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Safety and Efficacy of Portal Vein Embolization Before Planned Major or Extended Hepatectomy: An Institutional Experience of 358 Patients

  • 2013 SSAT Plenary Presentation
  • Published:
Journal of Gastrointestinal Surgery

Abstract

Introduction

Portal vein embolization (PVE) stimulates hypertrophy of the future liver remnant (FLR) and may improve the safety of extended hepatectomy. The efficacy of PVE was evaluated.

Methods

Records of 358 consecutive patients who underwent PVE before intended major hepatectomy at our institution from 1995 through 2012 were retrospectively reviewed.

Results

One hundred twelve patients (31.3 %) had right PVE alone; 235 (65.6 %) had right PVE plus segment IV embolization. The first-session PVE completion rate was 97.8 %. The PVE complication rate was 3.9 %. The median pre-PVE and post-PVE standardized FLRs were 19.5 % (interquartile range, 15.0–25.9) and 29.7 % (interquartile range, 22.5–38.2), respectively. Two hundred forty patients (67.0 %) underwent potentially curative resection. Sixty-two patients (25.8 %) had major post-hepatectomy complications; rates of postoperative hepatic insufficiency and 90-day liver-related mortality were 8.3 and 3.8 %, respectively. The proportion of patients with colorectal liver metastasis increased from 38.6 % before 2005 to 78.2 % in 2010–2012. Despite increased use of preoperative chemotherapy, postoperative hepatic insufficiency and 90-day liver-related mortality rates dropped from 10.6 and 4.1 %, respectively, before 2010 to 2.9 and 2.9 %, respectively, in 2010–2012.

Conclusions

PVE can be safely performed with minimal morbidity. Most patients can proceed to extended hepatectomy, which is associated with a minimal mortality rate.

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Acknowledgments

The University of Texas MD Anderson Cancer Center is supported in part by the National Institutes of Health through Cancer Center Support Grant CA016672.

Conflict of Interest

The authors have no conflicts of interest to disclose.

Author information

Authors and Affiliations

  1. Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcomb Boulevard, Unit 1484, Houston, TX, 77030, USA

    Junichi Shindoh, Ching-Wei D. Tzeng, Thomas A. Aloia, Steven A. Curley & Jean-Nicolas Vauthey

  2. Department of Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, Houston, USA

    Steven Y. Huang, Armeen Mahvash, Sanjay Gupta & Michael J. Wallace

Authors
  1. Junichi Shindoh
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  2. Ching-Wei D. Tzeng
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  3. Thomas A. Aloia
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  4. Steven A. Curley
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  6. Armeen Mahvash
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  7. Sanjay Gupta
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  9. Jean-Nicolas Vauthey
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Corresponding author

Correspondence to Jean-Nicolas Vauthey.

Additional information

Discussion

Dr. Jacques Belghiti (Clichy, France): Thank you for giving me the opportunity to review this superb, large, unicentric study. My comment is, you use sophisticated procedures including embolization of the segments IV in addition to right portal vein embolization, you confirm in line of the strategy that Jean-Nicolas Vauthey developed for more than 15 years (that it is safe, it is efficient), you have less than 25 % drop-out and especially in patients with colorectal liver metastases, and you showed that portal vein embolization does not affect long-term outcomes.

My questions:

How many patients in the whole series, with extensive fibrosis and cirrhosis, you have included?

Do you have any ideas whether portal vein embolization can overcome negative effects of chemotoxicity where patients will receive more than 12 weeks of chemotherapy or not? Should we apply portal vein embolization for patient with more than 30 % of future liver remnant?

Closing Discussant

Dr. Junichi Shindoh: Thank you Professor Belghiti for your important questions. Actually, more than 80 % of our series were colorectal liver metastases without liver fibrosis or cirrhosis. So, the number of patients with hepatocellular carcinoma was limited. But for the limited number of patients with liver fibrosis, we set the minimal requirement of FLR volumes as more than 40 % of standard liver volume as reported in Japanese series, and we have not experienced postoperative hepatic insufficiency for this patient group undergoing major hepatectomy. Regarding your second question, we have confirmed in our recent study that patients who underwent extended preoperative chemotherapy more than 12 weeks require more than 30 % of standardized future liver remnant (Shindoh J, Ann Surg Oncol 2013;20:2493-2500). However, for patients who underwent chemotherapy less than 12 weeks before surgery, our conventional criterion of 20 % is sufficient to prevent postoperative hepatic insufficiency or death from liver failure. So we think the cut-off value of “extensive” preoperative chemotherapy is 12 weeks, that is, six cycles of modern chemotherapy like FOLFOX or FOLFIRI, and more than 30 % of future liver remnant is needed for such patient.

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Shindoh, J., Tzeng, CW.D., Aloia, T.A. et al. Safety and Efficacy of Portal Vein Embolization Before Planned Major or Extended Hepatectomy: An Institutional Experience of 358 Patients. J Gastrointest Surg 18, 45–51 (2014). https://doi.org/10.1007/s11605-013-2369-0

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