Skip to main content
SpringerLink
Log in

Extended liver venous deprivation before major hepatectomy induces marked and very rapid increase in future liver remnant function

  • Interventional
  • Published:
European Radiology Aims and scope Submit manuscript

Abstract

Objective

The aim of this study was to assess the safety and efficacy of extended liver venous deprivation (eLVD), i.e. combination of right portal vein embolisation and right (accessory right) and middle hepatic vein embolisation before major hepatectomy for future remnant liver (FRL) functional increase.

Methods

eLVD was performed in non-cirrhotic patients referred for major hepatectomy in a context of small FRL (baseline FRL <25% of the total liver volume or FRL function <2.69%/min/m2). All patients underwent 99mTc-mebrofenin hepatobiliary scintigraphy (HBS) and computed tomographic evaluations.

Results

Ten consecutive patients underwent eLVD before surgery for liver metastases (n = 8), Klatskin tumour (n = 1) and gallbladder carcinoma (n = 1). FRL function increased by 64.3% (range = 28.1-107.5%) at day 21. In patients with serial measurements, maximum FRL function was at day 7 (+65.7 ± 16%). The FRL volume increased by +53.4% at 7 days (+25 ± 8 cc/day). Thirty-one days (range = 22-45 days) after eLVD, 9/10 patients were resected. No post-hepatectomy liver failure was reported. Two grade II and one grade III complications (Dindo-Clavien classification) occurred. No patient died with-in 90 days following surgery.

Conclusions

eLVD is safe and provides a marked and very rapid increase in liver function, unprecedented for an interventional radiology procedure.

Key Points

• eLVD is safe

• eLVD provides a marked and very rapid increase in liver function

• After eLVD, the FRL-F increased by 64.3% (28.1-107.5%) at day 21

• After eLVD, the maximum FRL-F was obtained at day 7 (+65.7 ± 16%)

• After eLVD, the FRL volume increased by +53.4% at 7 days (+25 ± 8 cc/day)

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5

Similar content being viewed by others

Abbreviations

CT:

Computed tomography

PVE:

portal vein embolisation

FRL:

future remnant liver

FRL-V:

future remnant liver volume

FRL-F:

future remnant liver function

HV:

hepatic vein

HVE:

hepatic vein embolisation

ALPPS:

associating liver partition and portal vein ligation for staged hepatectomy

MHV:

middle hepatic vein

PHLF:

post-hepatectomy liver failure

LVD:

liver venous deprivation

eLVD:

extended liver venous deprivation

HBS:

hepatobiliary scintigraphy

AST:

aspartate aminotransferase

ALT:

serum alanine aminotransferase

GGT:

gamma-glutamyl-transpeptidase

ALP:

alkaline phosphatase

PT:

prothrombin time

LDLT:

living donor liver transplantation

References

  1. Abulkhir A, Limongelli P, Healey AJ et al (2008) Preoperative portal vein embolization for major liver resection: a meta-analysis. Ann Surg 247:49–57

    Article  PubMed  Google Scholar 

  2. de Graaf W, van Lienden KP, van den Esschert JW, Bennink RJ, van Gulik TM (2011) Increase in future remnant liver function after preoperative portal vein embolization. Br J Surg 98:825–834

    Article  PubMed  Google Scholar 

  3. Asencio JM, Vaquero J, Olmedilla L, Garcia Sabrido JL (2013) "Small-for-flow" syndrome: shifting the "size" paradigm. Med Hypotheses 80:573–577

    Article  CAS  PubMed  Google Scholar 

  4. Cieslak KP, Olthof PB, van Lienden KP et al (2015) Assessment of liver function using (99m)Tc-mebrofenin hepatobiliary scintigraphy in ALPPS (associating liver partition and portal vein ligation for staged hepatectomy). Case Rep Gastroenterol 9:353–360

    Article  PubMed  PubMed Central  Google Scholar 

  5. Zappa M, Dondero F, Sibert A, Vullierme MP, Belghiti J, Vilgrain V (2009) Liver regeneration at day 7 after right hepatectomy: global and segmental volumetric analysis by using CT. Radiology 252:426–432

    Article  PubMed  Google Scholar 

  6. van Lienden KP, van den Esschert JW, de Graaf W et al (2013) Portal vein embolization before liver resection: a systematic review. Cardiovasc Intervent Radiol 36:25–34

    Article  PubMed  Google Scholar 

  7. Pommier R, Ronot M, Cauchy F et al (2014) Colorectal liver metastases growth in the embolized and non-embolized liver after portal vein embolization: influence of initial response to induction chemotherapy. Ann Surg Oncol 21:3077–3083

    Article  PubMed  Google Scholar 

  8. Schnitzbauer AA, Lang SA, Goessmann H et al (2012) Right portal vein ligation combined with in situ splitting induces rapid left lateral liver lobe hypertrophy enabling 2-staged extended right hepatic resection in small-for-size settings. Ann Surg 255:405–414

    Article  PubMed  Google Scholar 

  9. Schadde E, Raptis DA, Schnitzbauer AA et al (2015) Prediction of mortality after ALPPS stage-1: an analysis of 320 patients from the International ALPPS Registry. Ann Surg 262:780–785, discussion 785-786

    Article  PubMed  Google Scholar 

  10. Hwang S, Lee SG, Ko GY et al (2009) Sequential preoperative ipsilateral hepatic vein embolization after portal vein embolization to induce further liver regeneration in patients with hepatobiliary malignancy. Ann Surg 249:608–616

    Article  PubMed  Google Scholar 

  11. Guiu B, Chevallier P, Denys A et al (2016) Simultaneous trans-hepatic portal and hepatic vein embolization before major hepatectomy: the liver venous deprivation technique. Eur Radiol. doi:10.1007/s00330-016-4291-9

    Google Scholar 

  12. Nakamura S, Tsuzuki T (1981) Surgical anatomy of the hepatic veins and the inferior vena cava. Surg Gynecol Obstet 152:43–50

    CAS  PubMed  Google Scholar 

  13. Sano K, Makuuchi M, Miki K et al (2002) Evaluation of hepatic venous congestion: proposed indication criteria for hepatic vein reconstruction. Ann Surg 236:241–247

    Article  PubMed  PubMed Central  Google Scholar 

  14. Akamatsu N, Sugawara Y, Kaneko J et al (2003) Effects of middle hepatic vein reconstruction on right liver graft regeneration. Transplantation 76:832–837

    Article  PubMed  Google Scholar 

  15. de Graaf W, Bennink RJ, Vetelainen R, van Gulik TM (2010) Nuclear imaging techniques for the assessment of hepatic function in liver surgery and transplantation. J Nucl Med 51:742–752

    Article  PubMed  Google Scholar 

  16. Petrowsky H (2016) Does volume translate in function in interstage associating liver partition and portal vein ligation for staged hepatectomy?: Commentary on "Drop of total liver function in the interstages of the new associating liver partition and portal vein ligation for staged hepatectomy technique: analysis of the auxiliary liver by hepatobiliary iminodiacetic acid scintigraphy". Ann Surg 263, e35

    Article  PubMed  Google Scholar 

  17. de Graaf W, van Lienden KP, Dinant S et al (2010) Assessment of future remnant liver function using hepatobiliary scintigraphy in patients undergoing major liver resection. J Gastrointest Surg 14:369–378

    Article  PubMed  Google Scholar 

  18. Truant S, Baillet C, Deshorgue AC et al (2016) Drop of total liver function in the interstages of the new associating liver partition and portal vein ligation for staged hepatectomy technique: analysis of the "Auxiliary Liver" by HIDA scintigraphy. Ann Surg 263:e33–34

    Article  PubMed  Google Scholar 

  19. Oldhafer F, Ringe KI, Timrott K et al (2016) Monitoring of liver function in a 73-year old patient undergoing 'Associating Liver Partition and Portal vein ligation for Staged hepatectomy': case report applying the novel liver maximum function capacity test. Patient Saf Surg 10:16

    Article  PubMed  PubMed Central  Google Scholar 

  20. Truant S, Baillet C, Deshorgue AC et al (2016) Hepatobiliary scintigraphy in ALPPS: a response. Ann Surg. doi:10.1097/SLA.0000000000001941

    Google Scholar 

  21. Shindoh J, Vauthey JN, Zimmitti G et al (2013) Analysis of the efficacy of portal vein embolization for patients with extensive liver malignancy and very low future liver remnant volume, including a comparison with the associating liver partition with portal vein ligation for staged hepatectomy approach. J Am Coll Surg 217:126–133, discussion 133-124

    Article  PubMed  Google Scholar 

  22. Bennink RJ, Dinant S, Erdogan D et al (2004) Preoperative assessment of postoperative remnant liver function using hepatobiliary scintigraphy. J Nucl Med 45:965–971

    PubMed  Google Scholar 

  23. Ekman M, Fjälling M, Friman S, Carlson S, Volkmann R (1996) Liver uptake function measured by IODIDA clearance rate in liver transplant patients and healthy volunteers. Nucl Med Commun 17:235–242

    Article  CAS  PubMed  Google Scholar 

  24. Croome KP, Hernandez-Alejandro R, Parker M, Heimbach J, Rosen C, Nagorney DM (2015) Is the liver kinetic growth rate in ALPPS unprecedented when compared with PVE and living donor liver transplant? A multicentre analysis. HPB (Oxford) 17:477–484

    Article  Google Scholar 

  25. Scatton O, Plasse M, Dondero F, Vilgrain V, Sauvanet A, Belghiti J (2008) Impact of localized congestion related to venous deprivation after hepatectomy. Surgery 143:483–489

    Article  PubMed  Google Scholar 

  26. De Baere T, Roche A, Elias D, Lasser P, Lagrange C, Bousson V (1996) Preoperative portal vein embolization for extension of hepatectomy indications. Hepatology 24:1386–1391

    Article  PubMed  Google Scholar 

  27. Guiu B, Bize P, Gunthern D, Demartines N, Halkic N, Denys A (2013) Portal vein embolization before right hepatectomy: improved results using n-Butyl-Cyanoacrylate compared to microparticles plus coils. Cardiovasc Intervent Radiol. doi:10.1007/s00270-013-0565-7

    Google Scholar 

  28. Balzan S, Belghiti J, Farges O et al (2005) The "50-50 criteria" on postoperative day 5: an accurate predictor of liver failure and death after hepatectomy. Ann Surg 242:824–828, discussion 828-829

    Article  PubMed  PubMed Central  Google Scholar 

  29. Mullen JT, Ribero D, Reddy SK et al (2007) Hepatic insufficiency and mortality in 1,059 noncirrhotic patients undergoing major hepatectomy. J Am Coll Surg 204:854–862, discussion 862-854

    Article  PubMed  Google Scholar 

  30. Clavien PA, Barkun J, de Oliveira ML et al (2009) The Clavien-Dindo classification of surgical complications: five-year experience. Ann Surg 250:187–196

    Article  PubMed  Google Scholar 

  31. Mise Y, Hasegawa K, Satou S et al (2011) Venous reconstruction based on virtual liver resection to avoid congestion in the liver remnant. Br J Surg 98:1742–1751

    Article  CAS  PubMed  Google Scholar 

  32. Ko GY, Hwang S, Sung KB, Gwon DI, Lee SG (2010) Interventional oncology: new options for interstitial treatments and intravascular approaches: right hepatic vein embolization after right portal vein embolization for inducing hypertrophy of the future liver remnant. J Hepatobiliary Pancreat Sci 17:410–412

    Article  PubMed  Google Scholar 

  33. Schadde E, Ardiles V, Slankamenac K et al (2014) ALPPS offers a better chance of complete resection in patients with primarily unresectable liver tumors compared with conventional-staged hepatectomies: results of a multicenter analysis. World J Surg 38:1510–1519

    Article  PubMed  Google Scholar 

  34. Truant S, Scatton O, Dokmak S et al (2015) Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS): impact of the inter-stages course on morbi-mortality and implications for management. Eur J Surg Oncol 41:674–682

    Article  CAS  PubMed  Google Scholar 

  35. Buac S, Schadde E, Schnitzbauer AA, Vogt K, Hernandez-Alejandro R (2016) The many faces of ALPPS: surgical indications and techniques among surgeons collaborating in the international registry. HPB (Oxford) 18:442–448

    Article  Google Scholar 

  36. Dinant S, de Graaf W, Verwer BJ et al (2007) Risk assessment of posthepatectomy liver failure using hepatobiliary scintigraphy and CT volumetry. J Nucl Med 48:685–692

    Article  PubMed  Google Scholar 

  37. Erdogan D, Heijnen BHM, Bennink RJ et al (2004) Preoperative assessment of liver function: a comparison of 99mTc-mebrofenin scintigraphy with indocyanine green clearance test. Liver Int 24:117–123

    Article  CAS  PubMed  Google Scholar 

  38. Dinant S, Graaf W, Verwer BJ et al (2007) Risk assessment of posthepatectomy liver failure using hepatobiliary scintigraphy and CT volumetry. J Nucl Med 48:685–692

    Article  PubMed  Google Scholar 

  39. Kwon AH, Matsui Y, Kaibori M, Kamiyama Y (2004) Functional hepatic regeneration following hepatectomy using galactosyl-human serum albumin liver scintigraphy. Transplant Proc 36:2257–2260

    Article  PubMed  Google Scholar 

  40. Imai K, Benitez CC, Allard MA et al (2015) Failure to achieve a 2-stage hepatectomy for colorectal liver metastases: how to prevent it? Ann Surg 262:772–778, discussion 778-779

    Article  PubMed  Google Scholar 

Download references

Acknowledgements

The authors thank Dr. Hélène de Forges for editing and writing assistance, Dr. Julie Carr for revising the English, Dr. Raphael Tetreau for the CT-scan acquisitions and Prof. Samir Jaber for his helpful assistance.

Author information

Authors and Affiliations

  1. Department of Radiology, St-Eloi University Hospital, 34980, Montpellier, France

    Boris Guiu, Laure Escal & Lauranne Piron

  2. INSERM U1194, Montpellier Cancer Research Institute, 34298, Montpellier, France

    Boris Guiu, Pierre-Olivier Kotzki & Emmanuel Deshayes

  3. Department of Radiology, St-Eloi University Hospital, 80 avenue Augustin Fliche, 34295, Montpellier, France

    Boris Guiu

  4. Department of Surgery, Institut du Cancer de Montpellier (ICM), 34298, Montpellier, France

    François Quenet & Philippe Rouanet

  5. Department of Pathology, Institut du Cancer de Montpellier (ICM), 34298, Montpellier, France

    Frédéric Bibeau

  6. Department of Surgery, St-Eloi University Hospital, 34295, Montpellier, France

    Jean-Michel Fabre

  7. Department of Surgery, Beausoleil Clinic, 34980, Montpellier, France

    Eric Jacquet

  8. Department of Radiology, CHUV, Lausanne, Switzerland

    Alban Denys

  9. Department of Nuclear Medicine, Institut du Cancer de Montpellier (ICM), 34298, Montpellier, France

    Pierre-Olivier Kotzki & Emmanuel Deshayes

  10. Department of Anesthesiology, St-Eloi University Hospital, 34980, Montpellier, France

    Daniel Verzilli

Authors
  1. Boris Guiu
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. François Quenet
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Laure Escal
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Frédéric Bibeau
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Lauranne Piron
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Philippe Rouanet
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Jean-Michel Fabre
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Eric Jacquet
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Alban Denys
    View author publications

    You can also search for this author in PubMed Google Scholar

  10. Pierre-Olivier Kotzki
    View author publications

    You can also search for this author in PubMed Google Scholar

  11. Daniel Verzilli
    View author publications

    You can also search for this author in PubMed Google Scholar

  12. Emmanuel Deshayes
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Boris Guiu.

Ethics declarations

Guarantor

The scientific guarantor of this publication is Prof. Boris Guiu.

Conflict of interest

The authors of this manuscript declare no relationships with any companies, whose products or services may be related to the subject matter of the article.

Funding

The authors state that this work has not received any funding.

Statistics and biometry

No complex statistical methods were necessary for this paper.

Ethical approval

Institutional Review Board approval was obtained.

Informed consent

Written informed consent was waived by the Institutional Review Board.

Methodology

• retrospective

• observational study

• performed at one institution

Electronic supplementary material

Below is the link to the electronic supplementary material.

ESM 1

(DOCX 23 kb)

ESM 2

(DOCX 22 kb)

ESM 3

(DOCX 19 kb)

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Guiu, B., Quenet, F., Escal, L. et al. Extended liver venous deprivation before major hepatectomy induces marked and very rapid increase in future liver remnant function. Eur Radiol 27, 3343–3352 (2017). https://doi.org/10.1007/s00330-017-4744-9

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00330-017-4744-9

Keywords

Search

Navigation