Portal vein embolization before right hepatectomy: prospective clinical trial

Abstract

Objective: To assess the impact of liver hypertrophy of the future liver remnant volume (FLR) induced by preoperative portal vein embolization (PVE) on the immediate postoperative complications after a standardized major liver resection.

Summary background data: PVE is usually indicated when FLR is estimated to be too small for major liver resection. However, few data exist regarding the exact quantification of sufficient minimal functional hepatic volume required to avoid postoperative complications in both patients with or without chronic liver disease.

Methods: All consecutive patients in whom an elective right hepatectomy was feasible and who fulfilled the inclusion and exclusion criteria between 1998 and 2000 were assigned to have alternatively either immediate surgery or surgery after PVE. Among 55 patients (25 liver metastases, 2 cholangiocarcinoma, and 28 hepatocellular carcinoma), 28 underwent right hepatectomy after PVE and 27 underwent immediate surgery. Twenty-eight patients had chronic liver disease. FLR and estimated rate of functional future liver remnant (%FFLR) volumes were assessed by computed tomography.

Results: The mean increase of FLR and %FFLR 4 to 8 weeks after PVE were respectively 44 +/- 19% and 16 +/- 7% for patients with normal liver and 35 +/- 28% and 9 +/- 3% for those with chronic liver disease. All patients with normal liver and 86% with chronic liver disease experienced hypertrophy after PVE. The postoperative course of patients with normal liver who underwent PVE before right hepatectomy was similar to those with immediate surgery. In contrast, PVE in patients with chronic liver disease significantly decreased the incidence of postoperative complications as well as the intensive care unit stay and total hospital stay after right hepatectomy.

Conclusions: Before elective right hepatectomy, the hypertrophy of FLR induced by PVE had no beneficial effect on the postoperative course in patients with normal liver. In contrast, in patients with chronic liver disease, the hypertrophy of the FLR induced by PVE decreased significantly the rate of postoperative complications.

Figure 1. Liver function tests before portal vein embolization (PVE), after PVE, and before surgery in patients with normal liver and chronic liver disease. For transaminase, the peak value of aspartate aminotransferase was assessed before PVE, within 5 days after PVE, and within 5 days before surgery. At the time of surgery, all test results returned to pre-PVE values, except for gamma glutamyl transpeptidase and alkaline phosphatase, which increased continuously.

Figure 2. Postoperative kinetics of liver function tests in patients with no or minimal fibrosis of the nontumorous liver undergoing right hepatectomy with (circles) or without (triangles) preoperative portal vein embolization. Values are expressed as mean ± SD. (A) Serum bilirubin (μmol/L). (B) Prothrombin time expressed as a percentage of normal controls. (C) AST (plain line) and ALT (broken line) (IU/L). (D) Alkaline phosphatase (plain line) (IU/L) and gamma glutamyl transpeptidase (broken line) (IU/L).

Figure 3. Postoperative kinetics of liver function tests in patients with extensive fibrosis (grade 3) or cirrhosis (grade 4) of the parenchyma of the nontumorous liver undergoing right hepatectomy with (circles) or without (triangles) preoperative portal vein embolization. Values are expressed as mean ± SD. (A) Serum bilirubin (μmol/L). (B) Prothrombin time expressed as a percentage of normal controls. (C) AST (plain line) and ALT (broken line) (UI/L). (D) Alkaline phosphatase (plain line) (UI/L) and gamma glutamyl transpeptidase (broken line) (UI/L).