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Comparative Study
. 2013 Jul;217(1):126-33; discussion 133-4.
doi: 10.1016/j.jamcollsurg.2013.03.004. Epub 2013 Apr 28.

Analysis of the efficacy of portal vein embolization for patients with extensive liver malignancy and very low future liver remnant volume, including a comparison with the associating liver partition with portal vein ligation for staged hepatectomy approach

Junichi Shindoh  1 , Jean-Nicolas Vauthey, Giuzeppe Zimmitti, Steven A Curley, Steven Y Huang, Armeen Mahvash, Sanjay Gupta, Michael J Wallace, Thomas A Aloia
Affiliations
Comparative Study

Analysis of the efficacy of portal vein embolization for patients with extensive liver malignancy and very low future liver remnant volume, including a comparison with the associating liver partition with portal vein ligation for staged hepatectomy approach

Junichi Shindoh et al. J Am Coll Surg. 2013 Jul.

Abstract

Background: The primary reported indication for the associating liver partition with portal vein ligation for staged hepatectomy (ALPPS) technique is in patients with very low future liver remnant volumes. Given the elevated incidence of major morbidity (40%) and liver-related mortality (12%) with ALPPS, we sought to determine the safety and efficacy of percutaneous portal vein embolization (PVE) in a similar patient population.

Study design: Tumor resectability and morbidity and mortality rates were reviewed for 144 consecutive liver tumor patients with future liver remnant to body weight ratios (LR/BW) less than 0.5%. All patients were referred for preoperative percutaneous right plus segment IV PVE using embolic microspheres, with planned reassessment of the LR/BW 30 days after PVE. Post-PVE outcomes were compared with reported outcomes for ALPPS.

Results: Percutaneous PVE was successfully performed in 141 of the 144 study patients (97.9%). Adequate regeneration was observed in 139 patients (98.5%) with median post-PVE LR/BW rising from 0.33% to 0.52% (p < 0.0001), representing a per-patient median regeneration rate of 62% (range 0.3% to 379%). In total, 104 patients underwent extended right hepatectomy (n = 102) or right hepatectomy (n = 2). The remaining 40 patients (27.8%) were not resectable due to short-interval disease progression (27 patients, 18.5%), insufficient liver regeneration (5 patients, 3.5%), and medical comorbidities (8 patients, 5.6%). After resection, the following outcomes were observed: major morbidity: 33.0% (34 of 104), liver insufficiency: 12.5% (13 of 104), and 90-day liver-related mortality: 5.8% (6 of 104). These oncologic and technical results compare favorably with those of ALPPS.

Conclusions: Based on its ability to select oncologically resectable patients and superior safety and efficacy profiles, percutaneous right + segment IV PVE and interval surgery remains the standard of care for patients with very low future liver remnant volumes.

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Figures

Figure 1
Figure 1
Study population
Figure 2
Figure 2
Increase in future liver remnant – body weight ratio (LR/BW) after right and segment 4 portal vein embolization for patients with LR/BW <0.5 (n = 139)
Figure 3
Figure 3
Resectability after right and segment 4 portal vein embolization
Figure 4
Figure 4
Long-term outcomes after right and segment 4 portal vein embolization Overall survival from PVE (curative resection, n=104 vs. unresectable cases, n=40)
See this image and copyright information in PMC

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