Perioperative LiMAx Test Analysis: Impact of Portal Vein Embolisation, Chemotherapy and Major Liver Resection

BACKGROUND

Postoperative liver failure (PLF) is a severe complication after major liver resection (MLR). To increase the safety of patients, clinical bedside tests are of great importance. However, limitations of their applicability and validity impair their value.

METHODS

Preoperative measurements of the liver maximum capacity (LiMAx) were performed in n = 40 patients, who underwent MLR (≥3 segments). Matched postoperative LiMAx was measured in n = 21 patients. Liver function was compared between pretreated patients (n = 11 with portal vein embolisation (PVE) and n = 19 patients with preoperative chemotherapy) and therapy naïve patients. The LiMAx values were compared with liver-specific blood parameters and volumetric analysis.

RESULTS

In total, n = 40 patients were enrolled in this study. The majority of patients (n = 33; 82.5%) had high preoperative LiMAx values (>315 µg/kg/h), while only seven patients (17.5%) had medium values (140-315 µg/kg/h), and none of the patients had low values (<140 µg/kg/h). A comparison of pretreated patients (with PVE and/or chemotherapy) and therapy naïve patients showed no significant difference in the preoperative LiMAx values (p > 0.05). The preoperative LiMAx values were significantly higher than the matched postoperative values on postoperative day 1 (p < 0.0001). A comparison between the expected and measured postoperative LiMAx showed a difference (≥10%) in 7 out of 13 patients (53.8%). After an initial postoperative decrease in the LiMAx, the patients without complications (n = 12) showed a continuous increase until 14 days after surgery. In the patients with postoperative complications, a decrease in the LiMAx was associated with a prolonged recovery.

CONCLUSIONS

For patients undergoing MLR within the 0.5% rule, which is the clinical gold standard, the LiMAx values do not offer any additional information. Additionally, the LiMAx may have reflected liver function, but it did not deliver additional information regarding postoperative liver recovery. The clinical use of LiMAx might be relevant in selected patients beyond the 0.5% rule.

Vascular Interventions in Oncology

Vascular interventions are an important and established tool in the management of the oncology patient. The goal of these procedures may be curative, palliative or adjunctive in nature. Some of the common vascular interventions used in oncology include transarterial embolisation or chemoembolisation, selective internal radiation therapy, chemosaturation, venous access lines, superior vena cava stenting and portal vein embolisation. We provide an overview of the principles, technology and approach of vascular techniques for tumour therapy in both the arterial and venous systems. Arterial interventions are currently mainly used in the management of hepatocellular carcinoma. Transarterial embolisation, chemoembolisation and selective internal radiation therapy deliver targeted catheter-delivered treatments with the aim of reducing tumour burden, controlling tumour growth or increasing survival in patients not eligible for transplantation. Chemosaturation is a regional chemotherapy technique that delivers high doses of chemotherapy directly to the liver via the hepatic artery, while reducing the risks of systemic effects. Venous interventions are more adjunctive in nature. Venous access lines are used to provide a means of delivering chemotherapy and other medications directly into the bloodstream. Superior vena cava stenting is a palliative procedure that is used to relieve symptoms of superior vena cava obstruction. Portal vein embolisation is a procedure that allows hypertrophy of a healthy portion of the liver in preparation for liver resection. Interventional radiology-led vascular interventions play an essential part of cancer management. These procedures are minimally invasive and provide a safe and effective adjunct to traditional cancer treatment methods. Appropriate work-up and discussion of each patient-specific problem in a multidisciplinary setting with interventional radiology is essential to provide optimum patient-centred care.

Rapid Induction of Liver Regeneration for Major Hepatectomy (REBIRTH): A Randomized Controlled Trial of Portal Vein Embolisation versus ALPPS Assisted with Radiofrequency

To avoid liver insufficiency following major hepatic resection, portal vein embolisation (PVE) is used to induce liver hypertrophy pre-operatively. Associating liver partition with portal vein ligation for staged hepatectomy assisted with radiofrequency (RALPPS) was introduced as an alternative method. A randomized controlled trial comparing PVE with RALPPS for the pre-operative manipulation of liver volume in patients with a future liver remnant volume (FLRV) ≤25% (or ≤35% if receiving preoperative chemotherapy) was conducted. The primary endpoint was increase in size of the FLRV. The secondary endpoints were length of time taken for the volume gain, morbidity, operation length and post-operative liver function. Between July 2015 and October 2017, 57 patients were randomised to RALPPS (n = 29) and PVE (n = 28). The mean percentage of increase in the FLRV was 80.7 ± 13.7% after a median 20 days following RALPPS compared to 18.4 ± 9.8% after 35 days (p < 0.001) following PVE. Twenty-four patients after RALPPS and 21 after PVE underwent stage-2 operation. Final resection was achieved in 92.3% and 66.6% patients in RALPPS and PVE, respectively (p = 0.007). There was no difference in morbidity, and one 30-day mortality after RALPPS (p = 0.991) was reported. RALPPS is more effective than PVE in increasing FLRV and the number of patients for surgical resection.

Single-incision laparoscopic surgery portal vein embolisation before extended hepatectomy

Objective:

Portal vein embolisation (PVE) represents the standard procedure for augmentation of the contralateral lobe before extended right hepatectomy. However, possible limitations for the percutaneous transhepatic approach exist, for example, large tumours of the right lobe. Here, we present our experiences with single-incision laparoscopic surgery-PVE (SILS-PVE) as an alternative approach for settings where percutaneous routes are technically not feasible.

Methods:

A small umbilical incision is performed, and a GelPOINT Mini Advanced Access Platform (Santa Margarida, CA, USA) is placed. Staging laparoscopy is performed routinely followed by identification of an appropriate ileal segment, which is subsequently exteriorized through the small umbilical incision. A peripheral mesenteric vein is encircled and cannulated to access right portal vein branches. After sufficient embolisation of the right lobe, the peripheral vein is ligated, the single port is extracted and the umbilical wound is closed.

Results:

SILS-PVE was successfully applied in 10 patients (median age 60.5 years) between 12/2015 and 03/2018. The technique was indicated due to extensive tumours in the right lobe (n = 8), extensive hydatid cyst (n = 1) and during SILS right hemicolectomy in Stage IV colon cancer (n = 1). Mean operative time was 184 min (range 116–315). Patients were discharged on post-operative day 4 (range 2–9). Augmentation of the future liver remnant volume was assessed by computed tomography-volumetry 3–4 weeks after SILS-PVE and showed a mean relative increase of 64.95%, future remnant liver function showed a mean increase of 120.77%.

Conclusion:

The proposed SILS-PVE represents a technically simple and safe alternative to standard percutaneous transhepatic approaches. Perioperative risks can be minimised by minimally-invasive surgery, which is of explicit importance in multimodal approaches before major hepatectomy.

Portal vein embolisation with application of haematopoietic stem cells in patients with primarily or non-resectable colorectal liver metastases

BACKGROUND

Insufficient future liver remnant volume (FLRV) is the main cause of low resectability of liver metastases from colorectal cancer (CLMs). One option for enhancing FLVR growth is the use of portal vein embolisation (PVE) with the application of autologous haematopoietic stem cells (HSCs).

PATIENTS AND METHODS

PVE with the application of HSCs was used in 11 patients (group 1) with primarily non-resectable CLMs due to insufficient FLRV without signs of extrahepatic metastases. The control group (group 2) consisted of 14 patients in whom only PVE was performed. We evaluated the product quality, FLRV growth, CLM volume, median survival and progression-free survival (PFS).

RESULTS

Product quality was achieved in all collections. In all group-I patients, sufficient FLRV growth occurred within three weeks. In the first and second weeks, FLRV increased optimally in most patients (p<0.006). In 13 out of the 14 group-2 patients, optimum FLVR growth was observed within three weeks following PVE (p<0.002). More rapid FLVR growth was observed in group 1 patients (p<0.01). CLM volume was significantly increased in both the group-2 (p<0.0005) and group-1 (p<0.008) patients at the time of liver resection. There was no significant difference in the growth of the CLM volume between the groups (p<0.18). The median survival was 7.3 and 6.8 months for group 1 and 2 patients, respectively, and the two-year PFS was 28% and 22% (p<0.18), respectively.

CONCLUSION

PVE with HSC application is a promising method for effectively stimulating FLRV growth in patients with primarily non-resectable CLMs.

Pretreatment assessment of hepatocellular carcinoma: expert consensus statement

Staging of hepatocellular carcinoma (HCC) is complex and relies on multiple factors including tumor extent and hepatic function. No single staging system is applicable to all patients with HCC. The staging of the American Joint Committee on Cancer / International Union for Cancer Control should be used to predict outcome following resection or liver transplantation. The Barcelona Clinic Liver Cancer scheme is appropriate in patients with advanced HCC not candidate for surgery. Dual phase computed tomography or magnetic resonance imaging can be used for pretreatment assessment of tumor extent but the accuracy of these methods remains poor to characterize < 1 cm lesions. Assessment of tumor response should not rely only on tumor size and new imaging methods are available to evaluate response to therapy in HCC patients. Liver volumetry is part of the preoperative assessment of patients with HCC candidate for resection as it reflects liver function. Preoperative portal vein embolization is indicated in patients with small future liver remnant (≤ 20% in normal liver; ≤ 40% in fibrotic or cirrhotic liver). Tumor size is not a contraindication to liver resection. Liver resection can be proposed in selected patients with multifocal HCC. Besides tumor extent, surgical resection of HCC may be performed in selected patients with chronic liver disease.