1. Pre-op Portal Vein Embolization for Major Hepatectomy SL Sin

2. Introduction Surgery is the treatment of choice for primary and most metastatic liver tumours Limiting factor being insufficient future remnant liver (FRL) parenchyma volume, leading to fatal liver failure post-op Portal vein embolization followed by hepatectomy is a common treatment option

3. Introduction First described in Japan in 1986 by Kinoshita Embolization of the portal branches supplying the tumour-bearing liver redirects portal blood flow to the branches of the FRL Hypertrophy of the FRL resulted

4. Indications Patients with insufficient FRL based on FRL/ (TLV – tumour volume) ratio Liver volumetry determined by 3D CT reconstruction

5. Indications For patients with normal liver, for PVE if FRL/ TLV <25% Capussotti 2005 For patients with chronic liver disease, FRL/ TLV >40% should remain to minimize post-op complications Azoulay 2000 Kubota 1997

6. Precautions when PVE is considered Presence of systemic disease Diabetes mellitus; Insulin fasten rates of liver regeneration

7. Technique Transileocolic portal embolization (TIPE) Minilaparotomy performed under GA Catheterization of portal vein through a branch of the ileocolic vein Percutaneous transhepatic portal embolization (PTPE) Performed by interventional radiologist under LA Ipsilateral approach/ Contralateral approach

8. Technique Percutaneous transhepatic portal embolization (PTPE) Ipsilateral approach Through the portal venous system within the tumour- bearing liver Contralateral approach Through the portal venous system in the FRL

10. Technique Embolic materials n-butyl cyanoacrylate (NBCA), lipidiol, polyvinyl alcohol (PVA), microcoils Gelfoam, thrombin, urografin Gelfoam, coils

11. Complications Minor Complications Abdominal discomfort or pain Fever Nausea or vomiting Ileus Overflow of embolization materials Coil displacement Major complications Liver abscess Cholangitis Main or contralateral portal vein thrombosis Subscapular haematoma Portal hypertension Septic necrosis from hepatic artery injury

12. Results – Hypertrophy No consensus on the duration for adequate hypertrophy Average 4 to 5 weeks

13. Results – Hypertrophy Restaging and operation performed 4 to 6 weeks after PVE Mean increase in FRL = 8.4% (~35% functional liver mass) 79% patients proceeded to surgery 12% developed additional unresectable disease found after PVE but before surgery new lesion within FRL Lung metastasis 7% had unresectable disease at surgery Unsuspected extrahepatic disease Inability to achieve complete tumour clearance Hemming 2003

14. Hemming et al

15. Results – Hypertrophy Normal vs diseased liver Mean increase in %FFLR = 16% vs 9% Only 86% with chronic liver disease had hypertrophy Farges 2003

16. Results – Resection-related Overall Morbidity and Mortality Morbidity rate 16% transient liver failure, pleural effusion Mortality rate 1.7% acute liver failure Abulkhir 2008

17. Results – Resection-related Overall Morbidity and Mortality Alan W. Hemming. Ann Surg 2003 Retrospective study 39 patients with HCC/ liver metastasis/ Klatskin with PVE reviewed Results compared to a cohort of 21 patients with same type, number and size of tumour, complexity of surgery Preoperative Portal Vein Embolization for Extended Hepatectomy

19. Results – Resection-related Overall Morbidity and Mortality Portal Vein Embolization Before Right Hepatectomy Olivier Farges. Ann Surg 2003 Prospective comparative trial 55 patients planned for right hepatectomy selected, with diagnosis being HCC/ liver metastasis/ intrahepatic cholangiocarcinoma Prospectively assigned to have immediate surgery or PVE before surgery 28 patients had chronic liver disease (all Child’s A cirrhosis)

22. PVE for HCC Patients with underlying cirrhosis Doubtful effect of hypertrophy Successful hypertrophy can significantly reduce early post-op complications Comparable overall and disease-free survival at 1, 3, 5 years for PVE and non-PVE groups Azoulay 2000 Palavecino 2008

23. PVE for Colorectal Liver Metastasis (CLM) Comparable overall and disease- free survival at 1, 3, 5 years for PVE and non-PVE groups Azoulay 2000 Oussoultzoglou 2006 PVE and reduction of tumour shedding in CLM 33% patient with hepatectomy cancelled due to tumoural extension Azoulay 2000 Lower intra-hepatic recurrence rate in PVE group Oussoultzoglou 2006

24. Results for Biliary Cancer Higher incidence of obtaining a histologically –ve resection margin when scheduled extended hepatic resection was conducted Kawasaki et al Comparable 5 year survival in patients with cholangioCA with extended hepatectomy done Nagino et al

25. Conclusion PVE is a safe procedure that can alter the treatment of patients deemed not suitable for hepatectomy due to insufficient FRL For patients with HCC, successful hypertrophy of FRL can significantly reduces surgery related morbidity

26. Reference Extension of right portal vein embolization to segment IV portal branches. Capussotti L. Arch Surg 2005 Resection of nonresectable liver metastases from colorectal cancer after percutaneous portal vein embolization. Azoulay D. Ann Surg 2000 Measurement of liver volume and hepatic functional reserve as a guide to decision- making in resectional surgery for hepatic tumours. Kubota K. Hepatology 1997 Preoperative portal vein embolization for extended hepatectomy. Alan W Hemming. Ann Surg 2003 Portal vein embolization before right hepatectomy. Olivier Farges. Ann Surg 2003 Preoperative portal vein embolization for major liver resection. Adel Abulkhir. Ann Surg 2008 Major hepatic resection for hepatocellular carcinoma with or without portal vein embolization: perioperative outcome and survival. Martin Palavecino. J Surg 2008 Percutaneous portal vein embolization increases the feasibility and safety of major liver resection for hepatocellular carcinoma in injured liver. D Azoulay. Ann Surg 2000 Right portal vein embolization before right hepatectomy for unilobar colorectal liver metastasis reduces the intrahepatic recurrence rate. Elie Oussoultzoglou. Ann Surg 2006

27. Technique Percutaneous transhepatic portal embolization (PTPE) Ipsilateral approach Through the portal venous system within the tumour- bearing liver Avoid puncture of the healthy FRL parenchyma Efficient catheterization of segment 4 branches  More difficult catheterization of right portal branches  Risk of tumour seeding

28. Technique Percutaneous transhepatic portal embolization (PTPE) Contralateral approach Through the portal venous system in the FRL Smooth antegrade catheterization of right portal branches Can be performed for all right portal branches  FRL is traversed, planned surgery maybe affected

29. Technique Embolic materials NBCA is the best substance for PVE as it leads to fast and reliable hypertrophy of the FLR De Baere et al NBCA promote production of hepatic growth factor (HGF), triggering hepatocyte regeneration