Extension of Right Portal Vein Embolization to Segment IV Portal Branches

Abstract

Routine embolization of segment IV, combined with right portal vein embolization (PVE), has been suggested in patients who are candidates for right trisegmentectomy to induce higher and faster hypertrophy of segments II-III. Our objective was to compare hypertrophy of segments II-III induced by PVE with and without extension to segment IV in patients undergoing major hepatectomy. Methods: Twenty-six consecutive patients were prospectively evaluated; the future remnant liver volume was calculated using the portal phase of spiral computed tomographic scans before and 3 to 4 weeks after right PVE (group R, n = 13), which was extended to segment IV branches in 13 patients (group L). Results: Twenty patients (76.9%) underwent the scheduled hepatic resection. Of the 6 patients who did not undergo the planned operation, 5 showed disease progression ; in 1 patient (group L), there was an insufficient increase of the future remnant liver volume due to the presence of embolizing material in the left lobe. The mean ± SD time between PVE and volume measurements was 31.8±9.3 days. The overall mean±SD future remnant liver volume increase was 53.1%±24.8%; the increase for segment IV was significantly higher in group R than group L. The mean±SD post-PVE volumes of segments II-III and the rate of volume increase were similar in the 2 groups: group R, 348.4 ± 83.1 cm 3 and 67.8%±30.8%, respectively, vs group L, 391.2±78.05 cm 3 and 56.1%±35.1%, respectively (P =.20 and P= .40). Conclusion: Extension of embolization to segment IV portal branches should not be routinely used because a similar volume increase of segments II-III can be simply achieved by right PVE.

Two-Stage Portal Vein Ligation Facilitates Liver Regeneration in Rats

“…Studies have reported that hepatectomy cannot be performed following PVE in 7-30% of cases, because of cancer advancement while waiting for hepatectomy or insufficient hypertrophy of the future remnant liver [1,2,[4][5][6] . To allow hepatectomy in such patients, methods must be established to facilitate liver regeneration following PVE and shorten the waiting period.…”

“…This technique has improved safety and therapeutic outcomes [1][2][3] . However, PVE has several problems, and some studies have reported that resection cannot be performed on 13-30% of PVE patients due to cancer advancement while waiting for hepatectomy [1,2,4,5] . In addition, studies have reported that even when PVE is performed, scheduled hepatectomy cannot be performed on 7-11% of PVE patients because hypertrophy of the future remnant liver is insufficient [2,5,6] .…”

Optimizing the Liver for Resection in Patients Undergoing Extended Hepatectomy or Receiving Chemotherapy

“…Relating to this proposal, Capussotti et al [26] formulated an objective opinion based on their prospective study in which the increase in the volume of segments II-III after right PVE was similar with or without segment IV embolization. Therefore, the authors recommend simple right PVE to avoid the risk of accidental migration of embolizing agents.…”

Prolonged chemotherapy impairs liver regeneration after portal vein occlusion – An audit of 26 patients

“…Our standard technique was right portal embolisation since this has been shown to give a similar volume increase of the left lateral segment as right portal vein embolisation with inclusion of segment 4 branches [27]. We used polyvinyl particles only, which has been reported to provide efficient and durable portal vein occlusion [28], although other investigators add microcoils deployed in segmental portal branches [29].…”