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Pre-op Portal Vein Embolization for Major Hepatectomy

Pre-op Portal Vein Embolization for Major Hepatectomy. SL Sin. Introduction. Surgery is the treatment of choice for primary and most metastatic liver tumours Limiting factor being insufficient future remnant liver (FRL) parenchyma volume, leading to fatal liver failure post-op

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Pre-op Portal Vein Embolization for Major Hepatectomy

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  1. Pre-op Portal Vein Embolization for Major Hepatectomy SL Sin

  2. Introduction • Surgery is the treatment of choice for primary and most metastatic liver tumours • Limiting factor being insufficient future remnant liver (FRL) parenchyma volume, leading to fatal liver failure post-op • Portal vein embolization followed by hepatectomy is a common treatment option

  3. Introduction • First described in Japan in 1986 by Kinoshita • Embolization of the portal branches supplying the tumour-bearing liver redirects portal blood flow to the branches of the FRL • Hypertrophy of the FRL resulted

  4. Indications • Patients with insufficient FRL • based on FRL/ (TLV – tumour volume) ratio • Liver volumetry determined by 3D CT reconstruction

  5. Indications • For patients with normal liver, for PVE if FRL/ TLV <25% Capussotti 2005 • For patients with chronic liver disease, FRL/ TLV >40% should remain to minimize post-op complications Azoulay 2000 Kubota 1997

  6. Technique • Transileocolic portal embolization (TIPE) • Minilaparotomy performed under GA • Catheterization of portal vein through a branch of the ileocolic vein • Percutaneous transhepatic portal embolization (PTPE) • Performed by interventional radiologist under LA • Ipsilateral approach/ Contralateral approach

  7. Complications

  8. Results – Hypertrophy • No consensus on the duration for adequate hypertrophy • Average 4 to 5 weeks

  9. Results – Hypertrophy • Restaging and operation performed 4 to 6 weeks after PVE • Mean increase in FRL = 8.4% (~35% functional liver mass) • 79% patients proceeded to surgery • 12% developed additional unresectable disease found after PVE but before surgery • new lesion within FRL • Lung metastasis • 7% had unresectable disease at surgery • Unsuspected extrahepatic disease • Inability to achieve complete tumour clearance Hemming 2003

  10. Results – Hypertrophy • Normal vs diseased liver • Mean increase in %FFLR = 16% vs 9% • Only 86% with chronic liver disease had hypertrophy Farges 2003

  11. Results – Resection-related Overall Morbidity and Mortality • Morbidity rate 16% • transient liver failure, pleural effusion • Mortality rate 1.7% • acute liver failure Abulkhir 2008

  12. Results – Resection-related Overall Morbidity and Mortality Portal Vein Embolization Before Right Hepatectomy • Olivier Farges. Ann Surg 2003 • Prospective comparative trial • 55 patients planned for right hepatectomy selected, with diagnosis being HCC/ liver metastasis/ intrahepatic cholangiocarcinoma • Prospectively assigned to have immediate surgery or PVE before surgery • 28 patients had chronic liver disease (all Child’s A cirrhosis)

  13. PVE for HCC • Patients with underlying cirrhosis • Doubtful effect of hypertrophy • Successful hypertrophy can significantly reduce early post-op complications • Comparable overall and disease-free survival at 1, 3, 5 years for PVE and non-PVE groups Azoulay 2000 Palavecino 2008

  14. PVE for Colorectal Liver Metastasis (CLM) • Comparable overall and disease- free survival at 1, 3, 5 years for PVE and non-PVE groups Azoulay 2000 Oussoultzoglou 2006 • PVE and reduction of tumour shedding in CLM • 33% patient with hepatectomy cancelled due to tumoural extension Azoulay 2000 • Lower intra-hepatic recurrence rate in PVE group Oussoultzoglou 2006

  15. Conclusion • PVE is a safe procedure that can alter the treatment of patients deemed not suitable for hepatectomy due to insufficient FRL • For patients with HCC, successful hypertrophy of FRL can significantly reduces surgery related morbidity

  16. Reference • Extension of right portal vein embolization to segment IV portal branches. Capussotti L. Arch Surg 2005 • Resection of nonresectable liver metastases from colorectal cancer after percutaneous portal vein embolization. Azoulay D. Ann Surg 2000 • Measurement of liver volume and hepatic functional reserve as a guide to decision-making in resectional surgery for hepatic tumours. Kubota K. Hepatology 1997 • Preoperative portal vein embolization for extended hepatectomy. Alan W Hemming. Ann Surg 2003 • Portal vein embolization before right hepatectomy. Olivier Farges. Ann Surg 2003 • Preoperative portal vein embolization for major liver resection. Adel Abulkhir. Ann Surg 2008 • Major hepatic resection for hepatocellular carcinoma with or without portal vein embolization: perioperative outcome and survival. Martin Palavecino. J Surg 2008 • Percutaneous portal vein embolization increases the feasibility and safety of major liver resection for hepatocellular carcinoma in injured liver. D Azoulay. Ann Surg 2000 • Right portal vein embolization before right hepatectomy for unilobar colorectal liver metastasis reduces the intrahepatic recurrence rate. Elie Oussoultzoglou. Ann Surg 2006

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