Preoperative portal vein embolization for extension of hepatectomy indications

TLDR

The study aims to make hepatectomy feasible in patients with insufficient future remnant liver volume by redirecting portal blood flow toward the remnant. Preoperative portal vein embolization was performed percutaneously under fluoroscopy in 31 patients to redirect portal flow toward the future remnant liver. POPE was well tolerated, enabling surgery in 24 of 31 patients, and produced a median 79 % increase in future remnant liver volume, with overall survival up to 62 months and disease‑free survival up to 60 months, demonstrating that POPE expands curative hepatectomy options and that cyanoacrylate yields faster hypertrophy.

Abstract

To render hepatectomy feasible in patients with an initially deficient volume of the future remnant liver (FRL), we redistributed portal blood flow rich in hepatotrophic substances toward the FRL. Redistribution was achieved with preoperative portal vein embolization (POPE) feeding the future resected liver. POPE was performed in 31 patients, under fluoroscopic guidance, via a percutaneous access. POPE was well tolerated and surgery was practicable in 24 patients without severe postoperative liver failure. Seven operations were cancelled, but only one due to insufficient hypertrophy of the FRL. FRL volume values were 90 to 560 mL (mean 260 mL) before POPE and 160–783 mL (mean 443 mL) after POPE, which represents a median increase of 79% ± 50%. Hypertrophy of the FRL was 90% ± 52% after 30 days with cyanoacrylate, 53% ± 6% after 43 days with Gelfoam, and 44% ± 30% after 35 days with coils. Slight shrinkage was obtained in the volume of the embolized liver, for which resection was planned. Overall survival was 2–62 months (mean 26 months), disease–free survival was 0–60 months (mean 19 months), and 7 patients are disease–free and alive 14 to 60 months (mean 43 months) after surgery. Although exclusively applicable in a limited subset of patients, POPE widens the possibilities of curative hepatectomies, because it induces sound hypertrophy of unembolized liver segments. Cyanoacrylate seems to ensure better and faster hypertrophy.