japan.
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94
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Grazi GL. Liver resections: complications and survival outcome. Expert Rev Pharmacoecon Outcomes Res 2012; 7:269-79. [PMID: 20528313 DOI: 10.1586/14737167.7.3.269] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Today, liver resection represents one of the most effective therapies in the treatment of defined liver diseases, particularly for hepatocellular carcinomas, liver metastases and tumors originating from the bile ducts. There have been a number of improvements in the technique but the use of kellyclasia associated with meticulous control of hemostasis and biliostasis appears to be more effective and efficient. The procedure is still burdened with some postoperative complications, the more characteristic of which are liver insufficiency, biliary leakage and ascites. Several neoplastic diseases, both primitive and secondary, can benefit from this therapy with substantial improvement of long-term survival, and a notable change in the natural history of the disease. For these situations, a consultation should always be performed by a surgeon experienced in hepatic surgery.
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Affiliation(s)
- Gian Luca Grazi
- Associate Professor of General Surgery, University of Bologna, Liver & Multi Organ Transplant Unit, Sant'Orsola-Malpighi Hospital, Bologna, Italy. ; www.liversurgery.info
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95
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Optimal iodine dose for 3-dimensional multidetector-row CT angiography of the liver. Eur J Radiol 2012; 81:2450-5. [DOI: 10.1016/j.ejrad.2011.06.022] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2010] [Revised: 05/30/2011] [Accepted: 06/01/2011] [Indexed: 11/19/2022]
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96
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Portal vein embolization before liver resection: a systematic review. Cardiovasc Intervent Radiol 2012; 36:25-34. [PMID: 22806245 PMCID: PMC3549243 DOI: 10.1007/s00270-012-0440-y] [Citation(s) in RCA: 306] [Impact Index Per Article: 25.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2011] [Accepted: 06/18/2012] [Indexed: 02/08/2023]
Abstract
Purpose This is a review of literature on the indications, technique, and outcome of portal vein embolization (PVE). Methods A systematic literature search on outcome of PVE from 1990 to 2011 was performed in Medline, Cochrane, and Embase databases. Results Forty-four articles were selected, including 1,791 patients with a mean age of 61 ± 4.1 years. Overall technical success rate was 99.3 %. The mean hypertrophy rate of the FRL after PVE was 37.9 ± 0.1 %. In 70 patients (3.9 %), surgery was not performed because of failure of PVE (clinical success rate 96.1 %). In 51 patients (2.8 %), the hypertrophy response was insufficient to perform liver resection. In the other 17 cases, 12 did not technically succeed (0.7 %) and 7 caused a complication leading to unresectability (0.4 %). In 6.1 %, resection was cancelled because of local tumor progression after PVE. Major complications were seen in 2.5 %, and the mortality rate was 0.1 %. A head-to-head comparison shows a negative effect of liver cirrhosis on hypertrophy response. The use of n-butyl cyanoacrylate seems to have a greater effect on hypertrophy, but the difference with other embolization materials did not reach statistical significance. No difference in regeneration is seen in patients with cholestasis or chemotherapy. Conclusions Preoperative PVE has a high technical and clinical success rate. Liver cirrhosis has a negative effect on regeneration, but cholestasis and chemotherapy do not seem to have an influence on the hypertrophy response. The use of n-butyl cyanoacrylate may result in a greater hypertrophy response compared with other embolization materials used.
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97
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Kim BW, Park YK, Xu W, Wang HJ, Lee JM, Lee K. Clinical significance of right hepatectomy along the main portal fissure on donors in living donor liver transplantation. Transpl Int 2012; 25:1072-83. [PMID: 22805515 DOI: 10.1111/j.1432-2277.2012.01538.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
There might be discordance between inter-lobar borders of the main portal fissure (MPF) using the middle hepatic vein (MHV) and of the portal segmentation. Forty-five living donors who underwent right hepatectomy for the adult recipients from 2007 to 2011 in a tertiary hospital were retrospectively analyzed. The donors were classified into conventional right hepatectomy along the MPF (cRL group, n = 26) and modified right hepatectomy along right-side shifted transection plane from the MPF (mRL group, n = 19). The cRL donors had higher postoperative peak level of INR (1.84 vs. 1.62; P = 0.022), and bilirubin (3.37 mg/dl vs. 2.74 mg/dl; P = 0.065) than the mRL donors. cRL donors experienced greater depression of platelet count (144 per nL vs. 168 per nL; P = 0.042) and enlargement of splenic volume (52% vs. 37%; P = 0.025) than mRL donors for 7 days after hepatectomy. The regeneration of the left lateral sector was more accelerated in the cRL donors than the mRL donors for postoperative 3 months (148% vs. 84%; P = 0.015). There were no differences in the post-transplant graft function, incidence of complications, and graft survival rates between the two groups of recipients (P > 0.05). This study suggests that the conventional right hepatectomy along the MHV might increase donor risk by reducing parenchymal liver volume of the segment IV.
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Affiliation(s)
- Bong-Wan Kim
- Department of Hepatobiliary Surgery and Liver Transplantation, Ajou University School of Medicine, Suwon, Korea.
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98
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Bellemann N, Stampfl U, Sommer CM, Kauczor HU, Schemmer P, Radeleff BA. Portal vein embolization using a Histoacryl/Lipiodol mixture before right liver resection. Dig Surg 2012; 29:236-42. [PMID: 22797287 DOI: 10.1159/000339748] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2012] [Accepted: 05/29/2012] [Indexed: 12/23/2022]
Abstract
PURPOSE The purpose of this retrospective study was to evaluate the efficacy and safety of percutaneous transhepatic portal vein embolization (PVE) of the right liver lobe using Histoacryl/Lipiodol mixture to induce contralateral liver hypertrophy before right-sided (or extended right-sided) hepatectomy in patients with primarily unresectable liver tumors. METHODS Twenty-one patients (9 females and 12 males) underwent PVE due to an insufficient future liver remnant; 17 showed liver metastases and 4 suffered from biliary cancer. Imaging was performed prior to and 4 weeks after PVE. Surgery was scheduled for 1 week after a CT or MRI control. The primary study end point was technical success, defined as complete angiographical occlusion of the portal vein. The secondary study end point was evaluation of liver hypertrophy by CT and MRI volumetry and transfer to operability. RESULTS In all the patients, PVE could be performed with a Histoacryl/Lipiodol mixture (n = 20) or a Histoacryl/Lipiodol mixture with microcoils (n = 1). No procedure-related complications occurred. The volume of the left liver lobe increased significantly (p < 0.0001) by 28% from a mean of 549 ml to 709 ml. Eighteen of twenty-one patients (85.7%) could be transferred to surgery, and the intended resection could be performed as planned in 13/18 (72.3%) patients. CONCLUSION Preoperative right-sided PVE using a Histoacryl/Lipiodol mixture is a safe technique and achieves a sufficient hypertrophy of the future liver remnant in the left liver lobe.
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Affiliation(s)
- Nadine Bellemann
- Diagnostic and Interventional Radiology, University Hospital Heidelberg, Heidelberg, Germany.
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99
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Preoperative percutaneous transhepatic portal vein embolization with ethanol injection. AJR Am J Roentgenol 2012; 198:914-22. [PMID: 22451561 DOI: 10.2214/ajr.11.6515] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVE The purpose of this article is to evaluate the feasibility and efficacy of preoperative percutaneous transhepatic portal vein embolization with ethanol injection. MATERIALS AND METHODS We retrospectively evaluated 143 patients who underwent percutaneous transhepatic portal vein embolization. Hypertrophy of the future liver remnant was assessed by comparing the volumetric data obtained from CT image data before and after percutaneous transhepatic portal vein embolization. The evaluation of effectiveness was based on changes in the absolute volume of the future liver remnant and the ratio of the future liver remnant to the total estimated liver volume. RESULTS Ten of 143 patients (7.0%) underwent additional embolization because of recanalization and insufficient hypertrophy of the future liver remnant. The mean increase in the ratio of the future liver remnant was 33.6% (p < 0.0001), and the mean ratio of future liver remnant to total estimated liver volume increased from 34.9% to 45.7% (p < 0.0001). Although most of the patients complained of pain after ethanol injection, they were gradually relieved of pain in a few minutes by conservative treatment. Fever (38-39°C) was reported after 47 of 151 (31.1%) percutaneous transhepatic portal vein embolization sessions and was resolved within a few days. Transient elevation of the liver transaminases was observed after the procedures and resolved within about a week. Major complications occurred in nine of 151 (6%) percutaneous transhepatic portal vein embolization sessions, but no patients developed hepatic insufficiency or severe complications precluding successful resection. One hundred twenty patients underwent hepatic resection, and two patients developed hepatic failure after surgery. CONCLUSION Preoperative percutaneous transhepatic portal vein embolization with ethanol is a feasible and effective procedure to obtain hypertrophy of the future liver remnant for preventing hepatic failure after hepatectomy.
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100
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Lim C, Farges O. Portal vein occlusion before major hepatectomy in patients with colorectal liver metastases: rationale, indications, technical aspects, complications and outcome. J Visc Surg 2012; 149:e86-96. [PMID: 22504072 DOI: 10.1016/j.jviscsurg.2012.03.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Surgery is the only curative treatment for colorectal liver metastases (CRLM), but resection should be total with tumor-free margins and the remaining parenchyma, functionally evaluated. The rationale behind portal vein embolization (PVE) to reduce the risk of these hepatic resections is threefold: (i) surgery for CRLM has become more and more aggressive, and hepatocellular insufficiency represents the leading cause of mortality after major hepatectomy for hepatic metastasis (HM), (ii) underlying hepatic disease occurs more frequently than previously thought in these patients having undergone neoadjuvant chemotherapy, and can alter hepatic function and/or hinder postoperative regeneration, and (iii) the operative risk is increased if major hepatectomy is associated with resection of the primary tumor. The goal of this update is to review the reasons behind and the indications for PVE, to analyze the literature pertaining to whether PVE should be routine or selective, and to tackle certain technical aspects, all within the framework of the treatment of CRLM.
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Affiliation(s)
- C Lim
- Service de chirurgie hépatobiliaire et pancréatique, AP-HP, université Paris-7, hôpital Beaujon, 100, boulevard du Général-Leclerc, 92118 Paris, France
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