Portal Vein Embolization

Preoperative portal vein embolization (PVE) prior to extended liver resection is an option in selected patients if there is concern regarding possible postoperative liver failure or complications due to a small liver remnant volume. The rationale for this technique is to induce hypertrophy of the future liver remnant (FLR).

The first clinical report demonstrating this technique was by Kinoshita et al in 1986. In this study, 21 patients with a diagnosis of hepatocellular carcinoma underwent preoperative PVE and hepatic artery embolization. Postembolization CT scans and operative findings confirmed hypertrophy of the contralateral liver. Kawasaki et al (1994) reported on 5 patients with metastatic colorectal cancer who underwent preoperative right PVE to allow extended right hepatectomy in conjunction with wedge resections of the left lateral segment. Embolizations were performed between 9 days and 8 months before surgical resection, and the mean survival was 47 months. The procedure is associated with true DNA synthesis of the contralateral liver (nonembolized) and hypertrophy secondary to clonal expansion of the hepatocytes. Clinically, the procedure leads to improved function of the FLR, as demonstrated by studies showing increased biliary excretion of the FLR and improved postoperative liver function tests after resection in patients who have undergone PVE.

At M. D. Anderson, PVE is performed in the interventional radiology department under fluoroscopic guidance. Madoff et al (2003) recently reported on 26 patients who underwent PVE before major hepatic resection for hepatobiliary malignancy. In 25 of the patients, an ipsilateral percutaneous approach was used to access the portal vein, and the embolization material consisted of microspheres and coils. The median length of hospital stay was less than 24 hours, and an increase in FLR occurred in 23 of the 26 patients. PVE is well tolerated and in noncirrhotic livers induces a 25% to 80% increase in the absolute volume of the nonembolized liver (Figure 11-5). Four to 6 weeks are usually required to enable adequate hypertrophy in normal livers. After this period, sur-

Figure 11-5. Preoperative 3-dimensional reconstruction of the future liver remnant (FLR) prior to extended right lobectomy (segments 1, 2, and 3) before (left) and after (right) portal vein embolization. The FLR increased from 266 cm3 to 406 cm3 in 6 weeks. Reprinted with permission from Vauthey et al, 2000.

Figure 11-5. Preoperative 3-dimensional reconstruction of the future liver remnant (FLR) prior to extended right lobectomy (segments 1, 2, and 3) before (left) and after (right) portal vein embolization. The FLR increased from 266 cm3 to 406 cm3 in 6 weeks. Reprinted with permission from Vauthey et al, 2000.

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