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Girardet R, Knebel JF, Dromain C, Vietti Violi N, Tsoumakidou G, Villard N, Denys A, Halkic N, Demartines N, Kobayashi K, Digklia A, Schaefer N, Prior JO, Boughdad S, Duran R. Anatomical Quantitative Volumetric Evaluation of Liver Segments in Hepatocellular Carcinoma Patients Treated with Selective Internal Radiation Therapy: Key Parameters Influencing Untreated Liver Hypertrophy. Cancers (Basel) 2024; 16:586. [PMID: 38339337 PMCID: PMC10854872 DOI: 10.3390/cancers16030586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Revised: 01/22/2024] [Accepted: 01/25/2024] [Indexed: 02/12/2024] Open
Abstract
Background: Factors affecting morphological changes in the liver following selective internal radiation therapy (SIRT) are unclear, and the available literature focuses on non-anatomical volumetric assessment techniques in a lobar treatment setting. This study aimed to investigate quantitative changes in the liver post-SIRT using an anatomical volumetric approach in hepatocellular carcinoma (HCC) patients with different levels of treatment selectivity and evaluate the parameters affecting those changes. This retrospective, single-institution, IRB-approved study included 88 HCC patients. Whole liver, liver segments, tumor burden, and spleen volumes were quantified on MRI at baseline and 3/6/12 months post-SIRT using a segmentation-based 3D software relying on liver vascular anatomy. Treatment characteristics, longitudinal clinical/laboratory, and imaging data were analyzed. The Student's t-test and Wilcoxon test evaluated volumetric parameters evolution. Spearman correlation was used to assess the association between variables. Uni/multivariate analyses investigated factors influencing untreated liver volume (uLV) increase. Results: Most patients were cirrhotic (92%) men (86%) with Child-Pugh A (84%). Absolute and relative uLV kept increasing at 3/6/12 months post-SIRT vs. baseline (all, p ≤ 0.005) and was maximal during the first 6 months. Absolute uLV increase was greater in Child-Pugh A5/A6 vs. ≥B7 at 3 months (A5, p = 0.004; A6, p = 0.007) and 6 months (A5, p = 0.072; A6, p = 0.031) vs. baseline. When the Child-Pugh class worsened at 3 or 6 months post-SIRT, uLV did not change significantly, whereas it increased at 3/6/12 months vs. baseline (all p ≤ 0.015) when liver function remained stable. The Child-Pugh score was inversely correlated with absolute and relative uLV increase at 3 months (rho = -0.21, p = 0.047; rho = -0.229, p = 0.048). In multivariate analysis, uLV increase was influenced at 3 months by younger age (p = 0.013), administered 90Y activity (p = 0.003), and baseline spleen volume (p = 0.023). At 6 months, uLV increase was impacted by younger age (p = 0.006), whereas treatment with glass microspheres (vs. resin) demonstrated a clear trend towards better hypertrophy (f = 3.833, p = 0.058). The amount (percentage) of treated liver strongly impacted the relative uLV increase at 3/6/12 months (all f ≥ 8.407, p ≤ 0.01). Conclusion: Liver function (preserved baseline and stable post-SIRT) favored uLV hypertrophy. Younger patients, smaller baseline spleen volume, higher administered 90Y activity, and a larger amount of treated liver were associated with a higher degree of untreated liver hypertrophy. These factors should be considered in surgical candidates undergoing neoadjuvant SIRT.
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Affiliation(s)
- Raphaël Girardet
- Department of Radiology and Interventional Radiology, Lausanne University Hospital and Lausanne University, 1011 Lausanne, Switzerland; (R.G.); (J.-F.K.); (C.D.); (N.V.V.); (G.T.); (N.V.); (A.D.)
| | - Jean-François Knebel
- Department of Radiology and Interventional Radiology, Lausanne University Hospital and Lausanne University, 1011 Lausanne, Switzerland; (R.G.); (J.-F.K.); (C.D.); (N.V.V.); (G.T.); (N.V.); (A.D.)
| | - Clarisse Dromain
- Department of Radiology and Interventional Radiology, Lausanne University Hospital and Lausanne University, 1011 Lausanne, Switzerland; (R.G.); (J.-F.K.); (C.D.); (N.V.V.); (G.T.); (N.V.); (A.D.)
| | - Naik Vietti Violi
- Department of Radiology and Interventional Radiology, Lausanne University Hospital and Lausanne University, 1011 Lausanne, Switzerland; (R.G.); (J.-F.K.); (C.D.); (N.V.V.); (G.T.); (N.V.); (A.D.)
| | - Georgia Tsoumakidou
- Department of Radiology and Interventional Radiology, Lausanne University Hospital and Lausanne University, 1011 Lausanne, Switzerland; (R.G.); (J.-F.K.); (C.D.); (N.V.V.); (G.T.); (N.V.); (A.D.)
| | - Nicolas Villard
- Department of Radiology and Interventional Radiology, Lausanne University Hospital and Lausanne University, 1011 Lausanne, Switzerland; (R.G.); (J.-F.K.); (C.D.); (N.V.V.); (G.T.); (N.V.); (A.D.)
| | - Alban Denys
- Department of Radiology and Interventional Radiology, Lausanne University Hospital and Lausanne University, 1011 Lausanne, Switzerland; (R.G.); (J.-F.K.); (C.D.); (N.V.V.); (G.T.); (N.V.); (A.D.)
| | - Nermin Halkic
- Department of Visceral Surgery, Lausanne University Hospital and Lausanne University, 1011 Lausanne, Switzerland; (N.H.); (N.D.); (K.K.)
| | - Nicolas Demartines
- Department of Visceral Surgery, Lausanne University Hospital and Lausanne University, 1011 Lausanne, Switzerland; (N.H.); (N.D.); (K.K.)
| | - Kosuke Kobayashi
- Department of Visceral Surgery, Lausanne University Hospital and Lausanne University, 1011 Lausanne, Switzerland; (N.H.); (N.D.); (K.K.)
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo 135-8550, Japan
| | - Antonia Digklia
- Department of Medical Oncology, Lausanne University Hospital and Lausanne University, 1011 Lausanne, Switzerland;
| | - Niklaus Schaefer
- Department of Nuclear Medicine and Molecular Imaging, Lausanne University Hospital and Lausanne University, 1011 Lausanne, Switzerland; (N.S.); (J.O.P.); (S.B.)
| | - John O. Prior
- Department of Nuclear Medicine and Molecular Imaging, Lausanne University Hospital and Lausanne University, 1011 Lausanne, Switzerland; (N.S.); (J.O.P.); (S.B.)
| | - Sarah Boughdad
- Department of Nuclear Medicine and Molecular Imaging, Lausanne University Hospital and Lausanne University, 1011 Lausanne, Switzerland; (N.S.); (J.O.P.); (S.B.)
| | - Rafael Duran
- Department of Radiology and Interventional Radiology, Lausanne University Hospital and Lausanne University, 1011 Lausanne, Switzerland; (R.G.); (J.-F.K.); (C.D.); (N.V.V.); (G.T.); (N.V.); (A.D.)
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John N, Montorfano L, Nagarajan A, Simpfendorfer CH, Wexner SD, Amin P, Roy M. Liver Venous Deprivation for Rapid Liver Hypertrophy Before Major Hepatectomy: A Case Report. Am Surg 2023; 89:4944-4948. [PMID: 38050321 DOI: 10.1177/00031348221135787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/06/2023]
Abstract
Liver venous deprivation (LVD) is an emerging, minimally invasive strategy to induce rapid liver hypertrophy of the future liver remnant (FLR) before a major hepatectomy. LVD (aka "double vein embolization") entails same-session percutaneous embolization of the portal and hepatic veins of the planned liver resection. This report discusses LVD's utilization and technical challenges in managing a 49-year-old male with recurrent multifocal colorectal liver metastases (CRLM). The patient initially underwent neoadjuvant FOLFOX chemotherapy followed by a simultaneous laparoscopic sigmoid colectomy and liver surgery (microwave ablation of segment V and wedge resections of segment one and IVb), followed by completion of chemotherapy. The patient had an R0 resection with clear colon and liver surgical margins. Nine months after the initial surgery, the patient had a rise in tumor markers, and surveillance imaging demonstrated recurrence of liver metastases in segments I and V. LVD was performed by interventional radiology, which led to a 28% increase in FLR (segments II, III, and IV); initially measuring 464 cm3 before LVD and measuring 594 cm3 on post-procedure day 21. The patient underwent right hemi-hepatectomy and caudate resection on post-procedure day 29. The patient did not have any complications and was discharged on postoperative day 6. The patient remains disease-free with no evidence of recurrence at 12 months follow-up.
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Affiliation(s)
- Nathan John
- Department of General Surgery, Section of Hepatobiliary and Pancreatic Surgery, Digestive Disease Institute, Cleveland Clinic Florida, Weston, FL, USA
| | - Lisandro Montorfano
- Department of General Surgery, Section of Hepatobiliary and Pancreatic Surgery, Digestive Disease Institute, Cleveland Clinic Florida, Weston, FL, USA
| | - Arun Nagarajan
- Department of Hematology and Medical Oncology, Cleveland Clinic Florida, Weston, FL, USA
| | - Conrad H Simpfendorfer
- Department of General Surgery, Section of Hepatobiliary and Pancreatic Surgery, Digestive Disease Institute, Cleveland Clinic Florida, Weston, FL, USA
| | - Steven D Wexner
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic Florida, Weston, FL, USA
| | - Parag Amin
- Department of Imaging, Section of Interventional Radiology, Cleveland Clinic Florida, Weston, FL, USA
| | - Mayank Roy
- Department of General Surgery, Section of Hepatobiliary and Pancreatic Surgery, Digestive Disease Institute, Cleveland Clinic Florida, Weston, FL, USA
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Turk S, Plahuta I, Magdalenic T, Spanring T, Laufer K, Mavc Z, Potrc S, Ivanecz A. Two-stage hepatectomy in resection of colorectal liver metastases - a single-institution experience with case-control matching and review of the literature. Radiol Oncol 2023; 57:270-278. [PMID: 37341198 DOI: 10.2478/raon-2023-0026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2023] [Accepted: 05/15/2023] [Indexed: 06/22/2023] Open
Abstract
BACKGROUND Two-stage hepatectomy (TSH) has been proposed for patients with bilateral liver tumours who have a high risk of posthepatectomy liver failure after one-stage hepatectomy (OSH). This study aimed to determine the outcomes of TSH for extensive bilateral colorectal liver metastases. PATIENTS AND METHODS A retrospective review of a prospectively maintained database of liver resections for colorectal liver metastases was conducted. The TSH group was compared to the OSH group in terms of perioperative outcomes and survival. Case-control matching was performed. RESULTS A total of 632 consecutive liver resections for colorectal liver metastases were performed between 2000 and 2020. The study group (TSH group) consisted of 15 patients who completed TSH. The control group included 151 patients who underwent OSH. The case-control matching-OSH group consisted of 14 patients. The major morbidity and 90-day mortality rates were 40% and 13.3% in the TSH group, 20.5% and 4.6% in the OSH group and 28.6% and 7.1% in the case-control matching-OSH group, respectively. The recurrence-free survival, median overall survival, and 3- and 5-year survival rates were 5 months, 21 months, 33% and 13% in the TSH group; 11 months, 35 months, 49% and 27% in the OSH group; and 8 months, 23 months, 36% and 21%, respectively, in the case-control matching-OSH group, respectively. CONCLUSIONS TSH used to be a favourable therapeutic choice in a select population of patients. Now, OSH should be preferred whenever feasible because it has lower morbidity and equivalent oncological outcomes to those of completed TSH.
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Affiliation(s)
- Spela Turk
- Clinical Department of Abdominal and General Surgery, University Medical Centre Maribor, Maribor, Slovenia
- Department of Surgery, Faculty of Medicine, University of Maribor, Maribor, Slovenia
| | - Irena Plahuta
- Clinical Department of Abdominal and General Surgery, University Medical Centre Maribor, Maribor, Slovenia
- Department of Surgery, Faculty of Medicine, University of Maribor, Maribor, Slovenia
| | - Tomislav Magdalenic
- Clinical Department of Abdominal and General Surgery, University Medical Centre Maribor, Maribor, Slovenia
| | - Tajda Spanring
- Clinical Department of Abdominal and General Surgery, University Medical Centre Maribor, Maribor, Slovenia
- Department of Surgery, Faculty of Medicine, University of Maribor, Maribor, Slovenia
| | - Kevin Laufer
- Clinical Department of Abdominal and General Surgery, University Medical Centre Maribor, Maribor, Slovenia
- Department of Surgery, Faculty of Medicine, University of Maribor, Maribor, Slovenia
| | - Zan Mavc
- Clinical Department of Abdominal and General Surgery, University Medical Centre Maribor, Maribor, Slovenia
| | - Stojan Potrc
- Clinical Department of Abdominal and General Surgery, University Medical Centre Maribor, Maribor, Slovenia
- Department of Surgery, Faculty of Medicine, University of Maribor, Maribor, Slovenia
| | - Arpad Ivanecz
- Clinical Department of Abdominal and General Surgery, University Medical Centre Maribor, Maribor, Slovenia
- Department of Surgery, Faculty of Medicine, University of Maribor, Maribor, Slovenia
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Ning C, Liu G, Zhang J, Yang X, Xu Y, Zhao H. Case Report: The application of associating liver partition and portal vein ligation for staged hepatectomy in patients with hepatitis b virus-related hepatocellular carcinoma after undergoing treatment with an immune checkpoint inhibitor: a report of two cases. Front Immunol 2023; 14:1159885. [PMID: 37228608 PMCID: PMC10203512 DOI: 10.3389/fimmu.2023.1159885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 04/19/2023] [Indexed: 05/27/2023] Open
Abstract
Hepatocellular carcinoma (HCC) is often diagnosed at an unresectable stage without opportunities for curative therapy. Future liver remnant (FLR) insufficiency limits the range of patients who can undergo radical resection. Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) can ultimately achieve short-term hypertrophy of the FLR in patients with viral hepatitis-related fibrosis/cirrhosis and R0 resection. However, the influence of immune checkpoint inhibitors (ICIs) on liver regeneration remains unknown. We report two patients diagnosed with Barcelona Clinic Liver Cancer (BCLC)-B stage hepatitis B virus (HBV)-related HCC who underwent pioneering ALPPS after immunotherapy without posthepatectomy liver failure (PHLF). ALPPS has been shown to be safe and feasible in patients with HCC who underwent immunotherapy previously for the first time and might provide an alternative salvage option for future conversion therapy of HCC.
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Affiliation(s)
- Cong Ning
- Department of Liver Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College (CAMS and PUMC), Beijing, China
| | - Guanmo Liu
- Department of Breast Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College (CAMS and PUMC), Beijing, China
| | - Junwei Zhang
- Department of Liver Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College (CAMS and PUMC), Beijing, China
| | - Xiaobo Yang
- Department of Liver Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College (CAMS and PUMC), Beijing, China
| | - Yiyao Xu
- Department of Liver Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College (CAMS and PUMC), Beijing, China
| | - Haitao Zhao
- Department of Liver Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College (CAMS and PUMC), Beijing, China
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Bozkurt E, Sijberden JP, Abu Hilal M. Safety and Feasibility of Laparoscopic Right or Extended Right Hemi Hepatectomy Following Modulation of the Future Liver Remnant in Patients with Colorectal Liver Metastases: A Systematic Review. J Laparoendosc Adv Surg Tech A 2023. [PMID: 37015071 DOI: 10.1089/lap.2022.0609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/06/2023] Open
Abstract
Background: Major hepatectomies after future liver remnant (FLR) modulation are technically demanding procedures, especially when performed as minimally invasive surgery. The aim of this systematic review is to assess current evidence regarding the safety and feasibility of laparoscopic right or extended right hemihepatectomies after FLR modulation. Materials and Methods: The Medline, PubMed, Cochrane Library, and Embase databases were searched for studies involving laparoscopic right or extended right hemihepatectomies after FLR modulation, from their inception to December 2021. Two reviewers independently selected eligible articles and assessed their quality using the Newcastle-Ottawa Quality Assessment Scale (NOS). Baseline characteristics and outcomes were extracted from the included studies and summarized. Results: Six studies were included. In these studies, the median length of stay after the second stage ranged from 4.5 to 15.5 days and postoperative complication rates between 4.5% and 42.8%. Overall, 7.4% of patients developed liver failure, and 90-day mortality occurred in 3.2% of patients. The R0 resection rate was 93.5%. Only one study reported long-term outcomes, describing comparable 3-year overall survival rates following laparoscopic and open surgery (80% versus 54%, P = .154). Conclusions: The current evidence is scarce, but it suggests that in experienced centers, laparoscopic right or extended right hemihepatectomy, following FLR modulation, is a safe and feasible procedure.
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Affiliation(s)
- Emre Bozkurt
- Department of Surgery, Poliambulanza Foundation Hospital, Brescia, Italy
- Hepatopancreatobiliary Surgery Division, Department of Surgery, Koç University Hospital, Istanbul, Turkey
| | - Jasper P Sijberden
- Department of Surgery, Poliambulanza Foundation Hospital, Brescia, Italy
- Department of Surgery, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Mohammad Abu Hilal
- Department of Surgery, Poliambulanza Foundation Hospital, Brescia, Italy
- Department of Surgery, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
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Yamamura K, Beppu T. Makuuchi's criteria for liver resection in the modern era of functional liver remnant volume evaluation. Hepatol Res 2023; 53:91-92. [PMID: 36735243 DOI: 10.1111/hepr.13872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Affiliation(s)
- Kensuke Yamamura
- Department of Surgery, Yamaga City Medical Center, Kumamoto, Japan
| | - Toru Beppu
- Department of Surgery, Yamaga City Medical Center, Kumamoto, Japan
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Charles J, Nezami N, Loya M, Shube S, Davis C, Hoots G, Shaikh J. Portal Vein Embolization: Rationale, Techniques, and Outcomes to Maximize Remnant Liver Hypertrophy with a Focus on Contemporary Strategies. Life (Basel) 2023; 13. [PMID: 36836638 DOI: 10.3390/life13020279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 01/11/2023] [Accepted: 01/17/2023] [Indexed: 01/20/2023] Open
Abstract
Hepatectomy remains the gold standard for curative therapy for patients with limited primary or metastatic hepatic tumors as it offers the best survival rates. In recent years, the indication for partial hepatectomy has evolved away from what will be removed from the patient to the volume and function of the future liver remnant (FLR), i.e., what will remain. With this regard, liver regeneration strategies have become paramount in transforming patients who previously had poor prognoses into ones who, after major hepatic resection with negative margins, have had their risk of post-hepatectomy liver failure minimized. Preoperative portal vein embolization (PVE) via the purposeful occlusion of select portal vein branches to promote contralateral hepatic lobar hypertrophy has become the accepted standard for liver regeneration. Advances in embolic materials, selection of treatment approaches, and PVE with hepatic venous deprivation or concurrent transcatheter arterial embolization/radioembolization are all active areas of research. To date, the optimal combination of embolic material to maximize FLR growth is not yet known. Knowledge of hepatic segmentation and portal venous anatomy is essential before performing PVE. In addition, the indications for PVE, the methods for assessing hepatic lobar hypertrophy, and the possible complications of PVE need to be fully understood before undertaking the procedure. The goal of this article is to discuss the rationale, indications, techniques, and outcomes of PVE before major hepatectomy.
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Hu Q, Zeng Z, Zhang Y, Fan X. Study of ultrasound-guided percutaneous microwave ablation combined with portal vein embolization for rapid future liver remnant increase of planned hepatectomy. Front Oncol 2023; 12:926810. [PMID: 36686725 PMCID: PMC9846746 DOI: 10.3389/fonc.2022.926810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2022] [Accepted: 12/07/2022] [Indexed: 01/05/2023] Open
Abstract
Purpose To evaluate the efficacy of ultrasound-guided percutaneous microwave ablation (PMA) combined with portal vein embolization (PVE) for planned hepatectomy. Methods We retrospectively reviewed data of 18 patients with multiple right liver tumors or hilar tumor of liver invades the surrounding tissue and insufficient future liver remnant (FLR) for hepatectomy from July 2015 to March 2017. Ultrasound-guided PMA was performed by using PMCT cold circulation microwave treatment apparatus. PVE was performed after PMA. The increase of FLR was evaluated by computed tomography (CT) 6-22 days after PVE. The proportion of FLR, increase in the amplitude of FLR, procedure-related complications, perioperative morbidity and mortality, and overall survival (OS) rates, the median survival time were analyzed. Results The median volume of FLR before PMA and PVE was 369.7 ml (range: 239.4-493.1 ml). After a median waiting period of 11.5 days (range: 6-22 days), the median volume of FLR was increased to 523.4 ml (range: 355.4-833.3 ml). The changes in FLR before and after PMA and PVE were statistically significant (p<0.001). No serious perioperative complications or mortality were found. After a median follow-up time of 51.0 months (range: 2-54 months), the 6-month, 1-year, 2-year, 3-year and 4-year survival rates were 88.9%, 72.2%, 44.4%, 33.3%, 22.2%, respectively, and the median survival time was 15.0 ± 7.1 months. Conclusion PMA combined with PVE increases FLR rapidly, avoids touching malignant tumors, and produces fewer procedure-related complications. It appears safe and efficacious for planned hepatectomy.
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Affiliation(s)
- Qiaohong Hu
- Cancer Center, Department of Ultrasound Medicine, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Zeng Zeng
- Cancer Center, Department of Ultrasound Medicine, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Yuanbiao Zhang
- Department of Hepatobiliary and Pancreatic Surgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Xiaoming Fan
- Cancer Center, Department of Ultrasound Medicine, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, China,*Correspondence: Xiaoming Fan,
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Bell R, Begum S, Prasad R, Taura K, Dasari BVM. Volume and flow modulation strategies to mitigate post-hepatectomy liver failure. Front Oncol 2022; 12:1021018. [PMID: 36465356 PMCID: PMC9714434 DOI: 10.3389/fonc.2022.1021018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 10/20/2022] [Indexed: 07/21/2023] Open
Abstract
INTRODUCTION Post hepatectomy liver failure is the most common cause of death following major hepatic resections with a perioperative mortality rate between 40% to 60%. Various strategies have been devised to increase the volume and function of future liver remnant (FLR). This study aims to review the strategies used for volume and flow modulation to reduce the incidence of post hepatectomy liver failure. METHOD An electronic search was performed of the MEDLINE, EMBASE and PubMed databases from 2000 to 2022 using the following search strategy "Post hepatectomy liver failure", "flow modulation", "small for size flow syndrome", "portal vein embolization", "dual vein embolization", "ALPPS" and "staged hepatectomy" to identify all articles published relating to this topic. RESULTS Volume and flow modulation strategies have evolved over time to maximize the volume and function of FLR to mitigate the risk of PHLF. Portal vein with or without hepatic vein embolization/ligation, ALPPS, and staged hepatectomy have resulted in significant hypertrophy and kinetic growth of FLR. Similarly, techniques including portal flow diversion, splenic artery ligation, splenectomy and pharmacological agents like somatostatin and terlipressin are employed to reduce the risk of small for size flow syndrome SFSF syndrome by decreasing portal venous flow and increasing hepatic artery flow at the same time. CONCLUSION The current review outlines the various strategies of volume and flow modulation that can be used in isolation or combination in the management of patients at risk of PHLF.
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Affiliation(s)
- Richard Bell
- Department of Hepatobiliary and Transplant Surgery, St. James’s University Hospital, Leeds, United Kingdom
| | - Saleema Begum
- Department of Hepatobiliary and Pancreatic (HPB) and Transplant Surgery, University Hospital Birmingham, Birmingham, United Kingdom
| | - Raj Prasad
- Department of Hepatobiliary and Transplant Surgery, St. James’s University Hospital, Leeds, United Kingdom
| | - Kojiro Taura
- Division of Hepatobiliary and Pancreatic (HPB) Surgery and Transplantation, Department of Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Bobby V. M. Dasari
- Department of Hepatobiliary and Pancreatic (HPB) and Transplant Surgery, University Hospital Birmingham, Birmingham, United Kingdom
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom
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Botea F, Barcu A, Croitoru A, Tomescu D, Lupescu I, Dumitru R, Herlea V, Verdea C, Becker T, Popescu I, Linecker M. Parenchyma Sparing ALPPS Ultrasound Guided Partition Through Segment 4 to Maximize Resectability (with video). Chirurgia (Bucur) 2022; 117:81-93. [PMID: 34915689 DOI: 10.21614/chirurgia.2652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/01/2022] [Indexed: 11/23/2022]
Abstract
Background Associating liver partition and portal vein ligation (ALPPS) has evolved as a treatment strategy for patients with liver tumors who are not amenable for upfront hepatectomy because of an insufficient future liver remnant (FLR). Aim of this study was to test the applicability of ultrasound guided parenchyma sparing surgery to ALPPS concept, by non-anatomically shifting the plane of transection in favor of FLR, resulting in a new technical variant of ALPPS, entitled parenchyma sparing ALPPS (psALPPS). Materials and Methods Patients who could not safely undergo right trisectionectomy ALPPS because of insufficient FLR were considered eligible for psALPPS, consisting in liver partition through segment 4 using ultrasound guidance. Results Between April 2017 and April 2021, five patients with median age of 68 years (range: 66-78), four male and one female, underwent psALPPS for colorectal liver metastases (N=2), intrahepatic cholangiocarcinoma (N=2), and hepatocellular carcinoma (N=1). Standardized FLR (sFLR) for segments 2-3 before stage 1 surgery would have been a median of 11.6%. PsALPPS could double the sFLR at stage 1 resulting in an increase of ps-sFLR from a median of 22.7% (at stage 1) to 34.0% (at stage 2) after a median interstage interval of 15 days. All patients tolerated surgery well and no major complications were recorded. Conclusions Applying the principles of parenchyma sparing surgery to ALPPS offers the advantage to maximize FLR and simultaneously reduce ischemic injury of segment 4 compared to conventional ALPPS. In this way, psALPPS may markedly increase resectability while reducing morbidity. Video https://www.revistachirurgia.ro/pdfs/?EntryID=922974&art=2021-parenchyma-sparing-ALPPS-ultrasound-guided-partition.pdf
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Gutiérrez Sáenz de Santa María J, Herrero de la Parte B, Gutiérrez-Sánchez G, Ruiz Montesinos I, Iturrizaga Correcher S, Mar Medina C, García-Alonso I. Folinic Acid Potentiates the Liver Regeneration Process after Selective Portal Vein Ligation in Rats. Cancers (Basel) 2022; 14:cancers14020371. [PMID: 35053534 PMCID: PMC8773925 DOI: 10.3390/cancers14020371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 12/30/2021] [Accepted: 01/07/2022] [Indexed: 11/25/2022] Open
Abstract
Simple Summary Fewer than 30% of patients with liver metastases are eligible for major liver resection, because liver remaining after such a surgery would be insufficient to cover the patient’s needs; this is called a low percentage of future liver remnant (FLR). Folinic acid (FA) has been shown to play a crucial role in cellular synthesis, regeneration, and nucleotide and amino acid biosynthesis. The aim of this piece of research was to evaluate the effect of FA as a potential hypertrophic hepatic enhancer agent after selective portal vein ligation (PVL) to ensure adequate FLR. We have confirmed in our rodent model that FA accelerates liver regeneration after PVL and enhances recovery of liver function. These findings may allow more patients to be eligible for liver resection without jeopardizing postoperative liver function. Abstract Liver resection remains the gold standard for hepatic metastases. The future liver remnant (FLR) and its functional status are two key points to consider before performing major liver resections, since patients with less than 25% FLR or a Child–Pugh B or C grade are not eligible for this procedure. Folinic acid (FA) is an essential agent in cell replication processes. Herein, we analyze the effect of FA as an enhancer of liver regeneration after selective portal vein ligation (PVL). Sixty-four male WAG/RijHsd rats were randomly distributed into eight groups: a control group and seven subjected to 50% PVL, by ligation of left portal branch. The treated animals received FA (2.5 m/kg), while the rest were given saline. After 36 h, 3 days or 7 days, liver tissue and blood samples were obtained. FA slightly but significantly increased FLR percentage (FLR%) on the 7th day (91.88 ± 0.61%) compared to control or saline-treated groups (86.72 ± 2.5 vs. 87 ± 3.33%; p < 0.01). The hepatocyte nuclear area was also increased both at 36 h and 7days with FA (61.55 ± 16.09 µm2, and 49.91 ± 15.38 µm2; p < 0.001). Finally, FA also improved liver function. In conclusion, FA has boosted liver regeneration assessed by FLR%, nuclear area size and restoration of liver function after PVL.
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Affiliation(s)
| | - Borja Herrero de la Parte
- Department of Surgery and Radiology and Physical Medicine, Faculty of Medicine and Nursing, University of the Basque Country UPV/EHU, ES48940 Leioa, Spain;
- Interventional Radiology Research Group, Biocruces Bizkaia Health Research Institute, ES48903 Barakaldo, Spain
- Correspondence: (B.H.d.l.P.); (I.R.M.)
| | - Gaizka Gutiérrez-Sánchez
- Department of Anesthesiology, Santa Creu i Sant Pau University Hospital, ES08025 Barcelona, Spain;
| | - Inmaculada Ruiz Montesinos
- Department of Surgery and Radiology and Physical Medicine, Faculty of Medicine and Nursing, University of the Basque Country UPV/EHU, ES48940 Leioa, Spain;
- Department of Gastrointestinal Surgery, Donostia University Hospital, ES20014 Donostia, Spain
- Correspondence: (B.H.d.l.P.); (I.R.M.)
| | - Sira Iturrizaga Correcher
- Department of Clinical Analyses, Galdakao-Usansolo Hospital, ES48960 Galdakao, Spain; (S.I.C.); (C.M.M.)
| | - Carmen Mar Medina
- Department of Clinical Analyses, Galdakao-Usansolo Hospital, ES48960 Galdakao, Spain; (S.I.C.); (C.M.M.)
| | - Ignacio García-Alonso
- Department of Surgery and Radiology and Physical Medicine, Faculty of Medicine and Nursing, University of the Basque Country UPV/EHU, ES48940 Leioa, Spain;
- Interventional Radiology Research Group, Biocruces Bizkaia Health Research Institute, ES48903 Barakaldo, Spain
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12
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Akhaladze DG, Rabaev GS, Likar YN, Kireeva ED, Kachanov DY, Tereshchenko GV, Uskova NG, Merkulov NN, Semin KS, Tverdov IV, Grachev NS. [Analysis of future liver remnant parameters in children after extended liver resection]. Khirurgiia (Mosk) 2021:27-33. [PMID: 34941206 DOI: 10.17116/hirurgia202112127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To analyze the initial data on future liver remnant volume and its function evaluated by 99mTc-Bromesida hepatobiliary scintigraphy in children with liver tumors. MATERIAL AND METHODS Extended liver resections were performed in 58 patients aged 2 months - 208 months (median 26 months) for various neoplasms. Before hepatectomy, all children underwent contrast-enhanced CT with volumetry and hepatobiliary scintigraphy with 99mTc-Bromezida and subsequent quantitative assessment of its accumulation in the future liver remnant. All consecutive patients eligible for extended liver resection were retrospectively analyzed. RESULTS The analysis included patients who underwent extended liver resection between June 2017 and March 2021. Among 91 liver resections, 58 (64%) procedures were extended hepatectomies including 2 ALPPS procedures. Median volume of future liver remnant was 44.5% (16.5-91.4), median future liver remnant function - 10.14%/min/m2 (1.8-30). Four patients with adequate liver function had insufficient volume of future liver remnant. Insufficient future liver remnant volume and its appropriate function were observed in 2 patients. Not life-threatening post-resection liver failure developed in 2 patients. CONCLUSION Evaluation of future liver remnant function is the most sensitive method to predict post-hepatectomy liver failure in children. The cut off value of future liver remnant volume in children is below 25% and probably below 16.5%. Further data collection and research are warranted to determine significant values. These data will contribute to define the new indications for two-staged hepatectomies in children.
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Affiliation(s)
- D G Akhaladze
- Dmitry Rogachev National Medical Research Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - G S Rabaev
- Dmitry Rogachev National Medical Research Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - Yu N Likar
- Dmitry Rogachev National Medical Research Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - E D Kireeva
- Dmitry Rogachev National Medical Research Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - D Yu Kachanov
- Dmitry Rogachev National Medical Research Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - G V Tereshchenko
- Dmitry Rogachev National Medical Research Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - N G Uskova
- Dmitry Rogachev National Medical Research Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - N N Merkulov
- Dmitry Rogachev National Medical Research Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - K S Semin
- Dmitry Rogachev National Medical Research Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - I V Tverdov
- Dmitry Rogachev National Medical Research Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - N S Grachev
- Dmitry Rogachev National Medical Research Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
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13
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Entezari P, Gabr A, Kennedy K, Salem R, Lewandowski RJ. Radiation Lobectomy: An Overview of Concept and Applications, Technical Considerations, Outcomes. Semin Intervent Radiol 2021; 38:419-424. [PMID: 34629708 DOI: 10.1055/s-0041-1735530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Surgical resection has long been considered curative for patients with early-stage hepatocellular carcinoma (HCC). However, inadequate future liver remnant (FLR) renders many patients not amenable to surgery. Recently, lobar administration of yttrium-90 (Y90) radioembolization has been utilized to induce FLR hypertrophy while providing disease control, eventually facilitating resection in patients with hepatic malignancy. This has been termed "radiation lobectomy (RL)." The concept is evolving, with modified approaches combining RL and high-dose curative-intent radioembolization (radiation segmentectomy) to achieve tumor ablation. This article provides an overview of the concept and applications of RL, including technical considerations and outcomes in patients with hepatic malignancies.
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Affiliation(s)
- Pouya Entezari
- Section of Interventional Radiology, Department of Radiology, Northwestern Memorial Hospital, Chicago, Illinois
| | - Ahmed Gabr
- Section of Interventional Radiology, Department of Radiology, Northwestern Memorial Hospital, Chicago, Illinois
| | - Kristie Kennedy
- Section of Interventional Radiology, Department of Radiology, Northwestern Memorial Hospital, Chicago, Illinois
| | - Riad Salem
- Section of Interventional Radiology, Department of Radiology, Northwestern Memorial Hospital, Chicago, Illinois.,Division of Transplantation, Department of Surgery, Comprehensive Transplant Center, Northwestern University, Chicago, Illinois
| | - Robert J Lewandowski
- Section of Interventional Radiology, Department of Radiology, Northwestern Memorial Hospital, Chicago, Illinois.,Division of Transplantation, Department of Surgery, Comprehensive Transplant Center, Northwestern University, Chicago, Illinois
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14
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Yu T, Ye X, Wen Z, Zhu G, Su H, Han C, Huang K, Qin W, Liao X, Yang C, Liu Z, Wang X, Xu B, Su M, Lv Z, Lau WY, Peng T. Intraoperative Indocyanine Green Retention Test of Left Hemiliver in Decision-Making for Patients With Hepatocellular Carcinoma Undergoing Right Hepatectomy. Front Surg 2021; 8:709017. [PMID: 34604294 PMCID: PMC8484520 DOI: 10.3389/fsurg.2021.709017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Accepted: 07/07/2021] [Indexed: 11/13/2022] Open
Abstract
Introduction: The aim of this study was to select qualified patients with hepatocellular carcinoma (HCC) who underwent right hepatectomy (RH) via intraoperative indocyanine green retention test at 15 min (ICG-R15) of the left hemiliver, which prevents severe posthepatectomy liver failure (PHLF). Methods: Twenty HCC patients who were preoperatively planned to undergo RH were enrolled. Intraoperative ICG-R15 of left hemiliver was measured after the right Glissonean pedicle was completely blocked. Patients then underwent RH if intraoperative ICG-R15 was ≤ 10%. Otherwise, patients underwent staged RH (SRH), either associating liver partitioning and portal vein ligation for staged hepatectomy (ALPPS) or portal vein ligation (PVL), followed by stage-2 RH. The comparison group consisted of patients with a ratio of standard left liver volume (SLLV) of > 40% and preoperative ICG-R15 ≤ 10% who underwent RH. The clinical outcomes of these two groups were compared. Results: Of the 20 patients, six underwent stage-1 RH, six underwent ALPPS, five underwent PVL followed by stage-2 RH, and three failed to proceed to stage-2 RH after PVL. No significant differences were found among the 17 patients who underwent stage-1 or stage-2 RH in the study group, the 19 patients in the comparison group, the 11 patients in the stage-2 RH group, and the six patients in the stage-1 RH group in incidences of PHLF, postoperative complications, hospital stay, and HCC recurrence within 1 year after RH. Compared with the stage-1 ALPPS group, the mean operative time and blood loss of the stage-1 PVL group were significantly less (p <0.001 and p = 0.022, respectively). The stage-1 PVL group had a significantly longer waiting-time (43.4 vs. 14.0 days, p = 0.016) than the stage-1 ALPPS group to proceed to stage-2 RH. After stage-2 RH, tumor recurrence within 1 year was 20% (1/5) in patients after PVL and 50% (3/6) after stage-1 ALPPS. Conclusions: Intraoperative ICG-R15 ≤ 10% of left hemiliver was valuable in intraoperative decision-making for patients who were planned to undergo RH. There is a possibility that stage-1 PVL might help to select patients with more favorable biological behavior to undergo stage-2 RH.
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Affiliation(s)
- Tingdong Yu
- Department of Hepatobiliary Surgery, the First Affiliated Hospital of Guangxi Medical University, Nanning, China.,Department of Hepatobiliary Surgery, the Third Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Xinping Ye
- Department of Hepatobiliary Surgery, the First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Zhang Wen
- Department of Hepatobiliary Surgery, the First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Guangzhi Zhu
- Department of Hepatobiliary Surgery, the First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Hao Su
- Department of Hepatobiliary Surgery, the First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Chuangye Han
- Department of Hepatobiliary Surgery, the First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Ketuan Huang
- Department of Hepatobiliary Surgery, the First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Wei Qin
- Department of Hepatobiliary Surgery, the First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Xiwen Liao
- Department of Hepatobiliary Surgery, the First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Chengkun Yang
- Department of Hepatobiliary Surgery, the First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Zhen Liu
- Department of Hepatobiliary Surgery, the First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Xiangkun Wang
- Department of Hepatobiliary Surgery, the First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Banghao Xu
- Department of Hepatobiliary Surgery, the First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Ming Su
- Department of Hepatobiliary Surgery, the First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Zili Lv
- Department of Pathology, the First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Wan Yee Lau
- Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
| | - Tao Peng
- Department of Hepatobiliary Surgery, the First Affiliated Hospital of Guangxi Medical University, Nanning, China
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15
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Nozawa Y, Ashida H, Michimoto K, Kisaki S, Kano R, Ojiri H, Ikegami T. Efficacy of Portal Vein Embolization with a Procedure of Sheath Injection and Balloon Occlusion with Gelatin Sponge. J Belg Soc Radiol 2021; 105:42. [PMID: 34568747 DOI: 10.5334/jbsr.2485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 08/10/2021] [Indexed: 11/20/2022] Open
Abstract
Introduction: To evaluate the efficacy, safety, and associated complications of a novel and simple approach to portal vein embolization that utilizes sheath injection and balloon occlusion (PVE-SIBO) with gelatin sponge (GS) for the purpose of increasing future liver remnant (FLR) volume. Methods: Between 1 January, 2006, and 31 August, 2020, 20 patients (15 men, 5 women, aged 64.6 ± 10.2 years) diagnosed with hepatobiliary malignancy underwent presurgical PVE-SIBO at our institution via a percutaneous transhepatic approach to the right portal vein and embolization of the portal vein with GS. We evaluated the increased ratio of FLR volume, operation duration, recanalization rate, and complications following this procedure. Results: All procedures were successful and without complications such as subcapsular hematoma, intra-abdominal bleeding, and bile leakage. The increased ratio of FLR volume was 34.7 ± 23.7% after a mean of 14.3 ± 2.57 days, and there was a significant difference in the FLR volume before and after PVE (P < 0.01). Procedure time was 52.7 ± 11.4 minutes. Conclusion: PVE-SIBO with GS is a simple, effective, and safe procedure to increase the ratio of FLR volume prior to hepatic surgeries.
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Moreno Berggren M, Isaksson B, Nyman R, Ebeling Barbier C. Portal vein embolization with n-butyl-cyanoacrylate before hepatectomy: a single-center retrospective analysis of 46 consecutive patients. Acta Radiol 2021; 62:1170-1177. [PMID: 32938223 DOI: 10.1177/0284185120953802] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Preoperative portal vein embolization (PVE) is performed to induce hypertrophy of the future liver remnant enabling major liver resection in patients with various types of liver tumors. PURPOSE To evaluate safety and effectiveness of PVE with n-butyl-cyanoacrylate (NBCA). MATERIAL AND METHODS All consecutive patients referred to our hospital for PVE between July 2006 and July 2017 were retrospectively reviewed. Volumetry was performed on computed tomography images before and after PVE, segmenting the total liver volume and the future liver remnant (FLR), i.e. liver segments I-III. RESULTS PVE was performed in 46 patients (18 women, 28 men; mean age = 61 years) using local anesthesia. The ipsilateral technique was used in 45 patients. Adverse events were rare. The mean FLR volume increase was 56%, the degree of hypertrophy was 9.7%, and the kinetic growth rate was 2.1%/week. The median ± SD period between PVE and liver surgery was 7 ± 3 weeks. Forty-two patients (91%) had surgery; liver resection was performed in 37 (80%) patients. Three patients (7%) developed transient liver failure after surgery. There was no 90-day post-PVE or postoperative mortality. CONCLUSION PVE using NBCA through the ipsilateral approach in local anesthesia is safe and effective in inducing hypertrophy of the future liver remnant enabling surgery, and thereby increasing survival in patients with liver tumors.
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Affiliation(s)
- Marijela Moreno Berggren
- Department of Surgical Sciences, Section of Radiology, Uppsala University Hospital, Uppsala, Sweden
| | - Bengt Isaksson
- Department of Surgical Sciences, Section of Surgery, Uppsala University Hospital, Uppsala, Sweden
| | - Rickard Nyman
- Department of Surgical Sciences, Section of Radiology, Uppsala University Hospital, Uppsala, Sweden
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17
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Idrees M, Zhang L, Al-Ogaili Z, Yau HCV, Zhu S, Jaques B, Foo J, Mou L. Umbilical fissure vein, anatomical variation and potential surgical application. ANZ J Surg 2021; 91:E479-E483. [PMID: 34031976 DOI: 10.1111/ans.16963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 05/02/2021] [Accepted: 05/03/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND The umbilical fissure vein (UFV) is a hepatic vein that travels within the umbilical fissure (or its proximity), providing venous drainage for hepatic segments 3 and 4. Its preservation carries a potential importance in extended right hemi-hepatectomy, left lateral segmentectomy and extended segment 2 resections. METHODS Consecutive 1-mm slice thickness portovenous phase intravenous contrast computed tomography (CT) scans of the abdomen performed were retrospectively reviewed during the period of June 2019 to July 2019, with two independent investigators investigating the presence of UFV, its course, insertion and relation to the umbilical fissure. RESULTS A total of 244 CTs were identified and 186 included. The UFV was identified on 72.8% of participants, 109 (81.4%) drained into the main left hepatic vein, while the remaining ones drained either from the main middle hepatic vein (16.4%) or the bifurcation between main left and middle hepatic vein (2.2%). The veins course lay 2 mm or less along the length of umbilical fissure in 39.5%, while 57.5% ran within 1 cm along the length of the umbilical fissure. CONCLUSION Pre-operative identification of UFV could assist in operative planning. The vein can be used as a landmark in surgery and should be preserved in left lateral segmentectomy and extended right hepatectomy to avoid parenchymal congestion of remnant segments.
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Affiliation(s)
- Marwan Idrees
- WA Liver and Kidney Transplant Unit, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Leon Zhang
- Department of Radiology, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Zeyad Al-Ogaili
- Department of Molecular Imaging and Therapy, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - Ho-Cing V Yau
- WA Liver and Kidney Transplant Unit, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Shaun Zhu
- Faculty of Health and Medical Sciences, University of Western Australia, Perth, Western Australia, Australia
| | - Bryon Jaques
- WA Liver and Kidney Transplant Unit, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Jonathan Foo
- Faculty of Health and Medical Sciences, University of Western Australia, Perth, Western Australia, Australia
| | - Lingjun Mou
- WA Liver and Kidney Transplant Unit, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
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Matsuki R, Momose H, Kogure M, Suzuki Y, Sakamoto Y. Bisegmentectomy and venous reconstruction after portal vein embolization for the remnant hemiliver in a patient with recurrent colorectal liver metastases. Ann Gastroenterol Surg 2021; 5:259-264. [PMID: 33860147 PMCID: PMC8034697 DOI: 10.1002/ags3.12393] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 08/01/2020] [Accepted: 08/06/2020] [Indexed: 12/02/2022] Open
Abstract
Repeat hepatectomy for recurrent colorectal liver metastases (CRLM) for the remnant hemiliver is sometimes challenging due to the insufficient future liver remnant (FLR) volume. We present an aggressive strategy for resection of the recurrent CRLM involving bisegmentectomy of the remnant right hemiliver with the aid of portal vein embolization (PVE) and venous reconstruction. The patient was a 50-year-old woman who had undergone left hemihepatectomy for a CRLM 10 months ago. Three metastatic tumors were found in the remnant segments 7 and 8 (S7&8) of the liver, and one of them involved the right hepatic vein (RHV). Conducting bisegmentectomy of S7&8 with resection of the RHV, the non-congestive FLR volume was calculated as 34.9% of the remnant total liver volume, which was deemed insufficient considering the mild liver damage after repeated chemotherapy. After trans-ileocecal PVE of the portal branches in S7&8 in a hybrid angio room, the non-congestive FLR volume increased to 42.3%, which could be further advanced to 58.0% if the RHV was reconstructed. Segmentectomies of S7&8 with resection and reconstruction of the RHV using the right superficial femoral vein graft was performed. The patient was discharged without any complications, and the postoperative computed tomography (CT) scan showed the good patency of the reconstructed venous graft. Aggressive segmentectomies and venous reconstruction of the remnant hemiliver after PVE might be a new strategy to overcome the insufficient FLR volume.
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Affiliation(s)
- Ryota Matsuki
- Department of Hepato‐Biliary‐Pancreatic SurgeryKyorin University HospitalMitakaJapan
| | - Hirokazu Momose
- Department of Hepato‐Biliary‐Pancreatic SurgeryKyorin University HospitalMitakaJapan
| | - Masaharu Kogure
- Department of Hepato‐Biliary‐Pancreatic SurgeryKyorin University HospitalMitakaJapan
| | - Yutaka Suzuki
- Department of Hepato‐Biliary‐Pancreatic SurgeryKyorin University HospitalMitakaJapan
| | - Yoshihiro Sakamoto
- Department of Hepato‐Biliary‐Pancreatic SurgeryKyorin University HospitalMitakaJapan
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Li K, Jiang F, Aizpuru M, Larson EL, Xie X, Zhou R, Xiang B. Successful management and technical aspects of major liver resection in children: A retrospective cohort study. Medicine (Baltimore) 2021; 100:e24420. [PMID: 33578534 PMCID: PMC7886405 DOI: 10.1097/md.0000000000024420] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Accepted: 01/03/2021] [Indexed: 02/05/2023] Open
Abstract
Optimal treatment of patients with various types of liver tumors or certain liver diseases frequently demands major liver resection, which remains a clinical challenge especially in children.Eighty seven consecutive pediatric liver resections including 51 (59%) major resections (resection of 3 or more hepatic segments) and 36 (41%) minor resections (resection of 1 or 2 segments) were analyzed. All patients were treated between January 2010 and March 2018. Perioperative outcomes were compared between major and minor hepatic resections.The male to female ratio was 1.72:1. The median age at operation was 20 months (range, 0.33-150 months). There was no significant difference in demographics including age, weight, ASA class, and underlying pathology. The surgical management included functional assessment of the future liver remnant, critical perioperative management, enhanced understanding of hepatic segmental anatomy, and bleeding control, as well as refined surgical techniques. The median estimated blood loss was 40 ml in the minor liver resection group, and 90 ml in major liver resection group (P < .001). Children undergoing major liver resection had a significantly longer median operative time (80 vs 140 minutes), anesthesia time (140 vs 205 minutes), as well as higher median intraoperative total fluid input (255 vs 450 ml) (P < .001 for all). Fourteen (16.1%) patients had postoperative complications. By Clavien-Dindo classification, there were 8 grade I, 4 grade II, and 2 grade III-a complications. There were no significant differences in complication rates between groups (P = .902). Time to clear liquid diet (P = .381) and general diet (P = .473) was not significantly different. There was no difference in hospital length of stay (7 vs 7 days, P = .450). There were no 90-day readmissions or mortalities.Major liver resection in children is not associated with an increased incidence of postoperative complications or prolonged postoperative hospital stay compared to minor liver resection. Techniques employed in this study offered good perioperative outcomes for children undergoing major liver resections.
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Affiliation(s)
- Kewei Li
- Department of Pediatric Surgery, West China Hospital of Sichuan University
| | - Fanwen Jiang
- West China School of Medicine of Sichuan University, Chengdu, China
| | | | | | - Xiaolong Xie
- Department of Pediatric Surgery, West China Hospital of Sichuan University
| | - Rongxing Zhou
- Department of Biliary Surgery, West China Hospital of Sichuan University, Chengdu, China
| | - Bo Xiang
- Department of Pediatric Surgery, West China Hospital of Sichuan University
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20
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Huang Y, Ge W, Kong Y, Ding Y, Gao B, Qian X, Wang W. Preoperative Portal Vein Embolization for Liver Resection: An updated meta-analysis. J Cancer 2021; 12:1770-1778. [PMID: 33613766 PMCID: PMC7890316 DOI: 10.7150/jca.50371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Accepted: 12/26/2020] [Indexed: 11/25/2022] Open
Abstract
Background: Portal vein embolization (PVE) is performed before major liver resection to increase liver volume remnant, controversy remains on the adverse effect of PVE on liver tumor patients. The current study highlighted the effect of PVE on the degree of hypertrophy of future liver remnant (FLR) and summarized PVE-related complications, aiming to provide a guideline for surgeons. Methods: A search of current published studies on PVE was performed. Meta-analysis was conducted to assess the effect of PVE on hypertrophy of FLR and summarized PVE-related complications. Results: 26 studies including 2335 patients were enrolled in the meta-analysis. All enrolled studies reported data regarding FLR hypertrophy rate, pooled effect size (ES) for FLR hypertrophy rate using a fixed-effect model was 0.105 (95%CI: 0.094-0.117, p=0.000), indicating PVE is favored in inducing FLR hypertrophy. Metatrim method indicated no obvious evidence of publication bias in the present meta-analysis. 247 (10.6%) patients exhibited PVE-related complications, receiving expectant treatment without affecting planned liver resection. Total 1782 patients (76%) underwent a subsequent liver resection after PVE, which is an encouraging result comparing with traditional resection rate in liver tumor patients. Conclusions: PVE is a safe and effective procedure with a low occurrence of related complications for inducing sufficient hypertrophy of FLR in liver tumor patients, which could elevate the resection rate of liver tumor patients. Careful patient cohort selection is crucial to avoid overuse of PVE in technically resectable patients. Further multiple central clinical trials are conducive to select optimal patient cohorts and provide a guideline for surgeons.
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Affiliation(s)
- Yu Huang
- Department of Hepatobiliary and Pancreatic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang 310009.,Key Laboratory of Precision Diagnosis and Treatment for Hepatobiliary and Pancreatic Tumor of Zhejiang Province, Hangzhou, Zhejiang 310009.,Research Center of Diagnosis and Treatment Technology for Hepatocellular Carcinoma of Zhejiang Province, Hangzhou, Zhejiang 310009.,Clinical Medicine Innovation Center of Precision Diagnosis and Treatment for Hepatobiliary and Pancreatic Disease of Zhejiang University, Hangzhou, Zhejiang 310009.,Clinical Research Center of Hepatobiliary and Pancreatic Diseases of Zhejiang Province, Hangzhou, Zhejiang 310009
| | - Wenhao Ge
- Department of Hepatobiliary and Pancreatic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang 310009.,Key Laboratory of Precision Diagnosis and Treatment for Hepatobiliary and Pancreatic Tumor of Zhejiang Province, Hangzhou, Zhejiang 310009.,Research Center of Diagnosis and Treatment Technology for Hepatocellular Carcinoma of Zhejiang Province, Hangzhou, Zhejiang 310009.,Clinical Medicine Innovation Center of Precision Diagnosis and Treatment for Hepatobiliary and Pancreatic Disease of Zhejiang University, Hangzhou, Zhejiang 310009.,Clinical Research Center of Hepatobiliary and Pancreatic Diseases of Zhejiang Province, Hangzhou, Zhejiang 310009
| | - Yang Kong
- Department of Hepatobiliary and Pancreatic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang 310009.,Key Laboratory of Precision Diagnosis and Treatment for Hepatobiliary and Pancreatic Tumor of Zhejiang Province, Hangzhou, Zhejiang 310009.,Research Center of Diagnosis and Treatment Technology for Hepatocellular Carcinoma of Zhejiang Province, Hangzhou, Zhejiang 310009.,Clinical Medicine Innovation Center of Precision Diagnosis and Treatment for Hepatobiliary and Pancreatic Disease of Zhejiang University, Hangzhou, Zhejiang 310009.,Clinical Research Center of Hepatobiliary and Pancreatic Diseases of Zhejiang Province, Hangzhou, Zhejiang 310009
| | - Yuan Ding
- Department of Hepatobiliary and Pancreatic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang 310009.,Key Laboratory of Precision Diagnosis and Treatment for Hepatobiliary and Pancreatic Tumor of Zhejiang Province, Hangzhou, Zhejiang 310009.,Research Center of Diagnosis and Treatment Technology for Hepatocellular Carcinoma of Zhejiang Province, Hangzhou, Zhejiang 310009.,Clinical Medicine Innovation Center of Precision Diagnosis and Treatment for Hepatobiliary and Pancreatic Disease of Zhejiang University, Hangzhou, Zhejiang 310009.,Clinical Research Center of Hepatobiliary and Pancreatic Diseases of Zhejiang Province, Hangzhou, Zhejiang 310009
| | - Bingqiang Gao
- Department of Hepatobiliary and Pancreatic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang 310009.,Key Laboratory of Precision Diagnosis and Treatment for Hepatobiliary and Pancreatic Tumor of Zhejiang Province, Hangzhou, Zhejiang 310009.,Research Center of Diagnosis and Treatment Technology for Hepatocellular Carcinoma of Zhejiang Province, Hangzhou, Zhejiang 310009.,Clinical Medicine Innovation Center of Precision Diagnosis and Treatment for Hepatobiliary and Pancreatic Disease of Zhejiang University, Hangzhou, Zhejiang 310009.,Clinical Research Center of Hepatobiliary and Pancreatic Diseases of Zhejiang Province, Hangzhou, Zhejiang 310009
| | - Xiaohui Qian
- Department of Hepatobiliary and Pancreatic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang 310009.,Key Laboratory of Precision Diagnosis and Treatment for Hepatobiliary and Pancreatic Tumor of Zhejiang Province, Hangzhou, Zhejiang 310009.,Research Center of Diagnosis and Treatment Technology for Hepatocellular Carcinoma of Zhejiang Province, Hangzhou, Zhejiang 310009.,Clinical Medicine Innovation Center of Precision Diagnosis and Treatment for Hepatobiliary and Pancreatic Disease of Zhejiang University, Hangzhou, Zhejiang 310009.,Clinical Research Center of Hepatobiliary and Pancreatic Diseases of Zhejiang Province, Hangzhou, Zhejiang 310009
| | - Weilin Wang
- Department of Hepatobiliary and Pancreatic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang 310009.,Key Laboratory of Precision Diagnosis and Treatment for Hepatobiliary and Pancreatic Tumor of Zhejiang Province, Hangzhou, Zhejiang 310009.,Research Center of Diagnosis and Treatment Technology for Hepatocellular Carcinoma of Zhejiang Province, Hangzhou, Zhejiang 310009.,Clinical Medicine Innovation Center of Precision Diagnosis and Treatment for Hepatobiliary and Pancreatic Disease of Zhejiang University, Hangzhou, Zhejiang 310009.,Clinical Research Center of Hepatobiliary and Pancreatic Diseases of Zhejiang Province, Hangzhou, Zhejiang 310009
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21
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Khayat S, Cassese G, Quenet F, Cassinotto C, Assenat E, Navarro F, Guiu B, Panaro F. Oncological Outcomes after Liver Venous Deprivation for Colorectal Liver Metastases: A Single Center Experience. Cancers (Basel) 2021; 13:E200. [PMID: 33429913 DOI: 10.3390/cancers13020200] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Revised: 01/06/2021] [Accepted: 01/07/2021] [Indexed: 12/15/2022] Open
Abstract
Colorectal liver metastases (CRLM) are the major cause of death in patients with colorectal cancer (CRC). The cornerstone treatment of CRLM is surgical resection. Post-operative morbidity and mortality are mainly linked to an inadequate future liver remnant (FLR). Nowadays preoperative portal vein embolization (PVE) is the most widely performed technique to increase the size of the future liver remnant (FLR) before major hepatectomies. One method recently proposed to increase the FLR is liver venous deprivation (LVD), but its oncological impact is still unknown. The aim of this study is to report first short- and long-term oncological outcomes after LVD in patients undergoing right (or extended right) hepatectomy for CRLM. Seventeen consecutive patients undergoing LVD between July 2015 and May 2020 before an (extended) right hepatectomy were retrospectively analyzed from an institutional database. Post-operative and follow-up data were analyzed and reported. Primary outcomes were 1-year and 3-year overall survival (OS) and hepatic recurrence (HR). Postoperative complications occurred in 8 patients (47%). No deaths occurred after surgery. HR occurred in 9 patients (52.9%). 1-year and 3-year OS were 87% (95% confidence interval [CI]: ±16%) and 60.3%, respectively (95% CI: ±23%). Median Disease-Free Survival (DFS) was 6 months (CI 95%: 4.7-7.2). With all the limitations of a retrospective study with a small sample size, LVD showed similar oncological outcomes compared to literature reports for Portal Vein Embolization (PVE).
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22
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Abstract
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.
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Affiliation(s)
- Matthew Dixon
- Division of Surgical Oncology, Department of Surgery, The Pennsylvania State University, College of Medicine, Hershey, PA, USA
| | - Jeffrey Cruz
- Division of Surgical Oncology, Department of Surgery, The Pennsylvania State University, College of Medicine, Hershey, PA, USA.,Department of Radiology, The Pennsylvania State University, College of Medicine, Hershey, PA, USA.,Department of Medicine, The Pennsylvania State University, College of Medicine, Hershey, PA, USA
| | - Nabeel Sarwani
- Department of Radiology, The Pennsylvania State University, College of Medicine, Hershey, PA, USA
| | - Niraj Gusani
- Division of Surgical Oncology, Department of Surgery, The Pennsylvania State University, College of Medicine, Hershey, PA, USA.,Department of Medicine, The Pennsylvania State University, College of Medicine, Hershey, PA, USA.,Department of Public Health Sciences, The Pennsylvania State University, College of Medicine, Hershey, PA, USA
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23
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Abstract
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.
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Affiliation(s)
- DaeHee Kim
- Department of Radiology, Division of Interventional Radiology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Joshua Cornman-Homonoff
- Department of Radiology and Biomedical Imaging, Section of Interventional Radiology, Yale School of Medicine, New Haven, CT, USA
| | - David C Madoff
- Department of Radiology and Biomedical Imaging, Section of Interventional Radiology, Yale School of Medicine, New Haven, CT, USA
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24
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Linecker M, Kuemmerli C, Clavien PA, Petrowsky H. Dealing with insufficient liver remnant: Associating liver partition and portal vein ligation for staged hepatectomy. J Surg Oncol 2019; 119:604-612. [PMID: 30847941 DOI: 10.1002/jso.25435] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2019] [Revised: 02/16/2019] [Accepted: 02/18/2019] [Indexed: 12/12/2022]
Abstract
Liver resection for colorectal liver metastases has emerged to highly successful treatment in the last decades. Key to this success is complete hepatic tumor removal and systemic disease control by chemotherapy. Associating liver partition and portal vein ligation for staged hepatectomy is the most recent two-stage resection strategy for patients with very small future liver remnant making complete tumor removal possible within 1 to 2 weeks. Oncological outcome data are being collected at the moment and first results from small series reveal promising results.
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Affiliation(s)
- Michael Linecker
- Department of Surgery and Transplantation, Swiss HPB and Transplantation Center, University Hospital Zürich, Zürich, Switzerland
| | - Christoph Kuemmerli
- Department of Surgery and Transplantation, Swiss HPB and Transplantation Center, University Hospital Zürich, Zürich, Switzerland
| | - Pierre-Alain Clavien
- Department of Surgery and Transplantation, Swiss HPB and Transplantation Center, University Hospital Zürich, Zürich, Switzerland
| | - Henrik Petrowsky
- Department of Surgery and Transplantation, Swiss HPB and Transplantation Center, University Hospital Zürich, Zürich, Switzerland
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25
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Kawaguchi Y, Lillemoe HA, Vauthey JN. Dealing with an insufficient future liver remnant: Portal vein embolization and two-stage hepatectomy. J Surg Oncol 2019; 119:594-603. [PMID: 30825223 DOI: 10.1002/jso.25430] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Accepted: 02/09/2019] [Indexed: 12/18/2022]
Abstract
Colorectal liver metastases (CLM) are not always resectable at the time of diagnosis. An insufficient future liver remnant is a factor excluding patients from curative intent resection. To deal with this issue, two-stage hepatectomy was introduced approximately 20 years ago. It is a sequential treatment strategy for bilateral CLM, which consists of preoperative chemotherapy, portal vein embolization, and planned first and second liver resections. This study reviews current evidence supporting use of two-stage hepatectomy.
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Affiliation(s)
- Yoshikuni Kawaguchi
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Heather A Lillemoe
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jean-Nicolas Vauthey
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
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26
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Biggemann L, Uhlig J, Streit U, Sack H, Guo XC, Jung C, Ahmed S, Lotz J, Müller-Wille R, Seif Amir Hosseini A. Future liver remnant growth after various portal vein embolization regimens: a quantitative comparison. MINIM INVASIV THER 2019; 29:98-106. [PMID: 30821547 DOI: 10.1080/13645706.2019.1582067] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Purpose: To compare the efficacy of right portal vein embolization using ethylene vinyl alcohol (EVOH-PVE) compared to other embolic agents and surgical right portal vein ligation (PVL).Material and methods: Patients with right sided liver malignancies scheduled for extensive surgery and receiving induction of liver hypertrophy via right portal vein embolization/ligature between 2010-2016 were retrospectively evaluated. Treatments included were ethylene vinyl alcohol copolymer (Onyx®, EVOH-PVE), ethiodized oil (Lipiodol®, Lipiodol/PVA-PVE), polyvinyl alcohol (PVA-PVE) or surgical ligature (PVL). Liver segments S2/3 were used to assess hypertrophy. Primary outcome was future liver remnant growth in ml/day.Results: Forty-one patients were included (EVOH-PVE n = 11; Lipiodol/PVA-PVE n = 10; PVA-PVE n = 8; PVL n = 12), the majority presenting with cholangiocarcinoma and colorectal metastases (n = 11; n = 27). Pre-interventional liver volumes were comparable (p = .095). Liver hypertrophy was successfully induced in all but one patient receiving Lipiodol/PVA-PVE. Liver segment S2/3 growth was largest for EVOH-PVE (5.38 ml/d) followed by PVA-PVE (2.5 ml/d), with significantly higher growth rates than PVL (1.24 ml/d; p < .001; p = .007). No significant difference was evident for Lipiodol/PVA-PVE (1.43 ml/d, p = .809).Conclusions: Portal vein embolization using EVOH demonstrates fastest S2/3 growth rates compared to other embolic agents and PVL, potentially due to its permanent portal vein embolization and induction of hepatic inflammation.
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Affiliation(s)
- Lorenz Biggemann
- Department of Diagnostic and Interventional Radiology, University Medical Center Goettingen, Goettingen, Germany
| | - Johannes Uhlig
- Department of Diagnostic and Interventional Radiology, University Medical Center Goettingen, Goettingen, Germany
| | - Ulrike Streit
- Department of Diagnostic and Interventional Radiology, University Medical Center Goettingen, Goettingen, Germany
| | - Henrik Sack
- Department of Diagnostic and Interventional Radiology, University Medical Center Goettingen, Goettingen, Germany
| | - Xiao Chao Guo
- Department of Radiology, Peking University First Hospital, University of Beijing, Beijing, China
| | - Carlo Jung
- Department of Gastroenterology and Gastrointestinal Oncology, University Medical Center Göttingen, Göttingen, Germany
| | - Saheeb Ahmed
- Department of Diagnostic and Interventional Radiology, University Medical Center Goettingen, Goettingen, Germany
| | - Joachim Lotz
- Department of Diagnostic and Interventional Radiology, University Medical Center Goettingen, Goettingen, Germany
| | - Rene Müller-Wille
- Department of Diagnostic and Interventional Radiology, University Medical Center Goettingen, Goettingen, Germany
| | - Ali Seif Amir Hosseini
- Department of Diagnostic and Interventional Radiology, University Medical Center Goettingen, Goettingen, Germany
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27
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Shah JL, Zendejas-Ruiz IR, Thornton LM, Geller BS, Grajo JR, Collinsworth A, George TJ, Toskich B. Neoadjuvant transarterial radiation lobectomy for colorectal hepatic metastases: a small cohort analysis on safety, efficacy, and radiopathologic correlation. J Gastrointest Oncol 2017; 8:E43-E51. [PMID: 28736649 DOI: 10.21037/jgo.2017.01.26] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Colorectal cancer patients have a high incidence of liver metastasis (ml-CRC). Surgical resection is the gold standard for treatment of hepatic metastasis but only a small percent of patients are traditional candidates based on disease extent and adequate size of the future liver remnant (FLR). Interventions such as portal vein embolization (PVE) and associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) are performed to increase FLR for operative conversion. Limitations to PVE include intrahepatic disease progression, portal vascular invasion, and utilization with concurrent chemotherapy. ALPPS is associated with a high morbidly and mortality. Radiation lobectomy (RL) with yttrium-90 (Y-90) delivers transarterial ablative brachytherapy to the future hepatectomy site which generates FLR hypertrophy similar or greater than PVE. Early results indicate that RL is safe, effective, and may offer unique benefits by providing cytoreduction of hepatic metastases which extends FLR hypertrophy time and allows FLR surveillance to gauge disease biology. A retrospective analysis of four patients with ml-CRC treated with RL prior to hepatectomy was performed to evaluate initial safety, efficacy, FLR hypertrophy, and radiopathologic correlation. Adverse events after RL and hepatectomy were evaluated. Imaging findings were analyzed for efficacy defined as FLR hypertrophy and disease control. Radiopathologic correlation was performed after histologic analysis. RL was well tolerated without major adverse events or hepatic decompensation. FLR hypertrophy ranged from 24.9% to 119% at mean follow-up of three months. The majority of complications were related to surgical instrumentation of the FLR due to upstaging at time of surgery. Hepatectomy specimen histology demonstrated complete pathologic response in 50% of patients, 50% radiopathologic concordance rate, and no significant hepatic fibrosis. Initial experience with neoadjuvant RL for ml-CRC is safe and provides both durable disease control and FLR hypertrophy with concurrent chemotherapy. A 50% complete pathologic response rate raises the possibility of definitive chemoradiation in poor surgical candidates. Prospective investigation is required.
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Affiliation(s)
- Jehan L Shah
- Department of Radiology, University of Florida, Post Office Box 100374, Gainesville, Florida 32610-0374, USA
| | | | - Linday M Thornton
- Department of Radiology, University of Florida, Post Office Box 100374, Gainesville, Florida 32610-0374, USA
| | - Brian S Geller
- Department of Radiology, University of Florida, Post Office Box 100374, Gainesville, Florida 32610-0374, USA
| | - Joseph R Grajo
- Department of Radiology, University of Florida, Post Office Box 100374, Gainesville, Florida 32610-0374, USA
| | - Amy Collinsworth
- Department of Pathology, University of Florida, Immunology and Laboratory Medicine, Gainesville, FL 32608, USA
| | - Thomas J George
- Department of Medicine, University of Florida, Gainesville, FL 32608, USA
| | - Beau Toskich
- Department of Radiology, University of Florida, Post Office Box 100374, Gainesville, Florida 32610-0374, USA.,Department of Radiology, Mayo Clinic, Jacksonville, FL 32224, USA
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28
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Zou H, Tao Y, Wang ZM. Integration of Child-Pugh score with future liver remnant yields improved prediction of liver dysfunction risk for HBV-related hepatocellular carcinoma following hepatic resection. Oncol Lett 2017; 13:3631-3637. [PMID: 28521464 PMCID: PMC5431318 DOI: 10.3892/ol.2017.5919] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2016] [Accepted: 01/31/2017] [Indexed: 02/06/2023] Open
Abstract
Assessment of hepatic functional reserve is important to enable the selection of appropriate treatment methods and safe hepatic resection in hepatitis B virus (HBV)-related hepatocellular carcinoma (HCC). In the present study, an evaluation was made of the clinical value of combining the Child-Pugh score (CPS) with the standardized future liver remnant (sFLR) measurement to predict postoperative liver dysfunction (PLD). A total of 61 HBV-related HCC patients undergoing liver volumetry prior to hepatectomy were enrolled in the study. The sFLR was calculated as the ratio of FLR volume to standardized liver volume. PLD was defined as a prothrombin time of >18 sec or a peak serum bilirubin level of >51.3 µmol/l for 7 days after surgery. Univariate analysis and multivariate logistic regression analysis were performed to identify risk factors associated with PLD. The correlation between PLD and the combination of sFLR and CPS was analyzed. In total, 18 out of 61 patients developed PLD (29.5%), with a significantly higher PLD incidence for a CPS of 6 than a CPS of 5 (P<0.05). Multivariate logistic regression analysis revealed that a prothrombin time of <13.3 sec and an sFLR of <0.55 were independent risk factors for PLD. Receiver operating characteristic (ROC) curve analysis revealed that the cut-off values of sFLR and sFLR/CPS for predicting PLD were 54.5% and 0.0916, respectively, with areas under the ROC curve of 0.820 and 0.860, respectively. The combination of CPS and sFLR appears to yield improved prediction of the occurrence of PLD compared with either CPS or sFLR alone.
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Affiliation(s)
- Heng Zou
- Department of Hepatobiliary Surgery, Xiangya Hospital, Central South University, Changsha, Hunan 410008, P.R. China
| | - Yiming Tao
- Department of Hepatobiliary Surgery, Xiangya Hospital, Central South University, Changsha, Hunan 410008, P.R. China
| | - Zhi-Ming Wang
- Department of Hepatobiliary Surgery, Xiangya Hospital, Central South University, Changsha, Hunan 410008, P.R. China
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29
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Cai X, Tong Y, Yu H, Liang X, Wang Y, Liang Y, Li Z, Peng S, Lau WY. The ALPPS in the Treatment of Hepatitis B-Related Hepatocellular Carcinoma With Cirrhosis: A Single-Center Study and Literature Review. Surg Innov 2017; 24:358-364. [PMID: 28689487 DOI: 10.1177/1553350617697187] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) has been reported to be a new treatment strategy for patients with predicted small volumes of future liver remnant (FLR). ALPPS is associated with rapid hypertrophy of FLR but it has a high postoperative mortality and morbidity. Up to now, it is controversial to apply ALPPS in hepatocellular carcinoma, especially for patients with liver cirrhosis. METHODS Between May 2014 and June 2015, consecutive patients who underwent ALPPS with hepatitis B-related hepatocellular carcinoma with cirrhosis carried out in our center were included into the study. Demographic characteristics, surgical outcomes, and pathological results were evaluated. Subsequently, follow-up was still in progress. RESULTS The median operating time of the first (n = 12) and the second procedures (n = 10) were 285.0 and 212.5 minutes, respectively. The median blood loss were 200 and 800 mL for 2 stages of operations. The severe complication (≥IIIB) rates for the first and the second operations were 25.0% versus 40.0%, respectively. Six patients with too small future live remnant died of postoperative hepatic failure. On a median follow-up of 16 months of the 6 patients discharged, 4 patients were still alive and of 2 were disease-free. CONCLUSION In terms of the feasibility and safety, this study showed that ALPPS in the treatment of hepatocellular carcinoma with insufficient future liver remnant might be a double-edged sword, and careful patients selected was proposed. Too small of FLR/SLV, less than 30%, is not recommended for ALPPS in liver with cirrhosis.
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Affiliation(s)
- Xiujun Cai
- 1 Sir Run Run Shaw Hospital Affiliated to Medical College of Zhejiang University, Hangzhou, China
| | - Yifan Tong
- 1 Sir Run Run Shaw Hospital Affiliated to Medical College of Zhejiang University, Hangzhou, China
| | - Hong Yu
- 1 Sir Run Run Shaw Hospital Affiliated to Medical College of Zhejiang University, Hangzhou, China
| | - Xiao Liang
- 1 Sir Run Run Shaw Hospital Affiliated to Medical College of Zhejiang University, Hangzhou, China
| | - Yifan Wang
- 1 Sir Run Run Shaw Hospital Affiliated to Medical College of Zhejiang University, Hangzhou, China
| | - Yuelong Liang
- 1 Sir Run Run Shaw Hospital Affiliated to Medical College of Zhejiang University, Hangzhou, China
| | - Zheyong Li
- 1 Sir Run Run Shaw Hospital Affiliated to Medical College of Zhejiang University, Hangzhou, China
| | - Shuyong Peng
- 1 Sir Run Run Shaw Hospital Affiliated to Medical College of Zhejiang University, Hangzhou, China.,2 Second Affiliated Hospital, Zhejiang University, Hangzhou, Zhejiang, China
| | - W Y Lau
- 1 Sir Run Run Shaw Hospital Affiliated to Medical College of Zhejiang University, Hangzhou, China.,3 The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, New Territories, Hong Kong, China
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30
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Abstract
Portal vein embolization (PVE) is increasingly performed worldwide to reduce the possibility of liver failure after extended hepatectomy, by inducing future liver remnant (FLR) hypertrophy and atrophy of the liver planned for resection. The procedure is known to be very safe and to have few procedure-related complications.In this study, we described 2 elderly patients with Bismuth-Corlette type IV Klatskin tumor who underwent right trisectional PVE involving the embolization of the right portal vein, the left medial sectional portal branch, and caudate portal vein. Within 1 week after PVE, patients went into sepsis combined with bile leak and died within 1 month.Sepsis can cause acute liver failure in patients with chronic liver disease. In this study, the common patient characteristics other than sepsis, that is, trisectional PVE; chronic alcoholism; aged >65 years; heart-related comorbidity; and elevated serum total bilirubin (TB) level (7.0 mg/dL) at the time of the PVE procedure in 1 patient, and concurrent biliary procedure, that is, percutaneous transhepatic biliary drainage in the other patient might have affected the outcomes of PVE.These cases highlight that PVE is not a safe procedure. Care should be taken to minimize the occurrence of infectious events because sepsis following PVE can cause acute liver failure. Additionally, prior to performing PVE, the extent of PVE, chronic alcohol consumption, age, comorbidity, long-lasting jaundice, concurrent biliary procedure, etc. should be considered for patient safety.
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Abstract
Localized hepatocellular carcinoma (HCC) refers to a solitary or few tumors located within either the left or right hemiliver without evidence of bilobar or extrahepatic spread. This term encompasses a heterogeneous morphology with no regard to stage of prognosis of the disease. Surgical resection remains the mainstay of curative treatment for the localized HCC. Various biochemical and radiological tests constitute an indispensible part of preoperative assessment. Emergence of laparoscopic hepatectomy has brought liver resection into a new era. Improved understanding of the pathophysiology of HCC allows more aggressive surgical resection without compromising outcomes. New insights into the management of special situations, such as ruptured HCC, pyogenic transformation of HCC, and HCC with portal vein tumor thrombus, rekindle the hopes of curative resection in these terminal events. Amalgamating salvage liver transplantation into the surgical management of resectable HCC has revolutionized the treatment paradigm of this deadly disease.
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Affiliation(s)
- Ka Wing Ma
- Department of Surgery, Queen Mary Hospital, The University of Hong Kong, Pok Fu Lam, Hong Kong
| | - Tan To Cheung
- Department of Surgery, Queen Mary Hospital, The University of Hong Kong, Pok Fu Lam, Hong Kong
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32
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Björnsson B, Sparrelid E, Hasselgren K, Gasslander T, Isaksson B, Sandström P. Associating Liver Partition and Portal Vein Ligation for Primary Hepatobiliary Malignancies and Non-Colorectal Liver Metastases. Scand J Surg 2016; 105:158-62. [DOI: 10.1177/1457496915613650] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2015] [Accepted: 10/01/2015] [Indexed: 12/30/2022]
Abstract
Background and Aims: Associating liver partition and portal vein ligation for staged hepatectomy may increase the possibility of radical resection in the case of liver malignancy. Concerns have been raised about the high morbidity and mortality associated with the procedure, particularly when applied for diagnoses other than colorectal liver metastases. The aim of this study was to analyze the initial experience with associating liver partition and portal vein ligation for staged hepatectomy in cases of non-colorectal liver metastases and primary hepatobiliary malignancies in Scandinavia. Materials and Methods: A retrospective analysis of all associating liver partition and portal vein ligation for staged hepatectomy procedures performed at two Swedish university hospitals for non-colorectal liver metastases and primary hepatobiliary malignancies was performed. The primary focus was on the safety of the procedure. Results and Conclusion: Ten patients were included: four had hepatocellular cancer, three had intrahepatic cholangiocarcinoma, one had a Klatskin tumor, one had ocular melanoma metastasis, and one had a metastasis from a Wilms’ tumor. All patients completed both operations, and the highest grade of complication (according to the Clavien-Dindo classification) was 3A, which was observed in one patient. No 90-day mortality was observed. Radical resection (R0) was achieved in nine patients, while the resection was R2 in one patient. The low morbidity and mortality observed in this cohort compared with those of earlier reports on associating liver partition and portal vein ligation for staged hepatectomy for diagnoses other than colorectal liver metastases may be related to the selection of patients with limited comorbidity. In addition, procedures other than associating liver partition and portal vein ligation for staged hepatectomy had been avoided in most of the patients. In conclusion, associating liver partition and portal vein ligation for staged hepatectomy can be applied to primary hepatobiliary malignancies and non-colorectal liver metastases with acceptable rates of morbidity and mortality.
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Affiliation(s)
- B. Björnsson
- Department of Surgery, Linköping University Hospital, Linköping, Sweden
- Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - E. Sparrelid
- Department of Clinical Science, Intervention and Technology, Division of Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - K. Hasselgren
- Department of Surgery, Linköping University Hospital, Linköping, Sweden
- Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - T. Gasslander
- Department of Surgery, Linköping University Hospital, Linköping, Sweden
- Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - B. Isaksson
- Department of Clinical Science, Intervention and Technology, Division of Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - P. Sandström
- Department of Surgery, Linköping University Hospital, Linköping, Sweden
- Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
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Lewandowski RJ, Donahue L, Chokechanachaisakul A, Kulik L, Mouli S, Caicedo J, Abecassis M, Fryer J, Salem R, Baker T. (90) Y radiation lobectomy: Outcomes following surgical resection in patients with hepatic tumors and small future liver remnant volumes. J Surg Oncol 2016; 114:99-105. [PMID: 27103352 DOI: 10.1002/jso.24269] [Citation(s) in RCA: 82] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2015] [Accepted: 04/06/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND The purpose of this study is to assess operative, post-operative, and long-term outcomes in patients who underwent radiation lobectomy (RL) for tumor control and/or hypertrophy of small future liver remnant (FLR) prior to resection. METHODS Right lobar +/- segment 4 radioembolization was performed prior to lobectomy/tri-segmentectomy in patients with hepatic tumor but inadequate FLR. Parenchymal/tumor volumes were calculated from pre/post-RL imaging; FLR/%FLR hypertrophy were determined. Complications were graded by the Clavien-Dindo classification. RESULTS Thirteen patients (HCC n = 10, cholangiocarcinoma n = 2, mCRC n = 1) underwent RL prior to resection. The median time between RL and post-RL imaging was 40 days (23-190 days); the median time to resection was 86 days (30-210 days). Median FLR increased significantly [pre: 33% (22-43%); post: 43% (29-69%), P < 0.01] to yield a median %FLR hypertrophy of 30% (4-105%). The median hospital stay after resection was 4 days (3-11 days). Transient hepatobiliary toxicities normalized post-operatively. Ninety-two percent of resected tumors had >50% pathologic necrosis. Median follow up time after surgery was 604 days (144-1,416 days); one death occurred. CONCLUSIONS In this preliminary study, radiation lobectomy was a safe and effective method to achieve remnant liver hypertrophy while providing tumor control. This approach may facilitate safe resection and favorable post-operative outcomes.J. Surg. Oncol. 2016;114:99-105. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Robert J Lewandowski
- Department of Radiology, Section of Interventional Radiology, Northwestern University, Chicago, Illinois
| | - Larry Donahue
- Department of Radiology, Section of Interventional Radiology, Northwestern University, Chicago, Illinois
| | | | - Laura Kulik
- Division of Hepatology, Department of Medicine, Northwestern University, Chicago, Illinois
| | - Samdeep Mouli
- Department of Radiology, Section of Interventional Radiology, Northwestern University, Chicago, Illinois
| | - Juan Caicedo
- Division of Transplant Surgery, Department of Surgery, Northwestern University, Chicago, Illinois
| | - Michael Abecassis
- Division of Transplant Surgery, Department of Surgery, Northwestern University, Chicago, Illinois
| | - Jonathan Fryer
- Division of Transplant Surgery, Department of Surgery, Northwestern University, Chicago, Illinois
| | - Riad Salem
- Department of Radiology, Section of Interventional Radiology, Northwestern University, Chicago, Illinois
| | - Talia Baker
- Division of Transplant Surgery, Department of Surgery, Northwestern University, Chicago, Illinois
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Li D, Madoff DC. Portal vein embolization for induction of selective hepatic hypertrophy prior to major hepatectomy: rationale, techniques, outcomes and future directions. Cancer Biol Med 2016; 13:426-442. [PMID: 28154774 PMCID: PMC5250600 DOI: 10.20892/j.issn.2095-3941.2016.0083] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
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.
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Affiliation(s)
- David Li
- Department of Radiology, Division of Interventional Radiology, New York-Presbyterian Hospital, Weill Cornell Medical Center, New York 10065, NY, USA
| | - David C Madoff
- Department of Radiology, Division of Interventional Radiology, New York-Presbyterian Hospital, Weill Cornell Medical Center, New York 10065, NY, USA
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Björnsson B, Lundgren L. A Personal Computer Freeware as a Tool for Surgeons to Plan Liver Resections. Scand J Surg 2015; 105:153-7. [PMID: 26420775 DOI: 10.1177/1457496915607802] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2015] [Accepted: 08/25/2015] [Indexed: 01/06/2023]
Abstract
BACKGROUND AND AIMS The increase in liver surgery and the proportion of resections done on the margin to postoperative liver failure make preoperative calculations regarding liver volume important. Earlier studies have shown good correlation between calculations done with ImageJ and specimen weight as well as volume calculations done with more robust systems. The correlation to actual volumes of resected liver tissue has not been investigated, and this was the aim of this study. MATERIAL AND METHODS A total of 30 patients undergoing well-defined liver resections were included in this study. Volumes calculated with ImageJ were compared to volume measurements done after the retrieval of resected liver tissue. RESULTS AND CONCLUSIONS A strong correlation between calculated and measured liver volume was found with sample concordance correlation coefficient (ρc) = 0.9950. The knowledge on the nature of liver resections sets liver surgeons in a unique position to be able to accurately predict the volumes to be resected and, therefore, also the volume that will remain after surgery. This becomes increasingly important with the evolvement of methods to extend the boundaries of liver surgery. ImageJ is a reliable tool to preoperatively assess liver volume.
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Affiliation(s)
- B Björnsson
- Department of Surgery and Department of Experimental Medicine, Linköping University, Linköping, Sweden
| | - L Lundgren
- Department of Surgery and Department of Experimental Medicine, Linköping University, Linköping, Sweden
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Braat AJAT, Huijbregts JE, Molenaar IQ, Borel Rinkes IHM, van den Bosch MAAJ, Lam MGEH. Hepatic radioembolization as a bridge to liver surgery. Front Oncol 2014; 4:199. [PMID: 25126539 PMCID: PMC4115667 DOI: 10.3389/fonc.2014.00199] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2014] [Accepted: 07/15/2014] [Indexed: 12/11/2022] Open
Abstract
Treatment of oncologic disease has improved significantly in the last decades and in the future a vast majority of cancer types will continue to increase worldwide. As a result, many patients are confronted with primary liver cancers or metastatic liver disease. Surgery in liver malignancies has steeply improved and curative resections are applicable in wider settings, leading to a prolonged survival. Simultaneously, radiofrequency ablation (RFA) and liver transplantation (LTx) have been applied more commonly in oncologic settings with improving results. To minimize adverse events in treatments of liver malignancies, locoregional minimal invasive treatments have made their appearance in this field, in which radioembolization (RE) has shown promising results in recent years with few adverse events and high response rates. We discuss several other applications of RE for oncologic patients, other than its use in the palliative setting, whether or not combined with other treatments. This review is focused on the role of RE in acquiring patient eligibility for radical treatments, like surgery, RFA, and LTx. Inducing significant tumor reduction can downstage patients for resection or, through attaining stable disease, patients can stay on the LTx waiting list. Hereby, RE could make a difference between curative of palliative intent in oncologic patient management. Prior to surgery, the future remnant liver volume might be inadequate in some patients. In these patients, forming an adequate liver reserve through RE leads to prolonged survival without risking post-operative liver failure and minimizing tumor progression while inducing hypertrophy. In order to optimize results, developments in procedures surrounding RE are equally important. Predicting the remaining liver function after radical treatment and finding the right balance between maximum tumor irradiation and minimizing the chance of inducing radiation-related complications are still challenges.
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Affiliation(s)
- Arthur J A T Braat
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht , Utrecht , Netherlands
| | - Julia E Huijbregts
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht , Utrecht , Netherlands
| | - I Quintus Molenaar
- Department of Surgery, University Medical Center Utrecht , Utrecht , Netherlands
| | | | | | - Marnix G E H Lam
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht , Utrecht , Netherlands
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Abstract
Major and extended hepatic resections are being performed with increasing frequency as morbidity and mortality rates after major hepatectomies have declined and definitions of resectability have expanded for primary and metastatic hepatic malignancies. Systematic assessment of the anticipated functional remnant liver is essential before major hepatic resection to avoid postoperative hepatic insufficiency and its attendant sequelae. The volume of the future liver remnant (FLR) correlates with FLR function and postoperative outcome. This article describes the rationale for FLR measurement, methods of measuring FLR volume, and standardization to the total estimated liver volume. The indications for portal vein embolization based on standardized liver volumetry are summarized.
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Affiliation(s)
- Dario Ribero
- Department of Surgical Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, Texas
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Anaya DA, Blazer DG, Abdalla EK. Strategies for resection using portal vein embolization: hepatocellular carcinoma and hilar cholangiocarcinoma. Semin Intervent Radiol 2011; 25:110-22. [PMID: 21326552 DOI: 10.1055/s-2008-1076684] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Preoperative portal vein embolization (PVE) is increasingly used to optimize the volume and function of the future liver remnant (FLR) and to reduce the risk for complications of major hepatectomy for hepatocellular carcinoma (HCC) or hilar cholangiocarcinoma (CCA). In patients with HCC who are candidates for extended hepatectomy and in patients with HCC and well-compensated cirrhosis who are being considered for major hepatectomy, FLR volumetry is routinely performed, and PVE is employed in selected cases to optimize the volume and function of the FLR prior to surgery. Similarly, in patients with hilar CCA who are candidates for extended hepatectomy, careful preoperative preparation using biliary drainage, FLR volumetry, and PVE optimizes the volume and function of the FLR prior to surgery. Appropriate use of PVE has led to improved postoperative outcomes after major hepatectomy for these diseases and oncological outcomes similar to those in patients who undergo resection without PVE. Specific indications for PVE are being clarified. FLR volumetry is necessary for proper selection of patients for PVE. Analysis of the degree of hypertrophy of the FLR after PVE (a dynamic test of liver regeneration) complements analysis of the pre-PVE FLR volume (a static test). Together, FLR degree of hypertrophy and FLR volume are the best predictors of outcome after major hepatectomy in an individual patient, regardless of the degree of underlying liver disease. This article synthesizes the literature on the approach to patients with HCC and CCA who are candidates for major hepatectomy. The rationale and indications for FLR volumetry and PVE and outcomes following PVE and major hepatectomy for HCC and CCA are discussed.
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Affiliation(s)
- Daniel A Anaya
- Department of Surgical Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, Texas
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Abstract
BACKGROUND Patients noted to have an inadequate future liver remnant on pre operative volumetric assessment are considered to be candidates for portal vein embolization (PVE). A subset of patients undergo laparoscopic intervention prior to PVE for staging purposes or to address the primary in Stage IV colon cancer. These patients usually undergo PVE as a subsequent additional procedure by the transhepatic route. The aim of this study was to assess the feasibility of portal vein ligation by the laparoscopic approach in suitable patients. MATERIALS AND METHODS A retrospective review of a prospectively maintained database was performed to identify patients that underwent laparoscopic portal vein ligation (LPVL). The demographic, clinical, radiographic, operative and volumetric details were collected to determine the feasibility of portal vein ligation. RESULTS A total of nine patients underwent LPVL as part of a two stage procedure in preparation for subsequent major hepatectomy. With a median age of 67 yrs, the diagnoses included: colorectal metastasis (five patients), cholangiocarcinoma (three patients) and hepatocellular carcinoma (one patient). The ligation involved the right portal vein in all and was performed with silk ligature (seven patients) and clips (two patients). Volumetric data was available in six patients which showed a mean increase from 209.1 cc+/-97.76 to 495.83 cc+/-310.91 (increase by 181.5%) In two patients, inadequate hypertrophy mandated later embolization by percutaneous technique. Five patients underwent subsequent major hepatic resection as planned. The remaining four patients were noted to have progression of disease that precluded the planned procedure. There were no complications associated with LPVL. CONCLUSIONS LPVL is feasible and can be safely performed. In a select group of patients, it may be considered as an alternative to subsequent embolization and thereby potentially absolve the need for an additional procedure with its attendant complications.
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Affiliation(s)
- C. Are
- Department of Surgery, Eppley Cancer Centre, Division of Surgical Oncology, University of Nebraska Medical CentreOmaha USA
| | - S. Iacovitti
- Madre Guiseppina Vannini Hospital, Surgery, via della acqua bullicanteRomeItaly
| | - F. Prete
- University of Foggia, SurgeryFoggiaItaly
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