Pre-op Portal Vein Embolization for Major Hepatectomy

Pre-op Portal Vein Embolization for Major Hepatectomy

SL Sin

IntroductionIntroductionSurgery is the treatment of choice for primary and most metastatic liver tumours

Limiting factor being insufficient future remnant liver (FRL) parenchyma volume, leading to fatal liver failure post-op

Portal vein embolization followed by hepatectomy is a common treatment option

IntroductionIntroduction

First described in Japan in 1986 by Kinoshita

Embolization of the portal branches supplying the tumour-bearing liver redirects portal blood flow to the branches of the FRL

Hypertrophy of the FRL resulted

IndicationsIndications

Patients with insufficient FRLbased on FRL/ (TLV – tumour volume) ratio

Liver volumetry determined by 3D CT reconstruction

IndicationsIndications

For patients with normal liver, for PVE if FRL/ TLV <25%

Capussotti 2005

For patients with chronic liver disease, FRL/ TLV >40% should remain to minimize post-op complications

Azoulay 2000Kubota 1997

TechniqueTechnique

Transileocolic portal embolization (TIPE)Minilaparotomy performed under GA

Catheterization of portal vein through a branch of the ileocolic vein

Percutaneous transhepatic portal embolization (PTPE)Performed by interventional radiologist under LA

Ipsilateral approach/ Contralateral approach

ComplicationsComplications

Minor ComplicationsMinor Complications

Abdominal discomfort or painAbdominal discomfort or pain

FeverFever

Nausea or vomitingNausea or vomiting

IleusIleus

Overflow of embolization materialsOverflow of embolization materials

Coil displacementCoil displacement

Major complicationsMajor complications

Liver abscessLiver abscess

Cholangitis Cholangitis

Main or contralateral portal vein thrombosisMain or contralateral portal vein thrombosis

Subscapular haematomaSubscapular haematoma

Portal hypertensionPortal hypertension

Septic necrosis from hepatic artery injurySeptic necrosis from hepatic artery injury

Results – Hypertrophy

Results – Hypertrophy

No consensus on the duration for adequate hypertrophyAverage 4 to 5 weeks

Results – Hypertrophy

Results – Hypertrophy

Restaging and operation performed 4 to 6 weeks after PVE

Mean increase in FRL = 8.4% (~35% functional liver mass)

79% patients proceeded to surgery

12% developed additional unresectable disease found after PVE but before surgery

new lesion within FRLLung metastasis

7% had unresectable disease at surgeryUnsuspected extrahepatic diseaseInability to achieve complete tumour clearance

Hemming 2003

Results – Hypertrophy

Results – Hypertrophy

Normal vs diseased liverMean increase in %FFLR = 16% vs 9%

Only 86% with chronic liver disease had hypertrophy

Farges 2003

Results – Resection-related Overall Morbidity

and Mortality

Results – Resection-related Overall Morbidity

and Mortality

Morbidity rate 16%transient liver failure, pleural effusion

Mortality rate 1.7%acute liver failure

Abulkhir 2008

Results – Resection-related Overall Morbidity

and Mortality

Results – Resection-related Overall Morbidity

and Mortality

Portal Vein Embolization Before Right HepatectomyOlivier Farges. Ann Surg 2003

Prospective comparative trial

55 patients planned for right hepatectomy selected, with diagnosis being HCC/ liver metastasis/ intrahepatic cholangiocarcinoma

Prospectively assigned to have immediate surgery or PVE before surgery

28 patients had chronic liver disease (all Child’s A cirrhosis)

PVE for HCCPVE for HCC

Patients with underlying cirrhosisDoubtful effect of hypertrophy

Successful hypertrophy can significantly reduce early post-op complications

Comparable overall and disease-free survival at 1, 3, 5 years for PVE and non-PVE groups

Azoulay 2000Palavecino 2008

PVE for Colorectal Liver Metastasis (CLM)

PVE for Colorectal Liver Metastasis (CLM)

Comparable overall and disease- free survival at 1, 3, 5 years for PVE and non-PVE groups

Azoulay 2000Oussoultzoglou 2006

PVE and reduction of tumour shedding in CLM

33% patient with hepatectomy cancelled due to tumoural extension Azoulay 2000

Lower intra-hepatic recurrence rate in PVE groupOussoultzoglou 2006

ConclusionConclusion

PVE is a safe procedure that can alter the treatment of patients deemed not suitable for hepatectomy due to insufficient FRL

For patients with HCC, successful hypertrophy of FRL can significantly reduces surgery related morbidity

ReferenceReferenceExtension of right portal vein embolization to segment IV portal branches. Capussotti L. Arch Surg 2005

Resection of nonresectable liver metastases from colorectal cancer after percutaneous portal vein embolization. Azoulay D. Ann Surg 2000

Measurement of liver volume and hepatic functional reserve as a guide to decision-making in resectional surgery for hepatic tumours. Kubota K. Hepatology 1997

Preoperative portal vein embolization for extended hepatectomy. Alan W Hemming. Ann Surg 2003

Portal vein embolization before right hepatectomy. Olivier Farges. Ann Surg 2003

Preoperative portal vein embolization for major liver resection. Adel Abulkhir. Ann Surg 2008

Major hepatic resection for hepatocellular carcinoma with or without portal vein embolization: perioperative outcome and survival. Martin Palavecino. J Surg 2008

Percutaneous portal vein embolization increases the feasibility and safety of major liver resection for hepatocellular carcinoma in injured liver. D Azoulay. Ann Surg 2000

Right portal vein embolization before right hepatectomy for unilobar colorectal liver metastasis reduces the intrahepatic recurrence rate. Elie Oussoultzoglou. Ann Surg 2006