Efficacy and safety of preoperative percutaneous transhepatic portal embolization with absolute ethanol: a clinical study

Percutaneous portal vein embolization increases the feasibility and safety of major liver resection for hepatocellular carcinoma in injured liver

OBJECTIVE

To assess the influence of preoperative portal vein embolization (PVE) on the long-term outcome of liver resection for hepatocellular carcinoma (HCC) in injured liver.

SUMMARY BACKGROUND DATA

On an healthy liver, PVE of the liver to be resected induces hypertrophy of the remnant liver and increases the safety of hepatectomy. On injured liver, this effect is still debated.

METHODS

During the study period, 10 patients underwent preoperative PVE and 19 patients did not before resection of three or more liver segments for HCC in injured liver (cirrhosis or fibrosis). PVE was performed when the estimated rate of remnant functional liver parenchyma (ERRFLP) assessed by computed tomographic scan volumetry was less than 40%.

RESULTS

In all patients, PVE was feasible. There were no deaths or complications. The ERRFLP after PVE was significantly increased compared with the pre-PVE value. Liver resection was performed after PVE in 9 of 10 patients, with surgical death and complication rates of 0% and 45%, respectively. PVE increased the number of resections of three or more segments by 47% (9/19). Overall actuarial survival rates with or without previous PVE (89%, 67%, and 44% vs. 80%, 53%, and 53% at 1, 3 and 5 years, respectively) and disease-free actuarial survival rates (86%, 64%, and 21% vs. 55%, 17%, and 17% at 1, 3, and 5 years respectively) after hepatectomy were comparable.

CONCLUSION

With the use of PVE, more patients with previously unresectable HCC in injured liver can benefit from resection. Long-term survival rates are comparable to those after resection without PVE.

Resection of nonresectable liver metastases from colorectal cancer after percutaneous portal vein embolization

OBJECTIVE

To assess the influence of preoperative portal vein embolization (PVE) on the long-term outcome of liver resection for colorectal metastases.

SUMMARY BACKGROUND DATA

Preoperative PVE of the liver induces hypertrophy of the remnant liver and increases the safety of hepatectomy.

METHODS

Thirty patients underwent preoperative PVE and 88 patients did not before resection of four or more liver segments. PVE was performed when the estimated rate of remnant functional liver parenchyma (ERRFLP) assessed by CT scan volumetry was less than 40%.

RESULTS

PVE was feasible in all patients. There were no deaths. The complication rate was 3%. The post-PVE ERRFLP was significantly increased compared with the pre-PVE value. Liver resection was performed after PVE in 19 patients (63%), with surgical death and complication rates of 4% and 7% respectively. PVE increased the number of resections of more than four segments by 19% (17/88). Actuarial survival rates after hepatectomy with or without previous PVE were comparable: 81%, 67%, and 40% versus 88%, 61%, and 38% at 1, 3, and 5 years respectively.

CONCLUSIONS

PVE allows more patients with previously unresectable liver tumors to benefit from resection. Long-term survival is comparable to that after resection without PVE.

Portal vein embolization by fine needle ethanol injection: experimental and clinical studies

AIM: To improve the technique of intraportal embolization (PVE) therapy, a new embolic method, was devised and the safety, effectiveness and feasibility were evaluated.

METHODS: PVE with intraportal ethanol injection via a fine needl e was performed in 28 normal dogs, 22 SD rats, and 24 cirrhotic SD rats. After P VE, portography, histological and functional alteration of the liver were evaluated in dogs and rats, and the changes in portal hemodynamics as well as hepatic anatomy were observed in rats. In the clinical study, PVE by ethanol injection was performed in 61 patients with hepatocellular carcinoma under the guidance of portoechography with intraportal injection of CO₂. The effect of PVE was evaluated by ultrasonography and laparotomy.

RESULTS: The effectiveness and toxicity were dependent on the do se of ethanol. In the dogs, 0.25 mg/kg of ethanol caused incomplete embolization with least liver damage, while 1.0 mg/kg induced complete embolization with a high mortality of 57.1% (4/7) due to respiratory arrest. The dose of 0.5 mg/kg resulted in complete embolization with slight toxicity to the liver. In the rats, the survival rate was 100% in normal group but 40.9% in cirrhotic models after ethanol injection by dose of 0.05 mg/100 g. PVE for cirrhotic rats with 0.03 mg/100 g of ethanol induced satisfactory embolization with significant hypertrophy in nonembolized lobes, and only slight damage to the hepatic parenchyma, and transient alteration in liver function, portal pressure and portal flow. In the clinical study, 12 cases with reverse portal flow were excluded judged by portoechography. Satisfactory embolization was gained in 90.2% (55/61) of the remaining patients determined by ultrasonography and surgery. All cases ran an uneventful postembolization course with no aberrant embolization.

CONCLUSION: PVE with intraportal ethanol injection of appropriate dosage via a fine needle is safe and effective and has several advantages comparing with transcatheter method. Portoechography is a mandatory approach for the prevention of aberrant embolization.

Preoperative portal vein embolization: an audit of 84 patients

Preoperative portal vein embolization (PVE) was performed in 84 patients before extensive liver resection for various diseases. By the criteria of liver volumetric determination, some patients were candidates for PVE, whereas others were not, even though the same surgical procedure, such as extended right lobectomy (ERL), was scheduled. PVE using gelatin sponge powder induced hypertrophy in the nonembolized lobe (0%-171%; median, 30%) and proportional atrophy in the embolized lobe in 2 weeks without eliciting any major inflammatory or necrotic reaction, as evidenced histologically and by the minimal elevations in the serum aspartate transaminase (AST) and alanine transaminase (ALT) values. Alterations in the total bilirubin level and prothrombin time were also insignificant and transient, indicating that hepatocyte functions were not impaired by PVE. Not all patients who undergo PVE proceed with the scheduled hepatic resection procedure, so it is a great advantage that gelatin sponge causes minimal damage compared with other embolizing materials such as cyanoacrylate and absolute ethanol, which have been reported to induce an inflammatory reaction or histological alteration. Our multiple regression analysis showed that three factors, diabetes mellitus, a high total bilirubin level at the time of PVE, and being male, each reduced the extent of hypertrophy in the nonembolized lobe (r2 =.30). By contrast, cholestasis appeared to accelerate the process of atrophy in the embolized lobe (r2 =.16). In conclusion, PVE by gelatin sponge powder is a safe and effective preoperative maneuver that induces hypertrophy of the section of the liver that will remain after partial hepatectomy.

Mesocaval shunt inhibits primary and metastatic hepatoma growth and enhances apoptosis

BACKGROUND

Previous reports indicate that hepatocyte growth factor and other hepatic trophic factors reach the liver presumably by portal venous inflow and stimulate experimental hepatic tumor growth, invasion, and metastasis. This study tests this hypothesis by evaluating whether a mesocaval shunt (MCS) alters hepatic tumor growth, the mitotic rate, apoptosis, and incidence and growth of lung metastasis in rats with implanted hepatoma.

METHODS

Morris hepatoma (1 x 10(5)) cells were implanted intrahepatically in 19 ACI rats. One week after implantation, 10 rats underwent MCS operation and nine controls a sham operation. Rats were killed 21 days after the operation to assess tumor volume, tumor cell mitosis, apoptosis, area of tumor necrosis, pulmonary metastases and percentage of lung tumor area.

RESULTS

Mesocaval shunt induced a significant increase in the rate of tumor apoptosis (25 +/- 5 v 14 +/- 6, P < .01) and the percentage of area of tumor necrosis (29% +/- 17% v 13% +/- 8%, P < .05), a decreased tumor volume (839 +/- 1,195 v 2,909 +/- 2,572, P < .05), a reduction in tumor mitosis (70 +/- 28 v 93 +/- 11, P < .05) and decreased percentage area of pulmonary metastatic tumor (9.8 +/- 6.8 v 18.8 +/- 14, P < .05).

CONCLUSION

These observations show that growth of intrahepatic tumor is influenced by portal venous inflow and suggest that MCS or other methods of regulating portal vein flow may be useful as adjunctive therapy in the treatment of advanced hepatoma.