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Heil J, Schiesser M, Schadde E. Current trends in regenerative liver surgery: Novel clinical strategies and experimental approaches. Front Surg 2022; 9:903825. [PMID: 36157407 PMCID: PMC9491020 DOI: 10.3389/fsurg.2022.903825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 07/15/2022] [Indexed: 11/13/2022] Open
Abstract
Liver resections are performed to cure patients with hepatobiliary malignancies and metastases to the liver. However, only a small proportion of patients is resectable, largely because only up to 70% of liver tissue is expendable in a resection. If larger resections are performed, there is a risk of post-hepatectomy liver failure. Regenerative liver surgery addresses this limitation by increasing the future liver remnant to an appropriate size before resection. Since the 1980s, this surgery has evolved from portal vein embolization (PVE) to a multiplicity of methods. This review presents an overview of the available methods and their advantages and disadvantages. The first use of PVE was in patients with large hepatocellular carcinomas. The increase in liver volume induced by PVE equals that of portal vein ligation, but both result only in a moderate volume increase. While awaiting sufficient liver growth, 20%–40% of patients fail to achieve resection, mostly due to the progression of disease. The MD Anderson Cancer Centre group improved the PVE methodology by adding segment 4 embolization (“high-quality PVE”) and demonstrated that oncological results were better than non-surgical approaches in this previously unresectable patient population. In 2012, a novel method of liver regeneration was proposed and called Associating Liver Partition and Portal vein ligation for Staged hepatectomy (ALPPS). ALPPS accelerated liver regeneration by a factor of 2–3 and increased the resection rate to 95%–100%. However, ALPPS fell short of expectations due to a high mortality rate and a limited utility only in highly selected patients. Accelerated liver regeneration, however, was there to stay. This is evident in the multiplicity of ALPPS modifications like radiofrequency or partial ALPPS. Overall, rapid liver regeneration allowed an expansion of resectability with increased perioperative risk. But, a standardized low-risk approach to rapid hypertrophy has been missing and the techniques used and in use depend on local expertise and preference. Recently, however, simultaneous portal and hepatic vein embolization (PVE/HVE) appears to offer both rapid hypertrophy and no increased clinical risk. While prospective randomized comparisons are underway, PVE/HVE has the potential to become the future gold standard.
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Affiliation(s)
- Jan Heil
- Institute of Physiology, University of Zurich, Zurich, Switzerland
- Department of General, Visceral, Transplant and Thoracic Surgery, University Hospital, Goethe University Frankfurt, Frankfurt, Germany
| | - Marc Schiesser
- Chirurgisches Zentrum Zürich (CZZ), Klinik Hirslanden Zurich, Zurich, Switzerland
- Chirurgie Zentrum Zentralschweiz (CZZ), Hirslanden St. Anna, Lucerne, Switzerland
| | - Erik Schadde
- Institute of Physiology, University of Zurich, Zurich, Switzerland
- Chirurgisches Zentrum Zürich (CZZ), Klinik Hirslanden Zurich, Zurich, Switzerland
- Chirurgie Zentrum Zentralschweiz (CZZ), Hirslanden St. Anna, Lucerne, Switzerland
- Department of Surgery, Rush University Medical Center Chicago, Chicago, IL, United States
- Correspondence: Erik Schadde
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Heil J, Heid F, Bechstein WO, Björnsson B, Brismar TB, Carling U, Erdmann J, Fretland ÅA, Grunhagen D, Hana RA, Hohmann J, Linke R, Meyer Y, Nawawi A, Olthof PB, Sandström P, Schnitzbauer AA, Sparrelid E, Verhoef C, Metrakos P, Schadde E. Sarcopenia predicts reduced liver growth and reduced resectability in patients undergoing portal vein embolization before liver resection - A DRAGON collaborative analysis of 306 patients. HPB (Oxford) 2022; 24:413-421. [PMID: 34526229 DOI: 10.1016/j.hpb.2021.08.818] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 07/06/2021] [Accepted: 08/05/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND After portal vein embolization (PVE) 30% fail to achieve liver resection. Malnutrition is a modifiable risk factor and can be assessed by radiological indices. This study investigates, if sarcopenia affects resectability and kinetic growth rate (KGR) after PVE. METHODS A retrospective study was performed of the outcome of PVE at 8 centres of the DRAGON collaborative from 2010 to 2019. All malignant tumour types were included. Sarcopenia was defined using gender, body mass and skeletal muscle index. First imaging after PVE was used for liver volumetry. Primary and secondary endpoints were resectability and KGR. Risk factors impacting liver growth were assessed in a multivariable analysis. RESULTS Eight centres identified 368 patients undergoing PVE. 62 patients (17%) had to be excluded due to unavailability of data. Among the 306 included patients, 112 (37%) were non-sarcopenic and 194 (63%) were sarcopenic. Sarcopenic patients had a 21% lower resectability rate (87% vs. 66%, p < 0.001) and a 23% reduced KGR (p = 0.02) after PVE. In a multivariable model dichotomized for KGR ≥2.3% standardized FLR (sFLR)/week, only sarcopenia and sFLR before embolization correlated with KGR. CONCLUSION In this largest study of risk factors, sarcopenia was associated with reduced resectability and KGR in patients undergoing PVE.
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Affiliation(s)
- Jan Heil
- Institute of Physiology, University of Zurich, Zurich, Switzerland; Department of General, Visceral and Transplant Surgery, University Hospital Frankfurt, Goethe-University Frankfurt, Frankfurt, Main, Germany
| | - Franziska Heid
- Institute of Physiology, University of Zurich, Zurich, Switzerland; Department of Surgery, Cantonal Hospital Winterthur, Zurich, Switzerland
| | - Wolf O Bechstein
- Department of General, Visceral and Transplant Surgery, University Hospital Frankfurt, Goethe-University Frankfurt, Frankfurt, Main, Germany
| | - Bergthor Björnsson
- Department of Surgery in Linköping and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Torkel B Brismar
- Department of Clinical Science and Technology (CLINTEC), Radiology Unit, Karolinska Institutet, Stockholm, Sweden
| | - Ulrik Carling
- Department of Radiology Rikshospitalet, Oslo University Hospital, Oslo, Norway
| | - Joris Erdmann
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Åsmund A Fretland
- Department of Hepato-Pancreatic-Biliary Surgery, Oslo University Hospital, Oslo, Norway; The Intervention Centre, Oslo University Hospital, Oslo, Norway
| | - Dirk Grunhagen
- Department of Surgery, Erasmus MC Cancer Institute, Erasmus University, Rotterdam, the Netherlands
| | - Renato A Hana
- Department of Diagnostic Radiology, McGill General Hospital, Montreal, Canada
| | - Joachim Hohmann
- Department of Radiology and Nuclear Medicine, Cantonal Hospital Winterthur, Winterthur, Switzerland; Medical Faculty, University of Basel, Basel, Switzerland
| | - Richard Linke
- Department of General, Visceral and Transplant Surgery, University Hospital Frankfurt, Goethe-University Frankfurt, Frankfurt, Main, Germany
| | - Yannick Meyer
- Department of Surgery, Erasmus MC Cancer Institute, Erasmus University, Rotterdam, the Netherlands
| | - Abrar Nawawi
- Department of Surgery, McGill Health Center Research Institute, Cancer Program, Montreal, Canada
| | - Pim B Olthof
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands; Department of Surgery, Erasmus MC Cancer Institute, Erasmus University, Rotterdam, the Netherlands
| | - Per Sandström
- Department of Surgery in Linköping and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Andreas A Schnitzbauer
- Department of General, Visceral and Transplant Surgery, University Hospital Frankfurt, Goethe-University Frankfurt, Frankfurt, Main, Germany
| | - Ernesto Sparrelid
- Department of Clinical Science, Intervention and Technology, Division of Surgery, Karolinska Institutet, Karolinska Hospital, Stockholm, Sweden
| | - Cornelis Verhoef
- Department of Surgery, Erasmus MC Cancer Institute, Erasmus University, Rotterdam, the Netherlands
| | - Peter Metrakos
- Department of Surgery, McGill Health Center Research Institute, Cancer Program, Montreal, Canada
| | - Erik Schadde
- Institute of Physiology, University of Zurich, Zurich, Switzerland; Department of Surgery, Cantonal Hospital Winterthur, Zurich, Switzerland; Department of Surgery, Division of Transplant Surgery, Rush University Medical Center, Chicago, IL, USA.
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Simultaneous portal and hepatic vein embolization before major liver resection. Langenbecks Arch Surg 2020; 406:1295-1305. [PMID: 32839889 PMCID: PMC8370912 DOI: 10.1007/s00423-020-01960-6] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 08/06/2020] [Indexed: 11/17/2022]
Abstract
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.
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Lehwald-Tywuschik N, Vaghiri S, Schulte Am Esch J, Alaghmand S, Klosterkemper Y, Schimmöller L, Lachenmayer A, Ashmawy H, Krieg A, Topp SA, Rehders A, Knoefel WT. In situ split plus portal vein ligation (ISLT) - a salvage procedure following inefficient portal vein embolization to gain adequate future liver remnant volume prior to extended liver resection. BMC Surg 2020; 20:63. [PMID: 32252737 PMCID: PMC7333278 DOI: 10.1186/s12893-020-00721-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Accepted: 03/23/2020] [Indexed: 02/07/2023] Open
Abstract
Background Right extended liver resection is frequently required to achieve tumor-free margins. Portal venous embolization (PVE) of the prospective resected hepatic segments for conditioning segments II/III does not always induce adequate hypertrophy in segments II and III (future liver remnant volume (FLRV)) for extended right-resection. Here, we present the technique of in situ split dissection along segments II/III plus portal disruption to segments IV-VIII (ISLT) as a salvage procedure to overcome inadequate gain of FLRV after PVE. Methods In eight patients, FLRV was further pre-conditioned following failed PVE prior to hepatectomy (ISLT-group). We compared FLRV changes in the ISLT group with patients receiving extended right hepatectomy following sufficient PVE (PVEres-group). Survival of the ISLT-group was compared to PVEres patients and PVE patients with insufficient FLRV gain or tumor progress who did not receive further surgery (PVEnores-group). Results Patient characteristics and surgical outcome were comparable in both groups. The mean FLRV-to-body-weight ratio in the ISLT group was smaller than in the PVEres-group pre- and post-PVE. One intraoperative mortality due to a coronary infarction was observed for an ISLT patient. ISLT was successfully completed in the remaining seven ISLT patients. Liver function and 2-year survival of ~ 50% was comparable to patients with extended right hepatectomy after efficient PVE. Patients who received a PVE but who were not subsequently resected (PVEnores) demonstrated no survival beyond 4 months. Conclusion Despite extended embolization of segments I and IV-VIII, ISLT should be considered if hypertrophy was not adequate. Liver function and overall survival after ISLT was comparable to patients with trisectionectomy after efficient PVE.
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Affiliation(s)
- Nadja Lehwald-Tywuschik
- Department of Surgery A, University Hospital Duesseldorf, Duesseldorf, Germany.,Department of General, Visceral, Thorax and Pediatric Surgery,Heinrich-Heine-University Hospital, Moorenstr. 5, 40225, Duesseldorf, Germany
| | - Sascha Vaghiri
- Department of Surgery A, University Hospital Duesseldorf, Duesseldorf, Germany.,Department of General, Visceral, Thorax and Pediatric Surgery,Heinrich-Heine-University Hospital, Moorenstr. 5, 40225, Duesseldorf, Germany
| | - Jan Schulte Am Esch
- Present address: Center of Visceral Medicine, Department of Visceral Surgery, Protestant Hospital of Bethel Foundation, Bielefeld, Germany
| | - Salman Alaghmand
- Department of Surgery A, University Hospital Duesseldorf, Duesseldorf, Germany
| | - Yan Klosterkemper
- Department of Diagnostic and Interventional Radiology, University Hospital Duesseldorf, Duesseldorf, Germany
| | - Lars Schimmöller
- Department of Diagnostic and Interventional Radiology, University Hospital Duesseldorf, Duesseldorf, Germany
| | - Anja Lachenmayer
- Present ccaddress: Department of Visceral Surgery and Medicine, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Hany Ashmawy
- Department of Surgery A, University Hospital Duesseldorf, Duesseldorf, Germany.,Department of General, Visceral, Thorax and Pediatric Surgery,Heinrich-Heine-University Hospital, Moorenstr. 5, 40225, Duesseldorf, Germany
| | - Andreas Krieg
- Department of Surgery A, University Hospital Duesseldorf, Duesseldorf, Germany.,Department of General, Visceral, Thorax and Pediatric Surgery,Heinrich-Heine-University Hospital, Moorenstr. 5, 40225, Duesseldorf, Germany
| | - Stefan A Topp
- Present address: Department of Surgery, Ameos Hospital, Bremerhaven, Germany
| | - Alexander Rehders
- Department of Surgery A, University Hospital Duesseldorf, Duesseldorf, Germany.,Department of General, Visceral, Thorax and Pediatric Surgery,Heinrich-Heine-University Hospital, Moorenstr. 5, 40225, Duesseldorf, Germany
| | - Wolfram Trudo Knoefel
- Department of Surgery A, University Hospital Duesseldorf, Duesseldorf, Germany. .,Department of General, Visceral, Thorax and Pediatric Surgery,Heinrich-Heine-University Hospital, Moorenstr. 5, 40225, Duesseldorf, Germany.
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Loveday BPT, Jaberi A, Moulton CA, Wei AC, Gallinger S, Beecroft R, Fischer S, Ghanekar A, McGilvray I, Sapisochin G, Greig PD, Tan K, Cleary SP. Effect of portal vein embolization on treatment plan prior to major hepatectomy for hepatocellular carcinoma. HPB (Oxford) 2019; 21:1072-1078. [PMID: 30797726 DOI: 10.1016/j.hpb.2018.12.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Revised: 11/28/2018] [Accepted: 12/11/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Portal vein embolization (PVE) is used before major hepatectomy for hepatocellular carcinoma (HCC) to increase future liver remnant (FLR) volume. However, this may increase tumour growth rate, leading to more extensive resections. This study aimed to determine the effect of tumour growth, following PVE, on treatment plan. METHOD Retrospective cohort study conducted on patients treated from 2008 to 2015 with PVE before major hepatectomy for HCC. Liver and tumour volumetry was performed on pre- and post-PVE CT scans. Image-based and actioned plans were compared before and after PVE. RESULTS Thirty-one patients received PVE. Non-tumour total liver volume decreased (median 1440 to 1394 cm3; p = 0.031), while tumour (median 161-240 cm3; p < 0.001) and FLR volumes (median 430-574 cm3; p < 0.001) increased. The treatment plan changed in 15/31 patients: more extensive resection (n = 6), less extensive resection (n = 1), no resection as scheduled (n = 8). Tumour progression accounted for a clinically relevant change in treatment plan in 8/31 patients. CONCLUSION Following PVE in the setting of HCC, tumour progression accounts for a change in treatment plan in approximately a quarter of patients. Further research is warranted to determine whether additional liver directed therapy should routinely be used to slow the growth of HCC post-PVE.
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Affiliation(s)
| | - Arash Jaberi
- Division of Vascular and Interventional Radiology, Department of Medical Imaging, Toronto, Canada
| | | | - Alice C Wei
- Division of General Surgery, Department of Surgery, Toronto, Canada
| | - Steven Gallinger
- Division of General Surgery, Department of Surgery, Toronto, Canada
| | - Robert Beecroft
- Division of Vascular and Interventional Radiology, Department of Medical Imaging, Toronto, Canada
| | - Sandra Fischer
- Department of Pathology and Laboratory Medicine, Toronto General Hospital, University Health Network/University of Toronto, Toronto, Canada
| | - Anand Ghanekar
- Division of General Surgery, Department of Surgery, Toronto, Canada
| | - Ian McGilvray
- Division of General Surgery, Department of Surgery, Toronto, Canada
| | | | - Paul D Greig
- Division of General Surgery, Department of Surgery, Toronto, Canada
| | - Kongteng Tan
- Division of Vascular and Interventional Radiology, Department of Medical Imaging, Toronto, Canada
| | - Sean P Cleary
- Division of General Surgery, Department of Surgery, Toronto, Canada; Department of Surgery, Mayo Clinic, Rochester, MN, USA.
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Diaz KE, Schiano TD. Evaluation and Management of Cirrhotic Patients Undergoing Elective Surgery. Curr Gastroenterol Rep 2019; 21:32. [PMID: 31203525 DOI: 10.1007/s11894-019-0700-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
PURPOSE OF REVIEW Cirrhotic patients have an increased risk of surgical complications and higher perioperative morbidity and mortality based on the severity of their liver disease. Liver disease predisposes patients to perioperative coagulopathies, volume overload, and encephalopathy. The goal of this paper is to discuss the surgical risk of cirrhotic patients undergoing elective surgeries and to discuss perioperative optimization strategies. RECENT FINDINGS Literature thus far varies by surgery type and the magnitude of surgical risk. CTP and MELD classification scores allow for the assessment of surgical risk in cirrhotic patients. Once the decision has been made to undergo elective surgery, cirrhotic patients can be optimized pre-procedure with the help of a checklist and by the involvement of a multidisciplinary team. Elective surgeries should be performed at hospital centers staffed by healthcare providers experienced in caring for cirrhotic patients. Further research is needed to develop ways to prepare this complicated patient population before elective surgery.
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Affiliation(s)
- Kelly E Diaz
- Department of Medicine, Mount Sinai Medical Center, New York, NY, USA
| | - Thomas D Schiano
- Department of Medicine, Division of Liver Diseases, Recanati/Miller Transplantation Institute, Mount Sinai Medical Center, New York, NY, USA.
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Takahashi EA, Fleming CJ, Andrews JC. Future Liver Remnant Hypertrophy after Portal Vein Embolization Is Inversely Correlated with Intrahepatic Tumor Burden. J Vasc Interv Radiol 2019; 30:435-439. [PMID: 30819489 DOI: 10.1016/j.jvir.2018.10.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Revised: 10/10/2018] [Accepted: 10/11/2018] [Indexed: 02/07/2023] Open
Abstract
PURPOSE To determine if there is a correlation between intrahepatic tumor volume and future liver remnant (FLR) hypertrophy after portal vein embolization (PVE). MATERIALS AND METHODS Forty-four consecutive patients with hepatocellular carcinoma or metastatic colorectal cancer who underwent PVE from 2009 to 2017 and who had complete imaging follow-up were retrospectively reviewed. To maximize the accuracy of tumor volume measurements, 11 patients were excluded for having more than 5 intrahepatic tumors. Volumetric analyses of the patient livers before and after PVE, as well as pre-embolization intrahepatic tumor burden, were performed. RESULTS A significant inverse correlation was observed between tumor volume and FLR hypertrophy after PVE (Spearman ρ = -0.53, P = .002). Initial FLR volume was also inversely correlated with subsequent hypertrophy (P = .01). Fourteen patients received neoadjuvant chemotherapy 1 month prior to intervention. The number of chemotherapy cycles did not affect hypertrophy (P = .57). Patients with cirrhosis experienced less FLR hypertrophy than patients without cirrhosis (P = .02). CONCLUSIONS Patients with large intrahepatic tumor burden may experience limited FLR hypertrophy.
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Affiliation(s)
- Edwin A Takahashi
- Department of Radiology, Division of Vascular and Interventional Radiology, Mayo Clinic, 200 First Street SW, Rochester, Minnesota, 55905.
| | - Chad J Fleming
- Department of Radiology, Division of Vascular and Interventional Radiology, Mayo Clinic, 200 First Street SW, Rochester, Minnesota, 55905
| | - James C Andrews
- Department of Radiology, Division of Vascular and Interventional Radiology, Mayo Clinic, 200 First Street SW, Rochester, Minnesota, 55905
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Tustumi F, Ernani L, Coelho FF, Bernardo WM, Junior SS, Kruger JAP, Fonseca GM, Jeismann VB, Cecconello I, Herman P. Preoperative strategies to improve resectability for hepatocellular carcinoma: a systematic review and meta-analysis. HPB (Oxford) 2018; 20:1109-1118. [PMID: 30057123 DOI: 10.1016/j.hpb.2018.06.1798] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Revised: 06/14/2018] [Accepted: 06/16/2018] [Indexed: 02/06/2023]
Abstract
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.
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Affiliation(s)
- Francisco Tustumi
- Department of Gastroenterology, Digestive Surgery Division, Sao Paulo School of Medicine, Brazil.
| | - Lucas Ernani
- Department of Gastroenterology, Digestive Surgery Division, Sao Paulo School of Medicine, Brazil
| | - Fabricio F Coelho
- Department of Gastroenterology, Digestive Surgery Division, Sao Paulo School of Medicine, Brazil
| | - Wanderley M Bernardo
- Department of Gastroenterology, Digestive Surgery Division, Sao Paulo School of Medicine, Brazil
| | - Sérgio S Junior
- Department of Gastroenterology, Digestive Surgery Division, Sao Paulo School of Medicine, Brazil
| | - Jaime A P Kruger
- Department of Gastroenterology, Digestive Surgery Division, Sao Paulo School of Medicine, Brazil
| | - Gilton M Fonseca
- Department of Gastroenterology, Digestive Surgery Division, Sao Paulo School of Medicine, Brazil
| | - Vagner B Jeismann
- Department of Gastroenterology, Digestive Surgery Division, Sao Paulo School of Medicine, Brazil
| | - Ivan Cecconello
- Department of Gastroenterology, Digestive Surgery Division, Sao Paulo School of Medicine, Brazil
| | - Paulo Herman
- Department of Gastroenterology, Digestive Surgery Division, Sao Paulo School of Medicine, Brazil
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Portal Vein Embolization Reduces Postoperative Hepatic Insufficiency Associated with Postchemotherapy Hepatic Atrophy. J Gastrointest Surg 2018; 22:60-67. [PMID: 28585106 DOI: 10.1007/s11605-017-3467-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2017] [Accepted: 05/23/2017] [Indexed: 01/31/2023]
Abstract
BACKGROUND The risk of postoperative hepatic insufficiency (PHI) is increased among patients with significant postchemotherapy hepatic atrophy. The primary aim of this study was to evaluate whether the liver regeneration stimulated by portal vein embolization (PVE) can protect against PHI. METHODS Clinicopathological features of 177 patients treated with preoperative chemotherapy followed by PVE and hepatectomy were reviewed. Degree of atrophy was defined as the ratio of percentage difference in total liver volume (estimated by manual volumetry) to standardized liver volume. Kinetic growth rate (KGR, degree of hypertrophy [absolute % change in future liver remnant volume] divided by the number of weeks after PVE) and PHI events were compared between patients with degree of atrophy <10 vs ≥10%. Risk factors for the PHI were assessed using logistic regression. RESULTS Seventy patients (40%) experienced significant hepatic atrophy ≥10% following preoperative chemotherapy. PHI rates were not significantly increased in patients who experienced significant hepatic atrophy (5.6 vs 8.6%, P = 0.443). KGR <2%/week (odds ratio, 8.10, P = 0.037) was the sole independent preoperative predictor of PHI. KGR ≥2% was associated with decreased PHI in both patients with <10% atrophy (0 vs 9.5%, P = 0.035) and ≥10% atrophy (2.6 vs 16.0%, P = 0.044). CONCLUSIONS Even in high-risk patients with ≥10% degree of atrophy from preoperative chemotherapy, KGR ≥2% mitigates the deleterious effects of hepatic atrophy and significantly reduces PHI to almost zero. In these high-risk patients, PVE with KGR calculation remains the most important preoperative technique to reduce liver failure after major hepatectomy.
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Narula N, Aloia TA. Portal vein embolization in extended liver resection. Langenbecks Arch Surg 2017; 402:727-735. [DOI: 10.1007/s00423-017-1591-8] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Accepted: 05/15/2017] [Indexed: 02/07/2023]
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Liao M, Zhang T, Wang H, Liu Y, Lu M, Huang J, Zeng Y. Rabbit model provides new insights in liver regeneration after transection with portal vein ligation. J Surg Res 2017; 209:242-251. [DOI: 10.1016/j.jss.2016.10.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Revised: 09/28/2016] [Accepted: 10/26/2016] [Indexed: 02/07/2023]
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Glantzounis GK, Tokidis E, Basourakos SP, Ntzani EE, Lianos GD, Pentheroudakis G. The role of portal vein embolization in the surgical management of primary hepatobiliary cancers. A systematic review. Eur J Surg Oncol 2016; 43:32-41. [PMID: 27283892 DOI: 10.1016/j.ejso.2016.05.026] [Citation(s) in RCA: 75] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Revised: 05/17/2016] [Accepted: 05/23/2016] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Primary liver and biliary cancers are very aggressive tumors. Surgical treatment is the main option for cure or long term survival. The main purpose of this systematic review is to underline the indications for portal vein embolization (PVE), in patients with inadequate future liver remnant (FLR) and to analyze other parameters such as resection rate, morbidity, mortality, survival after PVE and hepatectomy for primary hepatobiliary tumors. Also the role of trans-arterial chemoembolization (TACE) before PVE, is investigated. METHODS A systematic search of the literature was performed in Pub Med and the Cochrane Library from 01.01.1990 to 30.09.2015. RESULTS Forty articles were selected, including 2144 patients with a median age of 61 years. The median excision rate was 90% for hepatocellular carcinomas (HCCs) and 86% for hilar cholangiocarcinomas (HCs). The main indications for PVE in patients with HCC and presence of liver fibrosis or cirrhosis was FLR <40% when liver function was good (ICGR15 < 10%) and FLR < 50% when liver function was affected (ICGR15:10-20%). The combination of TACE and PVE increased hypertrophy rate and was associated with better overall survival and disease free survival and should be considered in advanced HCC tumors with inadequate FLR. In patients with HCs PVE was performed, after preoperative biliary drainage, when FLR was <40%, in the majority of studies, with very good post-operative outcome. However indications should be refined. CONCLUSION PVE before major hepatectomy allows resection in a patient group with advanced primary hepato-biliary tumors and inadequate FLR, with good long term survival.
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Affiliation(s)
- G K Glantzounis
- Department of Surgery, School of Medicine, University of Ioannina, Ioannina, Greece.
| | - E Tokidis
- Department of Surgery, School of Medicine, University of Ioannina, Ioannina, Greece
| | - S-P Basourakos
- Department of Surgery, School of Medicine, University of Ioannina, Ioannina, Greece
| | - E E Ntzani
- Evidence-based Medicine Unit, Department of Hygiene and Epidemiology, School of Medicine, University of Ioannina, Ioannina, Greece
| | - G D Lianos
- Department of Surgery, School of Medicine, University of Ioannina, Ioannina, Greece
| | - G Pentheroudakis
- Department of Medical Oncology, School of Medicine, University of Ioannina, Ioannina, Greece
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Imaging Approach to Hepatocellular Carcinoma, Cholangiocarcinoma, and Metastatic Colorectal Cancer. Surg Oncol Clin N Am 2015; 24:19-40. [DOI: 10.1016/j.soc.2014.09.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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14
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Im GY, Lubezky N, Facciuto ME, Schiano TD. Surgery in patients with portal hypertension: a preoperative checklist and strategies for attenuating risk. Clin Liver Dis 2014; 18:477-505. [PMID: 24679507 DOI: 10.1016/j.cld.2014.01.006] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Patients with liver disease and portal hypertension are at increased risk of complications from surgery. Recent advances have allowed better optimization of patients with cirrhosis before surgery and a reduction in postoperative complications. Despite this progress, the estimation of surgical risk in a patient with cirrhosis is challenging. The MELD score has shown promise in predicting postoperative mortality compared with the Child-Turcotte-Pugh score. This article addresses current concepts in the perioperative evaluation of patients with liver disease and portal tension, including a preoperative liver assessment (POLA) checklist that may be useful towards mitigating perioperative complications.
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Affiliation(s)
- Gene Y Im
- Icahn School of Medicine at Mount Sinai, The Mount Sinai Medical Center, Recanati/Miller Transplantation Institute, One Gustave Levy Place, Box 1104, New York, NY 10029-6574, USA
| | - Nir Lubezky
- Icahn School of Medicine at Mount Sinai, The Mount Sinai Medical Center, Recanati/Miller Transplantation Institute, One Gustave Levy Place, Box 1104, New York, NY 10029-6574, USA
| | - Marcelo E Facciuto
- Icahn School of Medicine at Mount Sinai, The Mount Sinai Medical Center, Recanati/Miller Transplantation Institute, One Gustave Levy Place, Box 1104, New York, NY 10029-6574, USA
| | - Thomas D Schiano
- Icahn School of Medicine at Mount Sinai, The Mount Sinai Medical Center, Recanati/Miller Transplantation Institute, One Gustave Levy Place, Box 1104, New York, NY 10029-6574, USA.
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15
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Shindoh J, Tzeng CWD, Aloia TA, Curley SA, Zimmitti G, Wei SH, Huang SY, Gupta S, Wallace MJ, Vauthey JN. Portal vein embolization improves rate of resection of extensive colorectal liver metastases without worsening survival. Br J Surg 2014; 100:1777-83. [PMID: 24227364 DOI: 10.1002/bjs.9317] [Citation(s) in RCA: 80] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/04/2013] [Indexed: 11/11/2022]
Abstract
BACKGROUND Most patients requiring an extended right hepatectomy (ERH) have an inadequate standardized future liver remnant (sFLR) and need preoperative portal vein embolization (PVE). However, the clinical and oncological impact of PVE in such patients remains unclear. METHODS All consecutive patients presenting at the M. D. Anderson Cancer Center with colorectal liver metastases (CLM) requiring ERH at presentation from 1995 to 2012 were studied. Surgical and oncological outcomes were compared between patients with adequate and inadequate sFLRs at presentation. RESULTS Of the 265 patients requiring ERH, 126 (47·5 per cent) had an adequate sFLR at presentation, of whom 123 underwent a curative resection. Of the 139 patients (52·5 per cent) who had an inadequate sFLR and underwent PVE, 87 (62·6 per cent) had a curative resection. Thus, the curative resection rate was increased from 46·4 per cent (123 of 265) at baseline to 79·2 per cent (210 of 265) following PVE. Among patients who underwent ERH, major complication and 90-day mortality rates were similar in the no-PVE and PVE groups (22·0 and 4·1 per cent versus 31 and 7 per cent respectively); overall and disease-free survival rates were also similar in these two groups. Of patients with an inadequate sFLR at presentation, those who underwent ERH had a significantly better median overall survival (50·2 months) than patients who had non-curative surgery (21·3 months) or did not undergo surgery (24·7 months) (P = 0·002). CONCLUSION PVE enabled curative resection in two-thirds of patients with CLM who had an inadequate sFLR and were unable to tolerate ERH at presentation. Patients who underwent curative resection after PVE had overall and disease-free survival rates equivalent to those of patients who did not need PVE.
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16
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Shindoh J, Tzeng CWD, Aloia TA, Curley SA, Huang SY, Mahvash A, Gupta S, Wallace MJ, Vauthey JN. Safety and efficacy of portal vein embolization before planned major or extended hepatectomy: an institutional experience of 358 patients. J Gastrointest Surg 2014; 18:45-51. [PMID: 24129824 DOI: 10.1007/s11605-013-2369-0] [Citation(s) in RCA: 89] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2013] [Accepted: 09/20/2013] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Portal vein embolization (PVE) stimulates hypertrophy of the future liver remnant (FLR) and may improve the safety of extended hepatectomy. The efficacy of PVE was evaluated. METHODS Records of 358 consecutive patients who underwent PVE before intended major hepatectomy at our institution from 1995 through 2012 were retrospectively reviewed. RESULTS One hundred twelve patients (31.3 %) had right PVE alone; 235 (65.6 %) had right PVE plus segment IV embolization. The first-session PVE completion rate was 97.8 %. The PVE complication rate was 3.9 %. The median pre-PVE and post-PVE standardized FLRs were 19.5 % (interquartile range, 15.0-25.9) and 29.7 % (interquartile range, 22.5-38.2), respectively. Two hundred forty patients (67.0 %) underwent potentially curative resection. Sixty-two patients (25.8 %) had major post-hepatectomy complications; rates of postoperative hepatic insufficiency and 90-day liver-related mortality were 8.3 and 3.8 %, respectively. The proportion of patients with colorectal liver metastasis increased from 38.6 % before 2005 to 78.2 % in 2010-2012. Despite increased use of preoperative chemotherapy, postoperative hepatic insufficiency and 90-day liver-related mortality rates dropped from 10.6 and 4.1 %, respectively, before 2010 to 2.9 and 2.9 %, respectively, in 2010-2012. CONCLUSIONS PVE can be safely performed with minimal morbidity. Most patients can proceed to extended hepatectomy, which is associated with a minimal mortality rate.
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Affiliation(s)
- Junichi Shindoh
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcomb Boulevard, Unit 1484, Houston, TX, 77030, USA
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17
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Tschuor C, Croome KP, Sergeant G, Cano V, Schadde E, Ardiles V, Slankamenac K, Clariá RS, de Santibaňes E, Hernandez-Alejandro R, Clavien PA. Salvage parenchymal liver transection for patients with insufficient volume increase after portal vein occlusion -- an extension of the ALPPS approach. Eur J Surg Oncol 2013; 39:1230-5. [PMID: 23994139 DOI: 10.1016/j.ejso.2013.08.009] [Citation(s) in RCA: 82] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2013] [Revised: 08/05/2013] [Accepted: 08/08/2013] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Portal vein ligation (PVL) or embolization (PVE) are standard approaches to induce liver hypertrophy of the future liver remnant (FLR) prior to hepatectomy in primarily non-resectable liver tumors. However, this approach fails in about one third of patients. Recently, the new "ALPPS" approach has been described that combines PVL with parenchymal transection to induce rapid liver hypertrophy. This series explores whether isolated parenchymal transection boosts liver hypertrophy in scenarios of failed PVL/PVE. METHODS A multicenter database with 170 patients undergoing portal vein manipulation to increase the size of the FLR was screened for patients undergoing isolated parenchymal transection as a salvage procedure. Three patients who underwent PVL/PVE with subsequent insufficient volume gain and subsequently underwent parenchymal liver transection as a salvage procedure were identified. Patient characteristics, volume increase, postoperative complications and outcomes were analyzed. RESULTS The first patient underwent liver transection 16 weeks after failed PVL with a standardized FLR (sFLR) of 30%, which increased to 47% in 7 days. The second patient showed a sFLR of 25% 28 weeks after PVL and subsequent PVE of segment IV, which increased to 41% in 7 days after transection. The third patient underwent liver partition 8 weeks after PVE with a sFLR of 19%, which increased to 37% in six days. All patients underwent a R0 resection. CONCLUSION Failed PVE or PVL appears to represent a good indication for the isolated parenchymal liver transection according to the newly developed ALPPS approach.
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Affiliation(s)
- Ch Tschuor
- Swiss HPB Center, Department of Surgery and Transplantation, University Hospital Zurich, Raemistrasse 100, CH-8091 Zurich, Switzerland
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18
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Shindoh J, Vauthey JN, Zimmitti G, Curley SA, Huang SY, Mahvash A, Gupta S, Wallace MJ, Aloia TA. Analysis of the efficacy of portal vein embolization for patients with extensive liver malignancy and very low future liver remnant volume, including a comparison with the associating liver partition with portal vein ligation for staged hepatectomy approach. J Am Coll Surg 2013. [PMID: 23632095 DOI: 10.1016/j.amcollsurg.2013.03.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND The primary reported indication for the associating liver partition with portal vein ligation for staged hepatectomy (ALPPS) technique is in patients with very low future liver remnant volumes. Given the elevated incidence of major morbidity (40%) and liver-related mortality (12%) with ALPPS, we sought to determine the safety and efficacy of percutaneous portal vein embolization (PVE) in a similar patient population. STUDY DESIGN Tumor resectability and morbidity and mortality rates were reviewed for 144 consecutive liver tumor patients with future liver remnant to body weight ratios (LR/BW) less than 0.5%. All patients were referred for preoperative percutaneous right plus segment IV PVE using embolic microspheres, with planned reassessment of the LR/BW 30 days after PVE. Post-PVE outcomes were compared with reported outcomes for ALPPS. RESULTS Percutaneous PVE was successfully performed in 141 of the 144 study patients (97.9%). Adequate regeneration was observed in 139 patients (98.5%) with median post-PVE LR/BW rising from 0.33% to 0.52% (p < 0.0001), representing a per-patient median regeneration rate of 62% (range 0.3% to 379%). In total, 104 patients underwent extended right hepatectomy (n = 102) or right hepatectomy (n = 2). The remaining 40 patients (27.8%) were not resectable due to short-interval disease progression (27 patients, 18.5%), insufficient liver regeneration (5 patients, 3.5%), and medical comorbidities (8 patients, 5.6%). After resection, the following outcomes were observed: major morbidity: 33.0% (34 of 104), liver insufficiency: 12.5% (13 of 104), and 90-day liver-related mortality: 5.8% (6 of 104). These oncologic and technical results compare favorably with those of ALPPS. CONCLUSIONS Based on its ability to select oncologically resectable patients and superior safety and efficacy profiles, percutaneous right + segment IV PVE and interval surgery remains the standard of care for patients with very low future liver remnant volumes.
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Affiliation(s)
- Junichi Shindoh
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
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19
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Shindoh J, Vauthey JN, Zimmitti G, Curley SA, Huang SY, Mahvash A, Gupta S, Wallace MJ, Aloia TA. Analysis of the efficacy of portal vein embolization for patients with extensive liver malignancy and very low future liver remnant volume, including a comparison with the associating liver partition with portal vein ligation for staged hepatectomy approach. J Am Coll Surg 2013; 217:126-33; discussion 133-4. [PMID: 23632095 DOI: 10.1016/j.jamcollsurg.2013.03.004] [Citation(s) in RCA: 190] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2013] [Revised: 03/04/2013] [Accepted: 03/05/2013] [Indexed: 02/08/2023]
Abstract
BACKGROUND The primary reported indication for the associating liver partition with portal vein ligation for staged hepatectomy (ALPPS) technique is in patients with very low future liver remnant volumes. Given the elevated incidence of major morbidity (40%) and liver-related mortality (12%) with ALPPS, we sought to determine the safety and efficacy of percutaneous portal vein embolization (PVE) in a similar patient population. STUDY DESIGN Tumor resectability and morbidity and mortality rates were reviewed for 144 consecutive liver tumor patients with future liver remnant to body weight ratios (LR/BW) less than 0.5%. All patients were referred for preoperative percutaneous right plus segment IV PVE using embolic microspheres, with planned reassessment of the LR/BW 30 days after PVE. Post-PVE outcomes were compared with reported outcomes for ALPPS. RESULTS Percutaneous PVE was successfully performed in 141 of the 144 study patients (97.9%). Adequate regeneration was observed in 139 patients (98.5%) with median post-PVE LR/BW rising from 0.33% to 0.52% (p < 0.0001), representing a per-patient median regeneration rate of 62% (range 0.3% to 379%). In total, 104 patients underwent extended right hepatectomy (n = 102) or right hepatectomy (n = 2). The remaining 40 patients (27.8%) were not resectable due to short-interval disease progression (27 patients, 18.5%), insufficient liver regeneration (5 patients, 3.5%), and medical comorbidities (8 patients, 5.6%). After resection, the following outcomes were observed: major morbidity: 33.0% (34 of 104), liver insufficiency: 12.5% (13 of 104), and 90-day liver-related mortality: 5.8% (6 of 104). These oncologic and technical results compare favorably with those of ALPPS. CONCLUSIONS Based on its ability to select oncologically resectable patients and superior safety and efficacy profiles, percutaneous right + segment IV PVE and interval surgery remains the standard of care for patients with very low future liver remnant volumes.
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Affiliation(s)
- Junichi Shindoh
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
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20
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Shindoh J, Vauthey JN, Zimmitti G, Curley SA, Huang SY, Mahvash A, Gupta S, Wallace MJ, Aloia TA. Analysis of the efficacy of portal vein embolization for patients with extensive liver malignancy and very low future liver remnant volume, including a comparison with the associating liver partition with portal vein ligation for staged hepatectomy approach. J Am Coll Surg 2013. [PMID: 23632095 DOI: 10.1016/j.jamcollsurg.2013.03.04] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND The primary reported indication for the associating liver partition with portal vein ligation for staged hepatectomy (ALPPS) technique is in patients with very low future liver remnant volumes. Given the elevated incidence of major morbidity (40%) and liver-related mortality (12%) with ALPPS, we sought to determine the safety and efficacy of percutaneous portal vein embolization (PVE) in a similar patient population. STUDY DESIGN Tumor resectability and morbidity and mortality rates were reviewed for 144 consecutive liver tumor patients with future liver remnant to body weight ratios (LR/BW) less than 0.5%. All patients were referred for preoperative percutaneous right plus segment IV PVE using embolic microspheres, with planned reassessment of the LR/BW 30 days after PVE. Post-PVE outcomes were compared with reported outcomes for ALPPS. RESULTS Percutaneous PVE was successfully performed in 141 of the 144 study patients (97.9%). Adequate regeneration was observed in 139 patients (98.5%) with median post-PVE LR/BW rising from 0.33% to 0.52% (p < 0.0001), representing a per-patient median regeneration rate of 62% (range 0.3% to 379%). In total, 104 patients underwent extended right hepatectomy (n = 102) or right hepatectomy (n = 2). The remaining 40 patients (27.8%) were not resectable due to short-interval disease progression (27 patients, 18.5%), insufficient liver regeneration (5 patients, 3.5%), and medical comorbidities (8 patients, 5.6%). After resection, the following outcomes were observed: major morbidity: 33.0% (34 of 104), liver insufficiency: 12.5% (13 of 104), and 90-day liver-related mortality: 5.8% (6 of 104). These oncologic and technical results compare favorably with those of ALPPS. CONCLUSIONS Based on its ability to select oncologically resectable patients and superior safety and efficacy profiles, percutaneous right + segment IV PVE and interval surgery remains the standard of care for patients with very low future liver remnant volumes.
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Affiliation(s)
- Junichi Shindoh
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
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21
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Brouquet A, Andreou A, Shindoh J, Vauthey JN. Methods to improve resectability of hepatocellular carcinoma. Recent Results Cancer Res 2013; 190:57-67. [PMID: 22941013 DOI: 10.1007/978-3-642-16037-0_4] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Liver resection is associated with prolonged survival in selected patients with hepatocellular carcinoma (HCC). Surgical resection of HCC may be decided on an individual basis according to the extent of the tumor and the severity of chronic liver disease. In patients with compensated cirrhosis, the volume of the future liver remnant (FLR) is the most reliable factor for predicting postoperative liver function. Methods of increasing the FLR volume, including portal vein embolization and sequential transarterial chemoembolization in patients who are primarily not eligible for liver resection, have been shown to be safe and have contributed to the increase in the number of surgical candidates.
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Affiliation(s)
- Antoine Brouquet
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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22
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Kinetic growth rate after portal vein embolization predicts posthepatectomy outcomes: toward zero liver-related mortality in patients with colorectal liver metastases and small future liver remnant. J Am Coll Surg 2012; 216:201-9. [PMID: 23219349 DOI: 10.1016/j.jamcollsurg.2012.10.018] [Citation(s) in RCA: 200] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2012] [Revised: 10/30/2012] [Accepted: 10/31/2012] [Indexed: 12/16/2022]
Abstract
BACKGROUND Standardized future liver remnant (sFLR) volume and degree of hypertrophy after portal vein embolization (PVE) have been recognized as important predictors of surgical outcomes after major liver resection. However, the regeneration rate of the FLR after PVE varies among individuals and its clinical significance is unknown. STUDY DESIGN Kinetic growth rate (KGR) is defined as the degree of hypertrophy at initial volume assessment divided by number of weeks elapsed after PVE. In 107 consecutive patients who underwent liver resection for colorectal liver metastases with an sFLR volume >20%, the ability of the KGR to predict overall and liver-specific postoperative morbidity and mortality was compared with sFLR volume and degree of hypertrophy. RESULTS Using receiver operating characteristic analysis, the best cutoff values for sFLR volume, degree of hypertrophy, and KGR for predicting postoperative hepatic insufficiency were estimated as 29.6%, 7.5%, and 2.0% per week, respectively. Among these, KGR was the most accurate predictor (area under the curve 0.830 [95% CI, 0.736-0.923]; asymptotic significance, 0.002). A KGR of <2% per week vs ≥2% per week correlates with rates of hepatic insufficiency (21.6% vs 0%; p = 0.0001) and liver-related 90-day mortality (8.1% vs 0%; p = 0.04). The predictive value of KGR was not influenced by sFLR volume or the timing of initial volume assessment when evaluated within 8 weeks after PVE. CONCLUSIONS Kinetic growth rate is a better predictor of postoperative morbidity and mortality after liver resection for small FLR than conventional measured volume parameters (ie, sFLR volume and degree of hypertrophy).
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Sherman M, Burak K, Maroun J, Metrakos P, Knox JJ, Myers RP, Guindi M, Porter G, Kachura JR, Rasuli P, Gill S, Ghali P, Chaudhury P, Siddiqui J, Valenti D, Weiss A, Wong R. Multidisciplinary Canadian consensus recommendations for the management and treatment of hepatocellular carcinoma. ACTA ACUST UNITED AC 2011; 18:228-40. [PMID: 21980250 DOI: 10.3747/co.v18i5.952] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Globally, hepatocellular carcinoma (hcc) is the third most common cause of death from cancer, after lung and stomach cancer. The incidence of hcc in Canada is increasing and is expected to continue to increase over the next decade. Given the high mortality rate associated with hcc, steps are required to mitigate the impact of the disease. To address this challenging situation, a panel of 17 hcc experts, representing gastroenterologists, hepatologists, hepatobiliary surgeons, medical oncologists, pathologists, and radiologists from across Canada, convened to provide a framework that, using an evidence-based approach, will assist clinicians in optimizing the management and treatment of hcc. The recommendations, summarized here, were developed based on a rigorous methodology in a pre-specified process that was overseen by the steering committee. Specific topics were identified by the steering committee and delegated to a group of content experts within the expert panel, who then systematically reviewed the literature on that topic and drafted the related content and recommendations. The set of recommendations for each topic were reviewed and assigned a level of evidence and grade according to the levels of evidence set out by the Centre for Evidence-based Medicine, Oxford, United Kingdom. Agreement on the level of evidence for each recommendation was achieved by consensus. Consensus was defined as agreement by a two-thirds majority of the 17 members of the expert panel. Recommendations were subject to iterative review and modification by the expert panel until consensus could be achieved.
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Affiliation(s)
- M Sherman
- Department of Medicine, University of Toronto; University Health Network; and Canadian Liver Foundation, Toronto, ON
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Mittler J, McGillicuddy JW, Chavin KD. Laparoscopic liver resection in the treatment of hepatocellular carcinoma. Clin Liver Dis 2011; 15:371-84, vii-x. [PMID: 21689619 DOI: 10.1016/j.cld.2011.03.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Laparoscopic liver resection is an emerging technique in liver surgery. Although laparoscopy is well established for several abdominal procedures and is considered by some the preferred approach, laparoscopic hepatic resection has been introduced into clinical practice more widely since 2000. These procedures are performed only in experienced centers and only in a select group of patients. While initially performed only for benign hepatic lesions, the indications for laparoscopic resection have gradually broadened to encompass all kinds of malignant hepatic lesions, including hepatocellular carcinoma in patients with cirrhosis, for whom the advantages of the minimally invasive approach may be most evident.
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Affiliation(s)
- Jens Mittler
- Division of Transplant Surgery, Department of Surgery, Medical University of South Carolina (MUSC), 96 Jonathan Lucas Street Charleston, SC 29425, USA
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25
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Choi GH, Park JY, Hwang HK, Kim DH, Kang CM, Choi JS, Park YN, Kim DY, Ahn SH, Han KH, Chon CY, Lee WJ. Predictive factors for long-term survival in patients with clinically significant portal hypertension following resection of hepatocellular carcinoma. Liver Int 2011; 31:485-93. [PMID: 21382158 DOI: 10.1111/j.1478-3231.2010.02436.x] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/13/2023]
Abstract
BACKGROUND Hepatic resection for hepatocellular carcinoma (HCC) is not currently recommended for patients with clinically significant portal hypertension (PHT); however, recent studies have shown similar post-operative outcomes between patients with and without clinically significant PHT. AIM To clarify the post-operative prognostic relevance of clinically significant PHT in Child-Pugh A cirrhotic patients. METHODS A total of 100 Child-Pugh A cirrhotic patients who underwent curative resection of HCC were eligible for this analysis. Patients were divided into two groups: PHT group (n=47) and non-PHT group (n=53). RESULTS Clinicopathological variables showed no significant differences except for prothrombine time. Liver-related complications were significantly higher in the PHT group (P=0.015), and the 5-year overall survival rate was significantly higher in the non-PHT group (78.7 vs. 37.9%, P<0.001). The proportion of patients who died because of complications of cirrhosis was significantly higher in the PHT group (P=0.001). Multivariate analysis indicated that the presence of clinically significant PHT was the most powerful adverse prognostic factor for overall survival. Multivariate analysis of the 47 patients with clinically significant PHT indicated that gross vascular invasion and non-single nodular type were poor prognostic factors. The 5-year survival rate of patients with single nodular type and without gross vascular invasion (n=17) was 78.4%. CONCLUSIONS In Child-Pugh A cirrhotic patients, the presence of clinically significant PHT was significantly associated with post-operative hepatic decompensation and poor prognosis after resection of HCC. However, in patients with clinically significant PHT, those with single nodular tumours lacking gross vascular invasion may be good surgical candidates.
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Affiliation(s)
- Gi H Choi
- Department of Surgery, Yonsei University Health System, Seoul, Korea
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