Hypothesis: Hepatic resection is the only curative treatment for large hepatocellular carcinoma (HCC). Sequential, preoperative, selective transcatheter arterial chemoembolization (TACE) and portal vein embolization (PVE) allow feasible and safe major hepatic resections to be performed in HCC patients with chronic liver disease. Design: Retrospective cohort study. Setting: University hospital. Patients: Seventeen HCC patients who underwent preoperative PVE following selective TACE for planned major hepatic resections were enrolled. The indications for PVE were determined using the volumetric ratio of the future remnant liver parenchyma and the indocyanine green retention ratio at 15 minutes. Intervention: Preoperative TACE and PVE. Main Outcome Measures: Tumor characteristics and blood test results before and after TACE and PVE, changes in the volumes of the liver segments after PVE, the feasibility of major hepatic resections, and short-and longterm patient prognoses. Results: The liver function test results transiently worsened after TACE and PVE but returned to baseline levels within 1 (after TACE) or 2 (after PVE) weeks. Within 2 weeks after PVE, 22%±4% hypertrophy of the nonembolized segments was obtained; subsequent major hepatic resections were feasible in 16 patients. Four minor complications (25%) were experienced postoperatively; however, liver failure did not occur. The 5-year overall and disease-free survival rates after curative resection were 55.6% and 46.7%, respectively. Conclusions: Sequential TACE and PVE contribute to both the broadening of surgical indications and the safety of major hepatic resections performed in HCC patients with damaged livers. The long-term outcome of this treatment strategy is satisfactory.

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These results indicate that intracellular trypsinogen activation, which plays an important role in acute pancreatitis, requires a low-pH compartment, as well as serine protease activity.

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