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Kuhn TN, Engelhardt WD, Kahl VH, Alkukhun A, Gross M, Iseke S, Onofrey J, Covey A, Camacho JC, Kawaguchi Y, Hasegawa K, Odisio BC, Vauthey JN, Antoch G, Chapiro J, Madoff DC. Artificial Intelligence-Driven Patient Selection for Preoperative Portal Vein Embolization for Patients with Colorectal Cancer Liver Metastases. J Vasc Interv Radiol 2025; 36:477-488. [PMID: 39638087 DOI: 10.1016/j.jvir.2024.11.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2024] [Revised: 10/24/2024] [Accepted: 11/22/2024] [Indexed: 12/07/2024] Open
Abstract
PURPOSE To develop a machine learning algorithm to improve hepatic resection selection for patients with metastatic colorectal cancer (CRC) by predicting post-portal vein embolization (PVE) outcomes. MATERIALS AND METHODS This multicenter retrospective study (2000-2020) included 200 consecutive patients with CRC liver metastases planned for PVE before surgery. Data on radiomic features and laboratory values were collected. Patient-specific eigenvalues for each liver shape were calculated using a statistical shape model approach. After semiautomatic segmentation and review by a board-certified radiologist, the data were split 70%/30% for training and testing. Three machine learning algorithms predicting the total liver volume (TLV) after PVE, sufficient future liver remnant (FLR%), and kinetic growth rate (KGR%) were trained, with performance assessed using accuracy, sensitivity, specificity, area under the curve (AUC), or root mean squared error. Significance between the internal and external test sets was assessed by the Student t-test. One institution was kept separate as an external testing set. RESULTS A total of 114 (76 men; mean age, 56 years [SD± 12]) and 37 (19 men; mean age, 50 years ± [SD± 11]) patients met the inclusion criteria for the internal validation and external validation, respectively. Prediction accuracy and AUC for sufficient FLR% or liver growth potential (KGR%> 0%) were high in the internal testing set-85.81% (SD ± 1.01) and 0.91 (SD ± 0.01) or 87.44% (SD ± 0.10) and 0.66 (SD ± 0.03), respectively. Similar results occurred in the external testing set-79.66% (SD ± 0.60) and 0.88 (SD ± 0.00) or 72.06% (SD ± 0.30) and 0.69 (SD ± 0.01), respectively. TLV prediction showed discrepancy rates of 12.56% (SD ±4.20%; P = .86) internally and 13.57% (SD ± 3.76%; P = .91) externally. CONCLUSIONS Machine learning-based models incorporating radiomics and laboratory test results may help predict the FLR%, KGR%, and TLV as metrics for successful PVE.
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Affiliation(s)
- Tom N Kuhn
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, Connecticut; Department of Diagnostic and Interventional Radiology, University Düsseldorf, Medical Faculty, Düsseldorf, Germany
| | - William D Engelhardt
- Department of Biomedical Engineering, James McKlevey School of Engineering, Washington University, St. Louis, Missouri
| | - Vinzent H Kahl
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, Connecticut; Department of Radiology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität, and Berlin Institute of Health, Berlin, Germany
| | - Abedalrazaq Alkukhun
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, Connecticut
| | - Moritz Gross
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, Connecticut; Department of Radiology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität, and Berlin Institute of Health, Berlin, Germany
| | - Simon Iseke
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, Connecticut; Department of Diagnostic and Interventional Radiology, Pediatric Radiology and Neuroradiology, Rostock University Medical Center, Rostock, Germany
| | - John Onofrey
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, Connecticut; Department of Biomedical Engineering, Yale University, New Haven, Connecticut; Department of Urology, Yale School of Medicine, New Haven, Connecticut
| | - Anne Covey
- Interventional Radiology Service, Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Juan C Camacho
- Department of Clinical Sciences, Florida State University College of Medicine, Tallahassee, Florida
| | - Yoshikuni Kawaguchi
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Kiyoshi Hasegawa
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Bruno C Odisio
- Department of Interventional Radiology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jean-Nicolas Vauthey
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Gerald Antoch
- Department of Diagnostic and Interventional Radiology, University Düsseldorf, Medical Faculty, Düsseldorf, Germany
| | - Julius Chapiro
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, Connecticut; Department of Biomedical Engineering, Yale University, New Haven, Connecticut; Department of Internal Medicine, Section of Digestive Diseases, Yale School of Medicine, New Haven, Connecticut
| | - David C Madoff
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, Connecticut; Department of Internal Medicine, Section of Medical Oncology, Yale School of Medicine, New Haven, Connecticut; Department of Surgery, Section of Surgical Oncology, Yale School of Medicine, New Haven, Connecticut.
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Nakanuma S, Ogi T, Sugita H, Gabata R, Tokoro T, Takei R, Kato K, Takada S, Okazaki M, Makino I, Yagi S. Impact of aging on hepatic reserve after preoperative portal vein embolization in hepatectomy for perihilar cholangiocarcinoma. Asian J Surg 2024:S1015-9584(24)02485-0. [PMID: 39681505 DOI: 10.1016/j.asjsur.2024.10.152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2024] [Revised: 09/26/2024] [Accepted: 10/10/2024] [Indexed: 12/18/2024] Open
Abstract
PURPOSE In the current situation of an increasing older adult population with perihilar cholangiocarcinoma (PHCC), the benefits and risks of surgical treatment of PHCC in older people remain controversial. Portal vein embolization (PVE) is a useful preoperative procedure to improve hepatic reserve in the future remnant liver (FRL) and avoid postoperative liver failure after extended hepatectomy for PHCC. This study aimed to evaluate the influence of aging on PVE. METHODS We enrolled 25 patients who underwent right hepatectomy with percutaneous transhepatic PVE. Participants aged <70 years (n = 13) and ≥70 years (n = 12) were compared; correlation coefficients were evaluated using all cases. The FRL volume/total liver volume (FRLV/TLV) ratio and the indocyanine green (ICG) clearance rate (ICG-K) fraction of FRL to total liver (ICG-Krem) were analyzed as FRL hepatic reserves. RESULTS FRLV/TLV ratio increased after PVE in <70 years and ≥70 years groups (p = 0.002 and p = 0.013, respectively). The change in ICG-K values from before to after PVE varied between both groups (p = 0.040). The ICG-Krem value after PVE increased only in the <70 years group (p = 0.009). A review of all cases showed a negative correlation between the change (after - before PVE) in the ICG-K and ICG-Krem values and age (r = -0.4827, p = 0.0145 and r = -0.4328, p = 0.0306, respectively). CONCLUSIONS This study showed aging suppresses hepatic reserve improvement in the FRL, particularly in ICG clearance after PVE in PHCC cases.
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Affiliation(s)
- Shinichi Nakanuma
- Department of Hepato-Biliary-Pancreatic Surgery and Transplantation, Kanazawa University, 13-1 Takara-machi, Kanazawa, Ishikawa, 920-8641, Japan.
| | - Takahiro Ogi
- Department of Radiology, Kanazawa University Graduate School of Medical Sciences, 13-1 Takara-machi, Kanazawa, Ishikawa, 920-8641, Japan
| | - Hiroaki Sugita
- Department of Hepato-Biliary-Pancreatic Surgery and Transplantation, Kanazawa University, 13-1 Takara-machi, Kanazawa, Ishikawa, 920-8641, Japan
| | - Ryosuke Gabata
- Department of Hepato-Biliary-Pancreatic Surgery and Transplantation, Kanazawa University, 13-1 Takara-machi, Kanazawa, Ishikawa, 920-8641, Japan
| | - Tomokazu Tokoro
- Department of Hepato-Biliary-Pancreatic Surgery and Transplantation, Kanazawa University, 13-1 Takara-machi, Kanazawa, Ishikawa, 920-8641, Japan
| | - Ryohei Takei
- Department of Hepato-Biliary-Pancreatic Surgery and Transplantation, Kanazawa University, 13-1 Takara-machi, Kanazawa, Ishikawa, 920-8641, Japan
| | - Kaichiro Kato
- Department of Hepato-Biliary-Pancreatic Surgery and Transplantation, Kanazawa University, 13-1 Takara-machi, Kanazawa, Ishikawa, 920-8641, Japan
| | - Satoshi Takada
- Department of Hepato-Biliary-Pancreatic Surgery and Transplantation, Kanazawa University, 13-1 Takara-machi, Kanazawa, Ishikawa, 920-8641, Japan
| | - Mitsuyoshi Okazaki
- Department of Hepato-Biliary-Pancreatic Surgery and Transplantation, Kanazawa University, 13-1 Takara-machi, Kanazawa, Ishikawa, 920-8641, Japan
| | - Isamu Makino
- Department of Hepato-Biliary-Pancreatic Surgery and Transplantation, Kanazawa University, 13-1 Takara-machi, Kanazawa, Ishikawa, 920-8641, Japan
| | - Shintaro Yagi
- Department of Hepato-Biliary-Pancreatic Surgery and Transplantation, Kanazawa University, 13-1 Takara-machi, Kanazawa, Ishikawa, 920-8641, Japan
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Sakuhara Y. Preoperative Portal Vein Embolization: Basics Interventional Radiologists Need to Know. INTERVENTIONAL RADIOLOGY (HIGASHIMATSUYAMA-SHI (JAPAN) 2024; 9:134-141. [PMID: 39559802 PMCID: PMC11570156 DOI: 10.22575/interventionalradiology.2022-0024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/19/2022] [Accepted: 07/28/2022] [Indexed: 11/20/2024]
Abstract
One of the major reasons for unresectability of the liver is that the remnant liver volume is insufficient to support postoperative liver function. Post-hepatectomy liver insufficiency is one of the most serious complications in patients undergoing major hepatic resection. Preoperative portal vein embolization is performed with the aim of inducing hypertrophy of the future liver remnant and is thought to reduce the risk of liver insufficiency after hepatectomy. We, interventional radiologists, are required to safely complete the procedure to promote future liver remnant hypertrophy as possible and understand portal vein anatomy variations and hemodynamics, embolization techniques, and how to deal with possible complications. The basic information interventional radiologists need to know about preoperative portal vein embolization is discussed in this review.
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Affiliation(s)
- Yusuke Sakuhara
- Department of Diagnostic and Interventional Radiology, KKR Tonan Hospital, Japan
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Chan SM, Cornman-Homonoff J, Lucatelli P, Madoff DC. Image-guided percutaneous strategies to improve the resectability of HCC: Portal vein embolization, liver venous deprivation, or radiation lobectomy? Clin Imaging 2024; 111:110185. [PMID: 38781614 DOI: 10.1016/j.clinimag.2024.110185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 04/20/2024] [Accepted: 05/08/2024] [Indexed: 05/25/2024]
Abstract
Despite considerable advances in surgical technique, many patients with hepatic malignancies are not operative candidates due to projected inadequate hepatic function following resection. Consequently, the size of the future liver remnant (FLR) is an essential consideration when predicting a patient's likelihood of liver insufficiency following hepatectomy. Since its initial description 30 years ago, portal vein embolization has become the standard of care for augmenting the size and function of the FLR preoperatively. However, new minimally invasive techniques have been developed to improve surgical candidacy, chief among them liver venous deprivation and radiation lobectomy. The purpose of this review is to discuss the status of preoperative liver augmentation prior to resection of hepatocellular carcinoma with a focus on these three techniques, highlighting the distinctions between them and suggesting directions for future investigation.
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Affiliation(s)
- Shin Mei Chan
- Department of Radiology & Biomedical Imaging, University of California San Francisco, San Francisco, CA, USA; Department of Radiology and Biomedical Imaging, Section of Interventional Radiology, Yale School of Medicine, New Haven, CT, USA
| | - Joshua Cornman-Homonoff
- Department of Radiology and Biomedical Imaging, Section of Interventional Radiology, Yale School of Medicine, New Haven, CT, USA
| | - Pierleone Lucatelli
- Department of Radiological, Oncological, and Pathological Sciences, Sapienza University of Rome, Rome, Italy
| | - David C Madoff
- Department of Radiology and Biomedical Imaging, Section of Interventional Radiology, Yale School of Medicine, New Haven, CT, USA; Department of Medicine, Section of Medical Oncology, Yale School of Medicine, New Haven, CT, USA; Department of Surgery, Section of Surgical Oncology, Yale School of Medicine, New Haven, CT, USA.
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Malik AK, Mahendran B, Lochan R, White SA. Liver Transplantation for Nonresectable Colorectal Liver Metastases (CRLM). Indian J Surg Oncol 2024; 15:255-260. [PMID: 38818008 PMCID: PMC11133248 DOI: 10.1007/s13193-023-01827-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 09/28/2023] [Indexed: 06/01/2024] Open
Abstract
Transplantation represents the most radical locoregional therapy through removal of the liver, associated vasculature and locoregional lymph nodes, and replacing it with an allograft. Recent evidence has demonstrated that transplantation for unresectable CRLM is feasible with acceptable post-transplant outcomes in a highly selected cohort of patients. Controversy exists regarding whether transplantation is an appropriate treatment for such patients, due to concerns regarding disease recurrence in the transplanted graft in an immunosuppressed recipient along with utilising a donor liver which are in short supply. Expanding the indications for liver transplantation may also limit access for other patients with end-stage liver disease having ethical implications due to the effect of increasing the waiting list. In this review, we summarise the current evidence for liver transplantation in patients with nonresectable CRLM and highlight unresolved controversies and future directions for this type of treatment.
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Affiliation(s)
- Abdullah K. Malik
- Institute of Transplantation, Freeman Hospital, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
- NIHR Blood and Transplant Research Unit, Newcastle University, Newcastle Upon Tyne, UK
| | - Balaji Mahendran
- Institute of Transplantation, Freeman Hospital, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
- NIHR Blood and Transplant Research Unit, Newcastle University, Newcastle Upon Tyne, UK
| | - Rajiv Lochan
- Department of Hepatobiliary and Liver Transplantation Surgery, Manipal Hospitals, Bangalore, India
| | - Steven A. White
- Institute of Transplantation, Freeman Hospital, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
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Living Donor Liver Transplantation as a Backup Procedure: Treatment Strategy for Hepatocellular Adenomas Requiring Complex Resections. Case Rep Surg 2022; 2022:1015061. [PMID: 35223125 PMCID: PMC8872689 DOI: 10.1155/2022/1015061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 02/08/2022] [Indexed: 11/17/2022] Open
Abstract
Background & Aims. The most dangerous complications of hepatocellular adenomas are hemorrhage and malignant transformation, both of which require surgical treatment. The surgical treatment strategy for patients with benign large or central tumors is challenging because complex liver resections are required. The strategy of using a live donor as a backup procedure is described in this series. Methods. We present a series of three patients with large hepatocellular adenoma lesions showing a central location, for which the living donor liver transplantation strategy was used as a backup procedure. Results. Hepatocellular adenoma was confirmed by biopsy in all patients. Surgical resection was indicated because of the patients’ symptoms and lesion size and growth. All patients had a lesion that was central or in close contact with major vessels. The final decision to proceed with the resection was made intraoperatively. A live donor was prepared for all three patients. Two patients underwent portal vein embolization associated with extended hepatectomy, and a total hepatectomy plus liver transplantation with a living donor was performed in one patient. All patients had good postoperative outcomes. Conclusions. In the treatment of hepatocellular adenomas for which complex resections are necessary and resectability can only be confirmed intraoperatively, surgical safety can be improved through the use of a living donor backup. Center expertise with living donor liver transplantation is paramount for the success of this approach.
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Impact of preoperative biliary drainage on postoperative outcomes in hilar cholangiocarcinoma. Asian J Surg 2021; 45:993-1000. [PMID: 34588138 DOI: 10.1016/j.asjsur.2021.07.075] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 03/19/2021] [Accepted: 07/21/2021] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND/OBJECTIVE Complete resection is the most effective treatment of hilar cholangiocarcinoma (HC) but may result in high morbidity and mortality. Most HC patients have jaundice, and preoperative biliary drainage may reduce their risk of obstructive jaundice. ERCP and PTBD have been advocated for this purpose. This retrospective study investigated the influence of ERCP versus PTBD versus their combination on the short-term outcomes of curative HC resection. METHODS Patients having curative HC resection with preoperative biliary drainage in a span of 26 years were reviewed and divided into groups according to drainage modality. Drainage-related and surgical complications and hospital mortality were compared between groups. Intention-to-treat analysis using a separate set of initial drainage data was performed. RESULTS Eighty-six patients were divided into: Group A, ERCP only, n = 32 (32/86 = 37.2%); Group B, PTBD only, n = 10 (10/86 = 11.6%); Group C, ERCP + PTBD, n = 44 (44/86 = 51.2%). International normalized ratio was significantly higher in Group B (p = 0.008). The three groups were comparable in operative details, hospital stay, and mortality. Fifty-two patients had postoperative complications. Significantly more patients in Groups A and C had subphrenic abscess (A: 25%, B: 0%, C: 9.1%; p = 0.035) and subsequent radiological drainage. Group A had insignificantly more patients with wound infection (31.3% vs 10% vs 22.7%, p = 0.334), chest infection (28.1% vs 20% vs 11.4%, p = 0.178), and urinary tract infection (6.3% vs 0% vs 0%, p = 0.133). The three groups had similar rates of major complications (p = 0.501). They also had comparable survival outcomes (overall, p = 0.370; disease-free, p = 0.569). Fifteen and 71 patients received PTBD and ERCP respectively as first drainage mode. These two groups were comparable in liver function, preoperative comorbidity, intraoperative details, and postoperative outcomes. CONCLUSION In the preoperative management of HC, the use of ERCP, PTBD or their combination is acceptable and can optimize patients' condition for curative HC resection.
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Liu F, Hu HJ, Ma WJ, Wang JK, Ran CD, Regmi P, Li FY. Is radical resection of hilar cholangiocarcinoma plus partial resection of pancreatic head justified for advanced hilar cholangiocarcinoma? ANZ J Surg 2020; 90:1666-1670. [PMID: 32452116 DOI: 10.1111/ans.15955] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Revised: 04/13/2020] [Accepted: 04/19/2020] [Indexed: 02/05/2023]
Abstract
BACKGROUND To outline our experience with the radical resection of hilar cholangiocarcinoma (HCCA) combined with the partial resection of the pancreatic head (RRHCCAPRPH) as a treatment for HCCA with distal bile duct involvement and to appraise the feasibility of this challenging procedure. METHODS Between 2007 and 2017, 205 patients with HCCA who underwent curative surgery at our hospital were included. Among the patients, extrahepatic bile duct resection combined with hepatectomy (EBDRH), RRHCCAPRPH and hepatopancreaticoduodenectomy (HPD) was performed in 168, 21 and 16 patients, respectively. Clinical pathological factors, post-operative complications and survival were compared between the three groups. RESULTS There was a significant difference in operative blood loss, operative time, post-operative hospital stay and tumour size between EBDRH group, RRHCCAPRPH group and HPD group (P < 0.05). In terms of post-operative complications, there was no statistical difference between the three groups (P = 0.177). Further analysis showed that the incidence of pancreatic fistula (43.8%) and delayed gastric emptying (25%) after HPD were significantly higher than the other two groups. The median survival time and overall survival rate for 172 patients with R0 resection were 33 months and 85.5% at 1 year, 47.7% at 3 years, 28.4% at 5 years. Furthermore, the 1-, 3- and 5-year survival rates of patients with EBDRH, RRHCCAPRPH and HPD after R0 resection were 86.2%, 48.7%, 29.2%; 85.0%, 44.0%, 24.7% and 78.6%, 42.9%, 22.9%, respectively (P = 0.948). CONCLUSION The RRHCCAPRPH in some selected patients can actually replace HPD as a surgical treatment for HCCA with distal bile duct involvement.
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Affiliation(s)
- Fei Liu
- Department of Biliary Surgery, West China Hospital of Sichuan University, Chengdu, China
| | - Hai-Jie Hu
- Department of Biliary Surgery, West China Hospital of Sichuan University, Chengdu, China
| | - Wen-Jie Ma
- Department of Biliary Surgery, West China Hospital of Sichuan University, Chengdu, China
| | - Jun-Ke Wang
- Department of Biliary Surgery, West China Hospital of Sichuan University, Chengdu, China
| | - Cong-Dun Ran
- Department of Biliary Surgery, West China Hospital of Sichuan University, Chengdu, China
| | - Parbatraj Regmi
- Department of Biliary Surgery, West China Hospital of Sichuan University, Chengdu, China
| | - Fu-Yu Li
- Department of Biliary Surgery, West China Hospital of Sichuan University, Chengdu, China
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Balci D, Sakamoto Y, Li J, Di Benedetto F, Kirimker EO, Petrowsky H. Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) procedure for cholangiocarcinoma. Int J Surg 2020; 82S:97-102. [PMID: 32645441 DOI: 10.1016/j.ijsu.2020.06.045] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Accepted: 06/26/2020] [Indexed: 12/15/2022]
Abstract
Perihilar cholangiocarcinoma (PHCC) has been a great challenge for surgeons, requiring advanced skills and expertise and was often associated with high morbidity and mortality. Resectability rates are up to 75% even in experienced centers. In patients with PHCC, radical liver and bile duct resection aiming R0 surgical margins offers the best long-term survival. Therefore, extensive resections with low FLR are commonly needed and PVE is offered to induce remnant liver hypertrophy for a long period. Associating liver partition with portal vein ligation for staged hepatectomy (ALPPS) is considered a promising approach inducing rapid remnant hypertrophy to prevent dropouts due to complications or tumor progression and increase resectability. Although poor results were reported initially, refinements in technique and risk adjustment of patient selection improved outcomes. The procedure is still under debate for the indication of PHCC. This article reviews the current literature on ALPPS in treatment of perihilar and intrahepatic cholangiocarcinoma.
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Affiliation(s)
- Deniz Balci
- Department of Surgery and Liver Transplantation Unit, Ankara University School of Medicine, Ankara, Turkey.
| | - Yoshihiro Sakamoto
- Department of Hepato-Biliary-Pancreatic Surgery, Kyorin University Hospital, Japan.
| | - Jun Li
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| | - Fabrizio Di Benedetto
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University of Modena and Reggio Emilia, Modena, Italy.
| | - Elvan Onur Kirimker
- Department of Surgery and Liver Transplantation Unit, Ankara University School of Medicine, Ankara, Turkey.
| | - Henrik Petrowsky
- Swiss HPB and Transplantation Center, Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland.
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Madoff DC, Odisio BC, Schadde E, Gaba RC, Bennink RJ, van Gulik TM, Guiu B. Improving the Safety of Major Resection for Hepatobiliary Malignancy: Portal Vein Embolization and Recent Innovations in Liver Regeneration Strategies. Curr Oncol Rep 2020; 22:59. [PMID: 32415401 DOI: 10.1007/s11912-020-00922-x] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE OF REVIEW For three decades, portal vein embolization (PVE) has been the "gold-standard" strategy to hypertrophy the anticipated future liver remnant (FLR) in advance of major hepatectomy. During this time, CT volumetry was the most common method to preoperatively assess FLR quality and function and used to determine which patients are appropriate surgical candidates. This review provides the most up-to-date methods for preoperatively assessing the anticipated FLR and summarizes data from the currently available strategies used to induce FLR hypertrophy before surgery for hepatobiliary malignancy. RECENT FINDINGS Functional and physiological imaging is increasingly replacing standard CT volumetry as the method of choice for preoperative FLR assessment. PVE, associating liver partition and portal vein ligation, radiation lobectomy, and liver venous deprivation are all currently available techniques to hypertrophy the FLR. Each strategy has pros and cons based on tumor type, extent of resection, presence or absence of underlying liver disease, age, performance status, complication rates, and other factors. Numerous strategies can lead to FLR hypertrophy and improve the safety of major hepatectomy. Which is best has yet to be determined.
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Affiliation(s)
- David C Madoff
- Department of Radiology and Biomedical Imaging, Section of Interventional Radiology, Yale School of Medicine, New Haven, CT, USA.
| | - Bruno C Odisio
- Department of Interventional Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Erik Schadde
- Department of Surgery, Rush University Medical Center, Chicago, IL, USA
- Department of Surgery, Cantonal Hospital Winterthur, Zurich, Switzerland
- Institute of Physiology, Center for Integrative Human Physiology, University of Zurich, Zurich, Switzerland
| | - Ron C Gaba
- Department of Radiology, Interventional Radiology Section, University of Illinois Hospital, Chicago, IL, USA
| | - Roelof J Bennink
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Thomas M van Gulik
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Boris Guiu
- Department of Radiology, St-Eloi University Hospital-Montpellier, Montpellier, France
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Kim D, Cornman-Homonoff J, Madoff DC. Preparing for liver surgery with "Alphabet Soup": PVE, ALPPS, TAE-PVE, LVD and RL. Hepatobiliary Surg Nutr 2020; 9:136-151. [PMID: 32355673 PMCID: PMC7188547 DOI: 10.21037/hbsn.2019.09.10] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Accepted: 09/10/2019] [Indexed: 02/06/2023]
Abstract
Future liver remnant (FLR) size and function is a critical limiting factor for treatment eligibility and postoperative prognosis when considering surgical hepatectomy. Pre-operative portal vein embolization (PVE) has been proven effective in modulating FLR and now widely accepted as a standard of care. However, PVE is not always effective due to potentially inadequate augmentation of the FLR as well as tumor progression while awaiting liver growth. These concerns have prompted exploration of alternative techniques: associating liver partition and portal vein ligation for staged hepatectomy (ALPPS), transarterial embolization-portal vein embolization (TAE-PVE), liver venous deprivation (LVD), and radiation lobectomy (RL). The article aims to review the principles and applications of PVE and these newer hepatic regenerative techniques.
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Affiliation(s)
- DaeHee Kim
- Department of Radiology, Division of Interventional Radiology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Joshua Cornman-Homonoff
- Department of Radiology and Biomedical Imaging, Section of Interventional Radiology, Yale School of Medicine, New Haven, CT, USA
| | - David C. Madoff
- Department of Radiology and Biomedical Imaging, Section of Interventional Radiology, Yale School of Medicine, New Haven, CT, USA
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Nagino M. Fifty-year history of biliary surgery. Ann Gastroenterol Surg 2019; 3:598-605. [PMID: 31788648 PMCID: PMC6875948 DOI: 10.1002/ags3.12289] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Revised: 08/19/2019] [Accepted: 08/22/2019] [Indexed: 12/14/2022] Open
Abstract
There has been enormous progress in the surgical treatment of biliary tract cancers in the past 50 years. In preoperative management, biliary drainage methods have changed from percutaneous transhepatic biliary drainage to endoscopic nasobiliary drainage, while the advent of multidetector-row computed tomography in imaging diagnostics now enables visualization of three-dimensional anatomy, extent of cancer progression, and hepatic segment volume. Portal vein embolization has also greatly improved the safety of extended hepatectomy, and indication of extended hepatectomy can now be objectively determined with a combination of the indocyanine green test and computed tomography volumetry. In terms of surgery, combined resection and reconstruction of the portal vein and/or hepatic artery can now be safely carried out at specialized centers. Further, long-term survival can be attained with combined vascular resection if R0 resection can be achieved, even in locally advanced cancer. Hepatopancreatoduodenectomy, combined major hepatectomy with pancreatoduodenectomy, should be aggressively carried out for laterally advanced cholangiocarcinoma, whereas its indication for advanced gallbladder cancer should be carefully evaluated. Japanese surgeons have made a significant contribution to the progression of extended surgeries such as combined vascular resection and hepatopancreatoduodenectomy for biliary tract cancer.
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Affiliation(s)
- Masato Nagino
- Division of Surgical OncologyDepartment of SurgeryNagoya University Graduate School of MedicineNagoyaJapan
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13
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Garcia-Botella A, Sáez-Carlin P, Méndez R, Martin MP, Ortega L, Méndez JV, García-Paredes B, Diez-Valladares L, Torres AJ. CD133 + cell infusion in patients with colorectal liver metastases going to be submitted to a major liver resection (CELLCOL): A randomized open label clinical trial. Surg Oncol 2019; 33:224-230. [PMID: 32561087 DOI: 10.1016/j.suronc.2019.10.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Accepted: 10/04/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Treatment of liver metastases of colorectal carcinoma is surgical resection. However, only 10-15% of the patients in this context will be candidate for curative resection arising other 10-13% after response to neoadyuvant chemotherapy. In order to perform the liver metastases surgery, it is necessary to have a sufficient remnant liver volume (RLV) which allows maintaining an optimal liver function after resection. Studies on liver regeneration have determined that CD133 + stem cells are involved in liver hypertrophy developed after an hepatectomy with encouraging results. As presented in previous studies, CD133 + stem cells can be selected from peripheral blood after stimulation with G-CSF, being able to obtain a large number of them. We propose to treat patients who do not meet criteria for liver metastases surgery because of insufficient RLV (<40%) with CD133 + cells together with portal embolization, in order to achieve enough liver volume which avoids liver failure. METHODS /Design: The aim of this study is to evaluate the effectiveness of preoperative PVE plus the administration of CD133 + mobilized from peripheral blood with G-CSF compared to PVE only. SECONDARY AIMS ARE: to compare the grade of hypertrophy, speed and changes in liver function, anatomopathological study of hypertrophied liver, to determine the safety of the treatment and analysis of postoperative morbidity and surveillance. STUDY DESIGN Prospective randomized longitudinal phase IIb clinical trial, open, to evaluate the efficacy of portal embolization (PVE) together with the administration of CD133 + cells obtained from peripheral blood versus PVE alone, in patients with hepatic metastasis of colorectal carcinoma (CCRHM). DISCUSSION The number of CD133 + obtained from peripheral blood after G -CSF stimulation will be far greater than the number obtained with direct puncture of bone marrow. This will allow a greater intrahepatic infusion, which could have a direct impact on achieving a larger and quicker hypertrophy. Consequently, it will permit the treatment of a larger number of patients with an increase on their survival. TRIAL REGISTRATION ClinicalTrials.gov, ID NCT03803241.
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Affiliation(s)
| | - Patricia Sáez-Carlin
- Surgery (HepatoPancreatoBiliary Unit), Hospital Clínico San Carlos Madrid, Spain.
| | - Ramiro Méndez
- Department of Radiology, Hospital Universitario Clínico San Carlos, Madrid, Spain.
| | - Maria Paz Martin
- Department o Hematology, Hospital Universitario Clínico San Carlos, Madrid, Spain.
| | - Luis Ortega
- Department of Surgical Pathology, Hospital Clínico San Carlos, Madrid, Spain.
| | - Jose Vicente Méndez
- Department of Radiology, Hospital Universitario Clínico San Carlos, Madrid, Spain.
| | | | - L Diez-Valladares
- Surgery (HepatoPancreatoBiliary Unit), Hospital Clínico San Carlos Madrid, Spain.
| | - Antonio Jose Torres
- Surgery (HepatoPancreatoBiliary Unit), Hospital Clínico San Carlos Madrid, Spain.
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14
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Tsurusaki M, Oda T, Sofue K, Numoto I, Yagyu Y, Kashiwagi N, Murakami T. The technical aspects of a feasible new technique for ipsilateral percutaneous transhepatic portal vein embolization. Br J Radiol 2018; 91:20180124. [PMID: 30156870 DOI: 10.1259/bjr.20180124] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVE: To devise a simple new technique wherein absolute ethanol is injected via a sheath under proximal balloon occlusion of the right portal vein using a single-balloon catheter and to examine its feasibility and safety for ipsilateral portal vein embolization (PVE). METHODS: Between 2010 and 2016, PVE was performed in 19 patients prior to undergoing extended right hepatectomy. PVE was performed via a percutaneous transhepatic ipsilateral approach, the right portal branch was embolized under ultrasound guidance, and a balloon catheter was placed in the proximal site of the main right portal branch. Absolute ethanol was injected through a sheath under proximal balloon occlusion of the right portal vein using a double-lumen catheter. We evaluated its technical success and complications following PVE and changes in liver enzyme levels. Furthermore, we calculated changes in future liver remnant (FLR) and FLR/total functional liver volume (TFLV) ratio and assessed complications following hepatic resection. RESULTS: PVE was successfully performed in all patients. Mean FLR and FLR/TFLV significantly increased following PVE (p < 0.01). The change in the FLR and FLR/TFLV ratio was 39.6 ± 16.2%. One patient (6.5%) developed procedure-related complications following PVE (perihepatic hematoma). CONCLUSION: The new technique for ipsilateral right PVE is safe, effective, and convenient. ADVANCES IN KNOWLEDGE: This is the first study to investigate the efficacy of injecting ethanol via a sheath under proximal balloon occlusion of the right portal vein using a single-balloon catheter.
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Affiliation(s)
- Masakatsu Tsurusaki
- 1 Department of Radiology, Kindai University, Faculty of Medicine , Osakasayama , Japan
| | - Teruyoshi Oda
- 1 Department of Radiology, Kindai University, Faculty of Medicine , Osakasayama , Japan
| | - Keitaro Sofue
- 2 Department of Radiology, Kobe University, Graduate School of Medicine , Kobe , Japan
| | - Isao Numoto
- 1 Department of Radiology, Kindai University, Faculty of Medicine , Osakasayama , Japan
| | - Yukinobu Yagyu
- 1 Department of Radiology, Kindai University, Faculty of Medicine , Osakasayama , Japan
| | - Nobuo Kashiwagi
- 1 Department of Radiology, Kindai University, Faculty of Medicine , Osakasayama , Japan
| | - Takamichi Murakami
- 1 Department of Radiology, Kindai University, Faculty of Medicine , Osakasayama , Japan
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15
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Hung ML, McWilliams JP. Portal vein embolization prior to hepatectomy: Techniques, outcomes and novel therapeutic approaches. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2018. [DOI: 10.18528/gii180010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Affiliation(s)
- Matthew L. Hung
- Division of Interventional Radiology, Department of Radiology, UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Justin P. McWilliams
- Division of Interventional Radiology, Department of Radiology, UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
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16
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Komada T, Suzuki K, Mizuno T, Ebata T, Matsushima M, Naganawa S, Nagino M. Efficacy of percutaneous transhepatic portal vein embolization using gelatin sponge particles and metal coils. Acta Radiol Open 2018; 7:2058460118769687. [PMID: 29662687 PMCID: PMC5898667 DOI: 10.1177/2058460118769687] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2017] [Accepted: 03/13/2018] [Indexed: 01/18/2023] Open
Abstract
Background Percutaneous transhepatic portal vein embolization (PTPE) can increase the future liver remnant (FLR) volume before extended liver resection; however, there is no current consensus regarding the best embolic material for PTPE. Purpose To evaluate the efficacy of PTPE using gelatin sponge particles and coils. Material and Methods The medical records of 136 patients who underwent PTPE using gelatin sponge particles and metal coils were retrospectively reviewed. We evaluated the procedural details, liver volume on CT, and clinical status before and after PTPE. Results The mean FLR volume increased significantly from 390 ± 147 cm3 to 508 ± 141 cm3 (P < 0.001). A mean of 22.1 ± 9.4 days after PTPE, the mean increase in the ratio of FLR volume to total liver volume was 9.4 ± 6.5%. Complications related to PTPE occurred in five patients, including arterial damage (n = 4) and biloma (n = 1). The white blood cell count and C-reactive protein level increased significantly and then returned to baseline within seven days. Aspartate aminotransferase and alanine aminotransferase showed no significant changes. Fever (defined by the Common Terminology Criteria for Adverse Events v4.0) was reported in 74 patients (54%), but it was generally mild (Grade 1/2; n = 72). None of the patients experienced severe complications that required cancellation of surgery. Conclusion PTPE with gelatin sponge particles and coils may impose low physical stress on patients and is a safe method of inducing a significant increase of FLR.
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Affiliation(s)
- Tomohiro Komada
- Department of Radiology, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Kojiro Suzuki
- Department of Radiology, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan.,Department of Radiology, Aichi Medical University, Nagakute, Aichi, Japan
| | - Takashi Mizuno
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Tomoki Ebata
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Masaya Matsushima
- Department of Radiology, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Shinji Naganawa
- Department of Radiology, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Masato Nagino
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
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17
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Uneven acute non-alcoholic fatty change of the liver after percutaneous transhepatic portal vein embolization in a patient with hilar cholangiocarcinoma - a case report. BMC Gastroenterol 2017; 17:144. [PMID: 29207941 PMCID: PMC5718115 DOI: 10.1186/s12876-017-0715-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2016] [Accepted: 11/27/2017] [Indexed: 02/06/2023] Open
Abstract
Background Portal vein embolization is essential for patients with biliary cancer who undergo extended hepatectomy to induce hypertrophy of the future remnant liver. Over 830 patients have undergone the portal vein embolization at our institution since 1990. Non-alcoholic fatty liver disease is an entity of hepatic disease characterized by fat deposition in hepatocytes. It has a higher prevalence among persons with morbid obesity, type 2 diabetes, and hyperlipidemia. Neither the mechanism of hepatic hypertrophy after portal vein embolization nor the pathophysiology of non-alcoholic fatty liver disease has been fully elucidated. Some researchers integrated the evident insults leading to progression of fatty liver disease into the multiple-hit hypothesis. Among these recognized insults, the change of hemodynamic status of the liver was never mentioned. Case presentation We present the case of a woman with perihilar cholangiocarcinoma who received endoscopic biliary drainage and presented to our institute for surgical consultation. A left trisectionectomy with caudate lobectomy and extrahepatic bile duct resection was indicated for curative treatment. To safely undergo left trisectionectomy, she underwent selective portal vein embolization of the liver, in which uneven acute fatty change subsequently developed. The undrained left medial sector of the liver with dilated biliary tracts was spared the fatty change. The patient underwent planned surgery without any major complications 6 weeks after the event and has since resumed a normal life. The discrepancies in fatty deposition in the different sectors of the liver were confirmed by pathologic interpretations. Conclusion This is the first report of acute fatty change of the liver after portal vein embolization. The sparing of the undrained medial sector is unique and extraordinary. The images and pathologic interpretations presented in this report may inspire further research on how the change of hepatic total inflow after portal vein embolization can be one of the insults leading to non-alcoholic fatty liver disease/ change.
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18
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A novel utility of 99mTc-GSA SPECT/CT fusion imaging: detection of inadequate portal vein embolization. Jpn J Radiol 2017; 35:748-754. [PMID: 29039109 DOI: 10.1007/s11604-017-0689-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Accepted: 09/22/2017] [Indexed: 12/11/2022]
Abstract
PURPOSE Our aim was to determine the utility of Tc-99m-diethylenetriaminepentaacetic acid-galactosyl human serum albumin single-photon-emission computed tomography (99mTc-GSA SPECT/CT) fusion imaging for detecting incomplete portal vein embolization (PVE). MATERIALS AND METHODS Fifty-five candidates underwent PVE. Among them, five underwent second PVE. Detectability of first inadequate PVE using CT and 99mTc-GSA SPECT/CT fusion imaging was analyzed. RESULTS Cases of inadequate PVE were detected in three patients using CT and in five using 99mTc-GSA SPECT/CT fusion imaging. Fusion imaging detected two cases of insufficient PVE in which portal branches were apparently well embolized on CT. Median value for volumetric rate in the embolized liver was 63.3% after the first PVE and 54.7% after the second (P < 0.01). Median functional rate value in embolized liver was 60.1% after the first PVE and 49.4% after the second (P < 0.01). Median value for change of volumetric and functional rates in embolized liver after the second PVE was 7.1 and 10.3%, respectively, and change of functional rate was greater than that of volumetric rate (P < 0.01). CONCLUSIONS 99mTc-GSA SPECT/CT fusion imaging was useful for detecting inadequate PVE, and second PVE was effective for increasing volumetric and functional rates.
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19
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Luz JHM, Luz PM, Bilhim T, Martin HS, Gouveia HR, Coimbra É, Gomes FV, Souza RR, Faria IM, de Miranda TN. Portal vein embolization with n-butyl-cyanoacrylate through an ipsilateral approach before major hepatectomy: single center analysis of 50 consecutive patients. Cancer Imaging 2017; 17:25. [PMID: 28931429 PMCID: PMC5607591 DOI: 10.1186/s40644-017-0127-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Accepted: 09/12/2017] [Indexed: 02/06/2023] Open
Abstract
Purpose To evaluate the efficacy of portal vein embolization (PVE) with n-Butyl-cyanoacrylate (NBCA) through an ipsilateral approach before major hepatectomy. Secondary end-points were PVE safety, liver resection and patient outcome. Methods Over a 5-year period 50 non-cirrhotic consecutive patients were included with primary or secondary liver cancer treatable by hepatectomy with a liver remnant (FLR) volume less than 25% or less than 40% in diseased livers. Results There were 37 men and 13 women with a mean age of 57 years. Colorectal liver metastases were the most frequent tumor and patients were previously exposed to chemotherapy. FLR increased from 422 ml to 629 ml (P < 0.001) after PVE, corresponding to anincrease of 52%. The FLR ratio increased from 29.6% to 42.3% (P < 0.001). Kinetic growth rate was 2.98%/week. A negative association was observed between increase in the FLR and FLR ratio and FLR volume before PVE (P = 0.002). In 31 patients hepatectomy was accomplished and only one patient presented with liver insufficiency within 30 days after surgery. Conclusions PVE with NBCA through an ipsilateral puncture is effective before major hepatectomy. Meticulous attention is needed especially near the end of the embolization procedure to avoid complications. Trial registration Clinical Study ISRCTN registration number: ISRCTN39855523. Registered March 13th 2017.
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Affiliation(s)
- José Hugo Mendes Luz
- Department of Interventional Radiology, Radiology Division, National Cancer Institute, INCA, Praça Cruz Vermelha 23, Centro, Rio de Janeiro, CEP 20230-130, Brazil.
| | - Paula Mendes Luz
- National Institute of Infectious Disease EvandroChagas, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil
| | - Tiago Bilhim
- Department of Interventional Radiology, Centro Hepato-Bilio-Pancreático e de Transplantação.Hospital Curry Cabral, CHLC, Lisbon, Portugal
| | - Henrique Salas Martin
- Department of Interventional Radiology, Radiology Division, National Cancer Institute, INCA, Praça Cruz Vermelha 23, Centro, Rio de Janeiro, CEP 20230-130, Brazil
| | - Hugo Rodrigues Gouveia
- Department of Interventional Radiology, Radiology Division, National Cancer Institute, INCA, Praça Cruz Vermelha 23, Centro, Rio de Janeiro, CEP 20230-130, Brazil
| | - Élia Coimbra
- Department of Interventional Radiology, Centro Hepato-Bilio-Pancreático e de Transplantação.Hospital Curry Cabral, CHLC, Lisbon, Portugal
| | - Filipe Veloso Gomes
- Department of Interventional Radiology, Centro Hepato-Bilio-Pancreático e de Transplantação.Hospital Curry Cabral, CHLC, Lisbon, Portugal
| | - Roberto Romulo Souza
- Department of Interventional Radiology, Radiology Division, National Cancer Institute, INCA, Praça Cruz Vermelha 23, Centro, Rio de Janeiro, CEP 20230-130, Brazil
| | - Igor Murad Faria
- Department of Interventional Radiology, Radiology Division, National Cancer Institute, INCA, Praça Cruz Vermelha 23, Centro, Rio de Janeiro, CEP 20230-130, Brazil
| | - Tiago Nepomuceno de Miranda
- Department of Interventional Radiology, Radiology Division, National Cancer Institute, INCA, Praça Cruz Vermelha 23, Centro, Rio de Janeiro, CEP 20230-130, Brazil
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20
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Yokoyama Y, Ebata T, Igami T, Sugawara G, Mizuno T, Yamaguchi J, Nagino M. The Predictive Value of Indocyanine Green Clearance in Future Liver Remnant for Posthepatectomy Liver Failure Following Hepatectomy with Extrahepatic Bile Duct Resection. World J Surg 2017; 40:1440-7. [PMID: 26902630 DOI: 10.1007/s00268-016-3441-1] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Postoperative liver failure (PHLF) is one of the most common complications following major hepatectomy. The preoperative assessment of future liver remnant (FLR) function is critical to predict the incidence of PHLF. OBJECTIVE To determine the efficacy of the plasma clearance rate of indocyanine green clearance of FLR (ICGK-F) in predicting PHLF in cases of highly invasive hepatectomy with extrahepatic bile duct resection. METHODS Five hundred and eighty-five patients who underwent major hepatectomy with extrahepatic bile duct resection, from 2002 to 2014 in a single institution, were evaluated. Among them, 192 patients (33 %) had PHLF. The predictive value of ICGK-F for PHLF was determined and compared with other risk factors for PHLF. RESULTS The incidence of PHLF was inversely proportional to the level of ICGK-F. With multivariate logistic regression analysis, ICGK-F, combined pancreatoduodenectomy, the operation time, and blood loss were identified as independent risk factors of PHLF. The risk of PHLF increased according to the decrement of ICGK-F (the odds ratio of ICGK-F for each decrement of 0.01 was 1.22; 95 % confidence interval 1.12-1.33; P < 0.001). Low ICGK-F was also identified as an independent risk factor predicting the postoperative mortality. CONCLUSIONS ICGK-F is useful in predicting the PHLF and mortality in patients undergoing major hepatectomy with extrahepatic bile duct resection. This criterion may be useful for highly invasive hepatectomy, such as that with extrahepatic bile duct resection.
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Affiliation(s)
- Yukihiro Yokoyama
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan.
| | - Tomoki Ebata
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Tsuyoshi Igami
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Gen Sugawara
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Takashi Mizuno
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Junpei Yamaguchi
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Masato Nagino
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan.
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21
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Olthof PB, Huisman F, van Golen RF, Cieslak KP, van Lienden KP, Plug T, Meijers JCM, Heger M, Verheij J, van Gulik TM. Use of an absorbable embolization material for reversible portal vein embolization in an experimental model. Br J Surg 2016; 103:1306-15. [PMID: 27477877 DOI: 10.1002/bjs.10208] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2015] [Revised: 11/04/2015] [Accepted: 04/05/2016] [Indexed: 12/17/2022]
Abstract
BACKGROUND Portal vein embolization (PVE) is used to increase future remnant liver size in patients requiring major hepatic resection. PVE using permanent embolization, however, predisposes to complications and excludes the use of PVE in living donor liver transplantation. In the present study, an absorbable embolization material containing fibrin glue and different concentrations of the fibrinolysis inhibitor aprotinin was used in an experimental animal model. METHODS PVE of the cranial liver lobes was performed in 30 New Zealand White rabbits, which were divided into five groups, fibrin glue + 1000, 700, 500, 300 or 150 kunits/ml aprotinin, and were compared with a previous series of permanent embolization using the same experimental set-up. Caudal liver lobe hypertrophy was determined by CT volumetry, and portal recanalization was identified on contrast-enhanced CT images. Animals were killed after 7 or 42 days, and the results were compared with those of permanent embolization. RESULTS PVE using fibrin glue with aprotinin as embolic material was effective, with 500 kunits/ml providing the optimal hypertrophic response. Lower concentrations of aprotinin (150 and 300 kunits/ml) led to reduced hypertrophy owing to early recanalization of the embolized segments. The regeneration rate over the first 3 days was higher in the group with 500 kunits/ml aprotinin than in the groups with 300 or 150 kunits/ml or permanent embolization. In the 500-kunits/ml group, four of five animals showed recanalization 42 days after embolization, with minimal histological changes in the cranial lobes following recanalization. CONCLUSION Fibrin glue combined with 500 kunits/ml aprotinin resulted in reversible PVE in 80 per cent of animals, with a hypertrophy response comparable to that achieved with permanent embolization material. Surgical relevance Portal vein embolization (PVE) is used to increase future remnant liver volume in patients scheduled for major liver resection who have insufficient future remnant liver size to perform a safe resection. The current standard is PVE with permanent embolization materials, which renders patients found to have unresectable disease prone to complications owing to the permanently deportalized liver segments. Absorbable embolization might prevent the PVE-associated morbidity and lower the threshold for its application. In this study, PVE using fibrin glue and aprotinin resulted in an adequate hypertrophy response with 80 per cent recanalization after 42 days. Considering the minor histological changes following recanalization of embolized segments and potentially preserved function, reversible PVE might also be applied in living donor liver transplantation.
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Affiliation(s)
- P B Olthof
- Departments of Surgery, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - F Huisman
- Departments of Surgery, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - R F van Golen
- Departments of Surgery, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - K P Cieslak
- Departments of Surgery, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - K P van Lienden
- Departments of Radiology, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - T Plug
- Departments of Experimental Vascular Medicine, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - J C M Meijers
- Departments of Experimental Vascular Medicine, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands.,Department of Plasma Proteins, Sanquin Research, Amsterdam, The Netherlands
| | - M Heger
- Departments of Surgery, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - J Verheij
- Departments of Pathology, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - T M van Gulik
- Departments of Surgery, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
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22
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Jaberi A, Toor SS, Rajan DK, Mironov O, Kachura JR, Cleary SP, Smoot R, Tremblay St-Germain A, Tan K. Comparison of Clinical Outcomes following Glue versus Polyvinyl Alcohol Portal Vein Embolization for Hypertrophy of the Future Liver Remnant prior to Right Hepatectomy. J Vasc Interv Radiol 2016; 27:1897-1905.e1. [PMID: 27435682 DOI: 10.1016/j.jvir.2016.05.023] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2016] [Revised: 05/01/2016] [Accepted: 05/18/2016] [Indexed: 12/21/2022] Open
Abstract
PURPOSE To report outcomes after portal vein embolization (PVE) and right hepatectomy in patients receiving embolization with N-butyl cyanoacrylate (NBCA) glue + central AMPLATZER Vascular Plug (AVP; glue group) or polyvinyl alcohol (PVA) particles ± coils (PVA group). MATERIALS AND METHODS Between March 2008 and August 2013, all patients having PVE with NBCA + AVP or PVA ± coils before right hepatectomy were retrospectively reviewed; 85 patients underwent PVE with NBCA + AVP (n = 45) or PVA ± coils (n = 40). The groups were compared using Mann-Whitney U and χ2 tests. RESULTS Technical success of embolization was 100%. Degree of hypertrophy (16.2% ± 7.8 vs 12.3% ± 7.62, P = .009) and kinetic growth rate (3.5%/wk ± 2.0 vs 2.6%/wk ± 1.9, P = .016) were greater in the glue group versus the PVA group. Contrast volume (66.1 mL ± 44.8 vs 189.87 mL ± 62.6, P < .001) and fluoroscopy time (11.2 min ± 7.8 vs 23.49 min ± 11.7, P < .001) were significantly less during the PVE procedure in the glue group. Surgical outcomes were comparable between groups, including the number of patients unable to go onto surgery (P = 1.0), surgical complications (P = .30), length of hospital stay (P = .68), and intensive care unit admissions (P = .71). There was 1 major complication (hepatic abscess) in each group after PVE. CONCLUSIONS PVE performed with NBCA + AVP compared with PVA ± coils resulted in greater degree of hypertrophy of the future liver remnant, less fluoroscopic time and contrast volume, and similar complication rates.
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Affiliation(s)
- Arash Jaberi
- Division of Vascular and Interventional Radiology, Toronto General Hospital-University Health Network/University of Toronto, Toronto, Ontario M5G2N2, Canada.
| | - Sundeep S Toor
- Department of Diagnostic Imaging , Markham Stouffville Hospital, Markham, Ontario, Canada
| | - Dheeraj K Rajan
- Division of Vascular and Interventional Radiology, Toronto General Hospital-University Health Network/University of Toronto, Toronto, Ontario M5G2N2, Canada
| | - Oleg Mironov
- Division of Vascular and Interventional Radiology, Toronto General Hospital-University Health Network/University of Toronto, Toronto, Ontario M5G2N2, Canada
| | - John R Kachura
- Division of Vascular and Interventional Radiology, Toronto General Hospital-University Health Network/University of Toronto, Toronto, Ontario M5G2N2, Canada
| | - Sean P Cleary
- Department of Medical Imaging, and Division of General Surgery, Department of Surgery, Toronto General Hospital-University Health Network/University of Toronto, Toronto, Ontario M5G2N2, Canada
| | - Rory Smoot
- Department of Medical Imaging, and Division of General Surgery, Department of Surgery, Toronto General Hospital-University Health Network/University of Toronto, Toronto, Ontario M5G2N2, Canada
| | - Amélie Tremblay St-Germain
- Department of Medical Imaging, and Division of General Surgery, Department of Surgery, Toronto General Hospital-University Health Network/University of Toronto, Toronto, Ontario M5G2N2, Canada
| | - Kongteng Tan
- Division of Vascular and Interventional Radiology, Toronto General Hospital-University Health Network/University of Toronto, Toronto, Ontario M5G2N2, Canada
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Fukami Y, Kaneoka Y, Maeda A, Takayama Y, Onoe S. Major hepatopancreatoduodenectomy with simultaneous resection of the hepatic artery for advanced biliary cancer. Langenbecks Arch Surg 2016; 401:471-8. [PMID: 27023217 DOI: 10.1007/s00423-016-1413-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Accepted: 03/18/2016] [Indexed: 01/02/2023]
Abstract
BACKGROUND Major hepatopancreatoduodenectomy (HPD) with simultaneous resection of the hepatic artery (HA) for biliary cancer is the most extended surgery for obtaining curative resection, and its clinical significance is unclear. The aim of this study was to appraise the clinical value of this extended procedure as a treatment for biliary cancer. METHODS We retrospectively reviewed the medical records of 38 patients with biliary cancer who underwent major HPD from 1994 to 2014. Clinicopathological factors and survival following HPD were compared between patients with and without simultaneous resection of the HA. RESULTS Of the 38 study patients, 12 patients (32 %) underwent major HPD with HA. There was no significant difference in major complications between the two groups. The overall 2-year survival rate and the median survival time following major HPD with HA were 71 % and 42.3 months. The survival of the patients with gallbladder cancer was significantly worse than that of the patients with bile duct cancer (p = 0.001). CONCLUSIONS Major HPD with simultaneous resection of the HA can be a preferable treatment option for bile duct cancer that offers acceptable perioperative morbidity and mortality, as well as long-term survival. However, this procedure for gallbladder cancer should not be performed.
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Affiliation(s)
- Yasuyuki Fukami
- Department of Surgery, Ogaki Municipal Hospital, 4-86 Minaminokawa-cho, Ogaki, Gifu, 503-8502, Japan.
| | - Yuji Kaneoka
- Department of Surgery, Ogaki Municipal Hospital, 4-86 Minaminokawa-cho, Ogaki, Gifu, 503-8502, Japan
| | - Atsuyuki Maeda
- Department of Surgery, Ogaki Municipal Hospital, 4-86 Minaminokawa-cho, Ogaki, Gifu, 503-8502, Japan
| | - Yuichi Takayama
- Department of Surgery, Ogaki Municipal Hospital, 4-86 Minaminokawa-cho, Ogaki, Gifu, 503-8502, Japan
| | - Shunsuke Onoe
- Department of Surgery, Ogaki Municipal Hospital, 4-86 Minaminokawa-cho, Ogaki, Gifu, 503-8502, Japan
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Aoki T, Kubota K. Preoperative portal vein embolization for hepatocellular carcinoma: Consensus and controversy. World J Hepatol 2016; 8:439-445. [PMID: 27028706 PMCID: PMC4807305 DOI: 10.4254/wjh.v8.i9.439] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2015] [Revised: 10/29/2015] [Accepted: 03/09/2016] [Indexed: 02/06/2023] Open
Abstract
Thirty years have passed since the first report of portal vein embolization (PVE), and this procedure is widely adopted as a preoperative treatment procedure for patients with a small future liver remnant (FLR). PVE has been shown to be useful in patients with hepatocellular carcinoma (HCC) and chronic liver disease. However, special caution is needed when PVE is applied prior to subsequent major hepatic resection in cases with cirrhotic livers, and volumetric analysis of the liver segments in addition to evaluation of the liver functional reserve before PVE is mandatory in such cases. Advances in the embolic material and selection of the treatment approach, and combined use of PVE and transcatheter arterial embolization/chemoembolization have yielded improved outcomes after PVE and major hepatic resections. A novel procedure termed the associating liver partition and portal vein ligation for staged hepatectomy has been gaining attention because of the rapid hypertrophy of the FLR observed in patients undergoing this procedure, however, application of this technique in HCC patients requires special caution, as it has been shown to be associated with a high morbidity and mortality even in cases with essentially healthy livers.
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Orcutt ST, Kobayashi K, Sultenfuss M, Hailey BS, Sparks A, Satpathy B, Anaya DA. Portal Vein Embolization as an Oncosurgical Strategy Prior to Major Hepatic Resection: Anatomic, Surgical, and Technical Considerations. Front Surg 2016; 3:14. [PMID: 27014696 PMCID: PMC4786552 DOI: 10.3389/fsurg.2016.00014] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Accepted: 02/24/2016] [Indexed: 12/11/2022] Open
Abstract
Preoperative portal vein embolization (PVE) is used to extend the indications for major hepatic resection, and it has become the standard of care for selected patients with hepatic malignancies treated at major hepatobiliary centers. To date, various techniques with different embolic materials have been used with similar results in the degree of liver hypertrophy. Regardless of the specific strategy used, both surgeons and interventional radiologists must be familiar with each other's techniques to be able to create the optimal plan for each individual patient. Knowledge of the segmental anatomy of the liver is paramount to fully understand the liver segments that need to be embolized and resected. Understanding the portal vein anatomy and the branching variations, along with the techniques used to transect the portal vein during hepatic resection, is important because these variables can affect the PVE procedure and the eventual surgical resection. Comprehension of the advantages and disadvantages of approaches to the portal venous system and the various embolic materials used for PVE is essential to best tailor the procedures for each patient and to avoid complications. Before PVE, meticulous assessment of the portal vein branching anatomy is performed with cross-sectional imaging, and embolization strategies are developed based on the patient's anatomy. The PVE procedure consists of several technical steps, and knowledge of these technical tips, potential complications, and how to avoid the complications in each step is of great importance for safe and successful PVE and ultimately successful hepatectomy. Because PVE is used as an adjunct to planned hepatic resection, priority must always be placed on safety, without compromising the integrity of the future liver remnant, and close collaboration between interventional radiologists and hepatobiliary surgeons is essential to achieve successful outcomes.
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Affiliation(s)
- Sonia T Orcutt
- Section of Hepatobiliary Tumors, Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center & Research Institute , Tampa, FL , USA
| | - Katsuhiro Kobayashi
- Diagnostic and Therapeutic Care Line, Section of Radiology, Michael E. DeBakey VA Medical Center, Baylor College of Medicine , Houston, TX , USA
| | - Mark Sultenfuss
- Diagnostic and Therapeutic Care Line, Section of Radiology, Michael E. DeBakey VA Medical Center, Baylor College of Medicine , Houston, TX , USA
| | - Brian S Hailey
- Department of Radiology, Baylor College of Medicine , Houston, TX , USA
| | - Anthony Sparks
- Department of Radiology, Baylor College of Medicine , Houston, TX , USA
| | - Bighnesh Satpathy
- Department of Radiology, Baylor College of Medicine , Houston, TX , USA
| | - Daniel A Anaya
- Section of Hepatobiliary Tumors, Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center & Research Institute , Tampa, FL , USA
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Okuno M, Ebata T, Yokoyama Y, Igami T, Sugawara G, Mizuno T, Yamaguchi J, Nagino M. Evaluation of inflammation-based prognostic scores in patients undergoing hepatobiliary resection for perihilar cholangiocarcinoma. J Gastroenterol 2016; 51:153-61. [PMID: 26187429 DOI: 10.1007/s00535-015-1103-y] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2015] [Accepted: 06/29/2015] [Indexed: 02/04/2023]
Abstract
BACKGROUND Inflammation-based prognostic scores have prognostic value in several kinds of cancer. However, little is known about their value in perihilar cholangiocarcinoma. We evaluated whether inflammation-based prognostic scores are associated with survival of patients with perihilar cholangiocarcinoma. METHODS Inflammation-based scores (i.e., the modified Glasgow Prognostic Score (mGPS), neutrophil-lymphocyte ratio, platelet-lymphocyte ratio, and prognostic nutritional index) were retrospectively evaluated in 534 patients who underwent resection for perihilar cholangiocarcinoma. Blood samples obtained 1-3 days before surgery after jaundice had fully resolved with biliary drainage and after cholangitis had subsided were used to obtain the scores. RESULTS Of the four scores evaluated, the mGPS showed prognostic value, whereas the remaining three scores did not. Patients with an mGPS of 0 had significantly better survival than patients with an mGPS of 1 or 2 (41.9 % vs 26.3 % at 5 years, P < 0.001). An mGPS of 1 or 2 was significantly associated with a higher incidence of preoperative cholangitis, node metastasis, and distant metastasis (pM). Irrespective of the absence (n = 442) or presence (n = 92) of preoperative cholangitis, the survival of patients with an mGPS of 0 was significantly better than that of patients with an mGPS of 1 or 2. Multivariate analysis revealed that the mGPS, blood transfusion, histologic grade, curability (R status), lymph node metastasis, and distant metastasis were independent prognostic factors. CONCLUSIONS As in other solid cancers, the mGPS is an independent prognostic factor in resected perihilar cholangiocarcinoma. This simple and inexpensive scoring system plays an important role in refining patient stratification and predicting survival.
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Affiliation(s)
- Masataka Okuno
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Tomoki Ebata
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Yukihiro Yokoyama
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Tsuyoshi Igami
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Gen Sugawara
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Takashi Mizuno
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Junpei Yamaguchi
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Masato Nagino
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan.
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Li D, Madoff DC. Portal vein embolization for induction of selective hepatic hypertrophy prior to major hepatectomy: rationale, techniques, outcomes and future directions. Cancer Biol Med 2016; 13:426-442. [PMID: 28154774 PMCID: PMC5250600 DOI: 10.20892/j.issn.2095-3941.2016.0083] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
The ability to modulate the future liver remnant (FLR) is a key component of modern oncologic hepatobiliary surgery practice and has extended surgical candidacy for patients who may have been previously thought unable to survive liver resection. Multiple techniques have been developed to augment the FLR including portal vein embolization (PVE), associating liver partition and portal vein ligation (ALPPS), and the recently reported transhepatic liver venous deprivation (LVD). PVE is a well-established means to improve the safety of liver resection by redirecting blood flow to the FLR in an effort to selectively hypertrophy and ultimately improve functional reserve of the FLR. This article discusses the current practice of PVE with focus on summarizing the large number of published reports from which outcomes based practices have been developed. Both technical aspects of PVE including volumetry, approaches, and embolization agents; and clinical aspects of PVE including data supporting indications, and its role in conjunction with chemotherapy and transarterial embolization will be highlighted. PVE remains an important aspect of oncologic care; in large part due to the substantial foundation of information available demonstrating its clear clinical benefit for hepatic resection candidates with small anticipated FLRs.
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Affiliation(s)
- David Li
- Department of Radiology, Division of Interventional Radiology, New York-Presbyterian Hospital, Weill Cornell Medical Center, New York 10065, NY, USA
| | - David C Madoff
- Department of Radiology, Division of Interventional Radiology, New York-Presbyterian Hospital, Weill Cornell Medical Center, New York 10065, NY, USA
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She WH, Chok KS. Strategies to increase the resectability of hepatocellular carcinoma. World J Hepatol 2015; 7:2147-2154. [PMID: 26328026 PMCID: PMC4550869 DOI: 10.4254/wjh.v7.i18.2147] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2015] [Revised: 08/10/2015] [Accepted: 08/20/2015] [Indexed: 02/06/2023] Open
Abstract
Hepatocellular carcinoma (HCC) is best treated by liver transplantation, but the applicability of transplantation is greatly limited. Tumor resection in partial hepatectomy is hence resorted to. However, in most parts of the world, only 20%-30% of HCCs are resectable. The main reason for such a low resectability is a future liver remnant too small to be sufficient for the patient. To allow more HCC patients to undergo curative hepatectomy, a variety of ways have been developed to increase the resectability of HCC, mainly ways to increase the future liver remnants in patients through hypertrophy. They include portal vein embolization, sequential transarterial chemoembolization and portal vein embolization, staged hepatectomy, two-staged hepatectomy with portal vein ligation, and Associating Liver Partition and Portal Vein Ligation in Staged Hepatectomy. Herein we review, describe and evaluate these different ways, ways that can be life-saving.
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Affiliation(s)
- Wong Hoi She
- Wong Hoi She, Kenneth SH Chok, Department of Surgery, the University of Hong Kong, Hong Kong, China
| | - Kenneth Sh Chok
- Wong Hoi She, Kenneth SH Chok, Department of Surgery, the University of Hong Kong, Hong Kong, China
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Mizuno T, Ebata T, Yokoyama Y, Igami T, Sugawara G, Mori Y, Suzuki K, Nagino M. Percutaneous transhepatic portal vein stenting for malignant portal vein stenosis secondary to recurrent perihilar biliary cancer. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2015; 22:740-5. [PMID: 26084448 DOI: 10.1002/jhbp.265] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/24/2014] [Accepted: 05/07/2015] [Indexed: 01/28/2023]
Abstract
BACKGROUND Transhepatic portal vein (PV) stenting has been shown to be one of the most important treatments for patients with PV stenosis caused by hepatopancreatobiliary malignancy. METHODS Ten consecutive patients with PV stenosis caused by the recurrence of a perihilar biliary malignancy underwent transhepatic PV stenting. A self-expandable metallic stent was deployed at the stenosis site. The patients were retrospectively analyzed with regard to the procedure, complications, and survival after the stent placement. RESULTS The median interval between the primary resection and the PV stenting was 22 months. The initial hepatic resection was a left trisectionectomy with caudate lobectomy in seven patients, a left hepatectomy with caudate lobectomy in one patient, a right anterior sectionectomy with caudate lobectomy following a left hepatectomy in one patient and a partial liver resection in one patient. The angle of the PV around the stenosis was greater in the patients with PV stenosis located in the right posterior PV. Eight patients with successful PV stent placement were able to receive anticancer treatment, with a median survival of 14 months. The remaining two patients without successful PV stent placement survived less than 6 months. CONCLUSIONS Portal vein stenting might offer relief from the symptoms associated with PV hypertension and the opportunity for sustainable anticancer therapy in patients with recurrent perihilar biliary malignancy.
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Affiliation(s)
- Takashi Mizuno
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Tomoki Ebata
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Yukihiro Yokoyama
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Tsuyoshi Igami
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Gen Sugawara
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Yoshine Mori
- Department of Radiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kojiro Suzuki
- Department of Radiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Masato Nagino
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
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En bloc resection of the hepatoduodenal ligament for advanced biliary malignancy. J Gastrointest Surg 2015; 19:708-14. [PMID: 25560184 DOI: 10.1007/s11605-014-2731-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2014] [Accepted: 12/15/2014] [Indexed: 01/31/2023]
Abstract
BACKGROUND En bloc resection of the hepatoduodenal ligament (HDL) for advanced biliary malignancy by hepato-ligamento-pancreatoduodenectomy (HLPD) or hepatoligamentectomy (HL) remains challenging, and only short-term outcomes have been reported. We showed our surgical technique of HLPD and HL, and retrospectively investigated surgical outcomes of the patients. METHODS Between 2003 and 2014, we performed four HLPD and three HL including major hepatectomy with concomitant caudate lobectomy. Portal vein reconstruction (PVR) was performed with a right external iliac vein graft, and hepatic artery reconstruction (HAR) was accomplished with the heterogeneous artery using the continuous suturing method. RESULTS Mean operation time and blood loss were 575 ± 111 min and 1539 ± 950 mL, respectively, and patency of the reconstructed vessels was confirmed postoperatively in all cases. Histologically, negative surgical margins (R0) were achieved in 57% of patients, while the resected vascular invasion was confirmed in all patients. Overall morbidity was high at 57%, but we have achieved no postoperative mortality. Overall median survival time of the patients was 36 months, and a patient of HL survived over 5 years. CONCLUSIONS En bloc resection of the HDL based on steady vascular reconstruction can improve the surgical outcome of biliary cancer in selected patients.
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Abstract
OBJECTIVE Radical lymph node dissection in surgery for advanced gallbladder cancer is controversial. The purpose of this study is to evaluate the different extent of lymph node dissection for N2 stage gallbladder cancer patients. PATIENTS AND METHODS A retrospective analysis was made of 60 patients with N2 stage who underwent standard regional lymphadenectomy (SRLN) and extended regional lymphadenectomy (ERLN). Between September 2000 and June 2011, 60 advanced gallbladder cancer patients with N2 stage of lymph node metastasis were included in this study. The curative effects with different extent of lymphadenctomy for lymph node N2 stage of gallbladder cancer patients were compared. RESULTS The median survival time was 34.83 months in the SRLN group and 30.28 months in the ERLN group. There was no significant difference of survival rate between SRLN and ERLN group (P=0.51). Postoperative major morbidity and mortality rates were 64.3% and 7.14% in the SRLN group, 81.3% and 9.34% in the ERLN group, respectively. Moreover, the number of positive lymph nodes and chemotherapy were found to correlate with survival on univariate analyses (P<0.05). CONCLUSIONS For advanced gallbladder patients with N2 stage lymph node metastasis, ERLN cannot provide a significant survival benefit over SRLN and the rate of morbidity and mortality in ERLN is exceptionally high. ERLN therefore should not be considered in the advanced gallbladder cancers with N2 stage.
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Malinowski M, Stary V, Lock JF, Schulz A, Jara M, Seehofer D, Gebauer B, Denecke T, Geisel D, Neuhaus P, Stockmann M. Factors influencing hypertrophy of the left lateral liver lobe after portal vein embolization. Langenbecks Arch Surg 2015; 400:237-46. [DOI: 10.1007/s00423-014-1266-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2014] [Accepted: 12/14/2014] [Indexed: 11/29/2022]
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Hyodo R, Suzuki K, Ebata T, Komada T, Mori Y, Yokoyama Y, Igami T, Sugawara G, Naganawa S, Nagino M. Assessment of percutaneous transhepatic portal vein embolization with portal vein stenting for perihilar cholangiocarcinoma with severe portal vein stenosis. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2014; 22:310-5. [DOI: 10.1002/jhbp.200] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Affiliation(s)
- Ryota Hyodo
- Department of Radiology; Nagoya University Graduate School of Medicine; 65 Tsurumai-cho Showa-ku Nagoya 466-8550 Japan
| | - Kojiro Suzuki
- Department of Radiology; Nagoya University Graduate School of Medicine; 65 Tsurumai-cho Showa-ku Nagoya 466-8550 Japan
| | - Tomoki Ebata
- Division of Surgical Oncology; Department of Surgery; Nagoya University Graduate School of Medicine; Nagoya Aichi Japan
| | - Tomohiro Komada
- Department of Radiology; Nagoya University Graduate School of Medicine; 65 Tsurumai-cho Showa-ku Nagoya 466-8550 Japan
| | - Yoshine Mori
- Department of Radiology; Nagoya University Graduate School of Medicine; 65 Tsurumai-cho Showa-ku Nagoya 466-8550 Japan
| | - Yukihiro Yokoyama
- Division of Surgical Oncology; Department of Surgery; Nagoya University Graduate School of Medicine; Nagoya Aichi Japan
| | - Tsuyoshi Igami
- Division of Surgical Oncology; Department of Surgery; Nagoya University Graduate School of Medicine; Nagoya Aichi Japan
| | - Gen Sugawara
- Division of Surgical Oncology; Department of Surgery; Nagoya University Graduate School of Medicine; Nagoya Aichi Japan
| | - Shinji Naganawa
- Department of Radiology; Nagoya University Graduate School of Medicine; 65 Tsurumai-cho Showa-ku Nagoya 466-8550 Japan
| | - Masato Nagino
- Division of Surgical Oncology; Department of Surgery; Nagoya University Graduate School of Medicine; Nagoya Aichi Japan
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Yokoyama Y, Ebata T, Igami T, Sugawara G, Mizuno T, Nagino M. The adverse effects of preoperative cholangitis on the outcome of portal vein embolization and subsequent major hepatectomies. Surgery 2014; 156:1190-6. [DOI: 10.1016/j.surg.2014.04.036] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2013] [Accepted: 04/16/2014] [Indexed: 01/12/2023]
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Igami T, Ebata T, Yokoyama Y, Sugawara G, Takahashi Y, Nagino M. Portal vein embolization using absolute ethanol: evaluation of its safety and efficacy. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2014; 21:676-81. [PMID: 24816863 DOI: 10.1002/jhbp.113] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND Previously, we reported on the clinical efficacy and safety of portal vein embolization (PVE) with fibrin glue. Our embolic materials for PVE changed from fibrin glue to absolute ethanol (EOH) after 2001 due to prohibition of using fibrin glue for PVE. With introducing our technique of PVE with EOH, we evaluated its safety and efficacy with attention to the amount of EOH. METHODS The medical records of 154 patients who underwent PVE using EOH were retrospectively reviewed. RESULTS Changes with time in both the serum levels of aspartate aminotransferase (AST) and alanine aminotransferase (ALT) after PVE returned to the initial condition within 7 days after PVE. In the 96 patients who underwent CT volumerty 14 to 21 days after PVE, the volume of the embolized lobe decreased from 701 ± 165 cm(3) to 549 ± 148 cm(3) (P < 0.0001). Meanwhile, the volume of the non-embolized lobe increased from 388 ± 105 cm(3) to 481 ± 113 cm(3) (P < 0.0001). On simple linear regression, the amount of EOH was positively correlated with both the maximum of AST and that of ALT after PVE; however, it never correlated with changes in liver volume after PVE. CONCLUSIONS Portal vein embolization with EOH has a substantial effect on both hypertrophy of the non-embolized lobe and atrophy of the embolized lobe. Quick recoveries of changes with time in AST and ALT after PVE proved that PVE with EOH is a safe procedure. The amount of EOH affected the extent of liver damage but had no clinical effects on changes in liver volume after PVE.
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Affiliation(s)
- Tsuyoshi Igami
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
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Matsumoto N, Ebata T, Yokoyama Y, Igami T, Sugawara G, Shimoyama Y, Nagino M. Role of anatomical right hepatic trisectionectomy for perihilar cholangiocarcinoma. Br J Surg 2014; 101:261-8. [PMID: 24399779 DOI: 10.1002/bjs.9383] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/25/2013] [Indexed: 01/11/2023]
Abstract
BACKGROUND Right-sided hepatectomy is often selected for perihilar cholangiocarcinoma because the extrahepatic portion of the left hepatic duct is longer than that of the right hepatic duct. However, the length of resected left hepatic duct in right-sided hepatectomy has not been reported. METHODS Patients who underwent right-sided hepatectomy for perihilar cholangiocarcinoma were reviewed retrospectively. Trisectionectomies were performed according to a previously reported technique of anatomical right hepatic trisectionectomy. Right hepatectomy was performed according to standard operative procedures. The length of resected left hepatic duct was measured. RESULTS Thirty-three patients underwent right trisectionectomy and 141 had a right hemihepatectomy. Patients having a trisectionectomy had more advanced tumours and so required combined portal vein resection more frequently. Duration of surgery and blood loss were similar in the two groups. Morbidity and mortality rates tended to be higher following hemihepatectomy than after trisectionectomy. The mean(s.d.) length of resected left hepatic duct was significantly greater in trisectionectomy than in hemihepatectomy (25·0(6·9) versus 14·8(5·3) mm; P < 0·001). In patients with Bismuth type IV tumours, the percentage of negative left hepatic duct margins was significantly higher for trisectionectomy than for hemihepatectomy (89 versus 57 per cent; P = 0·021). Achievement of R0 resection was similar and survival did not differ between the two groups, despite different tumour load. CONCLUSION Compared with right hemihepatectomy, anatomical right hepatic trisectionectomy provides a greater length of resected hepatic duct, leading to a high proportion of negative proximal ductal margins even in patients with Bismuth type IV tumours.
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Affiliation(s)
- N Matsumoto
- Division of Surgical Oncology, Department of Surgery, Nagoya, Japan
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Mihara K, Sugiura T, Okamura Y, Kanemoto H, Mizuno T, Moriguchi M, Aramaki T, Uesaka K. A predictive factor of insufficient liver regeneration after preoperative portal vein embolization. ACTA ACUST UNITED AC 2013; 51:118-28. [PMID: 24247292 DOI: 10.1159/000356368] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2013] [Accepted: 10/14/2013] [Indexed: 01/10/2023]
Abstract
BACKGROUND Preoperative portal vein embolization (PVE) is performed to enhance the future remnant liver function (FRLF) and volume (FRLV). However, the volume of the nonembolized liver does not increase enough in some patients, which results in an insufficient FRLF. The aim of this study was to evaluate the predictors of insufficient FRLF after PVE for extended hepatectomy. METHODS This retrospective study included 172 patients (107 patients with cholangiocarcinoma, 40 patients with metastatic liver cancer and 25 patients with hepatocellular carcinoma) who underwent PVE before extended hepatectomy. The total liver function was evaluated by measuring the indocyanine green plasma clearance rate (KICG). Computed tomography volumetry was conducted to evaluate the total liver volume and FRLV. The KICG of the future remnant liver (remK) was calculated using the following formula: KICG × FRLV/total liver volume. The safety margin for hepatectomy was set at remK after PVE (post-PVE remK) ≥ 0.05. RESULTS One hundred and twenty-three patients with a post-PVE remK level of >0.05 underwent hepatectomy without postoperative liver failure [sufficient liver regeneration (SLR) group], and 9 patients with a post-PVE remK level of <0.05 did not due to insufficient FRLF [insufficient liver regeneration (ILR) group]. In the SLR group, the KICG values did not change after PVE (median, 0.144-0.146, p = 0.523); however, the %FRLV and remK increased significantly (35.0-44.3%, p < 0.001 and 0.0488-0.0610, p < 0001, respectively). In contrast, in the ILR group, the KICG values decreased significantly (0.128-0.108, p = 0.021) and the %FRLV increased marginally (27.4-32.6%, p = 0.051). As a result, the remK did not increase significantly (0.0351-0.0365, p = 0.213). A receiver operating characteristic curve demonstrated an remK value of 0.04 obtained before PVE (pre-PVE remK) to be the optimal cutoff point for defective liver regeneration. The univariate and multivariate analyses revealed that a pre-PVE remK value of <0.04 was a factor for ILR. It was also correlated with postoperative liver failure in the analysis of the patients who underwent hepatectomy. CONCLUSIONS The patients in the ILR group did not achieve SLR after PVE due to a significant decrease in the KICG and an insufficient increase in %FRLV. A pre-PVE remK value of <0.04 is a useful predictor of insufficient regeneration of the nonembolized liver, even after PVE.
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Affiliation(s)
- K Mihara
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center Hospital, Shizuoka, Japan
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Evolution of surgical treatment for perihilar cholangiocarcinoma: a single-center 34-year review of 574 consecutive resections. Ann Surg 2013; 258:129-40. [PMID: 23059502 DOI: 10.1097/sla.0b013e3182708b57] [Citation(s) in RCA: 489] [Impact Index Per Article: 40.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To review our 34-year experience with 574 consecutive resections for perihilar cholangiocarcinoma and to evaluate the progress made in surgical treatment of this disease. BACKGROUND Few studies have reported improved surgical outcomes for perihilar cholangiocarcinoma; therefore, it is still unclear whether surgical treatment of this intractable disease has progressed. METHODS Between April 1977 and December 2010, a total of 754 consecutive patients with perihilar cholangiocarcinoma were treated, of whom 574 (76.1%) underwent resection. The medical records of these resected patients were retrospectively reviewed. RESULTS The incidence of major hepatectomies has increased, and limited resections, including central hepatectomies and bile duct resections, were rarely performed. Combined vascular resection was being used more often. Operative time has become shorter, and intraoperative blood loss has also decreased significantly. Because of refinements in surgical techniques and perioperative management, morbidity decreased significantly but was still high, with a rate of 43.1% in the last 5 years. Mortality rate has also decreased significantly (P < 0.001) from 11.1% (8/72) before 1990 to 1.4% (3/218) in the last 5 years. The ratio of advanced disease defined as pStage IVA and IVB has increased significantly from 49.4% before 2000 to 61.4% after 2001. The disease-specific survival for the 574 study patients (including all deaths) was 44.3% at year 3, 32.5% at year 5, and 19.9% at year 10. The survival was significantly better in the later period of 2001 to 2010 than in the earlier period of 1977 to 2000 (38.1% vs 23.1% at year 5, P < 0.001). For pM0, R0, and pN0 patients (n = 243), the survival in the later period was good with 67.1% at year 5, which was significantly better than that of the earlier period (P < 0.001). For pM0, R0, and pN1 patients (n = 142), however, the survival in the later period was similar to that of the earlier period (22.1% vs 14.6% at year 5, P = 0.647). Multivariate analysis revealed that lymph node metastasis was the strongest prognostic indicator. CONCLUSIONS Surgical treatment of perihilar cholangiocarcinoma has been evolving steadily, with expanded surgical indication, decreased mortality, and increased survival. Survival for R0 and pN0 patients was satisfactory, whereas survival for pN1 patients was still poor, suggesting that establishment of effective adjuvant chemotherapy is needed.
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Aoba T, Ebata T, Yokoyama Y, Igami T, Sugawara G, Takahashi Y, Nimura Y, Nagino M. Assessment of nodal status for perihilar cholangiocarcinoma: location, number, or ratio of involved nodes. Ann Surg 2013; 257:718-25. [PMID: 23407295 DOI: 10.1097/sla.0b013e3182822277] [Citation(s) in RCA: 104] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVE To analyze lymph node status in resected perihilar cholangiocarcinoma, to clarify which index (ie, location, number, or ratio of involved nodes) is better for staging, and to determine the minimum requirements for node examination. BACKGROUND In the TNM classification for perihilar cholangiocarcinoma, the number or ratio of involved nodes is not considered for nodal staging. The minimum requirement for histologic examination of lymph nodes is arbitrary. METHODS This study involved 320 patients with perihilar cholangiocarcinoma who underwent resection from January 2000 to December 2009 at Nagoya University Hospital. The relationship between lymph node status and patient survival was retrospectively analyzed. RESULTS Total lymph node counts (TLNCs), ie, the number of lymph nodes examined histologically, averaged 12.9 ± 8.3 (range: 1-59). Lymph node metastasis was found in 146 (45.6%) patients and was an independent, powerful prognostic factor. The survival rates were not significantly different between patients with regional node metastasis alone and those with distant node metastasis (19.2% vs 11.5% at 5 years, P = 0.058). The survival for patients with multiple node metastases was significantly worse than that for patients with single metastasis (12.1% vs 27.6% at 5 years, P = 0.002), regardless of the presence or absence of distant lymph node metastasis. The survival for patients with lymph node ratios (LNRs) of 0.2 or less was significantly better than that for patients with LNRs greater than 0.2 (21.4% vs 13.5% at 5 years, P = 0.032). Upon multivariate analysis of the 146 patients with lymph node metastasis, the number of involved nodes (single vs multiple) was identified as an independent prognostic factor (RR of 1.61, P = 0.045), whereas the locations (regional alone vs distant) and ratios (LNR ≤ 0.2 vs LNR > 0.2) of involved nodes were not. When the 148 pN0-R0 patients were divided into 3 groups (ie, those with TLNC ≥ 8, with TLNC = 5, 6, or 7, and with TLNC ≤ 4), survivals were identical between the first and second groups, whereas they were largely different between the former two and the third. CONCLUSIONS Lymph node metastasis is a powerful, independent prognostic factor in perihilar cholangiocarcinoma and is better classified based not on location but on the number of involved nodes. To adequately assess nodal status, histologic examination of 5 or more nodes is recommended.
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Affiliation(s)
- Taro Aoba
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
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Mahnken AH, Pereira PL, de Baère T. Interventional oncologic approaches to liver metastases. Radiology 2013; 266:407-30. [PMID: 23362094 DOI: 10.1148/radiol.12112544] [Citation(s) in RCA: 76] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Metastatic liver disease is the most common cause of death in cancer patients. Complete surgical resection is currently considered the only curative treatment, with only about 25% of patients being amenable to surgery. Therefore, a variety of interventional oncologic techniques have been developed for treating secondary liver malignancies. The aim of these therapies is either to allow patients with unresectable tumors to become surgical candidates, provide curative treatment options in nonsurgical candidates, or improve survival in a palliative or even curative approach. Among these interventional therapies are transcatheter therapies such as portal vein embolization, hepatic artery infusion chemotherapy, transarterial chemoembolization, and radioembolization, as well as interstitial techniques, particularly radiofrequency ablation as the most commonly applied technique. The rationale, application and clinical results of each of these techniques are reviewed on the basis of the current literature. Future prospects such as gene therapy and immunotherapy are introduced.
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Affiliation(s)
- Andreas H Mahnken
- Department of Diagnostic and Interventional Radiology, University Hospital, RWTH Aachen University, Aachen, Germany
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Nagino M. Perihilar cholangiocarcinoma: a surgeon's viewpoint on current topics. J Gastroenterol 2012; 47:1165-76. [PMID: 22847554 DOI: 10.1007/s00535-012-0628-6] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2012] [Accepted: 06/09/2012] [Indexed: 02/07/2023]
Abstract
Perihilar cholangiocarcinomas are defined anatomically as "tumors that are located in the extrahepatic biliary tree proximal to the origin of the cystic duct". However, as the boundary between the extrahepatic and intrahepatic bile ducts is not well defined, perihilar cholangiocarcinomas potentially include two types of tumors: one is the "extrahepatic" type, which arises from the large hilar bile duct, and the other is the "intrahepatic" type, which has an intrahepatic component with the invasion of the hepatic hilus. The new TNM staging system published by the International Union Against Cancer (UICC) has been well revised with regard to perihilar cholangiocarcinoma, but it still lacks stratification of patient prognosis and has little applicability for assessing the feasibility of surgical treatment; therefore, further refinement is essential. Most patients with perihilar cholangiocarcinomas present with jaundice, and preoperative biliary drainage is mandatory. Previously, percutaneous transhepatic biliary drainage was used in many centers; however, it is accepted that endoscopic naso-biliary drainage is the most suitable method of preoperative drainage. Portal vein embolization is now widely used as a presurgical treatment for patients undergoing an extended hepatectomy to minimize postoperative liver dysfunction. The surgical resection of a perihilar cholangiocarcinoma is technically demanding and continues to be the most difficult challenge for hepatobiliary surgeons. Because of advances in diagnostic and surgical techniques, surgical outcomes and survival rates after resection have steadily improved. However, survival, especially for patients with lymph node metastasis, is still unsatisfactory, and the establishment of adjuvant chemotherapy is necessary. Further synergy of endoscopists, radiologists, oncologists, and surgeons is required to conquer this intractable disease.
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Affiliation(s)
- Masato Nagino
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya 466-8550, Japan.
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Abstract
Portal vein embolization (PVE) improves the safety of major hepatectomy through hypertrophy of the future liver remnant (FLR), atrophy of the liver volume to be resected, and improvement in patient selection. Because most patients with hepatocellular carcinoma (HCC) have liver parenchymal injury due to underlying viral hepatitis or alcoholic liver fibrosis/cirrhosis, indication of PVE is relatively complex and sequential procedures, including transarterial chemoembolization, are required to maximize the effect of PVE as well as to minimize tumor progression due to increased arterial flow after PVE. PVE is currently indicated for patients with relatively well-preserved hepatic function [Child-Pugh A and indocyanine green tolerance test (ICG-R15) <20%) to achieve minimal FLR volume for safe major hepatectomy. FLR volume >40% is the minimal requirement for patients with chronic hepatitis or cirrhosis, and further strict criteria (FLR volume >50%) have been recommended for patients with marginal liver functional reserve (ICG-R15, 10-20%). Recent clinical results have suggested that PVE can be safely performed in patients with HCC and that it contributes to improved survival after major hepatectomy.
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Affiliation(s)
| | | | - Jean-Nicolas Vauthey
- *Department of Surgical Oncology, The University of Texas, MD Anderson Cancer Center, 1515 Holcomb Boulevard, Unit 1484, Houston, TX 77030, (USA), Tel. +1 713 792 2022, E-mail
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Seki T, Igami T, Ebata T, Yokoyama Y, Sugawara G, Suzumura K, Nagino M. Six-year survival following left hepatic trisectionectomy with simultaneous resection of the portal vein and right hepatic artery for advanced perihilar cholangiocarcinoma without lymph node metastases: report of a case. Clin J Gastroenterol 2012; 5:327-31. [PMID: 26181070 DOI: 10.1007/s12328-012-0322-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2012] [Accepted: 07/08/2012] [Indexed: 11/24/2022]
Abstract
We report a case of survival for more than 6 years following left hepatic trisectionectomy and caudate lobectomy with simultaneous resection of the portal vein and right hepatic artery. The patient was a 65-year-old woman admitted to a local hospital with obstructive jaundice. The patient was diagnosed with perihilar cholangiocarcinoma and referred to our hospital. The tumor was located mainly in the left hilar region and occluded the left portal vein; furthermore, it involved the right portal vein and the right hepatic artery. The patient underwent left hepatic trisectionectomy and caudate lobectomy with simultaneous resection of the portal vein and right hepatic artery. The histological findings revealed that the tumor had invaded the portal vein and surrounded the right hepatic artery without any lymph node metastases. Microscopic curative (R0) resection was achieved. The patient is now healthy and still alive 6 years and 6 months after the surgery without any recurrence. Precise preoperative evaluation of the tumor and R0 resection by extended surgery contributed to a satisfactory outcome.
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Affiliation(s)
- Takashi Seki
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Tsuyoshi Igami
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Tomoki Ebata
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Yukihiro Yokoyama
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Gen Sugawara
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Kiyoshi Suzumura
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Masato Nagino
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan.
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Hepatopancreatoduodenectomy for cholangiocarcinoma: a single-center review of 85 consecutive patients. Ann Surg 2012; 256:297-305. [PMID: 22750757 DOI: 10.1097/sla.0b013e31826029ca] [Citation(s) in RCA: 147] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To outline our experience with hepatopancreatoduodenectomy (HPD) as a treatment for cholangiocarcinoma and to appraise the clinical significance of this challenging procedure. BACKGROUND Cholangiocarcinomas often exhibit an extensive ductal spread invading from the hepatic hilus to the lower bile duct, and such tumors can be completely resected only by HPD. Early experiences with HPD were associated with high mortality and morbidity, leading to an underestimation of the survival benefit of HPD. METHODS We retrospectively reviewed the medical records of 85 patients with cholangiocarcinoma who underwent HPD from 1992 to 2011. Major hepatectomy was performed in 79 patients (92.9%), and combined vascular resection was performed in 26 patients (30.6%). RESULTS The operating time was 762 ± 141 minutes, and blood loss was 2696 ± 1970 mL. Liver failure was the most common abdominal complication (n = 64), followed by pancreatic fistula (n = 60), wound sepsis (n = 33), intra-abdominal abscess (n = 22), refractory ascites (n = 17), bacteremia (n = 16), bile leakage (n = 13), and delayed gastric emptying (n = 12). Re-laparotomy was necessary in 9 cases (11.1%). Overall, 19 patients (22.4%) exhibited Clavien grade 0 to II complications, 58 (68.2%) exhibited grade III, 6 (7.1%) exhibited grade IV, and 2 (2.4%) exhibited grade V (mortality). The overall survival rate for the 85 patients was 79.7% after 1 year, 48.5% after 3 years, 37.4% after 5 years, and 32.1% after 10 years; 9 (10.5%) patients survived for more than 5 years. The rate of survival for the 53 patients with pM0 disease who underwent R0 resection was the most favorable, with 5- and 10-year survival rates of 54.3% and 46.6%, respectively. CONCLUSIONS HPD is technically demanding and is associated with high morbidity. However, this surgery can be performed with low mortality and offers a better probability of long-term survival in selected patients. As hepatobiliary surgeons, we should consider HPD to be a standard procedure for laterally advanced cholangiocarcinomas that are otherwise unresectable.
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Clinical significance of left trisectionectomy for perihilar cholangiocarcinoma: an appraisal and comparison with left hepatectomy. Ann Surg 2012; 255:754-62. [PMID: 22367444 DOI: 10.1097/sla.0b013e31824a8d82] [Citation(s) in RCA: 85] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To review our experiences with left-sided hepatectomy for perihilar cholangiocarcinoma, to compare left hepatectomy with left trisectionectomy, and to evaluate the clinical significance of left trisectionectomy from the viewpoint of surgical oncology. BACKGROUND Only 4 large case series have been reported on left trisectionectomy, with only a few patients diagnosed with perihilar cholangiocarcinoma. Therefore, the oncologic advantage of left trisectionectomy compared with left hepatectomy for perihilar cholangiocarcinoma is still unclear. METHODS This study involved 201 patients who underwent left-sided hepatectomy for perihilar cholangiocarcinoma (86 trisectionectomies and 115 hepatectomies). Surgical outcome and survival were compared between the 2 types of hepatectomy. The length of the resected right posterior bile duct was also measured. RESULTS Patients who underwent trisectionectomy had more advanced tumors, thus requiring combined vascular and/or other organ resection. Operative time and blood loss were significantly greater in trisectionectomy than in hepatectomy; therefore, overall morbidity was significantly higher in the former (59.3% vs 33.0%, P < 0.001). Mortality was similar (1.2% vs 0.9%) in both techniques. The length of the resected supraportal right posterior bile duct was significantly longer in trisectionectomy than in hepatectomy (20.7 ± 6.4 vs 13.6 ± 5.2 mm, P < 0.001). However, there was no difference in length of the infraportal type right posterior bile duct. The percentage of negative radial and distal common bile duct margins was similar, but the percentage of negative right posterior bile duct margins was significantly higher in trisectionectomy than in hepatectomy (97.7% vs 89.6%, P = 0.027). Overall, R0 resection was achieved in 84.9% of patients with trisectionectomy and in 70.4% of patients with hepatectomy (P = 0.019). Survival rates were similar between patients with trisectionectomy and those with hepatectomy (36.8% vs 34.0% at 5-year), despite the fact that the former had more advanced disease. CONCLUSIONS Left trisectionectomy for perihilar cholangiocarcinoma, although technically demanding, can be performed with similar mortality rates as left hepatectomy. From an oncologic viewpoint, this operation can increase the number of negative proximal ductal margins, leading to a high proportion of R0 resection, and, in turn, to improved survival rates of patients with advanced left-sided perihilar cholangiocarcinoma.
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Bellemann N, Stampfl U, Sommer CM, Kauczor HU, Schemmer P, Radeleff BA. Portal vein embolization using a Histoacryl/Lipiodol mixture before right liver resection. Dig Surg 2012; 29:236-242. [PMID: 22797287 DOI: 10.1159/000339748] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2012] [Accepted: 05/29/2012] [Indexed: 12/23/2022]
Abstract
PURPOSE The purpose of this retrospective study was to evaluate the efficacy and safety of percutaneous transhepatic portal vein embolization (PVE) of the right liver lobe using Histoacryl/Lipiodol mixture to induce contralateral liver hypertrophy before right-sided (or extended right-sided) hepatectomy in patients with primarily unresectable liver tumors. METHODS Twenty-one patients (9 females and 12 males) underwent PVE due to an insufficient future liver remnant; 17 showed liver metastases and 4 suffered from biliary cancer. Imaging was performed prior to and 4 weeks after PVE. Surgery was scheduled for 1 week after a CT or MRI control. The primary study end point was technical success, defined as complete angiographical occlusion of the portal vein. The secondary study end point was evaluation of liver hypertrophy by CT and MRI volumetry and transfer to operability. RESULTS In all the patients, PVE could be performed with a Histoacryl/Lipiodol mixture (n = 20) or a Histoacryl/Lipiodol mixture with microcoils (n = 1). No procedure-related complications occurred. The volume of the left liver lobe increased significantly (p < 0.0001) by 28% from a mean of 549 ml to 709 ml. Eighteen of twenty-one patients (85.7%) could be transferred to surgery, and the intended resection could be performed as planned in 13/18 (72.3%) patients. CONCLUSION Preoperative right-sided PVE using a Histoacryl/Lipiodol mixture is a safe technique and achieves a sufficient hypertrophy of the future liver remnant in the left liver lobe.
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Affiliation(s)
- Nadine Bellemann
- Diagnostic and Interventional Radiology, University Hospital Heidelberg, Heidelberg, Germany.
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Preoperative percutaneous transhepatic portal vein embolization with ethanol injection. AJR Am J Roentgenol 2012; 198:914-22. [PMID: 22451561 DOI: 10.2214/ajr.11.6515] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVE The purpose of this article is to evaluate the feasibility and efficacy of preoperative percutaneous transhepatic portal vein embolization with ethanol injection. MATERIALS AND METHODS We retrospectively evaluated 143 patients who underwent percutaneous transhepatic portal vein embolization. Hypertrophy of the future liver remnant was assessed by comparing the volumetric data obtained from CT image data before and after percutaneous transhepatic portal vein embolization. The evaluation of effectiveness was based on changes in the absolute volume of the future liver remnant and the ratio of the future liver remnant to the total estimated liver volume. RESULTS Ten of 143 patients (7.0%) underwent additional embolization because of recanalization and insufficient hypertrophy of the future liver remnant. The mean increase in the ratio of the future liver remnant was 33.6% (p < 0.0001), and the mean ratio of future liver remnant to total estimated liver volume increased from 34.9% to 45.7% (p < 0.0001). Although most of the patients complained of pain after ethanol injection, they were gradually relieved of pain in a few minutes by conservative treatment. Fever (38-39°C) was reported after 47 of 151 (31.1%) percutaneous transhepatic portal vein embolization sessions and was resolved within a few days. Transient elevation of the liver transaminases was observed after the procedures and resolved within about a week. Major complications occurred in nine of 151 (6%) percutaneous transhepatic portal vein embolization sessions, but no patients developed hepatic insufficiency or severe complications precluding successful resection. One hundred twenty patients underwent hepatic resection, and two patients developed hepatic failure after surgery. CONCLUSION Preoperative percutaneous transhepatic portal vein embolization with ethanol is a feasible and effective procedure to obtain hypertrophy of the future liver remnant for preventing hepatic failure after hepatectomy.
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Hasegawa Y, Abo D, Sakuhara Y, Kato F, Kamishimma T, Shimizu T, Ito YM, Terae S, Shirato H. Usefulness of portography and contrast-enhanced computed tomography to predict the embolized area in percutaneous transhepatic portal vein embolization with absolute ethanol under temporary balloon occlusion. Jpn J Radiol 2011; 30:53-61. [PMID: 22135113 DOI: 10.1007/s11604-011-0008-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2011] [Accepted: 08/03/2011] [Indexed: 01/10/2023]
Abstract
PURPOSE To assess the usefulness of portography and contrast-enhanced computed tomography (CECT) for predicting the embolized area after the first injection of absolute ethanol (AE) in right portal vein embolization (RPVE). MATERIALS AND METHODS Portograms were retrospectively reviewed in 50 patients (30 men and 20 women, mean age 65 years) who had undergone percutaneous transhepatic RPVE with AE under temporary balloon occlusion (TBO) between February 2002 and October 2009. The enhancement pattern before embolization and the embolization pattern after the first AE injection were analyzed by portography. The angles of portal branches against the horizontal plane were measured in 48 patients using pre-treatment CECT. RESULTS The enhancement pattern was not consistent with the embolization pattern in 35 patients (p < 0.001). When the anterior branch angles were divided into two groups at -5°, 0°, 10°, and 15°, the frequency of the posterior-branch-dominant embolization pattern was higher in the more negatively angled group (p = 0.002-0.041). CONCLUSION The distribution of AE is different from that of contrast medium in percutaneous transhepatic RPVE under TBO. The pre-treatment measurement of the angles of portal branches against the horizontal plane on CECT is suggested to be useful for predicting the embolized area.
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Affiliation(s)
- Yu Hasegawa
- Department of Radiology, Hokkaido University Graduate School of Medicine, N15 W7, Kita-ku, Sapporo 060-8638, Japan.
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Kalenderian AC, Chabrot P, Buc E, Cassagnes L, Ravel A, Pezet D, Boyer L. Embolisation portale préopératoire par Amplatzer® Vascular Plugs (AVP) : 17 patients. ACTA ACUST UNITED AC 2011; 92:899-908. [DOI: 10.1016/j.jradio.2011.06.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2011] [Revised: 06/16/2011] [Accepted: 06/23/2011] [Indexed: 12/12/2022]
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Thakrar PD, Madoff DC. Preoperative portal vein embolization: an approach to improve the safety of major hepatic resection. Semin Roentgenol 2011; 46:142-53. [PMID: 21338839 DOI: 10.1053/j.ro.2010.08.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Affiliation(s)
- Pooja D Thakrar
- Division of Diagnostic Imaging, Interventional Radiology Section, The University of Texas M D Anderson Cancer Center, Houston, TX 77030-4009, USA
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