Liver venous deprivation versus portal vein embolization before major hepatectomy: future liver remnant volumetric and functional changes

Abstract

Background: We previously showed that embolization of portal inflow and hepatic vein (HV) outflow (liver venous deprivation, LVD) promotes future liver remnant (FLR) volume (FLR-V) and function (FLR-F) gain.Here, we compared FLR-V and FLR-F changes after portal vein embolization (PVE) and LVD.Methods: This study included all patients referred for liver preparation before major hepatectomy over 26 months. Exclusion criteria were: unavailable baseline/follow-up imaging, cirrhosis, Klatskin tumor, twostage hepatectomy. 99mTc-mebrofenin SPECT-CT was performed at baseline and at day 7, 14 and 21 after PVE or LVD. FLR-V and FLR-F variations were compared using multivariate generalized linear mixed models (joint modelling) with/without missing data imputation.Results: Baseline FLR-F was lower in the LVD (n=29) than PVE group (n=22) (P<0.001). Technical success was 100% in both groups without any major complication. Changes in FLR-V at day 14 and 21 (+14.2% vs. +50%, P=0.002; and +18.6% vs. +52.6%, P=0.001), and in FLR-F at day 7, 14 and 21 (+23.1% vs. +54.3%, P=0.02; +17.6% vs. +56.1%, P=0.006; and +29.8% vs. +63.9%, P<0.001) differed between PVE and LVD group. LVD (P=0.009), age (P=0.027) and baseline FLR-V (P=0.001) independently predicted FLR-V variations, whereas only LVD (P=0.01) predicted FLR-F changes. After missing data handling, LVD remained an independent predictor of FLR-V and FLR-F variations.Conclusions: LVD is safe and provides greater FLR-V and FLR-F increase than PVE. These results are now evaluated in the HYPERLIV-01 multicenter randomized trial.

Liver venous deprivation: a bright future for liver metastases—but what about hepatocellular carcinoma?

“…Four monocentric studies comparing LVD to PVE were published in 2020 (1)(2)(3)(4). Despite technical variations, these reports are aligned towards greater FLR regeneration after LVD, both in terms of volume (1,2,4) and function (3).…”

“…Unfortunately, data on LVD in cirrhotic patients are scarce. In the five most recent studies, cirrhotic patients were excluded in two (1,3), not treated by LVD in one (4) and were very few (n=2-3) in the others (2,9). Regrettably, no outcome data were reported in this subgroup of patients, even though no specific safety concerns were raised.…”

Oncological Outcomes after Liver Venous Deprivation for Colorectal Liver Metastases: A Single Center Experience

“…This delay might be regarded as too long for a procedure supposed to hypertrophy the FLR faster. We must acknowledge that this delay could be significantly shortened since both volume and function hypertrophy of the FLR have been shown to occur as soon as 7 days after LVD [ 20 ]. Efforts should be made to shorten surgery planning, which remains difficult in daily practice especially in the context of COVID-19 pandemic with less resources.…”

“…It consists of simultaneous embolization of portal vein and one or two hepatic veins, in order to increase the damage to the liver leading to increased hypertrophy of the contralateral parenchyma [ 16 , 17 , 18 ], with a kinetic growth rate of 16 ± 7 cc/day according to first reports [ 19 ]. Recently, first comparative data have been published regarding FLR volume and function gains [ 20 ]. All of them were in favor of greater regeneration after LVD versus PVE.…”

Study protocol of the HYPER-LIV01 trial: a multicenter phase II, prospective and randomized study comparing simultaneous portal and hepatic vein embolization to portal vein embolization for hypertrophy of the future liver remnant before major hepatectomy for colo-rectal liver metastases

“…We reported that LVD was safe and provided fast and important hypertrophy of the FLR at 3 weeks [5]. More recently, we showed that LVD could provide marked and very rapid increase not only in FLR volume but also in FLR function [6,7] assessed with 99m Tc mebrofenin hepatobiliary scintigraphy with SPECT which has been validated as a quantitative method for evaluating liver function [8].…”