Effect of preoperative portal vein embolization on liver volume and hepatic energy status of the nonembolized liver lobe in humans

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

KEY POINTS

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

Dynamic Change of Total Bilirubin after Portal Vein Embolization is Predictive of Major Complications and Posthepatectomy Mortality in Patients with Hilar Cholangiocarcinoma

OBJECTIVES

This study aims to evaluate the role of dynamic change in total bilirubin after portal vein embolization (PVE) in predicting major complications and 30-day mortality in patients with hilar cholangiocarcinoma (HCCA).

METHODS

Retrospective analysis of prospectively maintained data of 64 HCCA patients who underwent PVE before hepatectomy in our institution was used. Total bilirubin and other parameters were measured daily in peri-PVE period. The difference between them and the baseline value from days 0-5 to day -1 (∆D1) and days 5-14 to day -1 (∆D2) were calculated. The relationship between ∆D1 and ∆D2 of total bilirubin and major complications as well as 30-day mortality was analyzed.

RESULTS

Out of 64 patients, 10 developed major complications (15.6 %) and 6 patients (9.3 %) had died within 30 days after surgery. The ∆D2 of total bilirubin after PVE was most significantly associated with major complications (P < 0.001) and 30-day mortality (P = 0.002). In addition, it was found to be an independent predictor of major complications after PVE (odds ratio (OR) = 1.050; 95 % CI 1.017-1.084). ASA >3 (OR = 12.048; 95 % CI 1.019-143.321), ∆D2 of total bilirubin (OR = 1.058; 95 % CI 1.007-1.112), and ∆D2 of prealbumin (OR = 0.975; 95 % CI 0.952-0.999) were associated with higher risk of 30-day mortality after PVE. Receiver operating characteristic curves showed that ∆D2 of total bilirubin were better predictors than ∆D1 for major complications (AUC (∆D2) 0.817; P = 0.002 vs. AUC (∆D1) 0.769; P = 0.007) and 30-day mortality (ACU(∆D2) 0.868; P = 0.003 vs. AUC(∆D1) 0.721;P = 0.076).

CONCLUSION

Patients with increased total bilirubin in 5-14 days after PVE may indicate a higher risk of major complications and 30-day mortality if the major hepatectomy were performed.

31P MR spectroscopic imaging detects regenerative changes in human liver stimulated by portal vein embolization

PURPOSE

First, to evaluate hepatocyte phospholipid metabolism and energetics during liver regeneration stimulated by portal vein embolization (PVE) using proton-decoupled (31)P MR spectroscopic imaging ((31)P-MRSI). Second, to compare the biophysiologic differences between hepatic regeneration stimulated by PVE and by partial hepatectomy (PH).

MATERIALS AND METHODS

Subjects included six patients with hepatic metastases from colorectal cancer who were scheduled to undergo right PVE before definitive resection of right-sided tumor. (31)P-MRSI was performed on the left liver lobe before PVE and 48 h following PVE. Normalized quantities of phosphorus-containing hepatic metabolites were analyzed from both visits. In addition, MRSI data at 48 h following partial hepatectomy were compared with the data from the PVE patients.

RESULTS

At 48 h after PVE, the ratio of phosphomonoesters to phosphodiesters in the nonembolized lobe was significantly elevated. No significant changes were found in nucleoside triphosphates (NTP) and Pi values. The phosphomonoester (PME) to phosphodiester (PDE) ratio in regenerating liver 48 h after partial hepatectomy was significantly greater than PME/PDE 48 h after PVE.

CONCLUSION

(31)P-MRSI is a valid technique to noninvasively evaluate cell membrane metabolism following PVE. The different degree of biochemical change between partial hepatectomy and PVE indicates that hepatic growth following these two procedures does not follow the same course.

Transcatheter selective portal vein embolization in treatment of hepatocellular carcinoma: an analysis of 20 cases

AIM: To evaluate the clinical value of transcatheter selective portal vein embolization (PVE) in treatment of hepatocellular carcinoma.

METHODS: Twenty patients, with unresectable advanced hepatocellular carcinoma, were treated with right PVE under fluoroscopic guidance. Left hepatic lobe volume was obtained by computerized tomography (CT) before and after PVE. Portal venous pressure, hepatic and thromboplastic functions were also detected before and after PVE.

RESULTS: Right portal vein were embolized successfully in 20 patients. Compensatory hypertrophy was observed in left hepatic lobe. The volume of left hepatic lobe increased significantly with a total percentage of 25% in 13 patients (65%) at 4 wk after PVE (P <0.01). Right hepatic lobe was successfully resected in 1 patient. No patients had complications such as portal hypertension after PVE. Slight damage of liver function after PVE was observed.

CONCLUSION: PVE can induce compensatory hypertrophy of liver lobes, which provides another operation chance for patients with unresectable hepatocellular carcinoma.

Cyclin expression in the atrophying and proliferating lobes of the liver after portal vein branch ligation and hepatectomy in rats

BACKGROUND

Portal vein branch ligation causes atrophy of the portal vein ligated lobes (PVL) and proliferation of the nonligated lobes (PVNL) of the liver. However, the mechanisms underlying atrophy of the PVL and proliferation of PVNL after portal vein branch ligation have not been clarified except that interleukin-6 (IL-6), nuclear factor kappa B (NF-kappaB), signal transducer and activator of transcription 3 (STAT3), and immediate-early gene expression are similarly induced in both the PVL and the PVNL. Thus, it is still unclear what factors cause the subsequent atrophy and proliferation.

MATERIALS AND METHODS

Male Wistar rats were randomly separated into a portal vein branch ligation group and partial hepatectomy group. In the portal vein branch ligation group, the branch of portal vein supplying the median and left lateral lobes of the liver was ligated. In the partial hepatectomy group, the correspondent lobes of the liver were excised. We examined cyclin expression in the PVL and PVNL after portal vein branch ligation in comparison to cyclin expression in the remaining liver (HEP) after partial hepatectomy. Cyclin D1, E, and A mRNA and protein expressions were analyzed by RT-PCR and Western blotting, respectively.

RESULTS

The mRNA and protein expressions of cyclin D1 and A were not up-regulated in the PVL, whereas those in the PVNL and HEP were up-regulated. Cyclin D1 mRNA and protein expressions were significantly lower in the PVL than in the PVNL and HEP at 18 h. The levels of mRNA and protein expression of cyclin A were significantly lower in the PVL than in the PVNL and HEP at 36 h. Liver regeneration, assessed by the relative liver weight, thymidine incorporation into DNA, and proliferating cell nuclear antigen (PCNA) labeling index was delayed significantly in the PVNL compared to that in the HEP. Cyclin D1 mRNA and protein expressions were significantly lower in the PVNL than in the HEP at 12 and 18 h, respectively.

CONCLUSIONS

Cell-cycle progression might be inhibited at G(1)-phase accompanied by impaired cyclin D1 expression in the PVL, which results in atrophy. The fact that liver proliferation of the PVNL is delayed in comparison to that of the HEP is likely due to delayed expression of cyclin D1.

Role of preoperative selective portal vein embolization in two-step curative hepatectomy for hepatocellular carcinoma

AIM: To determine the feasibility and role of ultrasound-guided preoperative selective portal vein embolization (POSPVE) in the two-step hepatectomy of patients with advanced primary hepatocellular carcinoma (HCC).

METHODS: Fifty patients with advanced HCC who were not suitable for curative hepatectomy were treated by ultrasound-guided percutaneous transhepatic POSPVE with fine needles. The successful rate, side effects and complications of POSPVE, changes of hepatic lobe volume and two-step curative hepatectomy rate after POSPVE were observed.

RESULTS: POSPVE was successfully performed in 47 (94.0%) patients. In patients whose right portal vein branches were embolized, their right hepatic volume decreased and left hepatic volume increased gradually. The ratio of right hepatic volume to total hepatic volume decreased from 62.4% before POSPVE to 60.5%, 57.2% and 52.8% after 1, 2 and 3 weeks respectively. The side effects included different degree of pain in liver area (38 cases), slight fever (27 cases), nausea and vomiting (9 cases). The level of aspartate alanine transaminase (AST), alanine transaminase (ALT) and total bilirubin (TBIL) increased after POSPVE, but returned to preoperative level in 1 week. After 2-4 weeks, two-step curative hepatectomy for HCC was successfully performed on 23 (52.3%) patients. There were no such severe complications as ectopic embolization, local hemorrhage and bile leakage.

CONCLUSION: Ultrasound-guided percutaneous transhepatic POSPVE with fine needles is feasible and safe. It can extend the indications of curative hepatectomy of HCC, and increase the safety of hepatectomy.

Evaluation of preoperative portal embolization for safe hepatectomy, with special reference to assessment of nonembolized lobe function with 99mTc-GSA SPECT scintigraphy

BACKGROUND

Preoperative portal embolization (PE) is used to stimulate liver hypertrophy in the nonembolized lobe. We studied liver volume and function with computed tomography and technetium-99m-galactosyl human serum albumin ((99m)Tc-GSA) scintigraphy before PE and at 1 or 2 weeks after PE.

METHODS

Right PE was performed in 30 patients. Morphologic and functional hypertrophy in the left lobe after PE was determined and related to the presence or absence of cholestasis, biliary drainage of the embolized lobe, and postoperative liver failure.

RESULTS

The volume of the left lobe and (99m)Tc-GSA uptake increased rapidly for the first week after PE, but no significant increase was seen during the second week. Morphologic hypertrophy was less pronounced in patients with jaundice (P =.03). When PE was performed at a total bilirubin level above 2 mg/dL, the interval between PE and surgery was prolonged because of cholangitis and liver abscess formation. The net morphologic hypertrophy ratio was significantly higher in livers that had undergone left lobe drainage only (9.1% +/- 0.9%) compared with those in which there was drainage of the embolized lobes (5.7% +/- 0.9%; P =.03). The volume and (99m)Tc-GSA uptake of the left lobe in the second week after PE was significantly smaller in patients with postoperative liver failure (33.7% +/- 2.4% and 18.0% +/- 2.1%, respectively) than in patients without liver failure (46.2% +/- 1.4% and 38.4% +/- 2.3%; P =.003 and P =.01, respectively).

CONCLUSION

In the nonembolized lobe, the functional increase in (99m)Tc-GSA uptake is more pronounced than suggested by the degree of morphologic hypertrophy. Whenever possible, biliary drainage should not be performed in the lobe undergoing hepatectomy. (99m)Tc-GSA SPECT scintigraphy is useful for the evaluation of postoperative liver failure.

[Portal vein embolization prior to hepatectomy. Techniques, indications and results]

Postoperative liver failure is a severe complication of major hepatectomies, in particular in patients with a chronic underlying liver disease. Preoperative interruption of the portal flow in the liver territories planned to be removed, induces their atrophy and the compensatory hypertrophy of the segments spared by the resection. This interruption can be induced by the surgical ligation of the portal branches or by the percutaneous intraportal injection, under ultrasound guidance, of glues or sclerosing agents. Preoperative portal vein embolisation is usually indicated when the remnant liver accounts for less than 25-40% of the total liver volume. Feasibility is close to 100% and the risk comparable to that of a percutaneous liver biopsy. It is well tolerated and the biological impact is minimal in patients without liver failure. Compensatory hypertrophy of the non-embolised segments is maximal during the first 2 weeks and persists, although to a lesser extent during approximately 6 weeks. The magnitude of hypertrophy is correlated with the volume of parenchyma embolised, and is reduced in diabetic or jaundiced patients or when there is an active chronic liver disease. Liver resection is performed 2 to 6 weeks after embolisation. Retrospective studies and one prospective study suggest that patients so prepared have a reduced perioperative risk and that their long term carcinologic results are not impaired.