Portal vein embolization before extended hepatectomy for biliary cancer: current technique and review of 494 consecutive embolizations

Efficacy of Preoperative Portal Vein Embolization Among Patients with Hepatocellular Carcinoma, Biliary Tract Cancer, and Colorectal Liver Metastases: A Comparative Study Based on Single-Center Experience of 319 Cases

BACKGROUND

Efficacy of preoperative portal vein embolization (PVE) has been established; however, differences of outcomes among diseases, including hepatocellular carcinoma (HCC), biliary tract cancer (BTC), and colorectal liver metastases (CLM), are unclear.

METHODS

Subjects included patients in a prospectively collected database undergoing PVE (from 1995 to 2013). A future liver remnant (FLR) volume ≥40% is the minimal requirement for patients with an indocyanine green retention rate at 15 min (ICGR15) <10%, and stricter criteria (FLR volume ≥50%) have been applied for patients with 20% > ICGR15 ≥ 10%. Patient characteristics and survivals were compared among those three diseases, and predictors of dropout and better FLR hypertrophy were determined.

RESULTS

In 319 consecutive patients undergoing PVE for HCC (n = 70), BTC (n = 172), and CLM (n = 77), the degree of hypertrophy did not significantly differ by cancer types (median 10, 9.6, and 10%, respectively). Eighty percent (256 of 319) of patients completed subsequent hepatectomy after a median waiting interval of 24 days (range 5-90), while dropout after PVE was more common in BTC or CLM (odds ratio 2.75, p = 0.018), mainly because of disease progression. Ninety-day liver-related mortality after hepatectomy was 0% in the entire cohort, and 5-year overall survival of patients with HCC, BTC, and CLM was 56, 50, and 51%, respectively (p = 0.948). No patients who dropped out survived more than 2.5 years after PVE.

CONCLUSION

PVE produced equivalent FLR hypertrophy among the three diseases as long as liver function was fulfilling the preset criteria; however, the completion rate of subsequent hepatectomy was highest in HCC. PVE followed by hepatectomy was a safe and feasible strategy for otherwise unresectable disease irrespective of cancer types.

[Portal vein embolization: Present and future]

Portal vein embolization consists of occluding a part of the portal venous system in order to achieve the hypertrophy of the non-embolized liver segments. This technique is used during the preoperative period of major liver resection when the future remnant liver (FRL) volume is insufficient, exposing to postoperative liver failure, main cause of death after major hepatectomy. Portal vein embolization indication depends on the FRL, commonly assessed by its volume. Nowadays, FRL function evaluation seems more relevant and can be measured by 99mTc labelled mebrofenin scintigraphy. Portal vein embolization procedure is mostly performed with percutaneous trans-hepatic access by using ultrasonography guidance and consists of embolic agent injection, such as cyanoacrylate, in the targeted portal vein branches with fluoroscopic guidance. It is a safe and well-tolerated technique, with extremely low morbi-mortality. Portal vein embolization leads to sufficient FRL hypertrophy in about 80% of patients, allowing them to undergo surgery from which they were initially rejected. The two main reasons of non-resection are tumor progression (≈15% of cases) and FRL insufficient hypertrophy (≈5% of cases). When portal vein embolization is not enough to obtain adequate FRL regeneration, hepatic vein embolization may potentiate its effect (liver venous deprivation technique).

High mortality after ALPPS for perihilar cholangiocarcinoma: case-control analysis including the first series from the international ALPPS registry

INTRODUCTION

Resection of perihilar cholangiocarcinoma (PHC) entails high-risk surgery with postoperative mortality reported up to 18%, even in specialized centers. The aim of this study was to compare outcomes of PHC patients who underwent associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) to patients who underwent resection without ALPPS.

METHODS

All patients who underwent ALPPS for PHC were identified from the international ALPPS registry and matched controls were selected from a standard resection cohort from two centers based on future remnant liver size. Outcomes included morbidity, mortality, and overall survival.

RESULTS

ALPPS for PHC was associated with 48% (14/29) 90-day mortality. 90-day mortality was 13% in 257 patients who underwent major liver resection for PHC without ALPPS. The 29 ALPPS patients were matched to 29 patients resected without ALPPS, with similar future liver remnant volume (P = 0.480). Mortality in the matched control group was 24% (P = 0.100) and median OS was 27 months, comparted to 6 months after ALPPS (P = 0.064).

DISCUSSION

Outcomes of ALPPS for PHC appear inferior compared to standard extended resections in high-risk patients. Therefore, portal vein embolization should remain the preferred method to increase future remnant liver volume in patients with PHC. ALPPS is not recommended for PHC.

The Predictive Value of Indocyanine Green Clearance in Future Liver Remnant for Posthepatectomy Liver Failure Following Hepatectomy with Extrahepatic Bile Duct Resection

BACKGROUND

Postoperative liver failure (PHLF) is one of the most common complications following major hepatectomy. The preoperative assessment of future liver remnant (FLR) function is critical to predict the incidence of PHLF.

OBJECTIVE

To determine the efficacy of the plasma clearance rate of indocyanine green clearance of FLR (ICGK-F) in predicting PHLF in cases of highly invasive hepatectomy with extrahepatic bile duct resection.

METHODS

Five hundred and eighty-five patients who underwent major hepatectomy with extrahepatic bile duct resection, from 2002 to 2014 in a single institution, were evaluated. Among them, 192 patients (33 %) had PHLF. The predictive value of ICGK-F for PHLF was determined and compared with other risk factors for PHLF.

RESULTS

The incidence of PHLF was inversely proportional to the level of ICGK-F. With multivariate logistic regression analysis, ICGK-F, combined pancreatoduodenectomy, the operation time, and blood loss were identified as independent risk factors of PHLF. The risk of PHLF increased according to the decrement of ICGK-F (the odds ratio of ICGK-F for each decrement of 0.01 was 1.22; 95 % confidence interval 1.12-1.33; P < 0.001). Low ICGK-F was also identified as an independent risk factor predicting the postoperative mortality.

CONCLUSIONS

ICGK-F is useful in predicting the PHLF and mortality in patients undergoing major hepatectomy with extrahepatic bile duct resection. This criterion may be useful for highly invasive hepatectomy, such as that with extrahepatic bile duct resection.

The role of interventional radiology in the treatment of intrahepatic cholangiocarcinoma

Intrahepatic cholangiocarcinoma (ICC) is the second most common primary hepatic malignancy after hepatocellular carcinoma. Complete surgical resection remains the only potentially curative option for patients with ICC. However, until now, early diagnosis with potential surgical intervention has been the exception rather than the rule with only 30% of patients qualifying for attempted surgical cure. Many patients are unresectable because of disease stage, anatomic conditions, medical comorbidities, and small future remnant liver. Interventional radiology procedures are available for these types of patients with intra-arterial therapies and/or ablative treatments both for curative and for palliative treatment. The goals of interventional therapy are to control local tumor growth, to relieve symptoms, and to improve and preserve quality of life. The choice of treatment depends largely on tumor extent and patient performance. No randomized studies exist to compare treatments. The present review describes the current evidence of the interventional treatments in the management of the ICC. Moreover, interventional procedures available to increase the future liver reserve before surgery were analyzed.

Cholangiocarcinoma

Biliary tract cancer accounts for <1% of all cancers and affects chiefly an elderly population, with predominance in men. We distinguish cholangiocarcinoma (intrahepatic, hilar and distal) and gallbladder cancer, with different pathogenesis and prognosis. The treatment is based on surgery (whenever possible), radiotherapy in selected cases, and chemotherapy. The standard cytotoxic treatment for advanced/metastatic disease is represented by the combination of gemcitabine and cisplatin, whereas fluoropyrimidines are generally administered in second line setting. At the present time, no biologic drug demonstrated a clear efficacy in this cancer, although the molecular characterisation could provide a promising basis for experimental treatments. A good supportive care and an early palliative care are warranted in most patients and should be delivered as a part of a global approach.

Meta-analysis of associating liver partition with portal vein ligation and portal vein occlusion for two-stage hepatectomy

BACKGROUND

Discussion is ongoing regarding whether associating liver partition with portal vein ligation for staged hepatectomy (ALPPS) or portal vein occlusion is better in staged hepatectomy. The aim of this study was to compare available strategies using a two-stage approach in extended hepatectomy.

METHODS

A literature search was performed in MEDLINE, Scopus, the Cochrane Library and Embase, and additional articles were identified by hand searching. Data from the international ALPPS registry were extracted. Clinical studies reporting volumetric changes, mortality, morbidity, feasibility of the second stage and tumour-free resection margins (R0) in two-stage hepatectomy were included.

RESULTS

Ninety studies involving 4352 patients, including 320 from the ALPPS registry, met the inclusion criteria. Among these, nine studies (357 patients) reported on comparisons with other strategies. In the comparison of ALPPS versus portal vein embolization (PVE), ALPPS was associated with a greater increase in the future liver remnant (76 versus 37 per cent; P < 0·001) and more frequent completion of stage 2 (100 versus 77 per cent; P < 0·001). Compared with PVE, ALPPS had a trend towards higher morbidity (73 versus 59 per cent; P = 0·16) and mortality (14 versus 7 per cent; P = 0·19) after stage 2. In the non-comparative studies, complication rates were 39 per cent in the PVE group, 47 per cent in the portal vein ligation (PVL) group and 70 per cent in the ALPPS group. After stage 2, mortality rates were 5, 7 and 12 per cent respectively.

CONCLUSION

ALPPS is associated with greater future liver remnant hypertrophy and a higher rate of completion of stage 2, but this may be at the price of greater morbidity and mortality.

Use of an absorbable embolization material for reversible portal vein embolization in an experimental model

BACKGROUND

Portal vein embolization (PVE) is used to increase future remnant liver size in patients requiring major hepatic resection. PVE using permanent embolization, however, predisposes to complications and excludes the use of PVE in living donor liver transplantation. In the present study, an absorbable embolization material containing fibrin glue and different concentrations of the fibrinolysis inhibitor aprotinin was used in an experimental animal model.

METHODS

PVE of the cranial liver lobes was performed in 30 New Zealand White rabbits, which were divided into five groups, fibrin glue + 1000, 700, 500, 300 or 150 kunits/ml aprotinin, and were compared with a previous series of permanent embolization using the same experimental set-up. Caudal liver lobe hypertrophy was determined by CT volumetry, and portal recanalization was identified on contrast-enhanced CT images. Animals were killed after 7 or 42 days, and the results were compared with those of permanent embolization.

RESULTS

PVE using fibrin glue with aprotinin as embolic material was effective, with 500 kunits/ml providing the optimal hypertrophic response. Lower concentrations of aprotinin (150 and 300 kunits/ml) led to reduced hypertrophy owing to early recanalization of the embolized segments. The regeneration rate over the first 3 days was higher in the group with 500 kunits/ml aprotinin than in the groups with 300 or 150 kunits/ml or permanent embolization. In the 500-kunits/ml group, four of five animals showed recanalization 42 days after embolization, with minimal histological changes in the cranial lobes following recanalization.

CONCLUSION

Fibrin glue combined with 500 kunits/ml aprotinin resulted in reversible PVE in 80 per cent of animals, with a hypertrophy response comparable to that achieved with permanent embolization material. Surgical relevance Portal vein embolization (PVE) is used to increase future remnant liver volume in patients scheduled for major liver resection who have insufficient future remnant liver size to perform a safe resection. The current standard is PVE with permanent embolization materials, which renders patients found to have unresectable disease prone to complications owing to the permanently deportalized liver segments. Absorbable embolization might prevent the PVE-associated morbidity and lower the threshold for its application. In this study, PVE using fibrin glue and aprotinin resulted in an adequate hypertrophy response with 80 per cent recanalization after 42 days. Considering the minor histological changes following recanalization of embolized segments and potentially preserved function, reversible PVE might also be applied in living donor liver transplantation.

A Nomogram to Predict Hypertrophy of Liver Segments 2 and 3 After Right Portal Vein Embolization

BACKGROUND

Portal vein embolization (PVE) reduces the risks of hepatic insufficiency after major hepatectomy for small predicted liver remnant. The extent of liver hypertrophy after PVE depends on various clinical factors. We sought to develop a nomogram for predicting the increase in the volume of segments 2 and 3 after right PVE (RPVE).

METHOD

In 360 patients who underwent RPVE from 1998 through 2013, clinicopathologic data were analyzed, including body mass index (BMI), diabetes, aspirin use, viral hepatitis status, preoperative albumin level, total bilirubin level, prothrombin time, platelet count, type of liver neoplasm, preoperative chemotherapy, previous laparotomy or hepatectomy, segment 4 embolization, two-stage hepatectomy, and liver volumes before and after PVE. Multivariate linear regression analysis was used to identify variables predicting the degree of hypertrophy of segments 2 and 3.

RESULTS

Multivariate regression analysis revealed that BMI (p = 0.002), previous hepatectomy (p = 0.03), RPVE in the setting of two-stage hepatectomy (p < 0.001), and segment 4 embolization (p = 0.003) independently predicted the degree of hypertrophy of segments 2 and 3. Based on the fitted model, a nomogram was constructed.

CONCLUSION

The constructed nomogram predicts the degree of hypertrophy of segments 2 and 3 after RPVE and can be used in clinical decision making for patients undergoing right hepatectomy.

The role of portal vein embolization in the surgical management of primary hepatobiliary cancers. A systematic review

BACKGROUND

Primary liver and biliary cancers are very aggressive tumors. Surgical treatment is the main option for cure or long term survival. The main purpose of this systematic review is to underline the indications for portal vein embolization (PVE), in patients with inadequate future liver remnant (FLR) and to analyze other parameters such as resection rate, morbidity, mortality, survival after PVE and hepatectomy for primary hepatobiliary tumors. Also the role of trans-arterial chemoembolization (TACE) before PVE, is investigated.

METHODS

A systematic search of the literature was performed in Pub Med and the Cochrane Library from 01.01.1990 to 30.09.2015.

RESULTS

Forty articles were selected, including 2144 patients with a median age of 61 years. The median excision rate was 90% for hepatocellular carcinomas (HCCs) and 86% for hilar cholangiocarcinomas (HCs). The main indications for PVE in patients with HCC and presence of liver fibrosis or cirrhosis was FLR <40% when liver function was good (ICGR15 < 10%) and FLR < 50% when liver function was affected (ICGR15:10-20%). The combination of TACE and PVE increased hypertrophy rate and was associated with better overall survival and disease free survival and should be considered in advanced HCC tumors with inadequate FLR. In patients with HCs PVE was performed, after preoperative biliary drainage, when FLR was <40%, in the majority of studies, with very good post-operative outcome. However indications should be refined.

CONCLUSION

PVE before major hepatectomy allows resection in a patient group with advanced primary hepato-biliary tumors and inadequate FLR, with good long term survival.

Surgical treatment of gallbladder carcinoma: a critical review

Gallbladder carcinoma is a relatively uncommon cancer of gastrointestinal (GI) tract. Medical literature is full of nihilistic reports about the treatment of gallbladder carcinoma, especially due to its resistance to current radiotherapeutic or chemotherapeutic treatment modalities and difficult surgical approach for complete resection of these tumors. Herein, we review current diagnostic and therapeutic approaches to this rare GI cancer.

Is gall bladder cancer a bad cancer per se?

Gall bladder cancer (GBC) has one of the poorest outcomes of all cancers. Early GBC is difficult to diagnose on even computed tomography. GB has no submucosa and the cancer infiltrates directly into the muscularis propria. GB wall is thin and important adjacent organs viz. liver, duodenum and pancreas get easily infiltrated. Tumor in the GB neck often needs extended right hepatectomy. Infiltration of duodenum/pancreas may necessitate pancreato-duodenectomy or even hepato-pancreato-duodenectomy. Mortality of surgical procedures, when performed for GBC, is higher than when performed for other cancers. Survival in GBC, even after R0 resection, is poor. There is no proven role of neo-adjuvant or adjuvant therapy for loco-regionally advanced GBC. There is no role of palliative surgery in metastatic GBC. Early GBC is diagnosed incidentally after cholecystectomy for stones and requires reoperation for completion extended cholecystectomy but unfortunately, most surgeons are not aware of this. GBC has a peculiar epidemiology and is uncommon in the West and has, therefore, not received much attention. Preventive cholecystectomy for asymptomatic stones is not recommended and there is no serum marker for screening. With all factors pitched against it, it does appear that GBC is a bad cancer per se!

Intrahepatic Cholangiocarcinoma

Cholangiocarcinoma is a rare malignancy that arises from epithelial cells of the biliary system. Its desmoplastic histology and the heterogeneity of its presentation have contributed to its poor prognosis, with limited therapeutic options previously available. However, recent advances using locoregional therapy may expand the treatment arsenal used to manage this resistant malignancy. Although surgical resection has previously been reserved for relatively few patients because of inadequate hepatic reserve, portal vein embolization can induce contralateral hepatic lobe hypertrophy to increase the number of patients eligible for resection. For unresectable cases, both transarterial chemoembolization and yttrium-90 radioembolization have shown effectiveness in controlling tumor growth and prolonging survival.

Surgical treatment of hilar cholangiocarcinoma: New advances

Hilar cholangiocarcinoma, a malignant tumor that occurs in the left and right hepatic duct, is the most common form of bile duct carcinoma. Early diagnosis of hilar cholangiocarcinoma is difficult, and the majority of patients are diagnosed in advanced stages. Therefore, surgery for this malignancy is difficult, has high risk, and is associated with a poor prognosis. In recent years, with the development of imaging technology and extended radical surgery, the preoperative diagnosis and surgical treatment of hilar cholangiocarcinoma have been improved. However, hilar cholangiocarcinoma still has a low cure rate, high complication rate, and poor prognosis. Therefore, we should strengthen the research on the susceptible factors and biological characteristics of hilar cholangiocarcinoma, and improve early diagnosis. Currently, although there has been no unified standard for the resectability of the tumor, surgery combined with partial hepatectomy is strongly recommended in patients without surgical contraindication. This paper reviews the recent progress in surgical treatment of hilar cholangiocarcinoma.

Preoperative estimation of future remnant liver function following portal vein embolization using relative enhancement on gadoxetic acid disodium-enhanced magnetic resonance imaging

Objective

To retrospectively evaluate relative enhancement (RE) in the hepatobiliary phase of gadoxetic acid disodium-enhanced magnetic resonance (MR) imaging as a preoperative estimation of future remnant liver (FRL) function in a patients who underwent portal vein embolization (PVE).

Materials and Methods

In 53 patients, the correlation between the indocyanine green clearance (ICG-K) and RE imaging was analyzed before hepatectomy (first analysis). Twenty-three of the 53 patients underwent PVE followed by a repeat RE imaging and ICG test before an extended hepatectomy and their results were further analyzed (second analysis). Whole liver function and FRL function were calculated on the MR imaging as follows: RE x total liver volume (RE Index) and FRL-RE x FRL volume (Rem RE Index), respectively. Regarding clinical outcome, posthepatectomy liver failure (PHLF) was evaluated in patients undergoing PVE.

Results

Indocyanine green clearance correlated with the RE Index (r = 0.365, p = 0.007), and ICG-K of FRL (ICG-Krem) strongly correlated with the Rem RE Index (r = 0.738, p < 0.001) in the first analysis. Both the ICG-Krem and the Rem RE Index were significantly correlated after PVE (r = 0.508, p = 0.013) at the second analysis. The rate of improvement of the Rem RE Index from before PVE to after PVE was significantly higher than that of ICG-Krem (p = 0.014). Patients with PHLF had a significantly lower Rem RE Index than patients without PHLF (p = 0.023).

Conclusion

Relative enhancement imaging can be used to estimate FRL function after PVE.

Does inchinkoto, a herbal medicine, have hepatoprotective effects in major hepatectomy? A prospective randomized study

OBJECTIVES

This randomized clinical trial was designed to investigate whether inchinkoto has a hepatoprotective effect on postoperative outcome after major hepatectomy.

METHODS

Sixty-one patients scheduled for major hepatectomy were randomly assigned to one of two groups in which preoperative inchinkoto was (inchinkoto group, n = 30) or was not (non-inchinkoto group, n = 31) administered. Inchinkoto was administered for at least 7 days before surgery. The primary endpoint was the incidence of post-hepatectomy liver damage. The expression of nuclear factor E2-related factor 2 (Nrf2) and other oxygen stress-related markers in the liver were also determined.

RESULTS

There was no significant difference in clinical characteristics between the inchinkoto and non-inchinkoto groups. Serum levels in liver function tests and incidences of post-hepatectomy liver failure did not differ significantly between the two groups. However, there was a significantly higher induction of antioxidant factors in the liver, such as Nrf2 protein and heme oxygenase-1 mRNA, after hepatectomy in the inchinkoto group than in the non-inchinkoto group.

CONCLUSIONS

The preoperative administration of inchinkoto did not have a significant impact on the overall outcome of major hepatectomy. However, inchinkoto induced the expression of Nrf2 during hepatectomy and may have exerted an antioxidative effect on the liver.

Clinical practice guidelines for the management of biliary tract cancers 2015: the 2nd English edition

BACKGROUND

The Japanese Society of Hepato-Biliary-Pancreatic Surgery launched the clinical practice guidelines for the management of biliary tract and ampullary carcinomas in 2008. Novel treatment modalities and handling of clinical issues have been proposed after the publication. New approaches for editing clinical guidelines, such as the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system, also have been introduced for better and clearer grading of recommendations.

METHODS

Clinical questions (CQs) were proposed in seven topics. Recommendation, grade of recommendation and statement for each CQ were discussed and finalized by evidence-based approach. Recommendation was graded to grade 1 (strong) and 2 (weak) according to the concept of GRADE system.

RESULTS

The 29 CQs covered seven topics: (1) prophylactic treatment, (2) diagnosis, (3) biliary drainage, (4) surgical treatment, (5) chemotherapy, (6) radiation therapy, and (7) pathology. In 27 CQs, 19 recommendations were rated strong and 11 recommendations weak. Each CQ included the statement of how the recommendation was graded.

CONCLUSIONS

This guideline provides recommendation for important clinical aspects based on evidence. Future collaboration with cancer registry will be a key for assessment of the guidelines and establishment of new evidence. Free full-text articles and a mobile application of this guideline are available via http://www.jshbps.jp/en/guideline/biliary-tract2.html.

Advances in the surgical treatment of hilar cholangiocarcinoma

With the improvement of perioperative management and surgical techniques as well as the accumulation of knowledge on the oncobiological behavior of bile duct carcinoma, the long-term prognosis of hilar cholangiocarcinoma has been improving. In this article, the authors review the recent developments in surgical strategies for hilar cholangiocarcinoma, focusing on diagnosis for characteristic disease extension, perioperative management to reduce postoperative morbidity and mortality, surgical techniques for extended curative resection and postoperative adjuvant therapy.

Intrahepatic cholangiocarcinoma

Intrahepatic cholangiocarcinoma (ICC) is a rare tumor, with an increasing incidence worldwide and an overall poor prognosis. Symptoms are usually nonspecific, contributing to an advanced tumor stage at diagnosis. The staging system for ICC has recently been updated and is based on number of lesions, vascular invasion, and lymph node involvement. Complete surgical resection to negative margins remains the only potentially curable treatment for ICC. Gemcitabine-based adjuvant therapy can be offered based on limited data from patients with unresectable ICC. Overall 5-year survivals after resection range from 17% to 44%, with median survivals of 19 to 43 months.

The determination of bile leakage in complex hepatectomy based on the guidelines of the International Study Group of Liver Surgery

BACKGROUND

The International Study Group of Liver Surgery (ISGLS) has defined bile leakage as a drain fluid-to-serum total bilirubin concentration (TBC) ratio (the bilirubin ratio) ≥ 3.0. The aim of the present study was to determine the clinical significance of this definition, and to outline characteristics of bile leakage in complex hepatectomy.

METHODS

The TBCs of the serum and drain fluid were measured on postoperative days (POD) 1, 3, and 7 in 241 patients who had undergone hepatobiliary resection. The validation of the bilirubin ratio and predictors of bile leakage were retrospectively assessed.

RESULTS

Grade A, B, or C bile leakage was found in 23 (9.5 %), 66 (27.4 %), and 0 patients, respectively. The median duration of drainage was 27 days in grade B bile leakage. The sensitivity and specificity of the bilirubin ratio for detecting grade B bile leakage were 59 and 87 %, respectively. The area under the receiver operating characteristics curve of the drain fluid TBC on POD 3 had the highest predictive value: 68 % sensitivity and 76 % specificity for a drain fluid TBC of 3.7 mg/dL. The multivariate analysis demonstrated that operative time, left trisectionectomy, bilirubin ratio, and TBC of the drain fluid on POD 3 were independent predictors of grade B bile leakage.

CONCLUSIONS

In complex hepatectomy, bile leakage develops most frequently after left trisectionectomy and often results in a refractory clinical course. The ISGLS biochemical definition is valid, and a combination of bilirubin ratio and drain fluid TBC may enhance risk prediction for grade B bile leakage.

Fibrin Sealant: The Only Approved Hemostat, Sealant, and Adhesive-a Laboratory and Clinical Perspective

Background. Fibrin sealant became the first modern era material approved as a hemostat in the United States in 1998. It is the only agent presently approved as a hemostat, sealant, and adhesive by the Food and Drug Administration (FDA). The product is now supplied as patches in addition to the original liquid formulations. Both laboratory and clinical uses of fibrin sealant continue to grow. The new literature on this material also continues to proliferate rapidly (approximately 200 papers/year). Methods. An overview of current fibrin sealant products and their approved uses and a comprehensive PubMed based review of the recent literature (February 2012, through March 2013) on the laboratory and clinical use of fibrin sealant are provided. Product information is organized into sections based on a classification system for commercially available materials. Publications are presented in sections based on both laboratory research and clinical topics are listed in order of decreasing frequency. Results. Fibrin sealant remains useful hemostat, sealant, and adhesive. New formulations and applications continue to be developed. Conclusions. This agent remains clinically important with the recent introduction of new commercially available products. Fibrin sealant has multiple new uses that should result in further improvements in patient care.

Safety and efficacy of portal vein embolization before planned major or extended hepatectomy: an institutional experience of 358 patients

INTRODUCTION

Portal vein embolization (PVE) stimulates hypertrophy of the future liver remnant (FLR) and may improve the safety of extended hepatectomy. The efficacy of PVE was evaluated.

METHODS

Records of 358 consecutive patients who underwent PVE before intended major hepatectomy at our institution from 1995 through 2012 were retrospectively reviewed.

RESULTS

One hundred twelve patients (31.3 %) had right PVE alone; 235 (65.6 %) had right PVE plus segment IV embolization. The first-session PVE completion rate was 97.8 %. The PVE complication rate was 3.9 %. The median pre-PVE and post-PVE standardized FLRs were 19.5 % (interquartile range, 15.0-25.9) and 29.7 % (interquartile range, 22.5-38.2), respectively. Two hundred forty patients (67.0 %) underwent potentially curative resection. Sixty-two patients (25.8 %) had major post-hepatectomy complications; rates of postoperative hepatic insufficiency and 90-day liver-related mortality were 8.3 and 3.8 %, respectively. The proportion of patients with colorectal liver metastasis increased from 38.6 % before 2005 to 78.2 % in 2010-2012. Despite increased use of preoperative chemotherapy, postoperative hepatic insufficiency and 90-day liver-related mortality rates dropped from 10.6 and 4.1 %, respectively, before 2010 to 2.9 and 2.9 %, respectively, in 2010-2012.

CONCLUSIONS

PVE can be safely performed with minimal morbidity. Most patients can proceed to extended hepatectomy, which is associated with a minimal mortality rate.

Portal vein embolization improves rate of resection of extensive colorectal liver metastases without worsening survival

BACKGROUND

Most patients requiring an extended right hepatectomy (ERH) have an inadequate standardized future liver remnant (sFLR) and need preoperative portal vein embolization (PVE). However, the clinical and oncological impact of PVE in such patients remains unclear.

METHODS

All consecutive patients presenting at the M. D. Anderson Cancer Center with colorectal liver metastases (CLM) requiring ERH at presentation from 1995 to 2012 were studied. Surgical and oncological outcomes were compared between patients with adequate and inadequate sFLRs at presentation.

RESULTS

Of the 265 patients requiring ERH, 126 (47·5 per cent) had an adequate sFLR at presentation, of whom 123 underwent a curative resection. Of the 139 patients (52·5 per cent) who had an inadequate sFLR and underwent PVE, 87 (62·6 per cent) had a curative resection. Thus, the curative resection rate was increased from 46·4 per cent (123 of 265) at baseline to 79·2 per cent (210 of 265) following PVE. Among patients who underwent ERH, major complication and 90-day mortality rates were similar in the no-PVE and PVE groups (22·0 and 4·1 per cent versus 31 and 7 per cent respectively); overall and disease-free survival rates were also similar in these two groups. Of patients with an inadequate sFLR at presentation, those who underwent ERH had a significantly better median overall survival (50·2 months) than patients who had non-curative surgery (21·3 months) or did not undergo surgery (24·7 months) (P = 0·002).

CONCLUSION

PVE enabled curative resection in two-thirds of patients with CLM who had an inadequate sFLR and were unable to tolerate ERH at presentation. Patients who underwent curative resection after PVE had overall and disease-free survival rates equivalent to those of patients who did not need PVE.

Right portal vein embolization by laparoscopic catheterization of the inferior mesenteric vein

Right portal vein embolization is often performed to prevent liver insufficiency after major hepatic resection. The procedure usually involves direct puncture of the portal vein, which requires hepatic hilum manipulation, and may be associated with liver injury, pneumothorax, and hemoperitoneum. This report describes a technique of laparoscopic insertion of a sheath into the inferior mesenteric vein followed by right portal vein embolization.

Chronological changes in the liver after temporary partial portal venous occlusion

AIM: To investigate time-dependent changes caused by temporal portal vein obstruction and subsequent reperfusion in the lobe with or without an occluded portal vein.

METHODS: The portal vein (PV) of the anterior lobe of the liver of a male Wistar rat (8 wk-old) was obstructed (70%) for 12, 24, 36 and 48 h, respectively, and models were sacrificed at 48 h after reperfusion (each group: n = 10). The histological changes and the status of liver regeneration were compared between a liver biopsy performed on each lobe after temporary obstruction of the portal vein in the same rat liver, and the liver extracted at the time of sacrifice (48 h after reperfusion).

RESULTS: With regard to the obstructed lobe, the liver weight/body weight ratio significantly decreased according to obstruction time. On the other hand, in the non-obstructed lobe, there were no significant differences within each group. The duration of PV occlusion did not seem to be strong enough to introduce liver weight increase. Stimulation of liver regeneration was brought about in the non-occluded lobe by 12-h occlusion, and was sustained even at 48 h after reperfusion. The obstructed lobe atrophied with the passage of time in the obstructed state. However, the proliferating-cell nuclear antigen labeling index also increased at 48 h after reperfusion, and a repair mechanism was observed.

CONCLUSION: Temporary blood flow obstruction of the portal vein may become a significant trigger for liver regeneration, even with an obstruction of 12 h.

Simultaneous biliary drainage and portal vein embolization before extended hepatectomy for hilar cholangiocarcinoma: preliminary experience

BACKGROUND

Patients with resectable hilar cholangiocarcinoma often present obstructive jaundice and a small future remnant liver (FRL) ratio. A sequential approach comprising preoperative biliary drainage followed by portal vein embolization (PVE) is usually performed but leads to long preoperative management (6-12 weeks) before patients can undergo resection. To simplify and shorten this phase of liver preparation, we developed a new preoperative approach that involves percutaneous biliary drainage and PVE during the same procedure. We report the outcomes of this combined procedure.

METHODS

During 1 year, four patients underwent simultaneous biliary drainage and PVE followed 1 month later by surgical resection of hilar cholangiocarcinoma. Liver volumes were assessed by CT before, and 1, and 3 months after the combined procedure. Serum liver enzymes were assessed before and 1 month after the combined procedure.

RESULTS

The combined procedure was feasible in all cases, with no related complications. After the combined procedure, transaminases remained stable or decreased, whereas gamma-glutamyl-transpeptidase, alkaline phosphatase, and bilirubin decreased. During the first month, the left lobe volume increased by +27.9 % (range 19-40.9 %). The FRL ratio increased from 24.9 to 33.2 %. All patients underwent R0 liver resection with a favorable postoperative outcome. The remnant liver volume increased by +132 % (range 78-245 %) between 1 and 3 months.

CONCLUSIONS

Simultaneous percutaneous biliary drainage and PVE is feasible. This all-in-one preoperative approach greatly decreases waiting time until surgical resection. These encouraging results warrant further investigation to confirm the safety and to evaluate the reduction in the dropout rate for liver resection in this tumor with poor prognosis.

Massive hepatic necrosis with toxic liver syndrome following portal vein ligation

Right portal vein ligation (PVL) is a safe and widespread procedure to induce controlateral liver hypertrophy for the treatment of bilobar colorectal liver metastases. We report a case of a 60-year-old man treated by both right PVL and ligation of the glissonian branches of segment 4 for colorectal liver metastases surrounding the right and median hepatic veins. After surgery, the patient developed massive hepatic necrosis with secondary pulmonary and renal insufficiency requiring transfer to the intensive care unit. This so-called toxic liver syndrome finally regressed after hemofiltration and positive oxygen therapy. Diagnosis of acute congestion of the ligated lobe was suspected. The mechanism suspected was an increase in arterial inflow secondary to portal vein ligation concomitant with a decrease in venous outflow due to liver metastases encircling the right and median hepatic vein. This is the first documented case of toxic liver syndrome in a non-cirrhotic patient with favorable issue, and a rare complication of PVL.

Perihilar cholangiocarcinoma: a surgeon's viewpoint on current topics

Perihilar cholangiocarcinomas are defined anatomically as "tumors that are located in the extrahepatic biliary tree proximal to the origin of the cystic duct". However, as the boundary between the extrahepatic and intrahepatic bile ducts is not well defined, perihilar cholangiocarcinomas potentially include two types of tumors: one is the "extrahepatic" type, which arises from the large hilar bile duct, and the other is the "intrahepatic" type, which has an intrahepatic component with the invasion of the hepatic hilus. The new TNM staging system published by the International Union Against Cancer (UICC) has been well revised with regard to perihilar cholangiocarcinoma, but it still lacks stratification of patient prognosis and has little applicability for assessing the feasibility of surgical treatment; therefore, further refinement is essential. Most patients with perihilar cholangiocarcinomas present with jaundice, and preoperative biliary drainage is mandatory. Previously, percutaneous transhepatic biliary drainage was used in many centers; however, it is accepted that endoscopic naso-biliary drainage is the most suitable method of preoperative drainage. Portal vein embolization is now widely used as a presurgical treatment for patients undergoing an extended hepatectomy to minimize postoperative liver dysfunction. The surgical resection of a perihilar cholangiocarcinoma is technically demanding and continues to be the most difficult challenge for hepatobiliary surgeons. Because of advances in diagnostic and surgical techniques, surgical outcomes and survival rates after resection have steadily improved. However, survival, especially for patients with lymph node metastasis, is still unsatisfactory, and the establishment of adjuvant chemotherapy is necessary. Further synergy of endoscopists, radiologists, oncologists, and surgeons is required to conquer this intractable disease.

Non-operative management of hepatic trauma and the interventional radiology: an update review

The growing trend to manage hepatic injuries nonoperatively has been increasing demand for advanced endovascular interventions. This brings up the necessity for general and trauma surgeons to update their knowledge in such matter. Effective treatment mandates a multispecialty team effort that is usually led by the trauma surgeon and includes vascular surgery, orthopedics, and, increasingly, interventional radiology. The focus on hemorrhage control and the angiographer's unique access to vascular structures gives interventional radiology (IR) an important and increasingly recognized role in the treatment of patients with hemodynamic instability. Our aim is to review the basic concepts of IR primarily in hepatic trauma and secondarily in some other special situations. A liver vascular anatomy review is also needed for better understanding the roles of IR. As a final point we propose a guideline for the operative/nonoperative management of traumatic hepatic injuries. The benefit of multidisciplinary approach (TAE) appears to be a powerful weapon in the medical arsenal against the high mortality of injured trauma liver patients.