Effect of structured use of preoperative portal vein embolization on outcomes after liver resection of perihilar cholangiocarcinoma

Abstract

Background: Portal vein embolization (PVE) is performed to reduce the risk of liver failure and subsequent mortality after major liver resection. Although a cut-off value of 2⋅7 per cent per min per m 2 has been used with hepatobiliary scintigraphy (HBS) for future remnant liver function (FRLF), patients with perihilar cholangiocarcinoma (PHC) potentially benefit from an additional cut-off of 8⋅5 per cent/min (not corrected for body surface area). Since January 2016 a more liberal approach to PVE has been adopted, including this additional cut-off for HBS of 8⋅5 per cent/min. The aim of this study was to assess the effect of this approach on liver failure and mortality. Methods: This was a single-centre retrospective study in which consecutive patients undergoing liver resection under suspicion of PHC in 2000-2015 were compared with patients treated in 2016-2019, after implementation of the more liberal approach. Primary outcomes were postoperative liver failure (International Study Group of Liver Surgery grade B/C) and 90-day mortality. Results: Some 191 patients with PHC underwent liver resection. PVE was performed in 6⋅4 per cent (9 of 141) of the patients treated in 2000-2015 and in 32 per cent (16 of 50) of those treated in 2016-2019. The 90-day mortality rate decreased from 16⋅3 per cent (23 of 141) to 2 per cent (1 of 50) (P = 0⋅009), together with a decrease in the rate of liver failure from 19⋅9 per cent (28 of 141) to 4 per cent (2 of 50) (P = 0⋅008). In 2016-2019, 24 patients had a FRLF greater than 8⋅5 per cent/min and no liver failure or death occurred, suggesting that 8⋅5 per cent/min is a reliable cut-off for patients with suspected PHC. Conclusion: The major decrease in liver failure and mortality rates in recent years and the simultaneous increased use of PVE suggests an important role for PVE in reducing adverse outcomes after surgery for PHC.

Primary and secondary liver failure after major liver resection for perihilar cholangiocarcinoma

“…Nevertheless, such a strategy has been shown to reduce LF and mortality rates drastically. 8,9 Using the 2 decades of experience with liver function assessment at the Amsterdam UMC, liver volume assessment is no longer part of routine clinical practice, due to the higher predictive value of mebrofenin scintigraphy for LF. 7,23 The rarity of the disease results in low numbers of resections for pCCA per center and 10 or more resections per year per center is very uncommon, especially in Western countries.…”

“…As of 2016, liver volume measurement has not been part of the standard work-up anymore. 8 At the Erasmus MC, future liver remnant volume assessment was performed for most patients who were scheduled for an extended right hemihepatectomy. Liver volume measurements were performed only after embolization.…”

“…5,7e9 Despite these efforts, LF and postoperative mortality remain high after resection of pCCA. 8,9 Beside numerous patient factors (eg, cirrhosis and advanced age), several intraoperative (eg, excessive blood loss) and postoperative events (eg, intra-abdominal infection) have been linked to an increased risk of postoperative LF. 10 To date, there is no classification of postoperative LF, while the clinical presentation can be diverse.…”

Nuclear imaging methods for the prediction of postoperative morbidity and mortality in patients undergoing localized, liver-directed treatments: a systematic review

“…Five studies reported historical comparisons on the outcome rate of LF and mortality in the period before and after implementation of nuclear imaging as a preoperative examination in patients undergoing liver surgery [ 16 , 20 , 25 , 56 , 58 ]. Overall, the historical comparisons involving [ 99m Tc]Tc-mebrofenin found that implementation of nuclear imaging in the preoperative assessment resulted in lower mortality and liver failure rates [ 16 , 20 , 25 ], whereas the historical comparisons on the use of [ 99m Tc]Tc-GSA did not result in a significant decrease in the number of liver failure cases in the period after implementation of [ 99m Tc]Tc-GSA liver scintigraphy [ 56 , 58 ].…”

“…Five studies reported historical comparisons on the outcome rate of LF and mortality in the period before and [16,20,25], whereas the historical comparisons on the use of [ 99m Tc]Tc-GSA did not result in a significant decrease in the number of liver failure cases in the period after implementation of [ 99m Tc]Tc-GSA liver scintigraphy [56,58].…”