Preoperative Portal Vein Embolization Alone with Biliary Drainage Compared to a Combination of Simultaneous Portal Vein, Right Hepatic Vein Embolization and Biliary Drainage in Klatskin Tumor

Propensity Score-Matched Analysis of Liver Venous Deprivation and Portal Vein Embolization Before Planned Hepatectomy in Patients with Extensive Colorectal Liver Metastases and High-Risk Factors for Inadequate Regeneration

BACKGROUND

Liver venous deprivation (LVD) is known to induce better future liver remnant (FLR) hypertrophy than portal vein embolization (PVE). The role of LVD, compared with PVE, in inducing FLR hypertrophy and allowing safe hepatectomy for patients with extensive colorectal liver metastases (CLM) and high-risk factors for inadequate hypertrophy remains unclear.

METHODS

Patients undergoing LVD (n = 22) were matched to patients undergoing PVE (n = 279) in a 1:3 ratio based on propensity scores, prior to planned hepatectomy for CLM at a single center (1998-2023). The propensity scores accounted for high-risk factors for inadequate hypertrophy, namely pre-procedure standardized FLR (sFLR), body mass index, number of systemic therapy cycles, an extension of PVE to segment IV portal vein branches, prior resection, and chemotherapy-associated liver injury.

RESULTS

The matched cohort included 78 patients (LVD, n = 22; PVE, n = 56). Baseline characteristics were comparable. The number of tumors in the whole liver was similar but more LVD patients had five or more tumors in the left liver (32% vs. 11%; p = 0.024). Post-procedure sFLR was similar but LVD patients had a significantly higher degree of hypertrophy (16% vs. 11%; p = 0.017) and kinetic growth rate (3.9 vs. 2.4% per week; p = 0.006). More LVD patients underwent extended right hepatectomy (93% vs. 55%; p = 0.008). Only one patient had postoperative hepatic insufficiency after PVE, and no patients died within 90 days of hepatectomy.

CONCLUSION

In patients with extensive CLM and high-risk factors, LVD is associated with better FLR hypertrophy compared with PVE and allows for safely performing curative-intent extended major hepatectomy.

Comparison of liver venous deprivation with portal vein embolization alone in patients undergoing major liver resection: a systematic review and meta-analysis

BACKGROUND

The clinical efficacy and safety between liver venous deprivation (LVD) and portal vein embolization (PVE) prior to major hepatectomy is still unclear.

METHODS

Studies comparing LVD and PVE were obtained by systemically searching PubMed, Embase, and Cochrane Library Central databases through 22 December 2023.

RESULTS

Ten studies including 588 patients were reviewed. Compared with PVE group, LVD group exhibited an increased liver resection rate (OR, 1.89; 95% CI, 1.13-3.15; P = 0.01), a faster KGR (MD, 1.37; 95% CI, 0.31-2.42; P = 0.01), and a shorter time to hepatectomy (MD, -6.66; 95% CI, -8.03 to -5.30; P < 0.0001). The pooled results showed that post-embolization complications (OR, 1.35; 95% CI, 0.66-2.74), overall postoperative complications (OR, 1.09; 95% CI, 0.68-1.75), severe complications (Clavien-Dindo ≥ III) (OR, 0.70; 95% CI, 0.43-1.14), and 90-day mortality (OR, 0.38; 95% CI, 0.13-1.09) were not significantly different in both groups. LVD group had significantly lower post-hepatectomy liver failure (PHLF) than PVE group (OR, 0.45; 95% CI, 0.22-0.91; P = 0.03).

CONCLUSION

LVD outperforms PVE regarding liver resection rate and future liver remnant (FLR) hypertrophy and shows comparable safety to PVE. In addition, LVD allowed for major hepatectomy with lower incidence of PHLF.

CIRSE Standards of Practice on Portal Vein Embolization and Double Vein Embolization/Liver Venous Deprivation

This CIRSE Standards of Practice document is aimed at interventional radiologists and provides best practices for performing liver regeneration therapies prior to major hepatectomies, including portal vein embolization, double vein embolization and liver venous deprivation. It has been developed by an expert writing group under the guidance of the CIRSE Standards of Practice Committee. It encompasses all clinical and technical details required to perform liver regeneration therapies, revising the indications, contra-indications, outcome measures assessed, technique and expected outcomes.

Combined portal and hepatic vein embolisation in perihilar cholangiocarcinoma

BACKGROUND

Major hepatectomy in perihilar cholangiocarcinoma (pCCA) patients with a small future liver remnant (FLR) risks posthepatectomy liver failure (PHLF). This study examines combined portal and hepatic vein embolisation (PVE/HVE) to increase preoperative FLR volume and potentially decrease PHLF rates.

METHODS

In this retrospective, multicentre, observational study, data was collected from centres affiliated with the DRAGON Trials Collaborative and the EuroLVD registry. The study included pCCA patients who underwent PVE/HVE between July 2016 and January 2023.

RESULTS

Following PVE/HVE, 28% of patients (9/32) experienced complications, with 22% (7/32) necessitating biliary interventions for cholangitis. The median degree of hypertrophy after a median of 16 days was 16% with a kinetic growth rate of 6.8% per week. 69% of patients (22/32) ultimately underwent surgical resection. Cholangitis after PVE/HVE was associated with unresectability. After resection, 55% of patients (12/22) experienced complications, of which 23% (5/22) were Clavien-Dindo grade III or higher. The 90-day mortality after resection was 0%.

CONCLUSION

PVE/HVE quickly enhances the kinetic growth rate in pCCA patients. Cholangitis impairs chances on resection significantly. Resection after PVE/HVE is associated with low levels of 90-day mortality. The study highlights the potential of PVE/HVE in improving safety and outcomes in pCCA undergoing resection.

Image-guided percutaneous strategies to improve the resectability of HCC: Portal vein embolization, liver venous deprivation, or radiation lobectomy?

Despite considerable advances in surgical technique, many patients with hepatic malignancies are not operative candidates due to projected inadequate hepatic function following resection. Consequently, the size of the future liver remnant (FLR) is an essential consideration when predicting a patient's likelihood of liver insufficiency following hepatectomy. Since its initial description 30 years ago, portal vein embolization has become the standard of care for augmenting the size and function of the FLR preoperatively. However, new minimally invasive techniques have been developed to improve surgical candidacy, chief among them liver venous deprivation and radiation lobectomy. The purpose of this review is to discuss the status of preoperative liver augmentation prior to resection of hepatocellular carcinoma with a focus on these three techniques, highlighting the distinctions between them and suggesting directions for future investigation.

Liver volumetry and liver-regenerative interventions: history, rationale, and emerging tools

BACKGROUND

Postoperative hepatic insufficiency (PHI) is the most feared complication after hepatectomy. Volume of the future liver remnant (FLR) is one objectively measurable indicator to identify patients at risk of PHI. In this review, we summarized the development and rationale for the use of liver volumetry and liver-regenerative interventions and highlighted emerging tools that could yield new advancements in liver volumetry.

METHODS

A review of MEDLINE/PubMed, Embase, and Cochrane Library databases was conducted to identify literature related to liver volumetry. The references of relevant articles were reviewed to identify additional publications.

RESULTS

Liver volumetry based on radiologic imaging was developed in the 1980s to identify patients at risk of PHI and later used in the 1990s to evaluate grafts for living donor living transplantation. The field evolved in the 2000s by the introduction of standardized FLR based on the hepatic metabolic demands and in the 2010s by the introduction of the degree of hypertrophy and kinetic growth rate as measures of the FLR regenerative and functional capacity. Several liver-regenerative interventions, most notably portal vein embolization, are used to increase resectability and reduce the risk of PHI. In parallel with the increase in automation and machine assistance to physicians, many semi- and fully automated tools are being developed to facilitate liver volumetry.

CONCLUSION

Liver volumetry is the most reliable tool to detect patients at risk of PHI. Advances in imaging analysis technologies, newly developed functional measures, and liver-regenerative interventions have been improving our ability to perform safe hepatectomy.

Efficacy and perioperative safety of different future liver remnant modulation techniques: a systematic review and network meta-analysis

BACKGROUND

In daily clinical practice, different future liver remnant (FLR) modulation techniques are increasingly used to allow a liver resection in patients with insufficient FLR volume. This systematic review and network meta-analysis aims to compare the efficacy and perioperative safety of portal vein ligation (PVL), portal vein embolization (PVE), liver venous deprivation (LVD) and associating liver partition and portal vein ligation for staged hepatectomy (ALPPS).

METHODS

A literature search for studies comparing liver resections following different FLR modulation techniques was performed in MEDLINE, Embase and Cochrane Central, and pairwise and network meta-analyses were conducted.

RESULTS

Overall, 23 studies comprising 1557 patients were included. LVD achieved the greatest increase in FLR (17.32 %, 95% CI 2.49-32.15), while ALPPS was most effective in preventing dropout before the completion hepatectomy (OR 0.29, 95% CI 0.15-0.55). PVL tended to be associated with a longer time to completion hepatectomy (MD 5.78 days, 95% CI -0.67-12.23). Liver failure occurred less frequently after LVD, compared to PVE (OR 0.35, 95% CI 0.14-0.87) and ALPPS (OR 0.28, 95% CI 0.09-0.85).

DISCUSSION

ALPPS and LVD seem superior to PVE and PVL in terms of achieved FLR increase and subsequent treatment completion. LVD was associated with lower rates of post hepatectomy liver failure, compared to both PVE and ALPPS. A summary of the protocol has been prospectively registered in the PROSPERO database (CRD42022321474).

A systematic review and meta-analysis of liver venous deprivation versus portal vein embolization before hepatectomy: future liver volume, postoperative outcomes, and oncological safety

Introduction

This systematic review aimed to compare liver venous deprivation (LVD) with portal vein embolization (PVE) in terms of future liver volume, postoperative outcomes, and oncological safety before major hepatectomy.

Methods

We conducted this systematic review and meta-analysis following the PRISMA guidelines 2020 and AMSTAR 2 guidelines. Comparative articles published before November 2022 were retained.

Results

The literature search identified nine eligible comparative studies. They included 557 patients, 207 in the LVD group and 350 in the PVE group. This systematic review and meta-analysis concluded that LVD was associated with higher future liver remnant (FLR) volume after embolization, percentage of FLR hypertrophy, lower failure of resection due to low FLR, faster kinetic growth, higher day 5 prothrombin time, and higher 3 years' disease-free survival. This study did not find any difference between the LVD and PVE groups in terms of complications related to embolization, FLR percentage of hypertrophy after embolization, failure of resection, 3-month mortality, overall morbidity, major complications, operative time, blood loss, bile leak, ascites, post hepatectomy liver failure, day 5 bilirubin level, hospital stay, and three years' overall survival.

Conclusion

LVD is as feasible and safe as PVE with encouraging results making some selected patients more suitable for surgery, even with a small FLR.

Systematic review registration

The review protocol was registered in PROSPERO before conducting the study (CRD42021287628).

A bibliometric and visualized analysis of preoperative future liver remnant augmentation techniques from 1997 to 2022

Background

The size and function of the future liver remnant (FLR) is an essential consideration for both eligibility for treatment and postoperative prognosis when planning surgical hepatectomy. Over time, a variety of preoperative FLR augmentation techniques have been investigated, from the earliest portal vein embolization (PVE) to the more recent Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) and liver venous deprivation (LVD) procedures. Despite numerous publications on this topic, no bibliometric analysis has yet been conducted.

Methods

Web of Science Core Collection (WoSCC) database was searched to identify studies related to preoperative FLR augmentation techniques published from 1997 to 2022. The analysis was performed using the CiteSpace [version 6.1.R6 (64-bit)] and VOSviewer [version 1.6.19].

Results

A total of 973 academic studies were published by 4431 authors from 920 institutions in 51 countries/regions. The University of Zurich was the most published institution while Japan was the most productive country. Eduardo de Santibanes had the most published articles, and Masato Nagino was the most frequently co-cited author. The most frequently published journal was HPB, and the most cited journal was Ann Surg, with 8088 citations. The main aspects of preoperative FLR augmentation technique is to enhance surgical technology, expand clinical indications, prevent and treat postoperative complications, ensure long-term survival, and evaluate the growth rate of FLR. Recently, hot keywords in this field include ALPPS, LVD, and Hepatobiliary Scintigraphy.

Conclusion

This bibliometric analysis provides a comprehensive overview of preoperative FLR augmentation techniques, offering valuable insights and ideas for scholars in this field.

How Can Machine Perfusion Change the Paradigm of Liver Transplantation for Patients with Perihilar Cholangiocarcinoma?

Perihilar cholangiocarcinomas (pCCA) are rare yet aggressive tumors originating from the bile ducts. While surgery remains the mainstay of treatment, only a minority of patients are amenable to curative resection, and the prognosis of unresectable patients is dismal. The introduction of liver transplantation (LT) after neoadjuvant chemoradiation for unresectable pCCA in 1993 represented a major breakthrough, and it has been associated with 5-year survival rates consistently >50%. Despite these encouraging results, pCCA has remained a niche indication for LT, which is most likely due to the need for stringent candidate selection and the challenges in preoperative and surgical management. Machine perfusion (MP) has recently been reintroduced as an alternative to static cold storage to improve liver preservation from extended criteria donors. Aside from being associated with superior graft preservation, MP technology allows for the safe extension of preservation time and the testing of liver viability prior to implantation, which are characteristics that may be especially useful in the setting of LT for pCCA. This review summarizes current surgical strategies for pCCA treatment, with a focus on unmet needs that have contributed to the limited spread of LT for pCCA and how MP could be used in this setting, with a particular emphasis on the possibility of expanding the donor pool and improving transplant logistics.

Influence of cholestasis on portal vein embolization-induced hypertrophy of the future liver remnant

PURPOSE

In the pre-clinical setting, hepatocellular bile salt accumulation impairs liver regeneration following partial hepatectomy. Here, we study the impact of cholestasis on portal vein embolization (PVE)-induced hypertrophy of the future liver remnant (FLR).

METHODS

Patients were enrolled with perihilar cholangiocarcinoma (pCCA) or colorectal liver metastases (CRLM) undergoing PVE before a (extended) right hemihepatectomy. Volume of segments II/III was considered FLR and assessed on pre-embolization and post-embolization CT scans. The degree of hypertrophy (DH, percentual increase) and kinetic growth rate (KGR, percentage/week) were used to assess PVE-induced hypertrophy.

RESULTS

A total of 50 patients (31 CRLM, 19 pCCA) were included. After PVE, the DH and KGR were similar in patients with CRLM and pCCA (5.2 [3.3-6.9] versus 5.7 [3.2-7.4] %, respectively, p = 0.960 for DH; 1.4 [0.9-2.5] versus 1.9 [1.0-2.4] %/week, respectively, p = 0.742 for KGR). Moreover, pCCA patients with or without hyperbilirubinemia had comparable DH (5.6 [3.0-7.5] versus 5.7 [2.4-7.0] %, respectively, p = 0.806) and KGR (1.7 [1.0-2.4] versus 1.9 [0.8-2.4] %/week, respectively, p = 1.000). For patients with pCCA, unilateral drainage in FLR induced a higher DH than bilateral drainage (6.7 [4.9-7.9] versus 2.7 [1.5-4.2] %, p = 0.012). C-reactive protein before PVE was negatively correlated with DH (ρ = - 0.539, p = 0.038) and KGR (ρ = - 0.532, p = 0.041) in patients with pCCA.

CONCLUSIONS

There was no influence of cholestasis on FLR hypertrophy in patients undergoing PVE. Bilateral drainage and inflammation appeared to be negatively associated with FLR hypertrophy. Further prospective studies with larger and more homogenous patient cohorts are desirable.

Current evidence on posthepatectomy liver failure: comprehensive review

INTRODUCTION

Despite important advances in many areas of hepatobiliary surgical practice during the past decades, posthepatectomy liver failure (PHLF) still represents an important clinical challenge for the hepatobiliary surgeon. The aim of this review is to present the current body of evidence regarding different aspects of PHLF.

METHODS

A literature review was conducted to identify relevant articles for each topic of PHLF covered in this review. The literature search was performed using Medical Subject Heading terms on PubMed for articles on PHLF in English until May 2022.

RESULTS

Uniform reporting on PHLF is lacking due to the use of various definitions in the literature. There is no consensus on optimal preoperative assessment before major hepatectomy to avoid PHLF, although many try to estimate future liver remnant function. Once PHLF occurs, there is still no effective treatment, except liver transplantation, where the reported experience is limited.

DISCUSSION

Strict adherence to one definition is advised when reporting data on PHLF. The use of the International Study Group of Liver Surgery criteria of PHLF is recommended. There is still no widespread established method for future liver remnant function assessment. Liver transplantation is currently the only effective way to treat severe, intractable PHLF, but for many indications, this treatment is not available in most countries.

Portal vein embolization versus dual vein embolization for management of the future liver remnant in patients undergoing major hepatectomy: meta-analysis

BACKGROUND

This meta-analysis aimed to compare progression to surgery, extent of liver hypertrophy, and postoperative outcomes in patients planned for major hepatectomy following either portal vein embolization (PVE) or dual vein embolization (DVE) for management of an inadequate future liver remnant (FLR).

METHODS

An electronic search was performed of MEDLINE, Embase, and PubMed databases using both medical subject headings (MeSH) and truncated word searches. Articles comparing PVE with DVE up to January 2022 were included. Articles comparing sequential DVE were excluded. ORs, risk ratios, and mean difference (MD) were calculated using fixed and random-effects models for meta-analysis.

RESULTS

Eight retrospective studies including 523 patients were included in the study. Baseline characteristics between the groups, specifically, age, sex, BMI, indication for resection, and baseline FLR (ml and per cent) were comparable. The percentage increase in hypertrophy was larger in the DVE group, 66 per cent in the DVE group versus 27 per cent in the PVE group, MD 39.07 (9.09, 69.05) (P = 0.010). Significantly fewer patients failed to progress to surgery in the DVE group than the PVE group, 13 per cent versus 25 per cent respectively OR 0.53 (0.31, 0.90) (P = 0.020). Rates of post-hepatectomy liver failure 13 per cent versus 22 per cent (P = 0.130) and major complications 20 per cent versus 28 per cent (Clavien-Dindo more than IIIa) (P = 0.280) were lower. Perioperative mortality was lower with DVE, 1 per cent versus 10 per cent (P = 0.010).

CONCLUSION

DVE seems to produce a greater degree of hypertrophy of the FLR than PVE alone which translates into more patients progressing to surgery. Higher quality studies are needed to confirm these results.

Simultaneous portal and hepatic vein embolization is better than portal embolization or ALPPS for hypertrophy of future liver remnant before major hepatectomy: A systematic review and network meta-analysis

BACKGROUND

Post-hepatectomy liver failure (PHLF) is the Achilles' heel of hepatic resection for colorectal liver metastases. The most commonly used procedure to generate hypertrophy of the functional liver remnant (FLR) is portal vein embolization (PVE), which does not always lead to successful hypertrophy. Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) has been proposed to overcome the limitations of PVE. Liver venous deprivation (LVD), a technique that includes simultaneous portal and hepatic vein embolization, has also been proposed as an alternative to ALPPS. The present study aimed to conduct a systematic review as the first network meta-analysis to compare the efficacy, effectiveness, and safety of the three regenerative techniques.

DATA SOURCES

A systematic search for literature was conducted using the electronic databases Embase, PubMed (MEDLINE), Google Scholar and Cochrane.

RESULTS

The time to operation was significantly shorter in the ALPPS cohort than in the PVE and LVD cohorts by 27 and 22 days, respectively. Intraoperative parameters of blood loss and the Pringle maneuver demonstrated non-significant differences between the PVE and LVD cohorts. There was evidence of a significantly higher FLR hypertrophy rate in the ALPPS cohort when compared to the PVE cohort, but non-significant differences were observed when compared to the LVD cohort. Notably, the LVD cohort demonstrated a significantly better FLR/body weight (BW) ratio compared to both the ALPPS and PVE cohorts. Both the PVE and LVD cohorts demonstrated significantly lower major morbidity rates compared to the ALPPS cohort. The LVD cohort also demonstrated a significantly lower 90-day mortality rate compared to both the PVE and ALPPS cohorts.

CONCLUSIONS

LVD in adequately selected patients may induce adequate and profound FLR hypertrophy before major hepatectomy. Present evidence demonstrated significantly lower major morbidity and mortality rates in the LVD cohort than in the ALPPS and PVE cohorts.

Dragon 1 Protocol Manuscript: Training, Accreditation, Implementation and Safety Evaluation of Portal and Hepatic Vein Embolization (PVE/HVE) to Accelerate Future Liver Remnant (FLR) Hypertrophy

STUDY PURPOSE

The DRAGON 1 trial aims to assess training, implementation, safety and feasibility of combined portal- and hepatic-vein embolization (PVE/HVE) to accelerate future liver remnant (FLR) hypertrophy in patients with borderline resectable colorectal cancer liver metastases.

METHODS

The DRAGON 1 trial is a worldwide multicenter prospective single arm trial. The primary endpoint is a composite of the safety of PVE/HVE, 90-day mortality, and one year accrual monitoring of each participating center. Secondary endpoints include: feasibility of resection, the used PVE and HVE techniques, FLR-hypertrophy, liver function (subset of centers), overall survival, and disease-free survival. All complications after the PVE/HVE procedure are documented. Liver volumes will be measured at week 1 and if applicable at week 3 and 6 after PVE/HVE and follow-up visits will be held at 1, 3, 6, and 12 months after the resection.

RESULTS

Not applicable.

CONCLUSION

DRAGON 1 is a prospective trial to assess the safety and feasibility of PVE/HVE. Participating study centers will be trained, and procedures standardized using Work Instructions (WI) to prepare for the DRAGON 2 randomized controlled trial. Outcomes should reveal the accrual potential of centers, safety profile of combined PVE/HVE and the effect of FLR-hypertrophy induction by PVE/HVE in patients with CRLM and a small FLR.

TRIAL REGISTRATION

Clinicaltrials.gov: NCT04272931 (February 17, 2020). Toestingonline.nl: NL71535.068.19 (September 20, 2019).

Liver Venous Deprivation (LVD) Versus Portal Vein Embolization (PVE) Alone Prior to Extended Hepatectomy: A Matched Pair Analysis

BACKGROUND

To investigate whether liver venous deprivation (LVD) as simultaneous, portal vein (PVE) and right hepatic vein embolization offers advantages in terms of hypertrophy induction before extended hepatectomy in non-cirrhotic liver.

MATERIALS AND METHODS

Between June 2018 and August 2019, 20 patients were recruited for a prospective, non-randomized study to investigate the efficacy of LVD. After screening of 134 patients treated using PVE alone from January 2015 to August 2019, 14 directly matched pairs regarding tumor entity (cholangiocarcinoma, CC and colorectal carcinoma, CRC) and hypertrophy time (defined as time from embolization to follow-up imaging) were identified. In both treatment groups, the same experienced reader (> 5 years experience) performed imaging-based measurement of the volumes of liver segments of the future liver remnant (FLR) prior to embolization and after the standard clinical hypertrophy interval (~ 30 days), before surgery. Percentage growth of segments was calculated and compared.

RESULTS

After matched follow-up periods (mean of 30.5 days), there were no statistically significant differences in relative hypertrophy of FLRs. Mean ± standard deviation relative hypertrophy rates for LVD/PVE were 59 ± 29.6%/54.1 ± 27.6% (p = 0.637) for segments II + III and 48.2 ± 22.2%/44.9 ± 28.9% (p = 0.719) for segments II-IV, respectively.

CONCLUSIONS

LVD had no significant advantages over the standard method (PVE alone) in terms of hypertrophy induction of the FLR before extended hepatectomy in this study population.

Imaging-guided interventions modulating portal venous flow: evidence and controversies

Portal hypertension is defined by an increase in the portosystemic venous gradient. In most cases, increased resistance to portal blood flow is the initial cause of elevated portal pressure. More than 90% of cases of portal hypertension are estimated to be due to advanced chronic liver disease or cirrhosis. Transjugular intrahepatic portosystemic shunts, a non-pharmacological treatment for portal hypertension, involve the placement of a stent between the portal vein and the hepatic vein or inferior vena cava which helps bypass hepatic resistance. Portal hypertension may also be a result of extrahepatic portal vein thrombosis or compression. In these cases, percutaneous portal vein recanalisation restores portal trunk patency, thus preventing portal hypertension-related complications. Any portal blood flow impairment leads to progressive parenchymal atrophy and triggers hepatic regeneration in preserved areas. This provides the rationale for using portal vein embolisation to modulate hepatic volume in preparation for extended hepatic resection. The aim of this paper is to provide a comprehensive evidence-based review of the rationale for, and outcomes associated with, the main imaging-guided interventions targeting the portal vein, as well as to discuss the main controversies around such approaches.

Minimizing the risk of small-for-size syndrome after liver surgery

BACKGROUND

Primary and secondary liver tumors are not always amenable to resection due to location and size. Inadequate future liver remnant (FLR) may prevent patients from having a curative resection or may result in increased postoperative morbidity and mortality from complications related to small-for-size syndrome (SFSS).

DATA SOURCES

This comprehensive review analyzed the principles, mechanism and risk factors associated with SFSS and presented current available options in the evaluation of FLR when planning liver surgery. In addition, it provided a detailed description of specific modalities that can be used before, during or after surgery, in order to optimize the conditions for a safe resection and minimize the risk of SFSS.

RESULTS

Several methods which aim to reduce tumor burden, preserve healthy liver parenchyma, induce hypertrophy of FLR or prevent postoperative complications help minimize the risk of SFSS.

CONCLUSIONS

With those techniques the indications of radical treatment for patients with liver tumors have significantly expanded. The successful outcome depends on appropriate patient selection, the individualization and modification of interventions and the right timing of surgery.

Liver venous deprivation for resection of advanced hilar cholangiocarcinoma—a case report and review of the literature

Hilar cholangiocarcinoma is a rare primary malignancy associated with a dismal prognosis. Currently, complete extended right or left-sided hepatectomy is the primary curative therapy. Achieving a negative resection margin is associated with long-term survival and better quality of life, while post-hepatectomy liver failure (PHLF) due to insufficient liver remnant remains the most dreaded complication with a negative effect on overall survival. Precise preoperative management with sufficient future remnant liver (FRL) volume is the key to achieving good results in the treatment of bile duct carcinoma. To present a case report and a literature review for preoperative FRL optimization prior to major hepatectomies for hilar cholangiocarcinoma. Improvement of postoperative outcomes after extended liver resections in the case of hilar cholangiocarcinoma. A 62-year-old Caucasian woman with Lynch syndrome presented to our department with a hilar cholangiocarcinoma Bismuth type IIIa. The patient had an insufficient future liver volume for extended liver resection. She underwent preoperative preconditioning using a liver venous deprivation (LVD) and underwent two weeks later a right trisectorectomy without any interventional complications. Liver function remained stable postoperatively. The patient was discharged on the 20th postoperative day without major surgical post-operative complications or the need for readmission. LVD is a technically feasible, safe, and effective procedure to increase the FRL in a short period of time with low intra and post-operative complications and therefore improving the survival of patients with hilar cholangiocarcinoma.

Induction of Robust Future Liver Remnant Hypertrophy Before Hepatectomy With a Modified Liver Venous Deprivation Technique Using a Trans-venous Access for Hepatic Vein Embolization

Purpose: Hepatic and/or portal vein embolization are performed before hepatectomy for patients with insufficient future liver remnant and usually achieved with a trans-hepatic approach. The aim of the present study is to describe a modified trans-venous liver venous deprivation technique (mLVD), avoiding the potential risks and limitations of a percutaneous approach to hepatic vein embolization, and to assess the safety, efficacy, and surgical outcome after mLVD. Materials and Methods: Retrospective single-center institutional review board-approved study. From March 2016 to June 2019, consecutive oncologic patients with combined portal and hepatic vein embolization were included. CT volumetric analysis was performed before and after mLVD to assess liver hypertrophy. Complications related to mLVD and surgical outcome were obtained from medical records. Results: Thirty patients (62.7 ± 14.5 years old, 20 men) with liver metastasis (60%) or primary liver cancer (40%) underwent mLVD. Twenty-one patients (70%) had hepatic vein anatomic variants. Technical success of mLVD was 100%. Four patients had complications (three minor and one major). FLR hypertrophy was 64.2% ± 51.3% (mean ± SD). Twenty-four patients (80%) underwent the planned hepatectomy and no surgery was canceled as a consequence of mLVD complications or insufficient hypertrophy. Fifty percent of patients (12/24) had no or mild complications after surgery (Clavien-Dindo 0-II), and 45.8% (11/24) had more serious complications (Clavien-Dindo III-IV). Thirty-day mortality was 4.2% (1/24). Conclusion: mLVD is an effective method to induce FLR hypertrophy. This technique is applicable in a wide range of oncologic situations and in patients with complex right liver vein anatomy.

Induction of liver hypertrophy for extended liver surgery and partial liver transplantation: State of the art of parenchyma augmentation-assisted liver surgery

Background

Liver surgery and transplantation currently represent the only curative treatment options for primary and secondary hepatic malignancies. Despite the ability of the liver to regenerate after tissue loss, 25–30% future liver remnant is considered the minimum requirement to prevent serious risk for post-hepatectomy liver failure.

Purpose

The aim of this review is to depict the various interventions for liver parenchyma augmentation–assisting surgery enabling extended liver resections. The article summarizes one- and two-stage procedures with a focus on hypertrophy- and corresponding resection rates.

Conclusions

To induce liver parenchymal augmentation prior to hepatectomy, most techniques rely on portal vein occlusion, but more recently inclusion of parenchymal splitting, hepatic vein occlusion, and partial liver transplantation has extended the technical armamentarium. Safely accomplishing major and ultimately total hepatectomy by these techniques requires integration into a meaningful oncological concept. The advent of highly effective chemotherapeutic regimen in the neo-adjuvant, interstage, and adjuvant setting has underlined an aggressive surgical approach in the given setting to convert formerly “palliative” disease into a curative and sometimes in a “chronic” disease.

Preoperative portal vein or portal and hepatic vein embolization: DRAGON collaborative group analysis

BACKGROUND

The extent of liver resection for tumours is limited by the expected functional reserve of the future liver remnant (FRL), so hypertrophy may be induced by portal vein embolization (PVE), taking 6 weeks or longer for growth. This study assessed the hypothesis that simultaneous embolization of portal and hepatic veins (PVE/HVE) accelerates hypertrophy and improves resectability.

METHODS

All centres of the international DRAGON trials study collaborative were asked to provide data on patients who had PVE/HVE or PVE on 2016-2019 (more than 5 PVE/HVE procedures was a requirement). Liver volumetry was performed using OsiriX MD software. Multivariable analysis was performed for the endpoints of resectability rate, FLR hypertrophy and major complications using receiver operating characteristic (ROC) statistics, regression, and Kaplan-Meier analysis.

RESULTS

In total, 39 patients had undergone PVE/HVE and 160 had PVE alone. The PVE/HVE group had better hypertrophy than the PVE group (59 versus 48 per cent respectively; P = 0.020) and resectability (90 versus 68 per cent; P = 0.007). Major complications (26 versus 34 per cent; P = 0.550) and 90-day mortality (3 versus 16 per cent respectively, P = 0.065) were comparable. Multivariable analysis confirmed that these effects were independent of confounders.

CONCLUSION

PVE/HVE achieved better FLR hypertrophy and resectability than PVE in this collaborative experience.

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.

Simultaneous portal and hepatic vein embolization before major liver resection

Background

Regenerative liver surgery expands the limitations of technical resectability by increasing the future liver remnant (FLR) volume before extended resections in order to avoid posthepatectomy liver failure (PHLF). Portal vein rerouting with ligation of one branch of the portal vein bifurcation (PVL) or embolization (PVE) leads to a moderate liver volume increase over several weeks with a clinical dropout rate of 20–40%, mostly due to tumor progression during the waiting period. Accelerated liver regeneration by the Associating Liver Partition and Portal vein Ligation for Staged hepatectomy (ALPPS) was poised to overcome this limitation by reduction of the waiting time, but failed due increased perioperative complications. Simultaneous portal and hepatic vein embolization (PVE/HVE) is a novel minimal invasive way to induce rapid liver growth without the need of two surgeries.

Purpose

This article summarizes published results of PVE/HVE and analyzes what is known about its efficacy to achieve resection, safety, and the volume changes induced.

Conclusions

PVE/HVE holds promise to induce accelerated liver regeneration in a similar safety profile to PVE. The demonstrated accelerated hypertrophy may increase resectability. Randomized trials will have to compare PVE/HVE and PVE to determine if PVE/HVE is superior to PVE.

Study protocol of the HYPER-LIV01 trial: a multicenter phase II, prospective and randomized study comparing simultaneous portal and hepatic vein embolization to portal vein embolization for hypertrophy of the future liver remnant before major hepatectomy for colo-rectal liver metastases

BACKGROUND

In patients undergoing major liver resection, portal vein embolization (PVE) has been widely used to induce hypertrophy of the non-embolized liver in order to prevent post-hepatectomy liver failure. PVE is a safe and effective procedure, but does not always lead to sufficient hypertrophy of the future liver remnant (FLR). Hepatic vein(s) embolization has been proposed to improve FLR regeneration when insufficient after PVE. The sequential right hepatic vein embolization (HVE) after right PVE demonstrated an incremental effect on the FLR but it implies two different procedures with no time gain as compared to PVE alone. We have developed the so-called liver venous deprivation (LVD), a combination of PVE and HVE during the same intervention, to optimize the phase of liver preparation before surgery. The main objective of this randomized phase II trial is to compare the percentage of change in FLR volume at 3 weeks after LVD or PVE.

METHODS

Patients eligible to this multicenter prospective randomized phase II study are subjects aged from 18 years old suffering from colo-rectal liver metastases considered as resectable and with non-cirrhotic liver parenchyma. The primary objective is the percentage of change in FLR volume at 3 weeks after LVD or PVE using MRI or CT-Scan. Secondary objectives are assessment of tolerance, post-operative morbidity and mortality, post-hepatectomy liver failure, rate of non-respectability due to insufficient FLR or tumor progression, per-operative difficulties, blood loss, R0 resection rate, post-operative liver volume and overall survival. Objectives of translational research studies are evaluation of pre- and post-operative liver function and determination of biomarkers predictive of liver hypertrophy. Sixty-four patients will be included (randomization ratio 1:1) to detect a difference of 12% at 21 days in FLR volumes between PVE and LVD.

DISCUSSION

Adding HVE to PVE during the same procedure is an innovative and promising approach that may lead to a rapid and major increase in volume and function of the FLR, thereby increasing the rate of resectable patients and limiting the risk of patient's drop-out.

TRIAL REGISTRATION

This study was registered on clinicaltrials.gov on 15th February 2019 (NCT03841305).

Improving the Safety of Major Resection for Hepatobiliary Malignancy: Portal Vein Embolization and Recent Innovations in Liver Regeneration Strategies

PURPOSE OF REVIEW

For three decades, portal vein embolization (PVE) has been the "gold-standard" strategy to hypertrophy the anticipated future liver remnant (FLR) in advance of major hepatectomy. During this time, CT volumetry was the most common method to preoperatively assess FLR quality and function and used to determine which patients are appropriate surgical candidates. This review provides the most up-to-date methods for preoperatively assessing the anticipated FLR and summarizes data from the currently available strategies used to induce FLR hypertrophy before surgery for hepatobiliary malignancy.

RECENT FINDINGS

Functional and physiological imaging is increasingly replacing standard CT volumetry as the method of choice for preoperative FLR assessment. PVE, associating liver partition and portal vein ligation, radiation lobectomy, and liver venous deprivation are all currently available techniques to hypertrophy the FLR. Each strategy has pros and cons based on tumor type, extent of resection, presence or absence of underlying liver disease, age, performance status, complication rates, and other factors. Numerous strategies can lead to FLR hypertrophy and improve the safety of major hepatectomy. Which is best has yet to be determined.

Preparing for liver surgery with "Alphabet Soup": PVE, ALPPS, TAE-PVE, LVD and RL

Future liver remnant (FLR) size and function is a critical limiting factor for treatment eligibility and postoperative prognosis when considering surgical hepatectomy. Pre-operative portal vein embolization (PVE) has been proven effective in modulating FLR and now widely accepted as a standard of care. However, PVE is not always effective due to potentially inadequate augmentation of the FLR as well as tumor progression while awaiting liver growth. These concerns have prompted exploration of alternative techniques: associating liver partition and portal vein ligation for staged hepatectomy (ALPPS), transarterial embolization-portal vein embolization (TAE-PVE), liver venous deprivation (LVD), and radiation lobectomy (RL). The article aims to review the principles and applications of PVE and these newer hepatic regenerative techniques.

Liver venous deprivation compared to portal vein embolization to induce hypertrophy of the future liver remnant before major hepatectomy: A single center experience

BACKGROUND

To assess the safety and efficacy of liver venous deprivation (simultaneous hepatic vein embolization with portal vein embolization) compared with portal vein embolization alone before major hepatectomy in patients with small future liver remnant.

METHODS

We assessed all consecutive patients who underwent ipsilateral liver venous deprivation before major hepatectomy (>4 Couinaud's segments) at the University Hospital Lausanne from 2016 to 2018. Postembolization, volumetric analysis after liver venous deprivation and postoperative outcomes were compared with patients who underwent portal vein embolization alone (portal vein embolization group) from 2010 to 2016.

RESULTS

During the study period, 21 patients underwent liver venous deprivation and 39 portal vein embolization alone. In the liver venous deprivation versus portal vein embolization groups, dropout rate owing to disease progression was 1 of 21 vs 9 of 39 (P = .053). There were no per procedural complications after liver venous deprivation and no difference in the postoperative outcomes. Future liver remnant hypertrophy was greater in the liver venous deprivation group (median 135%, interquartile range: 123%-154%) than in the portal vein embolization group (median 124%, interquartile range: 107%-140%) at a median time of 22 days after liver venous deprivation vs 26 days after portal vein embolization (P = .034). The median kinetic growth rate was also greater (2.9%/week, interquartile range: 1.9-4.3% vs 1.4%/week, interquartile range: 0.7-2.1%; P < .001).

CONCLUSION

Ipsilateral liver venous deprivation before major hepatectomy is safe and seems to induce a greater and faster future liver remnant hypertrophy than after portal vein embolization alone. More data are needed to analyze the impact of liver venous deprivation on tumor growth.

Perioperative impact of liver venous deprivation compared with portal venous embolization in patients undergoing right hepatectomy: preliminary results from the pioneer center

Background

Preoperative portal vein embolization (PVE) is currently the standard technique used routinely to increase the size of the future remnant liver (FRL) before major hepatectomies. The degree of hypertrophy (DH) is approximatively 10% and requires on average six weeks. ALPPS is faster and achieves a good DH but with a higher morbidity and mortality. One method recently proposed to increase the FRL is liver venous deprivation (LVD), but its clinical and operative impact is still unknown. The aim of this study is to compare intra- and postoperative morbidity/mortality and the histological evaluation of the liver parenchyma between PVE and LVD in patients undergoing anatomic right hepatectomy.

Methods

Fifty-three consecutive patients undergoing PVE and LVD before a major hepatectomy were retrospectively analysed between 2015 and 2017. In order to reduce the bias, only potential standard right hepatectomies were selected. Surgical resections and the radiologic procedures were performed by the same Institution. Intra-operative parameters (transfusions, perfusions, bleeding, operative time), postoperative complications (Clavien-Dindo and ISGLS criteria), and histological findings were compared.

Results

To induce FRL growth 16 patients underwent PVE and 13 LVD. One patient of the PVE group was not resected due to peritoneal metastases. Surgery was performed for hepatocellular carcinoma (PVE =9, LVD =3), metastases (PVE =5, LVD =10), or others diseases (PVE =2, LVD =0). Per- and post-operative morbidity/mortality rates after PVE and LVD procedures were null. No differences between the two groups were found in terms of intraoperative bleeding (median: 550 vs. 1,200 mL; P=0.36), hepatic pedicle clamping (5 vs. 3 patients; P=0.69), intraoperative red blood cells transfusions (median: 622 vs. 594; P=0.42) and operative time (median: 270 vs. 330 min; P=0.34). Post-operative course was similar when comparing both medical and surgical complications in the two arms (PVE n=7, LVD n=10, P=0.1). Major complications (Clavien-Dindo ≥ IIIa) occurred in 3 patients undergoing PVE and in 1 patient of the LVD group (P=0.6). No difference in biliary leak (P=0.1), haemorrhage (P=0.2) and liver failure (P=0.64) was found. One cirrhotic patient in the group of PVE died of post-operative liver failure due to left portal vein thrombosis. Although we experienced a more marked liver damage when assessing on neoplastic liver parenchyma, no statistical difference was observed in terms of atrophy (P=0.19), necrosis (P=0.5), hemorrhage (P=0.42) and sinusoidal dilatation (P=0.69).

Conclusions

Despite the limitations of our study, to our knowledge this is the first report to compare the two techniques LVD is a promising and safe procedure to induce a fast FRL hypertrophy, showing similar mortality/morbidity rates during and after surgery compared to PVE.