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Robles R, Marín C, Lopez-Conesa A, Capel A, Perez-Flores D, Parrilla P. Comparative study of right portal vein ligation versus embolisation for induction of hypertrophy in two-stage hepatectomy for multiple bilateral colorectal liver metastases. Eur J Surg Oncol 2012; 38:586-93. [PMID: 22560404 DOI: 10.1016/j.ejso.2012.03.007] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2011] [Revised: 03/13/2012] [Accepted: 03/26/2012] [Indexed: 12/12/2022] Open
Abstract
AIM In patients with two-stage hepatectomy (TSH) for multiple bilobar liver metastases from colorectal cancer, few clinical series compare functional remnant hypertrophy of the liver volume between right portal vein ligation (PVL) and embolisation (PVE). Our objective is to analyse the effectiveness of portal vein ligation to achieve hypertrophy of the functional remnant volume (FRV) of the liver and to compare the results with portal vein embolisation in a series of patients with multiple bilobar liver metastases from colorectal carcinoma. PATIENTS AND METHODS Between September 2001 and September 2011 we performed a TSH in 41 patients with multiple bilobar colorectal liver metastases. A right PVL was performed in 23 patients with an insufficient FRV (three patients did not complete the second stage due to tumour progression and were excluded). We prospectively compare these results with the increased remnant volume obtained in 18 patients with right PVE. RESULTS The median FRV was higher in the patients with PVE, rising from 501 ml (range 309-703) to 636 ml (range 387-649), than those with PVL, rising from 510 ml (range 203-824) to 595 ml (range 313-1213) (p < 0.05). The median %FRVI was higher in the patients with PVE (median 40%; range 21-65%) than those with PVL (median 30%; range 21-60%) (p < 0.05). CONCLUSIONS PVL and PVE were effective in all cases for obtaining hypertrophy of the FRV before major liver resection. Right PVE obtains better results and should be used where necessary to achieve a further increase in volume.
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Affiliation(s)
- R Robles
- Virgen de Arrixaca University Hospital, Faculty of Medicine, University of Murcia, Liver Surgery and Liver Transplantation Unit, Spain.
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52
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Portal Vein Embolization: What Do We Know? Cardiovasc Intervent Radiol 2011; 35:999-1008. [DOI: 10.1007/s00270-011-0300-1] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2011] [Accepted: 10/10/2011] [Indexed: 01/07/2023]
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53
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Tokue H, Takeuchi Y, Sofue K, Arai Y, Tsushima Y. Ultrasound-guided thrombin injection for the treatment of an iatrogenic hepatic artery pseudoaneurysm: a case report. J Med Case Rep 2011; 5:518. [PMID: 22017919 PMCID: PMC3212963 DOI: 10.1186/1752-1947-5-518] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2011] [Accepted: 10/21/2011] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Percutaneous transhepatic portal embolization is often performed to expand the indications for hepatic resection. Various etiologies of hepatic artery pseudoaneurysm have been reported, but regardless of the etiology, hepatic artery pseudoaneurysm is usually managed with an endovascular approach or open surgery, depending on the location and clinical symptomatology. However, it is difficult to manage hepatic artery pseudoaneurysm after percutaneous transhepatic portal embolization, since embolization of the hepatic artery may cause hepatic infarction CASE PRESENTATION A 58-year-old Japanese man with hilar bile duct cancer underwent percutaneous transhepatic portal embolization to expand the indication for hepatic resection. Two days after percutaneous transhepatic portal embolization, our patient suddenly complained of abdominal pain. Contrast-enhanced computed tomography confirmed a pseudoaneurysm arising from a segmental branch of his right hepatic artery. Since embolization of the hepatic arterial branches may cause hepatic infarction, ultrasound-guided thrombin injection therapy was successfully performed for the pseudoaneurysm. CONCLUSION We performed a thrombin injection instead of arterial embolization to avoid hepatic infarction. The rationale of this choice may be insufficient. However, ultrasound-guided percutaneous thrombin injection therapy may be considered as an alternative to percutaneous transarterial embolization or surgical intervention for an iatrogenic hepatic artery pseudoaneurysm.
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Affiliation(s)
- Hiroyuki Tokue
- Department of Diagnostic and Interventional Radiology, Gunma University Hospital, Maebashi, Gunma, Japan.
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Kalenderian AC, Chabrot P, Buc E, Cassagnes L, Ravel A, Pezet D, Boyer L. Embolisation portale préopératoire par Amplatzer® Vascular Plugs (AVP) : 17 patients. ACTA ACUST UNITED AC 2011; 92:899-908. [DOI: 10.1016/j.jradio.2011.06.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2011] [Revised: 06/16/2011] [Accepted: 06/23/2011] [Indexed: 12/12/2022]
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Arterial Versus Portal Venous Embolization for Induction of Hepatic Hypertrophy before Extended Right Hemihepatectomy in Hilar Cholangiocarcinomas: A Prospective Randomized Study. J Vasc Interv Radiol 2011; 22:1254-62. [DOI: 10.1016/j.jvir.2011.04.014] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2009] [Revised: 04/18/2011] [Accepted: 04/19/2011] [Indexed: 01/09/2023] Open
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Thakrar PD, Madoff DC. Preoperative portal vein embolization: an approach to improve the safety of major hepatic resection. Semin Roentgenol 2011; 46:142-53. [PMID: 21338839 DOI: 10.1053/j.ro.2010.08.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Affiliation(s)
- Pooja D Thakrar
- Division of Diagnostic Imaging, Interventional Radiology Section, The University of Texas M D Anderson Cancer Center, Houston, TX 77030-4009, USA
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57
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Avritscher R, de Baere T, Murthy R, Deschamps F, Madoff DC. Percutaneous transhepatic portal vein embolization: rationale, technique, and outcomes. Semin Intervent Radiol 2011; 25:132-45. [PMID: 21326554 DOI: 10.1055/s-2008-1076686] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Portal vein embolization (PVE) is used to induce preoperative liver hypertrophy in patients with anticipated marginal future liver remnant (FLR) volumes who are otherwise potential candidates for resection. PVE can be performed utilizing the transhepatic contralateral and ipsilateral approaches. The transhepatic contralateral approach is the most commonly used technique worldwide, largely owing to its technical ease. However, the contralateral approach risks injuring the FLR, thereby compromising the planned surgical resection. The transhepatic ipsilateral approach offers a potentially safer alternative because the complications associated with this approach affect only the hepatic lobe that will be resected and are usually not serious enough to preclude surgery. This article discusses PVE using the transhepatic ipsilateral and contralateral approaches, including patient selection criteria, anatomical and technical considerations, and patient complications and outcomes.
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Affiliation(s)
- Rony Avritscher
- Division of Diagnostic Imaging, Interventional Radiology Section, The University of Texas M. D. Anderson Cancer Center, Houston, Texas
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58
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Anaya DA, Blazer DG, Abdalla EK. Strategies for resection using portal vein embolization: hepatocellular carcinoma and hilar cholangiocarcinoma. Semin Intervent Radiol 2011; 25:110-22. [PMID: 21326552 DOI: 10.1055/s-2008-1076684] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Preoperative portal vein embolization (PVE) is increasingly used to optimize the volume and function of the future liver remnant (FLR) and to reduce the risk for complications of major hepatectomy for hepatocellular carcinoma (HCC) or hilar cholangiocarcinoma (CCA). In patients with HCC who are candidates for extended hepatectomy and in patients with HCC and well-compensated cirrhosis who are being considered for major hepatectomy, FLR volumetry is routinely performed, and PVE is employed in selected cases to optimize the volume and function of the FLR prior to surgery. Similarly, in patients with hilar CCA who are candidates for extended hepatectomy, careful preoperative preparation using biliary drainage, FLR volumetry, and PVE optimizes the volume and function of the FLR prior to surgery. Appropriate use of PVE has led to improved postoperative outcomes after major hepatectomy for these diseases and oncological outcomes similar to those in patients who undergo resection without PVE. Specific indications for PVE are being clarified. FLR volumetry is necessary for proper selection of patients for PVE. Analysis of the degree of hypertrophy of the FLR after PVE (a dynamic test of liver regeneration) complements analysis of the pre-PVE FLR volume (a static test). Together, FLR degree of hypertrophy and FLR volume are the best predictors of outcome after major hepatectomy in an individual patient, regardless of the degree of underlying liver disease. This article synthesizes the literature on the approach to patients with HCC and CCA who are candidates for major hepatectomy. The rationale and indications for FLR volumetry and PVE and outcomes following PVE and major hepatectomy for HCC and CCA are discussed.
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Affiliation(s)
- Daniel A Anaya
- Department of Surgical Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, Texas
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59
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Walser EM. Preoperative portal venous and hepatic arterial embolization of tumor. Semin Intervent Radiol 2011; 25:242-51. [PMID: 21326514 DOI: 10.1055/s-0028-1085926] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Although the goal of embolization is usually to create therapeutic ischemia or hemostasis without surgery, the rationale for preoperative embolotherapy is different in several respects. First, the aim is to prepare patients for definitive surgical resection rather than cure or palliation, and, thus, the goals and expectations are limited and defined by close communication between the interventionalist and the surgeon. Second, when considering segmental resection, the normal liver should be protected from procedural damage. Third, the search for extrahepatic disease is crucial for these patients because resection is typically abandoned in favor of alternative therapies for patients with systemic disease. Finally, intraoperative ultrasound should always be considered to survey the future liver remnant for unsuspected small tumors and allow ablation of these lesions to maximize the success of partial hepatectomy. This article describes preoperative hepatic arterial and portal venous embolization in patients with or without cirrhosis complicated by tumors judged eligible for surgical resection or orthotopic liver transplantation (OLT). Each type of embolization will be reviewed in terms of indications and contraindications, technique, and complications. Finally, the outcomes will be evaluated in terms of morbidity, mortality, and tumor recurrence rates.
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60
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Bilbao JI, Martínez-Cuesta A, Urtasun F, Cosín O. Complications of embolization. Semin Intervent Radiol 2011; 23:126-42. [PMID: 21326756 DOI: 10.1055/s-2006-941443] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Embolization is a remarkably versatile procedure used in nearly all vascular and nonvascular systems to treat a wide range of pathology. The published literature is rich with studies demonstrating the enormous therapeutic potential offered by embolization procedures, and the possibilities continue to expand with the advent of new embolization agents and techniques. Unfortunately, with this variety and innovation comes a wide spectrum of potential complications, not always easy to classify and summarize, associated with embolization. This article reviews the procedures and associated complications of arterial and venous embolization procedures, organized by vascular distribution.
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Affiliation(s)
- José I Bilbao
- Department of Radiology, Clínica Universitaria de Navarra, Pamplona, Spain
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61
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Chingkoe CM, Chang SD, Legiehn GM, Weiss A. Hepatic artery pseudoaneurysms arising from within a hepatocellular carcinoma. Br J Radiol 2010; 83:e252-4. [PMID: 21088082 DOI: 10.1259/bjr/55365425] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
We report a case of a 70-year-old man with a large hepatocellular carcinoma (HCC) containing two pseudoaneurysms measuring up to 2 cm in diameter. The pseudoaneurysms and part of the HCC were supplied by branches from the middle colic artery, which arises from the superior mesenteric artery. This complex arterial vasculature was visualised on CT and confirmed with conventional angiography.
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Affiliation(s)
- C M Chingkoe
- Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
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62
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Avritscher R, Duke E, Madoff DC. Portal vein embolization: rationale, outcomes, controversies and future directions. Expert Rev Gastroenterol Hepatol 2010; 4:489-501. [PMID: 20678021 DOI: 10.1586/egh.10.41] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Portal vein embolization (PVE) is now considered the standard of care to improve safety for patients undergoing extensive hepatectomy with an anticipated small future liver remnant (FLR). PVE is used to induce contralateral liver hypertrophy in preparation for major liver resection. Optimal patient selection is essential to maximize the clinical benefits of PVE. Computed tomography volumetry is used to calculate a standardized FLR and determine the need for preoperative PVE. Percutaneous PVE can be performed via the transhepatic ipsilateral or contralateral approaches, depending on operator preference. Several different embolic agents are available to the interventional radiologist, all with similar effectiveness in inducing hypertrophy. When an extended hepatectomy is planned, right PVE should include segment 4, in order to maximize FLR hypertrophy. Multiple studies have demonstrated the beneficial outcomes of PVE in both patients with healthy livers and with underlying liver diseases. Novel improvements to PVE should expand its scope to patients who were previously not candidates for the procedure.
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Affiliation(s)
- Rony Avritscher
- University of Texas MD Anderson Cancer Center, TX 77030-4009 , USA
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63
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64
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Ayiomamitis GD, Low JK, Alkari B, Lee SH, Ammori BJ. Role of laparoscopic right portal vein ligation in planning staged or major liver resection. J Laparoendosc Adv Surg Tech A 2009; 19:409-13. [PMID: 19215213 DOI: 10.1089/lap.2008.0238] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND AND AIMS Right portal vein ligation (PVL) has its recognized role in inducing hypertrophy of future liver remnant (FLR) prior to major liver resection. The aim of this study was to evaluate the safety, feasibility, and effectiveness of laparoscopic right PVL and to explore its applications. METHODS Laparoscopic right PVL was employed either during staging laparoscopy when a right hepatic trisectionectomy was indicated, leaving a small (<25%) FLR (indication 1), or during a laparoscopic left hepatic lobectomy (left lateral sectionectomy) when a second-stage right hemihepatectomy was to follow (indication 2). A follow up cross-sectional liver imaging was performed 4-6 weeks later with liver volumetry to confirm hypertrophy of the FLR before proceeding to major hepatectomy. RESULTS Six patients (female, 5), 74-83 years old, underwent a laparoscopic right PVL, of whom 4 patients fulfilled indication 1 while 2 patients fulfilled indication 2. The median operating time for indication 1 was 60 minutes. There were no intra- or postoperative complications, and all procedures were completed laparoscopically. Repeat imaging of the liver demonstrated a median (range) hypertrophy of FLR of 24.5% (range, 20.7-33.1%). The right liver experienced atrophy. CONCLUSIONS In the hands of the experienced laparoscopic hepatobiliary surgeon, laparoscopic right PVL is feasible and safe, and induces adequate regeneration of the FLR. Laparoscopic right PVL has its applications at the time of staging laparoscopy in patients requiring a right hepatic trisectionectomy in the presence of a small FLR and as part of a staged liver resection in patients with bilobar liver disease that spares segments 1 and 4.
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65
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Kondo S, Takada T, Miyazaki M, Miyakawa S, Tsukada K, Nagino M, Furuse J, Saito H, Tsuyuguchi T, Yamamoto M, Kayahara M, Kimura F, Yoshitomi H, Nozawa S, Yoshida M, Wada K, Hirano S, Amano H, Miura F. Guidelines for the management of biliary tract and ampullary carcinomas: surgical treatment. ACTA ACUST UNITED AC 2008; 15:41-54. [PMID: 18274843 PMCID: PMC2794356 DOI: 10.1007/s00534-007-1279-5] [Citation(s) in RCA: 153] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2007] [Accepted: 10/22/2007] [Indexed: 02/06/2023]
Abstract
The only curative treatment in biliary tract cancer is surgical treatment. Therefore, the suitability of curative resection should be investigated in the first place. In the presence of metastasis to the liver, lung, peritoneum, or distant lymph nodes, curative resection is not suitable. No definite consensus has been reached on local extension factors and curability. Measures of hepatic functional reserve in the jaundiced liver include future liver remnant volume and the indocyanine green (ICG) clearance test. Preoperative portal vein embolization may be considered in patients in whom right hepatectomy or more, or hepatectomy with a resection rate exceeding 50%–60% is planned. Postoperative complications and surgery-related mortality may be reduced with the use of portal vein embolization. Although hepatectomy and/or pancreaticoduodenectomy are preferable for the curative resection of bile duct cancer, extrahepatic bile duct resection alone is also considered in patients for whom it is judged that curative resection would be achieved after a strict diagnosis of its local extension. Also, combined caudate lobe resection is recommended for hilar cholangiocarcinoma. Because the prognosis of patients treated with combined portal vein resection is significantly better than that of unresected patients, combined portal vein resection may be carried out. Prognostic factors after resection for bile duct cancer include positive surgical margins, especially in the ductal stump; lymph node metastasis; perineural invasion; and combined vascular resection due to portal vein and/or hepatic artery invasion. For patients with suspected gallbladder cancer, laparoscopic cholecystectomy is not recommended, and open cholecystectomy should be performed as a rule. When gallbladder cancer invading the subserosal layer or deeper has been detected after simple cholecystectomy, additional resection should be considered. Prognostic factors after resection for gallbladder cancer include the depth of mural invasion; lymph node metastasis; extramural extension, especially into the hepatoduodenal ligament; perineural invasion; and the degree of curability. Pancreaticoduodenectomy is indicated for ampullary carcinoma, and limited operation is also indicated for carcinoma in adenoma. The prognostic factors after resection for ampullary carcinoma include lymph node metastasis, pancreatic invasion, and perineural invasion.
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Affiliation(s)
- Satoshi Kondo
- Department of Surgical Oncology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
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Ferrero A, Viganò L, Polastri R, Muratore A, Eminefendic H, Regge D, Capussotti L. Postoperative liver dysfunction and future remnant liver: where is the limit? Results of a prospective study. World J Surg 2008; 31:1643-51. [PMID: 17551779 DOI: 10.1007/s00268-007-9123-2] [Citation(s) in RCA: 146] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND The future remnant liver (FRL) limit for safe major hepatectomy with low risk of postoperative liver failure has not yet been well defined. METHODS Between April 2000 and September 2004, every patient scheduled for major hepatectomy in our institution underwent CT-volumetry of FRL. Patients with FRL <25% underwent portal vein embolization (PVE). Exclusion criteria were PVE, associated vascular resection and liver cirrhosis. The FRL was correlated with short-term results in patients with normal liver (group A) and those with impaired liver function secondary to neoadjuvant chemotherapy or cholestasis (bilirubin >2 mg/100 ml) (group B). Liver dysfunction was defined as both PT <50% and serum bilirubin level >5 mg/100 ml for three or more consecutive days. RESULTS A total of 119 patients were analyzed, 72 in group A and 47 in group B. The FRL value was the only significant risk factor for postoperative liver dysfunction in the univariate and multivariate analysis (p = 0.009). The FRL did not correlate with postoperative mortality and morbidity. Bilirubin and prothrombin time (PT) on days 3 and 7 were significantly correlated to FRL in both groups. In group A, patients with postoperative liver dysfunction had a FRL<30% (3 versus 0; p = 0.005). According to receiving operator characteristic (ROC) curve analysis, a FRL value of 26.5% predicted postoperative liver dysfunction with 66.7% sensitivity, 97.1% specificity, 50% positive predictive value (PPV), and 98.5% negative predictive value (NPV). In group B, patients with postoperative liver dysfunction had a FRL <35% (4 versus 0; p = 0.027). According to ROC curve analysis, a FRL value of 31.05% predicted postoperative liver dysfunction with 75% sensitivity, 79.1% specificity, 25% PPV, and 97.1% NPV. CONCLUSIONS Hepatectomy can be considered safe when FRL is >26.5% in patients with healthy liver and >31% in patients with impaired liver function.
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Affiliation(s)
- Alessandro Ferrero
- Unit of Surgical Oncology, Institute for Cancer Research and Treatment, Candiolo, Italy.
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67
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Ribero D, Abdalla EK, Madoff DC, Donadon M, Loyer EM, Vauthey JN. Portal vein embolization before major hepatectomy and its effects on regeneration, resectability and outcome. Br J Surg 2007; 94:1386-94. [PMID: 17583900 DOI: 10.1002/bjs.5836] [Citation(s) in RCA: 366] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND This study evaluated the safety of portal vein embolization (PVE), its impact on future liver remnant (FLR) volume and regeneration, and subsequent effects on outcome after liver resection. METHODS Records of 112 patients were reviewed. Standardized FLR (sFLR) and degree of hypertrophy (DH; difference between the sFLR before and after PVE), complications and outcomes were analysed to determine cut-offs that predict postoperative hepatic dysfunction. RESULTS Ten (8.9 per cent) of 112 patients had PVE-related complications. Postoperative complications occurred in 34 (44 per cent) of 78 patients who underwent hepatic resection and the 90-day mortality rate was 3 per cent. A sFLR of 20 per cent or less after PVE or DH of not more than 5 per cent (versus sFLR greater than 20 per cent and DH above 5 per cent) had a sensitivity of 80 per cent and a specificity of 94 per cent in predicting hepatic dysfunction. Overall, major and liver-related complications, hepatic dysfunction or insufficiency, hospital stay and 90-day mortality rate were significantly greater in patients with a sFLR of 20 per cent or less or DH of not more than 5 per cent compared with patients with higher values. CONCLUSION DH contributes prognostic information additional to that gained by volumetric evaluation in patients undergoing PVE.
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Affiliation(s)
- D Ribero
- Department of Surgical Oncology, University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA
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68
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Yokoyama Y, Nagino M, Nishio H, Ebata T, Igami T, Nimura Y. Recent advances in the treatment of hilar cholangiocarcinoma: portal vein embolization. ACTA ACUST UNITED AC 2007; 14:447-54. [PMID: 17909712 DOI: 10.1007/s00534-006-1193-2] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2006] [Accepted: 10/16/2006] [Indexed: 01/17/2023]
Abstract
The clinical application of portal vein embolization (PVE) has contributed to improving the postoperative outcome of hilar cholangiocarcinoma. The enlarged nonembolized lobe after PVE protects the patient from postoperative hepatic failure, due to the increased functional reserve, and shortens the hospital stay. Although numerous reports have shown beneficial effects of PVE on postoperative outcome after extended hepatectomy, no randomized controlled study has been performed so far. It is urgent to establish a "gold standard" of PVE, because the indications, approach to the portal vein, types of embolic materials, and methods used to evaluate the function of the future liver remnant are variable among institutions. The indications and procedures of PVE for hilar cholangiocarcinoma may be different from those for hepatocellular carcinoma or colorectal metastasis, because, in many patients with hilar cholangiocarcinoma, biliary cancer is associated with biliary obstruction and cholangitis. This review article summarizes the contribution of PVE to the outcome of postoperative management in patients with hilar cholangiocarcinoma needing extended hepatectomy. We also describe our PVE procedure, which has been established from our experience of more than 240 cases of biliary cancer. Furthermore, the drawbacks of PVE, which may reduce the pool of candidates for surgery, are also discussed.
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Affiliation(s)
- Yukihiro Yokoyama
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, 466-8550, Japan
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Menjot de Champfleur N, Pierredon Foulongne MA, Salaheddine T, Garibaldi F, Bruel JM, Gallix B. [Rare vascular complication from acute pancreatitis: intra-hepatic false aneurysm of the hepatic artery: a report of 2 cases]. ACTA ACUST UNITED AC 2007; 88:1185-8. [PMID: 17878881 DOI: 10.1016/s0221-0363(07)89931-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Affiliation(s)
- N Menjot de Champfleur
- Service de Radiologie, Hôpital Saint Eloi, 80, avenue Augustin Fliche, 34295 Montpellier Cedex 5.
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Shah RP, Bui JT, West DL, Oberholzer J, Hatipoglu BA, Martellotto JN, Owens CA. A case of pancreatic islet cell transplantation in a patient with situs ambiguous: anatomical and radiological considerations. Semin Intervent Radiol 2007; 24:43-6. [PMID: 21326735 DOI: 10.1055/s-2007-971190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Pancreatic islet cell transplantation is an evolving treatment of severe, refractory type 1 diabetes that has been gaining more use, particularly after one year rates of insulin independence post-transplantation were found to approach 80% under the Edmonton protocol. Islet cell transplantation involves percutaneous delivery of harvested allogeneic β cells into the portal venous circulation for implantation into the liver. We present the case of a 35-year-old woman with type 1 diabetes and situs ambiguous with left isomerism and resultant variant anatomy of her portal venous anatomy who underwent islet cell transplantation, which, to our knowledge, has not been previously reported.
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Affiliation(s)
- Rajesh P Shah
- Department of Radiology, University of Illinois Medical Center at Chicago, Chicago, Illinois
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Madoff DC, Gupta S, Pillsbury EP, Kan Z, Tinkey PT, Stephens LC, Ensor JE, Hicks ME, Wright KC. Transarterial versus Transhepatic Portal Vein Embolization to Induce Selective Hepatic Hypertrophy: A Comparative Study in Swine. J Vasc Interv Radiol 2007; 18:79-93. [PMID: 17296708 DOI: 10.1016/j.jvir.2006.10.018] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
PURPOSE Portal vein embolization (PVE) is used to induce liver hypertrophy for surgical candidates with marginal future liver remnant (FLR) volumes. We compared the feasibility, safety, and effectiveness of a transarterial approach for PVE (TA-PVE) with those of a transhepatic approach for PVE (TH-PVE) in a swine model. MATERIALS AND METHODS Ten experimental pigs (TA-PVE, n = 5; TH-PVE, n = 5) and six controls (TA, n = 3; TH, n = 3) were studied. For TA-PVE, a microcatheter was advanced into arteries supplying the left and left middle hepatic lobes. A 3 to 1 Ethiodol-ethanol mixture was infused into selected arteries to cross the arterioportal peribiliary plexus and remain within the portal veins (PVs). For TH-PVE, PVs in the same lobar distribution were embolized with 355- to 500-micro m polyvinyl alcohol particles and coils. Controls were similarly catheterized for saline infusion. Computed tomography with volumetry was performed before and 7, 14, 21, and 28 days after PVE to assess FLR hypertrophy (absolute FLR volume change and FLR/total liver volume [TLV]). Computed tomographic volumetry, laboratory data, and histopathology were compared between groups. RESULTS All procedures were technically successful. The increases in mean absolute FLR volume (TA-PVE, 148 +/- 84 cm(3); TH-PVE, 62 +/- 19 cm(3); P = .082), mean FLR hypertrophy (TA-PVE, 93.2%; TH-PVE, 48.4%; P = .178), and mean FLR/TLV (TA-PVE, 31.0%; TH-PVE, 16.2%; P = .130) from day 0 to day 28 between experimental groups were better for TA-PVE. Changes in laboratory data among all groups were minimal. Two complications occurred from TA-PVE (right gastric artery embolization [n = 2] without sequela) and two from TH-PVE (acute segmental right PV thrombosis [n = 1]; death 3 weeks after PVE of unknown cause [n = 1]). CONCLUSIONS Transarterial portal vein embolization is feasible, safe, and effective for inducing future liver remnant hypertrophy in swine and may represent an improvement over previously reported transhepatic portal vein embolization methods.
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Affiliation(s)
- David C Madoff
- John S Dunn Center for Radiological Sciences, Division of Diagnostic Imaging, Interventional Radiology Section, The University of Texas MD Anderson Cancer Center, Houston, TX 77030-4009, USA.
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Tsuda M, Kurihara N, Saito H, Yamaki T, Shimamura H, Narushima Y, Ishiyama S, Sato A, Takahashi S. Ipsilateral percutaneous transhepatic portal vein embolization with gelatin sponge particles and coils in preparation for extended right hepatectomy for hilar cholangiocarcinoma. J Vasc Interv Radiol 2006; 17:989-94. [PMID: 16778232 DOI: 10.1097/01.rvi.0000223716.61444.e4] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
PURPOSE To evaluate the effectiveness and safety of ipsilateral percutaneous transhepatic portal vein embolization (PTPVE) with gelatin sponge particles and coils to induce lobar hypertrophy in patients with hilar cholangiocarcinoma in preparation for extended right hepatectomy. MATERIALS AND METHODS Between 1999 and 2004, PTPVE was performed in 22 patients with hilar cholangiocarcinoma (mean age, 67 years; range, 57-77 y; 16 men and six women). Percutaneous puncture of the right portal vein was performed under ultrasound guidance. A reverse-curve catheter was used for right portal vein embolization. Coils were used to occlude second-order branches. The future liver remnant volume was assessed by comparing computed tomographic scans before and 14-24 days after PTPVE. RESULTS PTPVE was technically successful in all cases. The average increase in ratio of future liver remnant volume to total liver volume was 8.6%. Liver function tests after PTPVE but before surgery showed no significant changes. Nineteen patients underwent hepatic resection without liver failure. In three patients, tumors could not be removed because of detection of extrahepatic disease. One patient who underwent successful hepatic resection had an abscess in the removed right lobe. CONCLUSION Ipsilateral PTPVE with gelatin sponge and coils appears to be effective and safe for extended right hepatectomy for hilar cholangiocarcinoma.
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Affiliation(s)
- Masashi Tsuda
- Department of Radiology, Sendai Kousei Hospital, and Department of Diagnostic Radiology, Tohoku University Graduate School of Medicine, Sendai, Japan
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N/A, 于 洪, 姜 洪. N/A. Shijie Huaren Xiaohua Zazhi 2006; 14:1543-1547. [DOI: 10.11569/wcjd.v14.i16.1543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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Maleux G, Gillard P, Keymeulen B, Pipeleers D, Ling Z, Heye S, Thijs M, Mathieu C, Marchal G. Feasibility, safety, and efficacy of percutaneous transhepatic injection of beta-cell grafts. J Vasc Interv Radiol 2006; 16:1693-7. [PMID: 16371537 DOI: 10.1097/01.rvi.0000182506.88739.39] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
PURPOSE To evaluate the safety, feasibility, and clinical efficacy of percutaneous transhepatic injection of beta-cell grafts in patients with type 1 diabetes mellitus. MATERIALS AND METHODS Between December 2001 and November 2003, 15 patients with C-peptide-negative type 1 diabetes underwent 31 percutaneous injections for intraportal implantation of beta-cell grafts. Grafts consisted of cultured beta-cell preparations as previously described. In 13 cases, the transplant procedure was done under sedation, whereas in 18 cases, general anesthesia was given. In all procedures, percutaneous access to the right portal vein occurred under ultrasound (US) guidance with use of a microbore puncture needle. The subsequent catheterization of the main portal vein was performed under fluoroscopic and angiographic control with use of a microbore delivery catheter and guide wire. Clinical, biochemical, and radiologic evaluation was performed before and after the procedure. RESULTS In all cases, it was possible to access the portal vein (median number of needle passes, 1; range, 1-6). The volume of cultured beta-cell grafts injected for each transplantation averaged 0.58 mL (range, 0.26-1.60 mL) and the mean recorded procedure time (from puncture to catheter withdrawal) was 19 minutes (range, 10-80 min). Three patients presented with transient abdominal pain immediately after the procedure; postprocedural duplex US of the liver revealed a patent portal vein and end branches in all cases and a minor perihepatic fluid collection in another three patients. From the end of week 1 to week 3, a mean 3.8-fold increase in liver aminotransferase levels was measured in all recipients after the first implantation session. A similar increase was seen in only one patient after a second transplantation session. At 6 months after transplantation, 13 of 15 patients (86%) had a functioning graft with plasma C-peptide levels greater than 0.5 ng/mL. CONCLUSIONS The combined US, fluoroscopic, and angiographic monitoring of percutaneous transhepatic injection with use of a microbore delivery catheter is a safe and reproducible radiologic procedure for transplantation of beta-cell grafts in diabetic patients. Increased posttransplantation C-peptide levels, which demonstrate acceptable graft function, can be obtained.
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Affiliation(s)
- Geert Maleux
- Department of Radiology, University Hospitals Gasthuisberg, Leuven, Belgium.
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75
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Denys A, Lacombe C, Schneider F, Madoff DC, Doenz F, Qanadli SD, Halkic N, Sauvanet A, Vilgrain V, Schnyder P. Portal Vein Embolization with N-Butyl Cyanoacrylate before Partial Hepatectomy in Patients with Hepatocellular Carcinoma and Underlying Cirrhosis or Advanced Fibrosis. J Vasc Interv Radiol 2005; 16:1667-74. [PMID: 16371534 DOI: 10.1097/01.rvi.0000182183.28547.dc] [Citation(s) in RCA: 74] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
PURPOSE To describe the safety, complications, and liver regeneration associated with the left liver after embolization of the right portal vein (PV) in patients with hepatocellular carcinoma (HCC) developed in the setting of advanced liver fibrosis and cirrhosis. MATERIALS AND METHODS Forty patients (31 men, nine women; mean age, 62 years) with HCC underwent PV embolization over a 4-year period. Embolization was performed from a left PV percutaneous access with use of n-butyl cyanoacrylate (NBCA) mixed with iodized oil. Computed tomography (CT) volumetry was performed before and 1 month after PV embolization to measure the left lobe volume as well as the functional liver ratio defined by the ratio between the left lobe and the total liver volume minus tumoral volume. PV pressure and liver enzyme levels were compared before and 1 month after the procedure and complications were registered. Factors potentially affecting regeneration (age, sex, diabetes, chemoembolization, functional liver ratio before PV embolization, and Knodell histologic score) were evaluated by one-way and stepwise regression analysis. RESULTS PV embolization could be achieved successfully in all cases. Two patients had partial PV thrombosis on the 1-month follow-up CT and two patients developed transient ascites after PV embolization. The left lobe volume increase was 41% +/- 32% after PV embolization and the functional liver ratio increased from 28% +/- 10% to 36% +/- 10% (P < .0001). Hypertrophy of the left lobe was greater in patients with a low functional liver ratio before PV embolization and those with an F3 fibrosis score. Other factors had no influence on left lobe regeneration. CONCLUSION PV embolization with use of NBCA is feasible in patients with advanced fibrosis and cirrhosis. Hypertrophy of the left lobe of the liver after PV embolization has a statistically significant correlation with lower functional liver ratio and lower degrees of fibrosis.
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Affiliation(s)
- Alban Denys
- Department of Radiology and Interventional Radiology, Centre Hospitalier Universitaire Vaudois, 1011 Lausanne, Switzerland.
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Madoff DC, Abdalla EK, Vauthey JN. Portal vein embolization in preparation for major hepatic resection: evolution of a new standard of care. J Vasc Interv Radiol 2005; 16:779-90. [PMID: 15947041 DOI: 10.1097/01.rvi.0000159543.28222.73] [Citation(s) in RCA: 177] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Portal vein (PV) embolization (PVE) is gaining acceptance in the preoperative management of patients selected for major hepatic resection. PVE redirects portal blood flow to the intended liver remnant to induce hypertrophy of the nondiseased portion of the liver and thereby reduce complications and shorten hospital stays after resection. This article reviews the rationale and existing literature on PVE, including the mechanisms of liver regeneration, the pathophysiology of PVE, the imaging techniques used to measure liver volumes and estimate functional hepatic reserve, and the technical aspects of PVE, including approaches and embolic agents used. In addition, the indications and contraindications for performing PVE in patients with and without chronic liver disease and the multidisciplinary approach required for the treatment of these complex cases are emphasized.
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Affiliation(s)
- David C Madoff
- Division of Diagnostic Imaging, Interventional Radiology Section, The University of Texas M. D. Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 325, Houston, TX 77030-4009, USA.
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Ignacio Bilbao J, Cosín O, Bastarrika G, Vivas I, de la Cuesta AM, Rotellar F, Pardo F. Embolización portal prequirúrgica. RADIOLOGIA 2005. [DOI: 10.1016/s0033-8338(05)72816-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Di Stefano DR, de Baere T, Denys A, Hakime A, Gorin G, Gillet M, Saric J, Trillaud H, Petit P, Bartoli JM, Elias D, Delpero JR. Preoperative percutaneous portal vein embolization: evaluation of adverse events in 188 patients. Radiology 2004; 234:625-30. [PMID: 15591428 DOI: 10.1148/radiol.2342031996] [Citation(s) in RCA: 155] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE To retrospectively assess the frequency of adverse events related to percutaneous preoperative portal vein embolization (PPVE). MATERIALS AND METHODS Institutional review board did not require its approval or patient informed consent for this study. The adverse events that occurred during PPVE or until planned hepatic surgery was performed or cancelled were retrospectively obtained from clinical, imaging, and laboratory data files in 188 patients (109 male and 79 female patients; mean age, 60 years; range, 16-78 years). Liver resection was planned for metastases (n = 137), hepatocarcinoma (n = 31), cholangiocarcinoma (n = 15), fibrolamellar hepatoma (n = 1), and benign disease (n = 4). PPVE was performed with a single-lumen 5-F catheter and a contralateral approach with n-butyl cyanoacrylate mixed with iodized oil as the main embolic agent. The rate of complications in patients with cirrhosis was compared with that in patients without cirrhosis by using the chi(2) test. RESULTS Adverse events occurred in 24 (12.8%) of 188 patients, including 12 complications and 12 incidental imaging findings. Complications included thrombosis of the portal vein feeding the future remnant liver (n = 1); migration of emboli in the portal vein feeding the future remnant liver, which necessitated angioplasty (n = 2); hemoperitoneum (n = 1); rupture of a metastasis in the gallbladder (n = 1); transitory hemobilia (n = 1); and transient liver failure (n = 6). Incidental findings were migration of small emboli in nontargeted portal branches (n = 10) and subcapsular hematoma (n = 2). Among the 187 patients in whom PPVE was technically successful, there was a significant difference (P < .001) between the occurrence of liver failure after PPVE in patients with cirrhosis (five of 30) and those without (one of 157). Sixteen liver resections were cancelled due to cancer progression (n = 12), insufficient hypertrophy of the nonembolized liver (n = 3), and complete portal thrombosis (n = 1). CONCLUSION PPVE is a safe adjuvant technique for hypertrophy of the initially insufficient liver reserve. Post-PPVE transient liver failure is more common in patients with cirrhosis than in those without cirrhosis.
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N/A. N/A. Shijie Huaren Xiaohua Zazhi 2004; 12:1900-1904. [DOI: 10.11569/wcjd.v12.i8.1900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/26/2023] Open
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Morales MD, Robles R, Marín C, Capel A, Vázquez V, Reus M, Ramirez P, Sánchez-Bueno F, Ángel Fernández J, Parrilla P. Cálculo del volumen hepático mediante TC espiral: utilidad en la planificación de la resección hepática mayor en pacientes no cirróticos. Cir Esp 2004. [DOI: 10.1016/s0009-739x(04)78955-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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