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Review
. 2020 Apr;9(2):136-151.
doi: 10.21037/hbsn.2019.09.10.

Preparing for liver surgery with "Alphabet Soup": PVE, ALPPS, TAE-PVE, LVD and RL

DaeHee Kim  1 , Joshua Cornman-Homonoff  2 , David C Madoff  2
Affiliations
Review

Preparing for liver surgery with "Alphabet Soup": PVE, ALPPS, TAE-PVE, LVD and RL

DaeHee Kim et al. Hepatobiliary Surg Nutr. 2020 Apr.

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.

Keywords: Hepatic regeneration; embolization; future liver remnant.

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Conflict of interest statement

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at http://dx.doi.org/10.21037/hbsn.2019.09.10). The authors have no conflicts of interest to declare.

Figures

Figure 1
Figure 1
A 71-year-old man with intrahepatic cholangiocarcinoma who underwent right portal vein embolization (PVE) for small projected future liver remnant (FLR). (A) Pre-procedural contrast-enhanced CT showing the tumor (arrow) and left hepatic lobe (arrowheads); (B) pre-procedural 3D CT volumetry demonstrating segmentation (upper left) and isolation (upper right) of the left hepatic lobe with analysis of volumes (bottom left and right); (C) patient underwent right hepatic PVE with coils (arrows); (D) post-procedural contrast-enhance CT showing the tumor (white arrow), coils (black arrows), and hypertrophy of the left hepatic lobe (arrowheads); (E) post-procedural 3D CT volumetry confirms increase in left hepatic lobe volume.
Figure 2
Figure 2
A 54-year old man with hepatocellular carcinoma who underwent right portal vein embolization (PVE) with lipiodol for small projected future liver remnant (FLR). Pre- (A) and post- (B) embolization CT scans demonstrate significant increase in the volume of the left hepatic lobe (between arrowheads).
Figure 3
Figure 3
A 46-year-old man with metastatic colon cancer status post multiple hepatic wedge resections and hepatic arterial infusion pump placement, now planned for right hepatectomy and referred for pre-operative portal vein embolization due to small projected future liver remnant (FLR). (A) Pre-procedural contrast-enhanced CT showing multifocal tumor (arrows) in the right hepatic lobe; (B) digital substraction angiogram (DSA) demonstrating the pre-embolization appearance of the portal tree (arrows); (C) post-embolization DSA showing absence of filling in the right side of the portal tree (arrows).
Figure 4
Figure 4
A 63-year-old man with metastatic colon cancer, planned for right hepatectomy and referred for pre-operative portal vein embolization due to small projected future liver remnant (FLR). (A) Pre-procedural contrast-enhanced CT showing multifocal tumor in the right hepatic lobe (arrows); (B) DSA demonstrating the pre-embolization appearance of the portal tree (arrows); (C) After embolization with lipiodol, DSA confirms absence of filling in the right side of the portal tree (arrows).
Figure 5
Figure 5
A 66-year-old woman with metastatic breast cancer, planned for right hepatectomy and referred for pre-operative portal vein embolization (PVE) due to small projected future liver remnant (FLR). Patient underwent prior PVE embolization with inadequate hypertrophy of the FLR, so embolization of the hepatic vein was undertaken. Angiogram (A) and DSA (B) showing the pre-embolization appearance of the right hepatic vein (arrow). (C) After embolization with multiple Amplatzer plugs, flow within the right hepatic vein is occluded (arrow).
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Comment in

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