Strategies for resection using portal vein embolization: hepatocellular carcinoma and hilar cholangiocarcinoma

Abstract

Preoperative portal vein embolization (PVE) is increasingly used to optimize the volume and function of the future liver remnant (FLR) and to reduce the risk for complications of major hepatectomy for hepatocellular carcinoma (HCC) or hilar cholangiocarcinoma (CCA). In patients with HCC who are candidates for extended hepatectomy and in patients with HCC and well-compensated cirrhosis who are being considered for major hepatectomy, FLR volumetry is routinely performed, and PVE is employed in selected cases to optimize the volume and function of the FLR prior to surgery. Similarly, in patients with hilar CCA who are candidates for extended hepatectomy, careful preoperative preparation using biliary drainage, FLR volumetry, and PVE optimizes the volume and function of the FLR prior to surgery. Appropriate use of PVE has led to improved postoperative outcomes after major hepatectomy for these diseases and oncological outcomes similar to those in patients who undergo resection without PVE. Specific indications for PVE are being clarified. FLR volumetry is necessary for proper selection of patients for PVE. Analysis of the degree of hypertrophy of the FLR after PVE (a dynamic test of liver regeneration) complements analysis of the pre-PVE FLR volume (a static test). Together, FLR degree of hypertrophy and FLR volume are the best predictors of outcome after major hepatectomy in an individual patient, regardless of the degree of underlying liver disease. This article synthesizes the literature on the approach to patients with HCC and CCA who are candidates for major hepatectomy. The rationale and indications for FLR volumetry and PVE and outcomes following PVE and major hepatectomy for HCC and CCA are discussed.

Keywords: Portal vein embolization; future liver remnant; hepatocellular carcinoma; hilar cholangiocarcinoma; liver volumetry.

Figure 1

Indications for portal vein embolization (PVE) before major hepatectomy in terms of underlying liver disease and the volume of the expected future liver remnant (FLR) expressed as a percentage of the standardized total liver volume (TLV). In patients with normal liver, PVE is indicated when the FLR volume is ≤ 20% of the standardized TLV. In patients with well-compensated cirrhosis, PVE is indicated when the FLR volume is ≤ 40% of the standardized TLV. Although fewer data are available for patients with intermediate liver disease, there is consensus that those with significant fibrosis and those treated with aggressive preoperative chemotherapy should undergo PVE when the FLR volume is ≤ 30% of the standardized TLV. (Adapted with permission from Zorzi D, Laurent A, Pawlik TM, Lauwers GY, Vauthey JN, Abdalla EK. Chemotherapy-associated hepatotoxicity and surgery for colorectal liver metastases. Br J Surg 2007;94:274–286. © British Journal of Surgery Society Ltd. Reproduced with permission. Permission is granted by John Wiley & Sons Ltd on behalf of the BJSS Ltd.)

Figure 2

Hepatic venous phase of computed tomography in a patient with multifocal hepatocellular carcinoma involving the right liver before (left panel) and after (right panel) right portal vein embolization (PVE). The outlined left liver (with the main plane marked by the middle hepatic vein, arrow) increased from 36 to 46% of the standardized total liver volume as a result of PVE. Six days after an uneventful right hepatectomy, the patient was discharged from the hospital. The patient did not experience ascites, fluid retention, or cholestasis at any time during the postoperative course.

Figure 3

Described variations of biliary anatomy. A long left hepatic duct is present in 97% of all reported cases of variations in biliary anatomy. Thus, for cancer of the biliary confluence (hilar cholangiocarcinoma), whether it involves the right liver and confluence or the confluence only, extended right hepatectomy permits division of the left duct far enough away from the tumor to maximize the probability of a margin-negative resection. The right hepatic duct is consistently short; therefore, left or extended left hepatectomy is reserved for left-sided tumors. (Reprinted with permission from Couinaud C. Le Foie: Etudes Anatomiques et Chirurgicales. Paris: Masson; 1957:469–479.)

Figure 4

Portal phase of thin-cut computed tomograms in a patient with hilar cholangiocarcinoma before (left panel) and after (right panel) right trisectoral portal vein embolization (PVE) (embolization of segment IV and the right liver). Outlined is the future liver remnant, which increased in volume from 11 to 26% of the standardized total liver volume. Atrophy and arterialization of the right liver are apparent after PVE. Extended right hepatectomy with total caudate lobectomy was performed with negative margins and no postoperative hepatic dysfunction. The patient was discharged from the hospital on postoperative day 9.