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

The Guidelines for Percutaneous Transhepatic Portal Vein Embolization: English Version

Preoperative portal vein embolization is a beneficial option to reduce the risk of postoperative liver failure by promoting the growth of the future liver remnant. In particular, a percutaneous transhepatic procedure (percutaneous transhepatic portal vein embolization) has been developed as a less-invasive approach. Although percutaneous transhepatic portal vein embolization is widely recognized as a safe procedure, various complications, including rare but fatal adverse events, have been reported. Currently, there are no prospective clinical trials regarding percutaneous transhepatic portal vein embolization procedures and no standard guidelines for the PTPE procedure in Japan. As a result, various methods and various embolic materials are used in each hospital according to each physician's policy. The purpose of these guidelines is to propose appropriate techniques at present and to identify issues that should be addressed in the future for safer and more reliable percutaneous transhepatic portal vein embolization techniques.

Locoregional Approaches in Cholangiocarcinoma Treatment

Cholangiocarcinoma (CCA) is a rare hepatic malignant tumor with poor prognosis due to late detection and anatomic factors limiting the applicability of surgical resection. Without surgical resection, palliation is the most common approach. In non-surgical cases contained within the liver, locoregional therapies provide the best chance for increased survival and disease control. The most common methods, transarterial chemoembolization and transarterial radioembolization, target tumors by embolizing their blood supply and limiting the tumor's ability to metabolize. Other treatments induce direct damage via thermal ablation to tumor tissue to mediate their anti-tumor efficacy. Recent studies have begun to explore roles for these therapies outside their previous role of palliation. This review will outline the mechanisms of each of these treatments, along with their effects on overall survival, while comparing these to non-locoregional therapies.

Promoting Surgical Resection through Future Liver Remnant Hypertrophy

An inadequate future liver remnant (FLR) can preclude curative-intent surgical resection for patients with primary or secondary hepatic malignancies. For patients with normal baseline liver function and without risk factors, an FLR of 20% is needed to maintain postsurgical hepatic function. However, the FLR requirement is higher for patients who are exposed to systemic chemotherapy (FLR, >30%) or have cirrhosis (FLR, >40%). Interventional radiologic and surgical methods to achieve FLR hypertrophy are evolving, including portal vein ligation, portal vein embolization, radiation lobectomy, hepatic venous deprivation, and associating liver partition and portal vein ligation for staged hepatectomy. Each technique offers particular advantages and disadvantages. Knowledge of these procedures can help clinicians to choose the suitable technique for each patient. The authors review the techniques used to develop FLR hypertrophy, focusing on technical considerations, outcomes, and the advantages and disadvantages of each approach. Online supplemental material is available for this article. ^©RSNA, 2022.

Coil volume embolization ratio for preventing recanalization after portal vein embolization

PURPOSE

The purpose of this study was to evaluate the optimum volume embolization ratio (VER) for the prevention of recanalization after portal vein embolization (PVE) and the influence of recanalization on future liver remnant (FLR) function using technetium-99m galactosyl human serum albumin single-photon emission computed tomography (99mTc-GSA SPECT/CT) fusion imaging.

METHODS

We analyzed procedural data of 18 patients who underwent PVE from 2015 to 2018. A total of 29 portal branches were embolized (12 anterior branch, 11 posterior branch, 4 left branch, 2 right branch) with absolute ethanol and coils. Portal vein recanalization was evaluated three weeks after PVE by contrast-enhanced CT. We classified the treated portal branches as non-recanalized and recanalized. VER was compared between the groups. In addition, for each patient, we calculated and evaluated the ratio of FLR volume to total liver volume (volumetric %FLR), FLR count to total liver count on 99mTc-GSA SPECT/CT fusion imaging (functional %FLR), and functional-volumetric ratio (functional %FLR/ volumetric %FLR).

RESULTS

Twenty-six portal branches showed no recanalization (non-recanalized group, n=26, 89.7%), while three portal branches showed recanalization (recanalized group, n=3, 10.3%). The median VER was 4.94% (3.12%-11.1%) in the non-recanalized group and 3.49% (2.76%-4.32%) in the recanalized group, which was significantly different between the groups (p = 0.045, Mann-Whitney U test). The median functional-volumetric ratio was 1.16 (1.03-1.50) in non-recanalized patients (n=15, 83.3%) and 1.01 (0.96-1.13) in recanalized patients (n=3, 16.7%), and it was significantly higher in the non-recanalized patients (p = 0.021, Mann-Whitney U test).

CONCLUSION

The VER for preventing recanalization after PVE was approximately 5% (> 4.94%). 99mTc-GSA SPECT/CT fusion imaging revealed a decrease in FLR function due to recanalization after PVE.

The Future Liver Remnant : Definition, Evaluation, and Management

When considering patients for a major hepatectomy, one must carefully consider the volume of liver to be left behind and if additional procedures are necessary to augment its volume. This review considers the optimal volume of the future liver remnant (FLR) and analyzes the techniques of augmenting this volume, the various growth parameters to assess adequate growth of the FLR, as well as further management when there has been inadequate growth of the FLR.

Successful Thrombectomy via a Surgically Reopened Umbilical Vein for Extended Portal Vein Thrombosis Caused by Portal Vein Embolization prior to Extended Liver Resection

Selective portal vein embolization (PVE) before extended liver surgery is an accepted method to stimulate growth of the future liver remnant. Portal vein thrombosis (PVT) of the main stem and the non-targeted branches to the future liver remnant is a rare but major complication of PVE, requiring immediate revascularization. Without revascularization, curative liver surgery is not possible, resulting in a potentially life-threatening situation. We here present a new surgical technique to revascularize the portal vein after PVT by combining a surgical thrombectomy with catheter-based thrombolysis via the surgically reopened umbilical vein. This technique was successfully applied in a patient who developed thrombosis of the portal vein main stem, as well as the left portal vein and its branches to the left lateral segments after selective right-sided PVE in preparation for an extended right hemihepatectomy. The advantage of this technique is the avoidance of an exploration of hepatoduodenal ligament and a venotomy of the portal vein. The minimal surgical trauma facilitates additional intravascular thrombolytic therapy as well as the future right extended hemihepatectomy. We recommend this technique in patients with extensive PVT in which percutaneous less invasive therapies have been proven unsuccessful.

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.

Portal Vein Embolization with PVA and Coils before Major Hepatectomy: Single-Center Retrospective Analysis in Sixty-Four Patients

Objectives

Portal vein embolization (PVE) stimulates hypertrophy of the future liver remnant (FLR) and improves the safety of extended hepatectomy. This study evaluated the efficacy of PVE, performed with PVA and coils, in relation to its effect on FLR volume and ratio. Secondary endpoints were the assessment of PVE complications, accomplishment of liver surgery, and patient outcome after hepatectomy.

Materials and Methods

All patients who underwent PVE before planned major hepatectomy between 2013 and 2017 were retrospectively analyzed, comprising a total of 64 patients. Baseline patient clinical characteristics, imaging records, liver volumetric changes, complications, and outcomes were analyzed.

Results

There were 45 men and 19 women with a mean age of 64 years. Colorectal liver metastasis was the most frequent liver tumor. The majority of patients (n = 53) had a right PVE. FLR increased from a mean value of 484 ml ± 242 to 654 ml ± 287 (p < 0.001) after PVE. Two major complications were experienced after PVE: 1 case of left hepatic artery branch laceration and 1 case of hemoperitoneum and hemothorax. A total of 44 (69%) patients underwent liver surgery. Twenty-one patients were not taken to surgery due to disease progression (n = 18), liver insufficiency (n = 1), and insufficient FLR volume (n = 1), and one patient declined surgery (n = 1).

Conclusions

PVE with PVA and coils was accomplished safely and promoted a high FLR hypertrophy yield, enabling most of our patients to be submitted to the potentially curative treatment of liver tumor resection.

CD133 + cell infusion in patients with colorectal liver metastases going to be submitted to a major liver resection (CELLCOL): A randomized open label clinical trial

BACKGROUND

Treatment of liver metastases of colorectal carcinoma is surgical resection. However, only 10-15% of the patients in this context will be candidate for curative resection arising other 10-13% after response to neoadyuvant chemotherapy. In order to perform the liver metastases surgery, it is necessary to have a sufficient remnant liver volume (RLV) which allows maintaining an optimal liver function after resection. Studies on liver regeneration have determined that CD133 + stem cells are involved in liver hypertrophy developed after an hepatectomy with encouraging results. As presented in previous studies, CD133 + stem cells can be selected from peripheral blood after stimulation with G-CSF, being able to obtain a large number of them. We propose to treat patients who do not meet criteria for liver metastases surgery because of insufficient RLV (<40%) with CD133 + cells together with portal embolization, in order to achieve enough liver volume which avoids liver failure.

METHODS

/Design: The aim of this study is to evaluate the effectiveness of preoperative PVE plus the administration of CD133 + mobilized from peripheral blood with G-CSF compared to PVE only. SECONDARY AIMS ARE: to compare the grade of hypertrophy, speed and changes in liver function, anatomopathological study of hypertrophied liver, to determine the safety of the treatment and analysis of postoperative morbidity and surveillance.

STUDY DESIGN

Prospective randomized longitudinal phase IIb clinical trial, open, to evaluate the efficacy of portal embolization (PVE) together with the administration of CD133 + cells obtained from peripheral blood versus PVE alone, in patients with hepatic metastasis of colorectal carcinoma (CCRHM).

DISCUSSION

The number of CD133 + obtained from peripheral blood after G -CSF stimulation will be far greater than the number obtained with direct puncture of bone marrow. This will allow a greater intrahepatic infusion, which could have a direct impact on achieving a larger and quicker hypertrophy. Consequently, it will permit the treatment of a larger number of patients with an increase on their survival.

TRIAL REGISTRATION

ClinicalTrials.gov, ID NCT03803241.

Hepatic hypertrophy and hemodynamics of portal venous flow after percutaneous transhepatic portal embolization

Background

Percutaneous transhepatic portal embolization (PTPE) is useful for safe major hepatectomy. This study investigated the correlation between hepatic hypertrophy and hemodynamics of portal venous flow by ultrasound sonography after PTPE.

Methods

We analyzed 58 patients with PTPE, excluding those who underwent recanalization (n = 10). Using CT volumetry results 2 weeks after PTPE, the patients were stratified into a considerable hypertrophy group (CH; n = 15) with an increase rate of remnant liver volume (IR-RLV) ≥ 40% and a minimal hypertrophy group (MH; n = 33) with an IR-RLV < 40%. We investigated the hemodynamics of portal venous flow after PTPE and the favorable factors for hepatic hypertrophy.

Results

Univariate and multivariate analysis identified the indocyanine green retention rate at 15 min (ICGR15) and increase rate of portal venous flow volume (IR-pFV) at the non-embolized lobe on day 3 after PTPE as independent favorable factors of IR-RLV. Patients with IR-pFV on day 3 after PTPE ≥100% and ICGR15 ≤ 15% (n = 13) exhibited significantly increased IR-RLV compared with others (n = 35).

Conclusions

Cases with high IR-pFV on day 3 after PTPE exhibited better hepatic hypertrophy. Preserved liver function and increased portal venous flow on day 3 were important.

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.

The technical aspects of a feasible new technique for ipsilateral percutaneous transhepatic portal vein embolization

OBJECTIVE:

To devise a simple new technique wherein absolute ethanol is injected via a sheath under proximal balloon occlusion of the right portal vein using a single-balloon catheter and to examine its feasibility and safety for ipsilateral portal vein embolization (PVE).

METHODS:

Between 2010 and 2016, PVE was performed in 19 patients prior to undergoing extended right hepatectomy. PVE was performed via a percutaneous transhepatic ipsilateral approach, the right portal branch was embolized under ultrasound guidance, and a balloon catheter was placed in the proximal site of the main right portal branch. Absolute ethanol was injected through a sheath under proximal balloon occlusion of the right portal vein using a double-lumen catheter. We evaluated its technical success and complications following PVE and changes in liver enzyme levels. Furthermore, we calculated changes in future liver remnant (FLR) and FLR/total functional liver volume (TFLV) ratio and assessed complications following hepatic resection.

RESULTS:

PVE was successfully performed in all patients. Mean FLR and FLR/TFLV significantly increased following PVE (p < 0.01). The change in the FLR and FLR/TFLV ratio was 39.6 ± 16.2%. One patient (6.5%) developed procedure-related complications following PVE (perihepatic hematoma).

CONCLUSION:

The new technique for ipsilateral right PVE is safe, effective, and convenient.

ADVANCES IN KNOWLEDGE:

This is the first study to investigate the efficacy of injecting ethanol via a sheath under proximal balloon occlusion of the right portal vein using a single-balloon catheter.

Future Liver Remnant Indocyanine Green Plasma Clearance Rate as a Predictor of Post-hepatectomy Liver Failure After Portal Vein Embolization

PURPOSE

To evaluate the utility of future liver remnant plasma clearance rate of indocyanine green (ICGK-F) for predicting post-hepatectomy liver failure (PHLF) compared with percentage future liver remnant volume-to-total liver volume ratio (%FLR) after portal vein embolization (PVE).

MATERIALS AND METHODS

PVE procedures in 20 patients (15 patients underwent PVE with absolute ethanol; 5 patients with gelatin particles) from 2010 to 2017 were analyzed. %FLR = future liver remnant volume (ml)/[total liver volume (ml) - tumor volume (ml)] × 100; ICGK-F = plasma clearance rate of indocyanine green (ICGK) × %FLR/100 were calculated before and after PVE. PHLF was categorized according to the criteria of the International Study Group of Liver Surgery. For predicting PHLF, we compared the ICGK-F and %FLR after PVE between the grade A PHLF group and the non-grade A PHLF (grades B and C) group.

RESULTS

All PVE procedures were successful. While the ICGK-F of the grade A PHLF group (median 0.073, n = 16) was about twice that of the non-grade A PHLF group (median 0.043, n = 4), showing a significant difference (Mann-Whitney U test: P = 0.002), there was no significant difference in %FLR between the grade A PHLF group and the non-grade A PHLF group (Mann-Whitney U test: P = 0.335).

CONCLUSION

ICGK-F was significantly higher in the grade A PHLF group than in the non-grade A PHLF group (grades B and C), and ICGK-F was more useful for predicting PHLF than %FLR.

Portal Vein Embolization: Correlation of Future Liver Remnant Hypertrophy to Type of Embolic Agent Used

Purpose

The purpose of this study was to compare the effectiveness of portal vein embolization (PVE) with different embolic agents used at our centre. Specifically, the effectiveness of N-butyl cyanoacrylate (NBCA) glue is compared with that of polyvinyl alcohol (PVA) particles.

Methods

We performed a retrospective chart review of all patients (N = 77) who underwent PVE at our institution over a 5-year period. Pre- and postprocedural computed tomography or magnetic resonance imaging, when available, were used to measure the volume of total liver volume and future liver remnant (FLR). The absolute values obtained were used to calculate percentage of FLR. The growth in FLR was determined 4–6 weeks after PVE. Technical details of the procedure including the type and amount of embolic agent used were obtained from the chart reviews, electronic patient records, and radiology reports. Statistical analysis was performed using Kruskal-Wallis test, Wilcoxon rank sum test, and the Spearman correlation coefficient with post hoc analysis. Results are expressed as mean ± SD ( P < .05 considered statistically significant).

Results

NBCA (n = 29) produced a mean change in FLR of 14.8% compared with 9.3% for PVA particles (n = 24; P = .007). Mean change in FLR was 10.1% in the group where a combination of NBCA and PVA particles was used (n = 24). The effect of glue volume and glue-to-lipiodol ratio on the outcome was not found to be statistically significant ( P = .5 and .7, respectively).

Conclusions

We conclude that NBCA glue is a better embolic agent than PVA particles in inducing liver hypertrophy.

Alcohol injection into the portal vein prior to ligation increases liver regeneration rate

BACKGROUND

Failure of portal vein ligation (PVL) to induce hypertrophy is not uncommon. The aim of the study was to evaluate the impact of intraportal alcohol injection prior to ligation on liver regeneration.

METHOD

Forty-two patients with colorectal liver metastases who underwent PVL between 01/2004 and 06/2014 were analyzed. Beginning in 09/2011, alcohol was injected prior to PVL. Patients treated with PVL alone (Alc- group) were compared with those treated with alcohol injection plus PVL (Alc+ group). Liver regeneration was assessed by volumetric increase (VI).

RESULTS

Alc+ (23 patients) and Alc- (19 patients) groups were similar in terms of age, sex and pre-PVL FLRV. Alc- group had a higher risk of recanalization (12 vs. 1, p < 0.001) and cavernous transformation (7 vs. 2, p = 0.055) of the occluded portal vein. Post-PVL FLRV (43.3 ± 14.3% vs. 34.6 ± 6.4%, p = 0.013) and VI (0.44 ± 0.24 vs. 0.28 ± 0.20, p = 0.029) were higher in Alc+ group. On multivariate analysis male sex (B = -0.149) and alcohol injection (B = 0.143) significantly predicted VI.

CONCLUSIONS

Alcohol injection prior to PVL may increase the regeneration of the FLRV by reducing the recanalization of the occluded portal vein.

Ethanol ablation for refractory bile leakage after complex hepatectomy

BACKGROUND

Only a few reports exist on the use of ethanol ablation for posthepatectomy bile leakage. The aim of this study was to assess the value of ethanol ablation in refractory bile leakage.

METHODS

Medical records of consecutive patients who underwent a first hepatobiliary resection with bilioenteric anastomosis between 2007 and 2016 were reviewed retrospectively, with special attention to bile leakage and ethanol ablation therapy. Bile leakage was graded as A/B1/B2 according to the International Study Group of Liver Surgery definition. Absolute ethanol was injected into the target bile duct during fistulography.

RESULTS

Of the 609 study patients, 237 (38·9 per cent) had bile leakage, including grade A in 33, grade B1 in 18 and grade B2 in 186. Left trisectionectomy was more often associated with grade B2 bile leakage than other types of hepatectomy (P < 0·001). Of 186 patients with grade B2 bile leakage, 31 underwent ethanol ablation therapy. Ethanol ablation was started a median of 34 (range 15-122) days after hepatectomy. The median number of treatments was 3 (1-7), and the total amount of ethanol used was 15 (3-71) ml. Complications related to ethanol ablation included transient fever (27 patients) and mild pain (13). Following ethanol ablation, bile leakage resolved in all patients and drains were removed. The median interval between the first ablation and drain removal was 28 (1-154) days.

CONCLUSION

Ethanol ablation is safe and effective, and may be a treatment option for refractory bile leakage.

Transparenchymal glissonean approach: a novel surgical technique for advanced perihilar bile duct cancer

PURPOSE

To increase the surgical opportunities for locally advanced perihilar bile duct cancers that require left-sided hepatectomies, we developed the transparenchymal glissonean approach (TGA); it comprises intra-hepatic exposure and dissection of the Glisson's sheath to gain access to the hepatic artery and portal vein for reconstruction.

METHODS

Following skeletonization of the hepatoduodenal ligament, the proximal portions of invaded vessels are exposed. If extra-hepatic attempts to access the distal portions of the invaded vessels fail, TGA can be used. The distal portion of the invaded right or right posterior Glisson's sheath is exposed following liver transection. The anterior portion of the wall of bile duct is cut and transected circumferentially including the fibrous plate tissue. The non-invaded portal vein and hepatic artery are isolated and dissected towards the hepatic hilum until the invaded distal portion of the vessels, and vascular reconstructions are performed.

RESULTS

TGA was performed in 9 patients; 5 patients underwent left hemihepatectomy and 4 underwent left tri-sectionectomy. Eight patients needed vascular reconstruction. Clavien-Dindo classification (CDC) grades IIIa and IIIb were recorded in 6 and 1 patients, respectively. No patients had CDC grades IV and V disease. Pathologically, all cases were pT4; 3 cases were R0, 5 were R1 with microscopic positive margin, and 2 were R1 with microscopic metastasis. The overall median survival time was 25.0 months.

CONCLUSIONS

TGA is feasible with acceptable prognosis and expands the surgical opportunities.

A novel utility of 99mTc-GSA SPECT/CT fusion imaging: detection of inadequate portal vein embolization

PURPOSE

Our aim was to determine the utility of Tc-99m-diethylenetriaminepentaacetic acid-galactosyl human serum albumin single-photon-emission computed tomography (^99mTc-GSA SPECT/CT) fusion imaging for detecting incomplete portal vein embolization (PVE).

MATERIALS AND METHODS

Fifty-five candidates underwent PVE. Among them, five underwent second PVE. Detectability of first inadequate PVE using CT and ^99mTc-GSA SPECT/CT fusion imaging was analyzed.

RESULTS

Cases of inadequate PVE were detected in three patients using CT and in five using ^99mTc-GSA SPECT/CT fusion imaging. Fusion imaging detected two cases of insufficient PVE in which portal branches were apparently well embolized on CT. Median value for volumetric rate in the embolized liver was 63.3% after the first PVE and 54.7% after the second (P < 0.01). Median functional rate value in embolized liver was 60.1% after the first PVE and 49.4% after the second (P < 0.01). Median value for change of volumetric and functional rates in embolized liver after the second PVE was 7.1 and 10.3%, respectively, and change of functional rate was greater than that of volumetric rate (P < 0.01).

CONCLUSIONS

^99mTc-GSA SPECT/CT fusion imaging was useful for detecting inadequate PVE, and second PVE was effective for increasing volumetric and functional rates.

Postoperative Biliary Leak Treated with Chemical Bile Duct Ablation Using Absolute Ethanol: A Report of Two Cases

Case series

Patient: Female, 72 • Male, 78

Final Diagnosis: Postoperative biliary leakage

Symptoms: Refractory and intractable symptoms

Medication: —

Clinical Procedure: Chemical ablation

Specialty: Surgery

Analysis of Portal Vein Embolization Using Absolute Ethanol Before Major Hepatectomy

Portal vein embolization (PVE) is widely considered to improve the safety and extend the indication of major hepatectomy. There are various embolization materials and techniques in each facility. The safety and efficacy of absolute ethanol (EOH) in PVE were analyzed. Fifty-one patients who underwent PVE prior to major hepatectomy were enrolled in this study. Two types of embolization techniques were performed: transileocolic portal vein embolization (TIPE) and percutaneous transhepatic portal vein embolization (PTPE). The embolization material consisted of 20 mL of EOH and 2 mL of iodized oil. Multislice computed tomography (CT) scans were performed before and after PVE. The mean time interval between PVE and the follow-up CT scan was 16.3 ± 5.0 days. The mean future liver remnant ratio to total liver (FLR%) significantly increased from 32.1% ± 7.6% to 43.5% ± 9.5% after PVE (P &lt; 0.001). The mean hypertrophy ratio was 41.1% ± 34.5%. There were 3 major complications, subcutaneous hematoma in the TIPE group, hemobilia, and bile leakage in the PTPE group. Although the levels of aspartate transaminase and alanine transaminase increased dramatically after PVE, they subsequently returned to pre-PVE levels. There were no patients whose liver dysfunction was prolonged until hepatectomy. In conclusion, PVE using EOH is a safe and effective method to induce hypertrophy in the future remnant liver before major hepatectomy.

Controversies of preoperative portal vein embolization

Portal vein embolization (PVE) is a safe, percutaneous procedure that has been proven to lower the complication rates of curative intent large-volume hepatic resection by inducing hypertrophy of the future liver remnant. While the safety and efficacy of PVE has been well substantiated, there remains controversy with regards to the technical details, periprocedural management, and whether alternative methods of achieving future liver remnant hypertrophy are preferable to PVE. This paper will address those controversies and offer recommendations based on available data.

Preoperative portal vein embolization for hepatocellular carcinoma: Consensus and controversy

Thirty years have passed since the first report of portal vein embolization (PVE), and this procedure is widely adopted as a preoperative treatment procedure for patients with a small future liver remnant (FLR). PVE has been shown to be useful in patients with hepatocellular carcinoma (HCC) and chronic liver disease. However, special caution is needed when PVE is applied prior to subsequent major hepatic resection in cases with cirrhotic livers, and volumetric analysis of the liver segments in addition to evaluation of the liver functional reserve before PVE is mandatory in such cases. Advances in the embolic material and selection of the treatment approach, and combined use of PVE and transcatheter arterial embolization/chemoembolization have yielded improved outcomes after PVE and major hepatic resections. A novel procedure termed the associating liver partition and portal vein ligation for staged hepatectomy has been gaining attention because of the rapid hypertrophy of the FLR observed in patients undergoing this procedure, however, application of this technique in HCC patients requires special caution, as it has been shown to be associated with a high morbidity and mortality even in cases with essentially healthy livers.

Portal Vein Embolization as an Oncosurgical Strategy Prior to Major Hepatic Resection: Anatomic, Surgical, and Technical Considerations

Preoperative portal vein embolization (PVE) is used to extend the indications for major hepatic resection, and it has become the standard of care for selected patients with hepatic malignancies treated at major hepatobiliary centers. To date, various techniques with different embolic materials have been used with similar results in the degree of liver hypertrophy. Regardless of the specific strategy used, both surgeons and interventional radiologists must be familiar with each other's techniques to be able to create the optimal plan for each individual patient. Knowledge of the segmental anatomy of the liver is paramount to fully understand the liver segments that need to be embolized and resected. Understanding the portal vein anatomy and the branching variations, along with the techniques used to transect the portal vein during hepatic resection, is important because these variables can affect the PVE procedure and the eventual surgical resection. Comprehension of the advantages and disadvantages of approaches to the portal venous system and the various embolic materials used for PVE is essential to best tailor the procedures for each patient and to avoid complications. Before PVE, meticulous assessment of the portal vein branching anatomy is performed with cross-sectional imaging, and embolization strategies are developed based on the patient's anatomy. The PVE procedure consists of several technical steps, and knowledge of these technical tips, potential complications, and how to avoid the complications in each step is of great importance for safe and successful PVE and ultimately successful hepatectomy. Because PVE is used as an adjunct to planned hepatic resection, priority must always be placed on safety, without compromising the integrity of the future liver remnant, and close collaboration between interventional radiologists and hepatobiliary surgeons is essential to achieve successful outcomes.

Portal vein embolization for induction of selective hepatic hypertrophy prior to major hepatectomy: rationale, techniques, outcomes and future directions

The ability to modulate the future liver remnant (FLR) is a key component of modern oncologic hepatobiliary surgery practice and has extended surgical candidacy for patients who may have been previously thought unable to survive liver resection. Multiple techniques have been developed to augment the FLR including portal vein embolization (PVE), associating liver partition and portal vein ligation (ALPPS), and the recently reported transhepatic liver venous deprivation (LVD). PVE is a well-established means to improve the safety of liver resection by redirecting blood flow to the FLR in an effort to selectively hypertrophy and ultimately improve functional reserve of the FLR. This article discusses the current practice of PVE with focus on summarizing the large number of published reports from which outcomes based practices have been developed. Both technical aspects of PVE including volumetry, approaches, and embolization agents; and clinical aspects of PVE including data supporting indications, and its role in conjunction with chemotherapy and transarterial embolization will be highlighted. PVE remains an important aspect of oncologic care; in large part due to the substantial foundation of information available demonstrating its clear clinical benefit for hepatic resection candidates with small anticipated FLRs.

Preoperative portal vein embolization in liver cancer: indications, techniques and outcomes

Postoperative liver failure is a severe complication of major hepatectomies, in particular in patients with a chronic underlying liver disease. Portal vein embolization (PVE) is an approach that is gaining increasing acceptance in the preoperative treatment of selected patients prior to major hepatic resection. Induction of selective hypertrophy of the non-diseased portion of the liver with PVE in patients with either primary or secondary hepatobiliary, malignancy with small estimated future liver remnants (FLR) may result in fewer complications and shorter hospital stays following resection. Additionally, PVE performed in patients initially considered unsuitable for resection due to lack of sufficient remaining normal parenchyma may add to the pool of candidates for surgical treatment. A thorough knowledge of hepatic segmentation and portal venous anatomy is essential before performing PVE. In addition, the indications and contraindications for PVE, the methods for assessing hepatic lobar hypertrophy, the means of determining optimal timing of resection, and the possible complications of PVE need to be fully understood before undertaking the procedure. Technique may vary among operators, but cyanoacrylate glue seems to be the best embolic agent with the highest expected rate of liver regeneration for PVE. The procedure is usually indicated when the remnant liver accounts for less than 25-40% of the total liver volume. Compensatory hypertrophy of the non-embolized segments is maximal during the first 2 weeks and persists, although to a lesser extent during approximately 6 weeks. Liver resection is performed 2 to 6 weeks after embolization. The goal of this article is to discuss the rationale, indications, techniques and outcomes of PVE before major hepatectomy.

Portal vein embolization with plug/coils improves hepatectomy outcome

BACKGROUND

Portal vein embolization (PVE) has become the standard of care before extended hepatectomy. Various PVE methods using different embolization materials have been described. In this study, we compared PVE with polyvinyl alcohol particles alone (PVA only) versus PVA with plug or coils (PVA + plug/coils).

MATERIALS AND METHODS

Patients undergoing PVE before hepatectomy were included. PVA alone was used until December 2013, thereafter plug or coils were placed in addition. The volume of left lateral liver lobe (LLL), clinical parameters, and liver function tests were measured before PVE and resection.

RESULTS

A total of 43 patients were recruited into the PVA only group and 42 were recruited into the PVA + plug/coils group. There were no major differences between groups except significantly higher total bilirubin level before PVE in the PVA only group, which improved before hepatectomy. Mean LLL volume increased by 25.7% after PVE in the PVA only group and by 44% in the PVA + plug/coils group (P < 0.001). Recanalization was significantly less common in the PVA + plug/coils group. In multivariate regression, initial LLL volume and use of plug or coils were the only parameters influencing LLL volume increase. The postoperative liver failure rate was significantly reduced in PVA + plug/coils group (P = <0.001).

CONCLUSIONS

PVE using PVA particles together with plug or coils is a safe and efficient method to increase future liver remnant volume. The additional central embolization with plug or coils led to an increased hypertrophy, due to lower recanalization rates, and subsequently decreased incidence of postoperative liver failure. No additional procedure-specific complications were observed in this series.

Central hepatectomy with pancreatoduodenectomy for diffusely spread bile duct cancer

BACKGROUND

Major hepatectomy with concomitant pancreatoduodenectomy (major-HPD) is the only procedure that provides a curative resection for diffusely spread extrahepatic bile duct cancer (DSEBDC). We sometimes encounter patients who cannot undergo major-HPD because of a poor functional hepatic reserve. The aim of the present study was to assess the feasibility of central hepatectomy with pancreatoduodenectomy (central-HPD) for patients with DSEBDC as an alternative to major-HPD.

METHODS

Between 2002 and 2010, six patients with DSEBDC underwent central-HPD. The hepatectomy procedures for central-HPD included central bisectionectomy with S1 resection (S1r) and right anterior sectionectomy with S1r.

RESULTS

The estimated resection liver volume was decreased from 77.5% to 46.6% by the application of central-HPD. The median operative duration was 929 min, and the median blood loss was 2568 ml. Postoperative complications were observed in five patients. The proximal ductal stump was histologically positive with non-invasive cancer in three patients and positive with invasive cancer in one. The overall survival of the six patients was 62.5% at 5 years after surgery.

CONCLUSIONS

While central-HPD was a technically complicated procedure associated with a high morbidity rate, it offered a favorable overall survival and might be an alternative option for DSEBDC patients with a poor hepatic functional reserve.

Right portal vein embolization with absolute ethanol in major hepatic resection for hepatobiliary malignancy

BACKGROUND

This study aimed to evaluate the safety and efficacy of preoperative right portal vein embolization (PVE) with absolute ethanol in patients with hepatobiliary malignancies.

METHODS

PVE was performed via a percutaneous transhepatic ipsilateral approach, and the right portal branch was embolized with absolute ethanol. Technical success and complications following PVE, and changes in liver enzyme levels were evaluated. Changes in future liver remnant (FLR) and FLR/total functional liver volume ratio were calculated. Complications following hepatic resection were assessed.

RESULTS

A total of 83 patients with hepatobiliary malignancies (53 men, 30 women; mean age 68 years) underwent right PVE. Tumour types were hilar cholangiocarcinoma (37), liver metastases (14), gallbladder cancer (13), intrahepatic cholangiocellular carcinoma (10) and hepatocellular carcinoma (HCC) (9). PVE was performed successfully in all patients. Four patients (5 per cent) developed complications following PVE (liver abscess 2, left portal vein thrombosis 1, pseudoaneurysm 1), but this did not preclude hepatic resection. Liver enzyme levels rose transiently after PVE. The mean FLR and FLR/total functional liver volume increased after PVE (from 366 to 513 cm(3) and from 31 to 43 per cent respectively; both P < 0·001). Changes in the FLR and FLR/total functional liver volume ratio were comparable between patients with HCC and those with other malignancies (42 and 44 per cent, and 12 and 12 per cent, respectively). Sixty-nine of 83 patients underwent hepatic resection at a median of 25 days after PVE, with no postoperative mortality.

CONCLUSION

Preoperative right PVE with absolute ethanol is safe and effective for induction of selective hepatic hypertrophy in patients with hepatobiliary malignancy.

Portal vein embolization using absolute ethanol: evaluation of its safety and efficacy

BACKGROUND

Previously, we reported on the clinical efficacy and safety of portal vein embolization (PVE) with fibrin glue. Our embolic materials for PVE changed from fibrin glue to absolute ethanol (EOH) after 2001 due to prohibition of using fibrin glue for PVE. With introducing our technique of PVE with EOH, we evaluated its safety and efficacy with attention to the amount of EOH.

METHODS

The medical records of 154 patients who underwent PVE using EOH were retrospectively reviewed.

RESULTS

Changes with time in both the serum levels of aspartate aminotransferase (AST) and alanine aminotransferase (ALT) after PVE returned to the initial condition within 7 days after PVE. In the 96 patients who underwent CT volumerty 14 to 21 days after PVE, the volume of the embolized lobe decreased from 701 ± 165 cm(3) to 549 ± 148 cm(3) (P < 0.0001). Meanwhile, the volume of the non-embolized lobe increased from 388 ± 105 cm(3) to 481 ± 113 cm(3) (P < 0.0001). On simple linear regression, the amount of EOH was positively correlated with both the maximum of AST and that of ALT after PVE; however, it never correlated with changes in liver volume after PVE.

CONCLUSIONS

Portal vein embolization with EOH has a substantial effect on both hypertrophy of the non-embolized lobe and atrophy of the embolized lobe. Quick recoveries of changes with time in AST and ALT after PVE proved that PVE with EOH is a safe procedure. The amount of EOH affected the extent of liver damage but had no clinical effects on changes in liver volume after PVE.

Portal vein embolization before right hepatectomy or extended right hepatectomy using sodium tetradecyl sulfate foam: technique and initial results

PURPOSE

To evaluate the safety and efficacy of portal vein embolization (PVE) with sodium tetradecyl sulfate (STS) foam.

MATERIALS AND METHODS

A single-center retrospective review of 35 patients (27 men and 8 women; mean age, 61 y) who underwent PVE with STS foam was performed. The technical success rate, rate of PVE at producing adequate future liver remnant (FLR) hypertrophy, and rate of disease progression precluding resection after PVE were analyzed. Complications of PVE and liver resection after PVE were recorded.

RESULTS

PVE was performed on 35 patients before right hepatic resection for both primary and secondary hepatic malignancies (22 hepatocellular carcinoma, 10 metastasis, 2 cholangiocarcinoma, 1 invasive gallbladder carcinoma). Technical success was achieved in 97.1% (34 of 35) of patients. Mean FLR of the total estimated liver volume increased from 24.5% (SD, 7.7%) to 36.5% (SD, 14.5%), a mean percentage increase of 48.8% (SD, 34.3%). PVE produced adequate FLR hypertrophy in 31 of 35 patients (88.6%). Proposed right hepatectomy was subsequently performed in 27 patients (77.1%). One patient remains scheduled for surgery, two had peritoneal spread at surgery and resection was aborted, two had disease progression on imaging after PVE, and three had inadequate FLR hypertrophy with no surgery. One major complication was observed related to PVE that involved nontarget embolization to segment III, which was managed conservatively.

CONCLUSIONS

Preoperative PVE with STS foam is a safe and effective method to induce hypertrophy of the FLR.

Role of portal vein embolization in hepatocellular carcinoma management and its effect on recurrence: a case-control study

Background

Liver regeneration that occurs after portal vein embolization (PVE) may have adverse effects on the microscopic tumor foci in the residual liver mass in patients with hepatocellular carcinoma (HCC).

Methods

Fifty-four HCC patients with inadequate functional residual liver volume were offered PVE during a seven-year period. Among them, 34 (63%) patients underwent curative resection. They were compared with a matched control group (n = 102) who underwent surgery without PVE. Postoperative complications, pattern of recurrence, and survival were compared between groups.

Results

In the PVE group, a pre-embolization functional residual liver volume of 23% (12–33.5%) improved to 34% (20–54%) (p = 0.005) at the time of surgery. When the two groups were compared, minor (PVE, 24%; control, 29%; p = 0.651) and major (PVE, 18%; control, 15%; p = 0.784) complications were similar. After a follow-up period of 35 months (standard deviation 25 months), extrahepatic recurrences were detected in 10 PVE patients (29%) and 41 control patients (40%) (p = 0.310). Intrahepatic recurrences were seen in 10 (29%) and 47 (46%) cases (p = 0.109) in the PVE and control groups, respectively. In the PVE group, 41% (n = 14) of the recurrences were detected before one year, compared with 42% (n = 43) in the control group (p = 1). Disease-free survival rates at 1, 3, and 5 years were 57, 29, and 26% in the control group and 60, 42, and 42% in the PVE group (log-rank, p = 0.335). On multivariate analysis, PVE was not a factor affecting survival (p = 0.821).

Conclusions

Portal vein embolization increases the resectability of initially unresectable HCC due to inadequate functional residual liver volume, and it has no deleterious oncological effect after major resection of HCC.

Preoperative percutaneous transhepatic portal vein embolization with ethanol injection

OBJECTIVE

The purpose of this article is to evaluate the feasibility and efficacy of preoperative percutaneous transhepatic portal vein embolization with ethanol injection.

MATERIALS AND METHODS

We retrospectively evaluated 143 patients who underwent percutaneous transhepatic portal vein embolization. Hypertrophy of the future liver remnant was assessed by comparing the volumetric data obtained from CT image data before and after percutaneous transhepatic portal vein embolization. The evaluation of effectiveness was based on changes in the absolute volume of the future liver remnant and the ratio of the future liver remnant to the total estimated liver volume.

RESULTS

Ten of 143 patients (7.0%) underwent additional embolization because of recanalization and insufficient hypertrophy of the future liver remnant. The mean increase in the ratio of the future liver remnant was 33.6% (p < 0.0001), and the mean ratio of future liver remnant to total estimated liver volume increased from 34.9% to 45.7% (p < 0.0001). Although most of the patients complained of pain after ethanol injection, they were gradually relieved of pain in a few minutes by conservative treatment. Fever (38-39°C) was reported after 47 of 151 (31.1%) percutaneous transhepatic portal vein embolization sessions and was resolved within a few days. Transient elevation of the liver transaminases was observed after the procedures and resolved within about a week. Major complications occurred in nine of 151 (6%) percutaneous transhepatic portal vein embolization sessions, but no patients developed hepatic insufficiency or severe complications precluding successful resection. One hundred twenty patients underwent hepatic resection, and two patients developed hepatic failure after surgery.

CONCLUSION

Preoperative percutaneous transhepatic portal vein embolization with ethanol is a feasible and effective procedure to obtain hypertrophy of the future liver remnant for preventing hepatic failure after hepatectomy.

Usefulness of portography and contrast-enhanced computed tomography to predict the embolized area in percutaneous transhepatic portal vein embolization with absolute ethanol under temporary balloon occlusion

PURPOSE

To assess the usefulness of portography and contrast-enhanced computed tomography (CECT) for predicting the embolized area after the first injection of absolute ethanol (AE) in right portal vein embolization (RPVE).

MATERIALS AND METHODS

Portograms were retrospectively reviewed in 50 patients (30 men and 20 women, mean age 65 years) who had undergone percutaneous transhepatic RPVE with AE under temporary balloon occlusion (TBO) between February 2002 and October 2009. The enhancement pattern before embolization and the embolization pattern after the first AE injection were analyzed by portography. The angles of portal branches against the horizontal plane were measured in 48 patients using pre-treatment CECT.

RESULTS

The enhancement pattern was not consistent with the embolization pattern in 35 patients (p < 0.001). When the anterior branch angles were divided into two groups at -5°, 0°, 10°, and 15°, the frequency of the posterior-branch-dominant embolization pattern was higher in the more negatively angled group (p = 0.002-0.041).

CONCLUSION

The distribution of AE is different from that of contrast medium in percutaneous transhepatic RPVE under TBO. The pre-treatment measurement of the angles of portal branches against the horizontal plane on CECT is suggested to be useful for predicting the embolized area.

Preoperative portal venous and hepatic arterial embolization of tumor

Although the goal of embolization is usually to create therapeutic ischemia or hemostasis without surgery, the rationale for preoperative embolotherapy is different in several respects. First, the aim is to prepare patients for definitive surgical resection rather than cure or palliation, and, thus, the goals and expectations are limited and defined by close communication between the interventionalist and the surgeon. Second, when considering segmental resection, the normal liver should be protected from procedural damage. Third, the search for extrahepatic disease is crucial for these patients because resection is typically abandoned in favor of alternative therapies for patients with systemic disease. Finally, intraoperative ultrasound should always be considered to survey the future liver remnant for unsuspected small tumors and allow ablation of these lesions to maximize the success of partial hepatectomy. This article describes preoperative hepatic arterial and portal venous embolization in patients with or without cirrhosis complicated by tumors judged eligible for surgical resection or orthotopic liver transplantation (OLT). Each type of embolization will be reviewed in terms of indications and contraindications, technique, and complications. Finally, the outcomes will be evaluated in terms of morbidity, mortality, and tumor recurrence rates.

Foam sclerotherapy using polidocanol (aethoxysklerol) for preoperative portal vein embolization in 16 patients

PURPOSE

To evaluate the clinical safety and effectiveness of foam sclerotherapy using polidocanol for preoperative portal vein embolization (PVE) before hemihepatectomy of the liver.

MATERIALS AND METHODS

From March 2006 to October 2008, foam sclerotherapy using polidocanol was performed in 16 patients (male-to-female ratio of 12:4, age range 48-75 years [mean 62]) for PVE. Patients were diagnosed with Klatskin tumor (n = 13), gallbladder (GB) cancer (n = 2), or hepatocellular carcinoma (HCC) (n = 1). The foam was composed of a 1:2:1 ratio of 3% polidocanol (Aethoxysklerol; Kreussler Pharma, Wiesbaden, Germany), room air, and contrast media (Xenetix 350; Guerbet, Aulnay-Sous-Bois, France). The total amount of polidocanol used (2 to 8 mL [mean 4.6]) varied according to the volume of the target portal vein. We calculated the volume of future liver remnant (FLR) before and after PVE and evaluated complications associated with the use of polidocanol foam sclerotherapy for PVE.

RESULTS

Technical success was achieved in all patients. All patients were comfortable throughout the procedure and did not experience pain during sclerotherapy. No periprocedural morbidity or mortality occurred. Patients underwent a liver dynamic computed tomography (CT) scan 2-4 weeks after PVE. FLR increased significantly after PVE using polidocanol foam from 19.3% (range 16-35%) before PVE to 27.8% (range 23-42%) after PVE (p = 0.001). All patients were operable for hemihepatectomy of the liver and achieved effective resection.

CONCLUSION

Foam sclerotherapy using polidocanol is clinically safe and effective for preoperative PVE.

Selective portal vein ligation and embolization induce different tumoral responses in the rat liver

BACKGROUND

Portal vein ligation (PVL) and portal vein embolization (PVE) are used to enhance liver volume before hepatectomy for colorectal liver metastasis (LM). Impact of such techniques on tumor growth is not well known. This experimental study aimed to assess impact of PVE and PVL on LM growth in a murine model of colorectal LM.

METHODS

Single macroscopic tumor was induced by injection of 0.5 × 10(6) DHD/K12 cells under the liver capsule of BDIX rats at day 0. Multiple microscopic tumors were obtained by intra-portal injection of 1 × 10(6) cells at day 7. At day 8, rats were divided in 3 groups: PVE group (selective 70% PVE), PVL group (selective 70% PVL); control group (sham laparotomy). Rats were sacrificed at day 37 (11 in PVE, 12 in PVL, and 10 rats in control groups). Liver volume and LM volumes were assessed.

RESULTS

Nonoccluded liver volume was larger in the PVE and PVL groups vs control group (P < .0001 and P < .0001, respectively) but showed no difference in PVE vs PVL groups (P = .08). LM volume in the occluded liver was smaller in the PVE vs control groups (P = .006) and larger in the PVL vs control groups (P = .001). LM volume in the nonoccluded liver was larger in the PVE and PVL groups vs control group (P = .010 and P = .010, respectively) but showed no difference in PVE vs PVL groups (P= .878).

CONCLUSION

Both PVL and PVE modify tumor growth, especially in nonoccluded lobe. These results could be of clinical importance in humans where both techniques are widely used.

Sequential transcatheter arterial chemoembolization and portal vein embolization versus portal vein embolization only before major hepatectomy for patients with hepatocellular carcinoma

PURPOSE

To evaluate the safety and efficacy of sequential transcatheter arterial chemoembolization (TACE) and portal vein embolization (PVE) prior to surgery in hepatocellular carcinoma (HCC) patients and to compare the clinical outcome of the combined procedure with that of a matched group of patients undergoing PVE alone.

PATIENTS AND METHODS

From 1997 to 2008, 135 patients with HCC underwent sequential TACE and PVE (n = 71) or PVE alone (n = 64) before right hepatectomy. PVE was performed mean 1.2 months after TACE. In both groups, computed tomography (CT) and liver volumetry were performed before and 2 weeks after PVE to assess degree of left lobe hypertrophy.

RESULTS

Baseline patient and tumor characteristics were similar in the two groups. After PVE, the chronological changes of liver enzymes were similar in the two groups. The mean increase in percentage future liver remnant (FLR) volume was higher in the TACE + PVE group (7.3%) than in the PVE-only group (5.8%) (P = 0.035). After surgery, incidence of hepatic failure was higher in the PVE-only group (12%) than in the TACE + PVE (4%) group (P = 0.185). Overall (P = 0.028) and recurrence-free (P = 0.001) survival rates were significantly higher in the TACE + PVE group than in the PVE-only group.

CONCLUSION

Sequential TACE and PVE before surgery is a safe and effective method to increase the rate of hypertrophy of the FLR and leads to longer overall and recurrence-free survival in patients with HCC.

Portal vein embolization: rationale, outcomes, controversies and future directions

Portal vein embolization (PVE) is now considered the standard of care to improve safety for patients undergoing extensive hepatectomy with an anticipated small future liver remnant (FLR). PVE is used to induce contralateral liver hypertrophy in preparation for major liver resection. Optimal patient selection is essential to maximize the clinical benefits of PVE. Computed tomography volumetry is used to calculate a standardized FLR and determine the need for preoperative PVE. Percutaneous PVE can be performed via the transhepatic ipsilateral or contralateral approaches, depending on operator preference. Several different embolic agents are available to the interventional radiologist, all with similar effectiveness in inducing hypertrophy. When an extended hepatectomy is planned, right PVE should include segment 4, in order to maximize FLR hypertrophy. Multiple studies have demonstrated the beneficial outcomes of PVE in both patients with healthy livers and with underlying liver diseases. Novel improvements to PVE should expand its scope to patients who were previously not candidates for the procedure.

Hilar cholangiocarcinoma: current management

OBJECTIVE

To review the literature with regard to outcome of surgical management for hilar cholangiocarcinoma (Klatskin tumor).

BACKGROUND

Hilar cholangiocarcinoma is a rare tumor with a poor prognosis. Surgical resection provides the only possibility for cure. Advances in hepatobiliary imaging and surgical strategies to treat this disease have resulted in improved postoperative outcomes.

METHODS

We performed a review of the English literature on hilar cholangiocarcinoma from 1990 to 2007. This review included preoperative evaluation, surgical techniques, issues and controversies in management, prognostic variables, and considerations for future directions.

RESULTS

Complete resection remains the most effective and only potentially curative therapy for hilar cholangiocarcinoma. Negative resection margins are associated with improved outcomes, and major hepatic resections have enhanced the likelihood of R0 resection. Portal vein embolization may be indicated in selected patients before extensive hepatic resection. Staging laparoscopy should be considered to detect occult metastatic disease. Orthotopic liver transplantation might be applicable for a highly selected subgroup.

CONCLUSIONS

Surgical resection including major hepatic resection remains the mainstay of treatment of hilar cholangiocarcinoma. Additional evidence is needed to fully define the role of orthotopic liver transplantation. Improvements in adjuvant therapy are essential for improving long-term outcome.

Preoperative right portal vein embolisation: indications and results

PURPOSE

The purpose of this retrospective study was to evaluate the efficacy of right portal vein embolisation (PVE) in inducing contralateral liver hypertrophy before extended hepatectomy.

MATERIALS AND METHODS

Twenty-six consecutive patients, 14 with liver metastases (ten from colorectal cancer; four from carcinoid tumours) and 12 with biliary cancers (ten Klatskin tumours; one gallbladder tumour; one intrahepatic cholangiocarcinoma) with insufficient predicted future remnant liver (FRL) underwent right PVE to induce hypertrophy of the contralateral hemiliver prior to surgical resection. Total liver volume, tumour volume and FRL volume were calculated on a 3D workstation. The ratio of the FRL to the total functional liver volume was <30% in all patients.

RESULTS

The FRL volume increased by 5%-25% (15% on average) after right PVE in patients with liver metastases and by 9%-19% (14% on average) in patients with biliary cancers. In all patients, the ratio of FRL to functional liver volume was >or=30% after right PVE. No postoperative deaths due to severe liver failure occurred in the 20 patients who underwent extended hepatectomy.

CONCLUSIONS

Right PVE extends the indications for hepatectomy in patients with liver metastases and those with biliary cancers who have an insufficient potential hepatic functional reserve.