Transhepatic portal vein embolization: anatomy, indications, and technical considerations.
ABSTRACT Portal vein embolization (PVE) is increasingly being accepted as a useful procedure in the preoperative treatment of patients selected for major hepatic resection. PVE is performed via either the percutaneous transhepatic or the transileocolic route and is usually reserved for patients whose future liver remnants are too small to allow resection. It is a safe and effective method for inducing selective hepatic hypertrophy of the nondiseased portion of the liver and may thereby reduce complications and shorten hospital stays after resection. A thorough knowledge of hepatic segmentation and portal venous anatomy is essential before performing PVE. In addition, the indications and contraindications for PVE, the methods for assessing hepatic lobar hypertrophy, the means of determining optimal timing of resection, and the possible complications of PVE need to be fully understood before undertaking the procedure. Technique may vary among operators, and further research is necessary to determine the best embolic agents available and the expected rates of liver regeneration for PVE. Nevertheless, as hepatobiliary surgeons become more experienced at performing extended hepatic resections, PVE may be requested more frequently.
- SourceAvailable from: Michael Vouche[Show abstract] [Hide abstract]
ABSTRACT: Portal vein embolization (PVE) is a standard technique for patients not amenable to liver resection due to small future liver remnant ratio (FLR). Radiation lobectomy (RL) with Y90-loaded microspheres (Y90) is hypothesized to induce comparable volumetric changes in liver lobes, while potentially controlling the liver tumor and limiting tumor progression in the untreated lobe. We aimed to test this concept by performing a comprehensive time-dependent analysis of liver volumes following radioembolization. 83 patients with right unilobar disease with hepatocellular carcinoma (HCC; N=67), cholangiocarcinoma (CC; N=8) or colorectal cancer (CRC; N=8) were treated by Y90 RL. The total liver volume, lobar (parenchymal) and tumor volumes, FLR and percentage of FLR hypertrophy from baseline (%FLR hypertrophy) were assessed on pre- and post-Y90 CT/MRI scans in a dynamic fashion. Right lobe atrophy (p=0.003), left lobe hypertrophy (p<0.001) and FLR hypertrophy (p<0.001) were observed 1 month after Y90 and was consistent at all follow-up timepoints. Median%FLR hypertrophy reached 45% (5-186) after 9 months (p<0.001). The median maximal%FLR hypertrophy was 26% (-14→86). Portal vein thrombosis was correlated to%FLR hypertrophy (p=0.02). Median Child-Pugh score worsening (6→7) was seen at 1 to 3 months (p=0.03) and 3 to 6 months (p=0.05) after treatment. Five patients underwent successful right lobectomy (HCC N=3, CRC N=1, CC N=1) and 6 HCCs were transplanted. Radiation lobectomy by Y90 is a safe and effective technique to hypertrophy the FLR. Volumetric changes are comparable (albeit slightly slower) to PVE while the right lobe tumor is treated synchronously. This novel technique is of particular interest in the bridge-to-resection setting.Journal of Hepatology 06/2013; · 9.86 Impact Factor
- [Show abstract] [Hide abstract]
ABSTRACT: OBJECTIVE: The purpose of this article is to describe the role of cross-sectional imaging before portal vein embolization, the normal imaging findings after the procedure, and the imaging findings of postprocedural complications. CONCLUSION: With the increasing emphasis on aggressive resection of hepatic malignancies, portal vein embolization has evolved into a leading technique. Radiologists need to be familiar with the normal imaging findings after this procedure and with the imaging findings of postprocedural complications.American Journal of Roentgenology 12/2012; 199(6):1275-82. · 2.90 Impact Factor
- [Show abstract] [Hide abstract]
ABSTRACT: To prevent hepatic failure after major hepatectomy, it is important to assess preoperative factors related to liver failure. We examined 80 patients who underwent right-sided hepatectomy. Hyperbilirubinemia, uncontrolled ascites, and prolonged postoperative hospital stay were defined as liver failure after hepatectomy, and these 3 factors were evaluated in relation to clinicopathological and surgical factors. In the 80 patients, hyperbilirubinemia was observed in 10 (12.7%) patients, uncontrolled ascites in 18 (22.5%) patients, and prolonged hospital stay after surgery in 39 (48.8%) patients. Multivariate analyses identified platelet count as a risk factor of hyperbilirubinemia, uncontrolled ascites, and prolonged postoperative hospital stay, and the ratio of remnant liver volume to body surface area (RLV/BSA ratio) as an additional risk factor of hyperbilirubinemia and prolonged postoperative hospital stay. Platelet count and RLV/BSA ratio are useful risk factors for prediction of liver failure after right-sided hepatectomy.American journal of surgery 07/2013; · 2.36 Impact Factor