Preoperative portal vein embolization (PVE) for patients with hepatocellular carcinoma can improve resectability and may improve disease-free survival

Therapies for hepatocellular carcinoma: overview, clinical indications, and comparative outcome evaluation-part one: curative intention

Hepatocellular carcinoma (HCC) offers unique management challenges as it commonly occurs in the setting of underlying chronic liver disease. The management of HCC is directed primarily by the clinical stage. The most commonly used staging system is the Barcelona-Clinic Liver Cancer system, which considers tumor burden based on imaging, liver function and the patient's performance status. Early-stage HCC can be managed with therapies of curative intent including surgical resection, liver transplantation, and ablative therapies. This manuscript reviews the various treatment options for HCC with a curative intent, such as locablative therapy types, surgical resection, and transplant. Indications, contraindications and outcomes of the various treatment options are reviewed. Multiple concepts relating to liver transplant are discussed including Milan criteria, OPTN policy, MELD exception points, downstaging to transplant and bridging to transplant.

Novel Approach via the Round Ligament in Portal Vein Embolization

BACKGROUND

The objective of this study was to describe the detailed technique and clinical outcomes of portal vein embolization via the round ligament (RL-PVE) prior to major hepatectomy.

METHODS

Between January 2010 and March 2020, a total of 50 portal vein embolization (PVE) procedures were performed in 50 patients. Of them, seven patients who underwent RL-PVE were enrolled in this study. Percutaneous transhepatic portal vein embolization (PTPE) was not indicated due to the following reasons: bile duct dilation (n = 4), difficulty in visualizing the portal vein on ultrasonography because of severe fatty liver (n = 1), large tumor size (n = 1), and combined surgery with staging laparoscopy (n = 1). The following were reasons for avoiding trans-ileocecal PVE: past laparotomy (n = 5), difficulty in accessing the portal vein due to a large tumor (n = 1), and purpose of preventing small intestinal adhesions before hepatopancreatoduodenectomy (n = 1). The percentage of functional hepatic remnant rates was calculated before and after RL-PVE.

RESULTS

Technical success was achieved in all cases. Five patients underwent embolization of the right portal vein, while two underwent embolization of the left portal vein. The median operative time and blood loss during RL-PVE were 181 min and 33 g, respectively. Morbidity and mortality related to RL-PVE were not observed. The median functional hepatic remnant rate before and after PVE was 55.6% and 63.2%, respectively. Liver functions including Child-Pugh classification were equivalent before and after RL-PVE.

CONCLUSIONS

The RL-PVE technique may be useful in elective cases for which it is difficult to safely perform PTPE or trans-ileocecal approaches.

Oncological benefits of portal vein embolization for patients with hepatocellular carcinoma

Portal vein embolization (PVE) for hepatocellular carcinoma (HCC) was first introduced in 1986 and has been continuously developed throughout the years. Basically, PVE has been applied to expand the indication of liver resection for HCC patients of insufficient future liver remnant. Importantly, PVE can result in tumor progression in both embolized and non-embolized livers; however, long-term survival after liver resection following PVE is at least not inferior compared with liver resection alone despite the smaller future liver remnant volume. Five-year disease-free survival and 5-year overall survival were 17% to 49% and 12% to 53% in non-PVE patients, and 21% to 78% and 44% to 72% in PVE patients, respectively. At present, it has proven that PVE has multiple oncological advantages for both surgical and nonsurgical treatments. PVE can also enhance the anticancer effects of transarterial chemoembolization and can avoid intraportal tumor cell dissemination. Additional interventional transarterial chemoembolization and hepatic vein embolization as well as surgical two-stage hepatectomy and associated liver partition and portal vein ligation for staged hepatectomy can enhance the oncological benefit of PVE monotherapy. Taken together, PVE is an important treatment which we recommend for listing in the guidelines for HCC treatment strategies.

Minimally invasive versus open radical resection surgery for hilar cholangiocarcinoma: Comparable outcomes associated with advantages of minimal invasiveness

Background

Minimally invasive surgery (MIS) provides a new approach for patients with hilar cholangiocarcinoma (HCCA). However, whether it can achieve similar outcomes to traditional open surgery (OS) remains controversial.

Methods

To assess the safety and feasibility of MIS for HCCA, a systematic review and meta-analysis was performed to compare the outcomes of MIS with OS. Seventeen outcomes were assessed.

Results

Nine studies involving 382 patients were included. MIS was comparable in blood transfusion rate, R0 resection rate, lymph nodes received, overall morbidity, severe morbidity (Clavien–Dindo classification > = 3), bile leakage rate, wound infection rate, intra-abdominal infection rate, days until oral feeding, 1-year overall survival, 2-year overall survival and postoperative mortality with OS. Although operation time was longer (mean difference (MD) = 93.51, 95% confidence interval (CI) = 64.10 to 122.91, P < 0.00001) and hospital cost (MD = 0.68, 95% CI = 0.03 to 1.33, P = 0.04) was higher in MIS, MIS was associated with advantages of minimal invasiveness, that was less blood loss (MD = -81.85, 95% CI = -92.09 to -71.62, P < 0.00001), less postoperative pain (MD = -1.21, 95% CI = -1.63 to -0.79, P < 0.00001), and shorter hospital stay (MD = -4.22, 95% CI = -5.65 to -2.80, P < 0.00001).

Conclusions

The safety and feasibility of MIS for HCCA is acceptable in selected patients. MIS is a remarkable alternative to OS for providing comparable outcomes associated with a benefit of minimal invasiveness and its application should be considered more.

A comparative study of portal vein embolization versus radiation lobectomy with Yttrium-90 micropheres in preparation for liver resection for initially unresectable hepatocellular carcinoma

BACKGROUND

Portal vein embolization before liver resection is considered the therapy of choice for patients with inadequate future liver remnants. The concept of radioembolization with Yttrium-90 to achieve the same goal has limited data.

METHODS

We retrospectively compared patients who underwent portal vein embolization and Yttrium-90 lobectomy before resection of hepatocellular carcinoma in patients with chronic liver disease.

RESULTS

Seventy-three patients underwent portal vein embolization and 22 patients underwent Yttrium-90. Forty-seven percent of patients before portal vein embolization required additional procedures for tumor control, and 27% of patients after Yttrium-90 required additional procedure to mainly induce further hypertrophy. Both therapies achieved the goal of future liver remnants >40%, but the degree of hypertrophy was significantly higher in Yttrium-90 patients (63% for Yttrium-90, 36% for portal vein embolization, P < .01). Tumor response was significantly better with Yttrium-90, achieving complete response in 50% of patients. Resectability rate was higher after portal vein embolization (85% for portal vein embolization, 64% for Yttrium-90, P = .03). Tumor progression was the most common reason precluding surgery. Complete tumor control was the reason not to pursue surgery in 18% of patients after Yttrium-90.

CONCLUSION

Both preoperative portal vein embolization and Yttrium-90, increases liver resectability rates by inducing hypertrophy of future liver remnants in patients with hepatocellular carcinoma and chronic liver disease. Yttrium-90 lobectomy achieved better tumor control and provided more time to assess therapy response, optimizing the indication for surgery.

Portal vein embolization with N-butyl cyanoacrylate glue is superior to other materials: a systematic review and meta-analysis

OBJECTIVES

It remains uncertain which embolization material is best for portal vein embolization (PVE). We investigated the various materials for effectiveness in inducing future liver remnant (FLR) hypertrophy, technical and growth success rates, and complication and resection rates.

METHODS

A systematic review from 1998 to 2019 on embolization materials for PVE was performed on Pubmed, Embase, and Cochrane. FLR growth between the two most commonly used materials was compared in a random effects meta-analysis. In a separate analysis using local data (n = 52), n-butyl cyanoacrylate (NBCA) was compared with microparticles regarding costs, radiation dose, and procedure time.

RESULTS

In total, 2896 patients, 61.0 ± 4.0 years of age and 65% male, from 51 papers were included in the analysis. In 61% of the patients, either NBCA or microparticles were used for embolization. The remaining were treated with ethanol, gelfoam, or sclerosing agents. The FLR growth with NBCA was 49.1% ± 29.7 compared to 42.2% ± 40 with microparticles (p = 0.037). The growth success rate with NBCA vs microparticles was 95.3% vs 90.7% respectively (p < 0.001). There were no differences in major complications between NBCA and microparticles. In the local analysis, NBCA (n = 41) entailed shorter procedure time and reduced fluoroscopy time (p < 0.001), lower radiation exposure (p < 0.01), and lower material costs (p < 0.0001) than microparticles (n = 11).

CONCLUSION

PVE with NBCA seems to be the best choice when combining growth of the FLR, procedure time, radiation exposure, and costs.

KEY POINTS

• The meta-analysis shows that n-butyl cyanoacrylate (NBCA) is superior to microparticles regarding hypertrophy of the future liver remnant, 49.1% ± 29.7 vs 42.2% ± 40.0 (p = 0.037). • There is no significant difference in major complication rates for portal vein embolization using NBCA, 4% (24/681), compared with microparticles, 5% (25/494) (p > 0.05). • Local data shows a shorter procedure time, 215 vs 348 mins from arrival to departure at the interventional radiology unit, and fluoroscopy time, 43 vs 96 mins (p < 0.001), lower radiation dosage, 573 vs 1287 Gycm² (p < 0.01), and costs, €816 vs €4233 (p < 0.0001) for NBCA compared to microparticles.

Preoperative Portal Vein Embolization for Liver Resection: An updated meta-analysis

Background: Portal vein embolization (PVE) is performed before major liver resection to increase liver volume remnant, controversy remains on the adverse effect of PVE on liver tumor patients. The current study highlighted the effect of PVE on the degree of hypertrophy of future liver remnant (FLR) and summarized PVE-related complications, aiming to provide a guideline for surgeons.

Methods: A search of current published studies on PVE was performed. Meta-analysis was conducted to assess the effect of PVE on hypertrophy of FLR and summarized PVE-related complications.

Results: 26 studies including 2335 patients were enrolled in the meta-analysis. All enrolled studies reported data regarding FLR hypertrophy rate, pooled effect size (ES) for FLR hypertrophy rate using a fixed-effect model was 0.105 (95%CI: 0.094-0.117, p=0.000), indicating PVE is favored in inducing FLR hypertrophy. Metatrim method indicated no obvious evidence of publication bias in the present meta-analysis. 247 (10.6%) patients exhibited PVE-related complications, receiving expectant treatment without affecting planned liver resection. Total 1782 patients (76%) underwent a subsequent liver resection after PVE, which is an encouraging result comparing with traditional resection rate in liver tumor patients.

Conclusions: PVE is a safe and effective procedure with a low occurrence of related complications for inducing sufficient hypertrophy of FLR in liver tumor patients, which could elevate the resection rate of liver tumor patients. Careful patient cohort selection is crucial to avoid overuse of PVE in technically resectable patients. Further multiple central clinical trials are conducive to select optimal patient cohorts and provide a guideline for surgeons.

Laparoscopic surgery and robotic surgery for hilar cholangiocarcinoma: an updated systematic review

BACKGROUND

The role of laparoscopic surgery (Lap) and robotic surgery (Rob) for radical resection of hilar cholangiocarcinoma (HC) is not clear. We summarized the safety and feasibility of Lap and Rob for HC.

METHODS

A search of all HC studies in English published on PubMed up to April 2020 was conducted. References from retrieved articles were reviewed to broaden the search.

RESULTS

In total, 23 reports were enrolled: 15 involving Lap, seven using Rob and one study reporting a minimally invasive approach (Lap or Rob, not specified). A total of 205 cases of HC were documented (Lap/Rob/not specified, 99/101/5): 37 cases of Bismuth type-I (Lap/Rob, 17/20), 22 cases of Bismuth type-II (Lap/Rob, 15/7), 68 cases of type-III (Lap/Rob, 39/29) and 13 cases of type-IV (Lap/Rob, 9/4). The pooled prevalence of R0 resection was 80.1% (Lap/Rob, 85.9%/71.0%). The weighted mean for operative time, blood loss and post-operative hospital stay was 458.4 min (Lap/Rob, 423.3/660.8 min), 615.3 mL (Lap/Rob, 521.0/1188.5 mL) and 14.0 days (Lap/Rob, 14.0/13.7 days), respectively. The pooled prevalence of conversion to open surgery, post-operative complications, and perioperative mortality was 9.1% (Lap/Rob, 12.2%/3.8%), 47.2% (Lap/Rob, 38.4%/61.3%) and 3.0% (Lap/Rob, 4.0%/2.0%), respectively.

CONCLUSION

With innovations in technology and gradual accumulation of surgical experience, the feasibility and safety of performing Lap and Rob for HC will improve.

Effect of portal vein embolization on treatment plan prior to major hepatectomy for hepatocellular carcinoma

BACKGROUND

Portal vein embolization (PVE) is used before major hepatectomy for hepatocellular carcinoma (HCC) to increase future liver remnant (FLR) volume. However, this may increase tumour growth rate, leading to more extensive resections. This study aimed to determine the effect of tumour growth, following PVE, on treatment plan.

METHOD

Retrospective cohort study conducted on patients treated from 2008 to 2015 with PVE before major hepatectomy for HCC. Liver and tumour volumetry was performed on pre- and post-PVE CT scans. Image-based and actioned plans were compared before and after PVE.

RESULTS

Thirty-one patients received PVE. Non-tumour total liver volume decreased (median 1440 to 1394 cm³; p = 0.031), while tumour (median 161-240 cm³; p < 0.001) and FLR volumes (median 430-574 cm³; p < 0.001) increased. The treatment plan changed in 15/31 patients: more extensive resection (n = 6), less extensive resection (n = 1), no resection as scheduled (n = 8). Tumour progression accounted for a clinically relevant change in treatment plan in 8/31 patients.

CONCLUSION

Following PVE in the setting of HCC, tumour progression accounts for a change in treatment plan in approximately a quarter of patients. Further research is warranted to determine whether additional liver directed therapy should routinely be used to slow the growth of HCC post-PVE.

Neoadjuvant Radiation Lobectomy As an Alternative to Portal Vein Embolization in Hepatocellular Carcinoma

Surgical resection is considered first line and potentially curative for early stage hepatocellular carcinoma. However, many patients presenting with small tumors might not qualify as candidates for surgical resection given their small future liver remnant (FLR); such patients tend to undergo neoadjuvant therapies prior to resection to minimize the risk of hepatic decompensation after major hepatic resection. While there are several techniques for inducing FLR hypertrophy, a recent approach in hepatocellular carcinoma is Y90 radiation lobectomy (RL). RL was discovered serendipitously after noticing contralateral lobar hypertrophy in patients who had ipsilateral lobar Y90 radioembolization. This is now proactively used in bridging patients to surgical resection by inducing FLR hypertrophy. In this article we discuss the evolution of RL as an alternative to portal vein embolization which has been long used to induce FLR hypertrophy, albeit mostly in metastatic liver disease.

Preoperative strategies to improve resectability for hepatocellular carcinoma: a systematic review and meta-analysis

BACKGROUND

Preoperative strategies to increase the future liver remnant are useful methods to improve resectability rates for patients with hepatocellular carcinoma (HCC). The aim of this study was to perform a systematic review and meta-analysis of the main strategies used for this purpose.

METHODS

A systematic review was performed in PubMed, EMBASE, Cochrane and Scielo/LILACS. The procedures included for analysis were portal vein embolization or ligation (PVE/PVL), sequential transarterial embolization and PVE (TACE + PVE), radioembolization (RE) and associated liver partition and portal vein ligation for staged hepatectomy (ALPPS). Perioperative morbidity and mortality, post-hepatectomy liver failure (PHLF), and survival rates were evaluated.

RESULTS

A total of 46 studies were included in the systematic review (1284 patients). Resection rate was higher in TACE + PVE (90%; N = 315) when compared to PVE/PVL (75%; N = 254; P = <0.001) and similar to ALPPS (84%; N = 43; P = 0.374) and RE (100%; N = 28; P = 0.14). ALPPS was associated with higher PHLF and perioperative mortality rates when compared to PVE/PVL and TACE + PVE. ALPPS and RE showed higher risk of major complications than PVE/PVL and TACE + PVE.

CONCLUSION

Preoperative strategies to increase liver volume are effective in achieving resectability of HCC. TACE + PVE is as safe as PVL/PVE providing higher OS. ALPPS is associated with a higher risk of PHLF, major complications, and mortality. RE despite the small experience seems to present similar resection rate and OS as TACE + PVE with higher rate of major complications.

Is disease progression a contraindication for the strategy of portal vein embolization followed by hepatectomy for hepatocellular carcinoma?

BACKGROUND

Portal vein embolization has been used worldwide to induce hypertrophy of the future liver remnant and to reduce the risk of hepatic insufficiency and death after major hepatectomy. However, whether disease progression after portal vein embolization can affect long-term oncologic outcomes in patients with hepatocellular carcinoma is uncertain.

METHODS

From a total of 107 patients who underwent portal vein embolization and subsequent hepatectomy between 2000 and 2016, 57 patients with hepatocellular carcinoma were enrolled. We evaluated their long-term oncologic outcomes and investigated whether the disease progression between portal vein embolization and subsequent hepatectomy affected survival.

RESULTS

The 5-year overall survival and disease-free survival after hepatectomy were 74.5% and 31.7%, respectively. Multivariate analyses revealed that tumor number before hepatectomy ≥3 (hazard ratio 3.59, P = .019), des-γ-carboxy prothrombin >200 mAU/mL (hazard ratio 3.36, P = .045), and red blood cell transfusion (hazard ratio 11.03, P = .0008) were independent prognostic factors for overall survival. Male sex (hazard ratio 3.74, P = .029), bilobar tumor distribution (hazard ratio 3.65, P = .004), and red blood cell transfusion (hazard ratio 6.22, P = .0026) were independent prognostic factors for disease-free survival. Disease progressions after portal vein embolization, including increases in tumor size, tumor number, α-fetoprotein, lens culinaris agglutinin-reactive fraction of α-fetoprotein, and des-γ-carboxy prothrombin, were observed in 22.8%, 14.0%, 29.8%, 19.3%, and 47.4% of patients, respectively. Only an increase of tumor number significantly decreased the disease-free survival rate after hepatectomy in a univariate analysis, and none of the variables affected overall survival.

CONCLUSION

Disease progression after portal vein embolization did not affect long-term survival in patients with hepatocellular carcinoma if the planned subsequent hepatectomy could be completed.

Feasibility of a Modified E-PASS and POSSUM System for Postoperative Risk Assessment in Patients with Spinal Disease

OBJECTIVE

This retrospective case control study aimed to evaluate the feasibility of using Estimation of Physiological Ability and Surgical Stress (E-PASS) and Physiological and Operative Severity Score for the enumeration of Mortality and Morbidity (POSSUM) systems in patients undergoing spinal surgical procedures. Degenerative spine disease has increased in incidence in aging societies, as has the number of older adult patients undergoing spinal surgery. Many older adults are at a high surgical risk because of comorbidity and poor general health.

METHODS

We retrospectively reviewed 217 patients who had undergone spinal surgery at a single tertiary care. We investigated complications within 1 month after surgery. Criteria for both skin incision in E-PASS and operation magnitude in the POSSUM system were modified to fit spine surgery. We calculated the E-PASS and POSSUM scores for enrolled patients, and investigated the relationship between postoperative complications and both surgical risk scoring systems. To reinforce the predictive ability of the E-PASS system, we adjusted equations and developed modified E-PASS systems.

RESULTS

The overall complication rate for spinal surgery was 22.6%. Forty-nine patients experienced 58 postoperative complications. Nineteen major complications, including hematoma, deep infection, pleural effusion, progression of weakness, pulmonary edema, esophageal injury, myocardial infarction, pneumonia, reoperation, renal failure, sepsis, and death, occurred in 17 patients. The area under the receiver operating characteristic curve (AUC) for predicted postoperative complications after spine surgery was 0.588 for E-PASS and 0.721 for POSSUM. For predicted major postoperative complications, the AUC increased to 0.619 for E-PASS and 0.842 for POSSUM. The AUC of the E-PASS system increased from 0.588 to 0.694 with the Modified E-PASS equation.

CONCLUSIONS

The POSSUM system may be more useful than the E-PASS system for estimating postoperative surgical risk in patients undergoing spine surgery. The preoperative risk scores of E-PASS and POSSUM can be useful for predicting postoperative major complications. To enhance the predictability of the scoring systems, using of modified equations based on spine surgery-specific factors may help ensure surgical outcomes and patient safety.

The role of portal vein embolization in the surgical management of primary hepatobiliary cancers. A systematic review

BACKGROUND

Primary liver and biliary cancers are very aggressive tumors. Surgical treatment is the main option for cure or long term survival. The main purpose of this systematic review is to underline the indications for portal vein embolization (PVE), in patients with inadequate future liver remnant (FLR) and to analyze other parameters such as resection rate, morbidity, mortality, survival after PVE and hepatectomy for primary hepatobiliary tumors. Also the role of trans-arterial chemoembolization (TACE) before PVE, is investigated.

METHODS

A systematic search of the literature was performed in Pub Med and the Cochrane Library from 01.01.1990 to 30.09.2015.

RESULTS

Forty articles were selected, including 2144 patients with a median age of 61 years. The median excision rate was 90% for hepatocellular carcinomas (HCCs) and 86% for hilar cholangiocarcinomas (HCs). The main indications for PVE in patients with HCC and presence of liver fibrosis or cirrhosis was FLR <40% when liver function was good (ICGR15 < 10%) and FLR < 50% when liver function was affected (ICGR15:10-20%). The combination of TACE and PVE increased hypertrophy rate and was associated with better overall survival and disease free survival and should be considered in advanced HCC tumors with inadequate FLR. In patients with HCs PVE was performed, after preoperative biliary drainage, when FLR was <40%, in the majority of studies, with very good post-operative outcome. However indications should be refined.

CONCLUSION

PVE before major hepatectomy allows resection in a patient group with advanced primary hepato-biliary tumors and inadequate FLR, with good long term survival.

Portal Vein Embolization Followed by Right-Side Hemihepatectomy for Hepatocellular Carcinoma Patients: A Japanese Multi-Institutional Study

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.

Effect of branched-chain amino acid supplementation on functional liver regeneration in patients undergoing portal vein embolization and sequential hepatectomy: a randomized controlled trial

BACKGROUND

Portal vein embolization (PVE) can decrease the resection ratio for major hepatectomy. (99m)Tc-galactosyl human serum albumin (GSA) scintigraphy is useful for evaluating quantitative functional liver volume. Branched chain amino acids (BCAAs) modulate liver function and regeneration. We analyzed the effects of BCAAs, in terms of liver function and regeneration after PVE, in combination with major hepatectomy.

METHODS

This randomized controlled trial was conducted for patients receiving PVE through to complete hepatectomy from September, 2011 to June, 2013. BCAA granules were added two times a day to a conventional diet in the BCAA administration group (BCAA group). The primary end point was functional liver regeneration of the future remnant liver after PVE followed by hepatic resection. Functional liver regeneration was assessed by the liver uptake value obtained from (99m)Tc-GSA scintigraphy single-photon-emission computed tomography/computed tomography fusion images. The secondary end points were volumetric liver regeneration and changes in liver function and laboratory data.

RESULTS

A BCAA group (n = 13) and a non-BCAA group (control group; n = 15) were included. The primary end point was partially met: the liver uptake value significantly increased in the BCAA group compared with the control group 6 months after hepatic resection (266.7% vs 77.6%, P = 0.04) and marginally increased after PVE (43.8% vs 17.4%, P = 0.079). Following PVE, the increment of the uptake ratio of the liver to the liver plus heart at 15 min was significantly less in the BCAA group than in the control group (0.0 and 0.01, P = 0.023).

CONCLUSIONS

BCAA supplementation improved functional liver regeneration and function in patients undergoing PVE followed by major hepatic resection.

Strategies to increase the resectability of hepatocellular carcinoma

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.

Predictive value of E-PASS and POSSUM systems for postoperative risk assessment of spinal surgery

Object

The Estimation of Physiological Ability and Surgical Stress (E-PASS) and Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity (POSSUM) systems are surgical risk scoring systems that take into account both the patient's preoperative condition and intraoperative variables. While they predict postoperative morbidity and mortality rates for several types of surgery, spinal surgeries are currently not included. The authors assessed the usefulness of E-PASS and POSSUM algorithms and compared the predictive ability of both systems in patients with spinal disorders considered for surgery.

Methods

The E-PASS system includes a preoperative risk score, a surgical stress score, and a comprehensive risk score that is determined by both the preoperative risk score and surgical stress score. The POSSUM system is composed of a physiological score and an operative severity score; its total score is based on both the physiological score and operative severity score. The authors calculated the E-PASS and POSSUM scores for 601 consecutive patients who had undergone spinal surgery and investigated the relationship between the individual scores of both systems and the incidence of postoperative complications. They also assessed the correctness of the predicted morbidity rate of both systems.

Results

Postoperative complications developed in 64 patients (10.6%); there were no in-hospital deaths. All EPASS scores (p ≤ 0.001) and the operative severity score and total score of the POSSUM (p < 0.03) were significantly higher in patients with postoperative complications than in those without postoperative complications. The morbidity rates correlated linearly and significantly with all E-PASS scores (p ≤ 0.001); their coefficients (preoperative risk score, ρ = 0.179; surgical stress score, ρ = 0.131; and comprehensive risk score, ρ = 0.198) were higher than those for the POSSUM scores (physiological score, ρ = 0.059; operative severity score, ρ = 0.111; and total score, ρ = 0.091). The area under the receiver operating characteristic curve for the predicted morbidity rate was 0.668 for the E-PASS and 0.588 for the POSSUM system.

Conclusions

As E-PASS predicted morbidity more correctly than POSSUM, it is useful for estimating the postoperative risk of patients considered for spinal surgery.

Validity of E-PASS System for Postoperative Morbidity of Spinal Surgery

STUDY DESIGN

A single-center retrospective cohort study.

OBJECTIVE

To evaluate the ability of the Estimation of Physiologic Ability and Surgical Stress (E-PASS) system to predict postoperative risk in patients scheduled for spinal surgery.

SUMMARY OF BACKGROUND DATA

The E-PASS system is a surgical audit to predict postoperative morbidity and mortality in general surgery. It is currently not applied in patients with spinal disorders.

METHODS

The E-PASS system is comprised of a preoperative risk score (PRS), a surgical stress score (SSS), and a comprehensive risk score (CRS). The latter reflects both the PRS and SSS. We calculated the E-PASS scores for 275 consecutive patients who underwent spinal surgery and evaluated the relationship between the incidence of postoperative complications and each score of the E-PASS system and their ability to predict postoperative morbidity.

RESULTS

Postoperative complications developed in 31 patients (11.3%). All E-PASS scores were significantly higher in patients with postoperative complications and they were linearly correlated with the overall incidence of postoperative complications. In particular, PRS was correlated with complications at nonsurgical sites and SSS with surgical site complications. The area under the receiver operating characteristic curve (AUC) for PRS and SSS was higher in patients with complications at nonsurgical and surgical sites, respectively. The AUC for CRS exhibited good predictive power for both types of complication.

CONCLUSIONS

The E-PASS system correctly predicted morbidity. The predictive ability of CRS was good for overall morbidity. The E-PASS system is useful for the accurate prediction of the risk for in-hospital morbidity in individual patients scheduled for spinal surgery.

Percentage of future liver remnant volume before portal vein embolization influences the degree of liver regeneration after hepatectomy

BACKGROUND

Clinical determinants of liver regeneration induced by portal vein embolization (PVE) and hepatectomy remain unclear. The aims of this study were to investigate how liver regeneration occurs after PVE followed by hepatectomy and to determine which factors strongly promote liver regeneration.

METHODS

Thirty-six patients who underwent both preoperative PVE and major hepatectomy were enrolled in this study. Percentage of future liver remnant volume before PVE (%FLR-pre) was compared with the remnant liver volume after PVE (%FLR-post-PVE) and on postoperative day 7 after hepatic resection (%FLR-post-HR). Clinical indicators contributing to liver regeneration induced by both PVE and hepatectomy were examined by logistic regression analysis.

RESULTS

PVE and hepatectomy caused a two-step regeneration. FLR-pre, FLR-post-PVE, and FLR-post-HR were 448, 579, and 761 cm(3), respectively. The %FLR-pre was significantly associated with liver regeneration induced by both PVE and hepatectomy (r = 0.63, p < 0.0001). Multiple regression analysis showed that only %FLR-pre was independently correlated with posthepatectomy liver regeneration (p = 0.027, odds ratio = 13.8).

CONCLUSION

After PVE and the subsequent hepatectomy, liver regeneration was accomplished in a two-step manner. Liver regeneration was strongly influenced by the %FLR-pre.

Remnant liver volume-based predictors of postoperative liver dysfunction after hepatectomy: analysis of 625 consecutive patients from a single institution

BACKGROUND

During hepatic resection, accurate estimation of remnant liver volume and hepatic function is crucial for avoiding postoperative liver failure. The purpose of this study was to identify preoperative factors related to postoperative liver dysfunction according to the percentage of future liver remnant volume (%FLR).

METHODS

A total of 625 patients who underwent hepatectomy were enrolled in this study. Total bilirubin level >50 μmol/L and/or prothrombin time index <50 % on postoperative day 5 were used as criteria for postoperative liver dysfunction (PLD). Patients were classified into 3 groups according to the %FLR: 35-60 (n = 116), 60-80 (n = 157), and >80 (n = 351). Multivariate logistic regression analysis was performed to identify factors related to postoperative liver dysfunction in each group.

RESULTS

Among the patients with 35-80 %FLR, the morbidity and mortality rates were significantly higher in patients with PLD than in patients without PLD. There was no postoperative death in patients with >80 %FLR . Multivariate analysis showed that PLD was associated with receptor index (LHL15) ≤0.93 (odds ratio [OR] = 7.96) in patients with 35-60 %FLR. The sensitivity and specificity for PLD were 87.5 and 96.1 %, respectively. In patients with 60-80 %FLR, PLD was associated with platelet count <10.0 × 10(4)/mL (OR = 6.12). The sensitivity and specificity for PLD were 73.3 and 96.2 %, respectively.

CONCLUSION

LHL15 ≤0.93 and platelet count <10.0 × 10(4)/mL are pivotal indicators for predicting PLD in patients with 35-60 %FLR and 60-80 %FLR, respectively.

Hepatic resection versus transcatheter arterial chemoembolization for the treatment of hepatocellular carcinoma with portal vein tumor thrombus

BACKGROUND

The long-term survival outcomes of hepatic resection (HR) compared with transcatheter arterial chemoembolization (TACE) for resectable hepatocellular carcinoma (HCC) with portal vein tumor thrombus (PVTT) are unclear.

MATERIALS AND METHODS

Between December 2002 and December 2007, 201 consecutive patients diagnosed with resectable HCC with PVTT received HR as an initial treatment in our center. These patients were compared with 402 case-matched controls selected from a pool of 1798 patients (with a 1:2 ratio) who received TACE as an initial treatment during the study period. PVTT was classified to 4 types: PVTT involving the segmental branches of the portal vein or above (type I), PVTT extending to involve the right/left portal vein (type II), the main portal vein (type III), or the superior mesenteric vein (type IV).

RESULTS

The 1-, 3-, and 5-year overall survivals for the HR and TACE groups were 42.0%, 14.1%, and 11.1% and 37.8%, 7.3%, and 0.5%, respectively (P < .001). On subgroup analyses, the overall survivals for the HR group were better than the TACE group for type I PVTT, type II PVTT, single tumor, and tumor size >5 cm (P < .001, P = .002, P < .001, P < .001, respectively), but not for type III PVTT, type IV PVTT, multiple tumors, and tumor size <5 cm (P = .541, P = .371, P = .264, P = .338, P = .125, respectively). Multivariate analysis showed the type of PVTT and initial treatment allocation were significant prognostic factors for overall survival.

CONCLUSIONS

Compared with TACE, HR provided survival benefits for patients with resectable HCC with PVTT, especially for those with a type I PVTT or a type II PVTT.