Safe Major Hepatectomy after Preoperative Liver Regeneration: Preopearative PVE, Two-Satage Hepatetomy, ALPPS and Hepatic Vein Deprivation

Safe Major Hepatectomy After Preoperative Liver Regeneration: Preoperative PVE, Two-Stage Hepatectomy, ALPPS and Hepatic Vein Deprivation provides both the history and recent topics of major hepatectomy after liver regeneration as well as the basic background of liver regeneration allowing liver surgeons, general surgeons and hepatologists to increase the safety of major hepatectomy in patients suffering from advanced liver disease.

The mortality rate after major hepatectomies is high worldwide and there is a need to establish a strategy for safe major hepatectomies after liver regeneration. This reference provides importance guidance to cutting edge topics including the molecular mechanism of liver regeneration after preoperative portal vein embolization (PVE), two-stage hepatectomy, associating liver partition and portal vein occlusion for staged hepatectomy (ALPPS), as well as the background, technique, and results of hepatic vein occlusion. Using the evaluation of the risk-benefit balance will aid in avoiding post-hepatectomy liver failure and subsequent patient death.

• Covers various methods of accelerating regeneration of the hemiliver volume, such as portal vein embolization (PVE), two-stage hepatectomy, associating liver partition and portal vein occlusion for staged hepatectomy (ALPPS) and hepatic vein occlusion
• Provides guidance to increase future liver remnant (FLR) volume as the key to avoid posthepatectomy liver failure and succeeding patients’ death after major hepatectomy
• Helps guide the optimal way to program major surgery with decreased risk of liver failure

• Language: English
• Publisher: Academic Press
• Release date: Jan 19, 2024
• ISBN: 9780323996990

Book preview

Preface

In the beginning of 1980, the mortality rate after major hepatectomy for perihilar cholangiocarcinoma was more than 15% in Japan. The first preoperative portal vein embolization (PVE) to increase the future liver remnant volume before major hepatectomy was performed by Makuuchi in June 1982 in a patient with gallbladder cancer 20 days before left hepatectomy at National Cancer Center Hospital, Tokyo. He published the first report on 14 PVEs in 1984 and described that, Even after adequate biliary drainage, patients with biliary cancer sometimes develop posthepatectomy liver failure (PHLF) after major hepatectomy, However, PHLF is nil in cases with cancer involvement of the right/left portal branches, and Thus, we performed PVE to increase the portal pressure and accelerated the compensate hypertrophy of the future liver remnant. This resulted in the load reduction of the remnant liver and decreased the surgical complications. (English translation by Sakamoto) His concept was well accepted by many liver surgeons in the world and the first preliminary report on PVE [1] has been cited more than 1400 times. The mortality rate after major hepatectomy for perihilar cholangiocarcinoma has decreased to less than 5% in high volume centers in Japan and the indication of preoperative PVE has been expanded for resection of other hepatic malignancies. There is no doubt that preoperative PVE and subsequent hepatectomy after liver regeneration increased the safety of major hepatectomy.

However, the molecular mechanism of liver regeneration after PVE has not been fully understood and the limitation or adequate waiting time after PVE to prevent PHLF has not been elucidated exactly. It is still difficult to find the minimal requirement of the future liver remnant volume after hepatectomy in patients with liver dysfunction. Meanwhile, the recent innovative two-stage hepatectomy named ALPPS (Associating Liver Partition and Portal ligation for Staged hepatectomy) developed in Europe has been increasingly performed to increase the resection rate in cases requiring extensive hepatic resection. Although not a few surgical mortalities have been reported after original ALPPS procedures, improved short-term outcomes have been reported after modified procedures.

This book covers the topic on the major hepatectomy after preoperative liver regeneration using PVE, two-stage hepatectomy, ALPPS, and hepatic vein deprivation. These procedures can be framed in gradual hepatectomies waiting for the liver regeneration. I hope that this could be a guide to further increase the safety of major hepatectomy.

On September, 2023

Yoshihiro Sakamoto

Co-Editor with Prof. Makuuchi

Reference

1. Makuuchi M, Thai B.L, Takayasu K, Takayama T, Kosuge T, Gunvén P, et al. Preoperative portal embolization to increase safety of major hepatectomy for hilar bile duct carcinoma: a preliminary report.. Surgery. 1990;107:521–527.

Chapter 1: Toward safe major hepatectomy after preoperative liver regeneration

Nobuyuki Takemura, and Norihiro Kokudo     Department of Surgery, Hepato-Biliary Pancreatic Surgery Division, National Center for Global Health and Medicine, Toyama, Tokyo, Japan

Abstract

Since Makuuchi et al. first published the portal vein embolization (PVE) inspired by the portal vein ligation performed by Honjyo et al. to improve the safety of major hepatectomy, various modifications have been developed to safely and reliably remove tumors adjacent to the hepatic hilum or located in multiple bi-lobar liver. Two-stage hepatectomy was developed for the purpose of safe and radical tumor removal of multiple bi-lober liver metastases. Right and additional segment 4 PVE and PVE plus hepatic vein embolization procedures were developed for further enlargement of future liver remnant. Another modification of PVE to gain rapid and further remnant liver hypertrophy was associated with liver partition and portal vein ligation for staged hepatectomy (ALPPS). Initially ALPPS procedure had a high morbidity and mortality, various modifications had been developed up until the present.

Keywords

Associated liver partition and portal vein ligation for staged hepatectomy (ALPPS); Hepatic vein embolization (HVE); Modification of ALPPS procedure; Portal vein embolization (PVE); Portal vein ligation (PVL); Two-stage hepatectomy (TSH)

History and development of portal vein embolization

Despite recent advances in chemotherapy for hepato-biliary malignancies, chemotherapy alone seldom achieves a cure for these intractable diseases. Major hepatectomy with or without bile duct resection remains the standard and only potentially curative treatment, especially for perihilar cancers or multiple bi-lobar colorectal metastases. The first publications on successful right hepatectomy were reported by French and Japanese surgeons in 1950s [1,2]. In the 1970s, surgery-related mortality after hepatectomy remained 15% [3,4]; however, it rapidly decreased since 1980s with the advancement of perioperative management [5], diagnostic tools [6], and surgical techniques.

An extensive major hepatectomy provides a chance for the above advanced malignancies; however, there is a risk of insufficient remnant liver volume, which may lead to postoperative liver failure. Even in 2020s, it is still the main cause of postoperative mortality after major hepatectomy. In addition, even in recent reports, postoperative morbidity and mortality rates after extensive hepatectomy for perihilar cholangiocarcinoma remain high [7,8].

To overcome this problem, various approaches such as portal vein occlusion, two-stage hepatectomy, hepatic parenchymal disconnection, and hepatic vein deprivation have been developed to increase the volume of the future liver remnant (FLR), allowing extended hepatectomy to be performed safely. Historically, Honjo et al. were the first to apply the portal vein ligation (PVL) procedure into humans to control hepatic malignancies in 20 patients [9]. They reported that there were no serious complications and compensatory hypertrophy of the FLR was observed after PVL. In 1982, Makuuchi et al. first performed portal vein embolization (PVE) as a preoperative management to increase the safety of major hepatectomy for hilar bile duct carcinoma [10,11]. In their era, extended hemi-hepatectomy with biliary reconstruction led to a serious turnaround if liver failure occurred even temporarily; therefore, they performed PVE inspired by the results of the PVL performed by Honjo et al. The rationale for the development of PVE was follows: (1) minimal postoperative complications associated with PVL; (2) hepatic atrophy on the ligated side and hypertrophy on the nonligated side; (3) high postoperative morbidity and mortality rates after extensive hepatectomy; and (4) obstruction of the portal vein branch due to cancer invasion had a relatively good postoperative course with compensatory liver hypertrophy on the nonoccluded side. Furthermore, they mentioned that another advantage of PVE was the avoidance of a sudden increase in portal pressure on the remnant liver after major hepatectomy by progressive adaptation of the unoccluded portal vein after PVE. They applied two approaches toward the portal vein, percutaneous transhepatic portal vein embolization (PTPE) and trans-ileocecal portal vein embolization (TIPE), with equal success rates. PTPE is a simpler procedure because it can be performed under local anesthesia; however, there is a risk of hepatic bleeding and bile duct injury. In patients with multiple liver metastases, it may not be possible to puncture the portal vein owing to the presence of a tumor on the puncture route. On the other hand, TIPE requires general anesthesia and carries the risk of bowel obstruction associated with laparotomy; however, it is useful when the puncture route cannot be secured, such as when a tumor or colon is present on the surface of the liver.

Subsequently, Kinoshita et al. reported the effect of PVE as a part of the treatments for HCC with transarterial embolization (TAE) [12]. They noticed hypertrophy of the liver after PVE and mentioned that PVE not only potentiated the anticancer effect of TAE by preventing intrahepatic metastasis but also might be useful as a preparation for hepatectomy.

Since the introduction of PVE, the safety of extended major hepatectomy for the treatment of hilar bile duct carcinoma was improved. Thus, PVE has been utilized for the preoperative managements of multiple liver metastases [13] and HCC [14].

Regarding the comparison between PVE and PVL, some studies have reported that the rate of hepatic hypertrophy of FLR is the same [15,16], while others have mentioned that PVE had better hypertrophy rates [17–19]. However, unlike PVL, PVE does not require hepatic hilum dissection, which often leads to severe adhesions and makes the manipulation of hepatic hilum difficult in the subsequent major hepatectomy after PVL. Furthermore, Denys et al. reported failure of liver hypertrophy after PVL due to intrahepatic portoportal collaterals [20]. Overall, PVE is less invasive to perform preoperatively and is able to accelerate better hypertrophy of FLR. On the other hand, PVL can be easily performed during staging laparotomy or two-staged hepatectomy for patients with multiple hepatic metastases.

Modifications of portal vein embolization and two-stage hepatectomy

PVE has become a standard preoperative procedure before extensive major hepatectomy worldwide, because of its technical simplicity and constant attainment of hypertrophy of FLR. Although PVE of the right portal vein increases the FLR volume by approximately 40%–50% [15,16], its volume increase is occasionally insufficient especially for the extensive hilar cholangiocarcinoma and bilobar multiple colorectal metastases that required right trisectionectomy as a curative resection. Nagino et al. first introduced right trisection PVE, that is, right and segment 4 PVE, for biliary tract carcinoma [21]. They reported approximately 50% increase of the FLR volume and an acceptable postoperative mortality rate of 7% among patients who underwent right trisectionectomy in the 2000s. Kishi et al. evaluated the effect of additional Segment 4 portal vein embolization in patients with colorectal liver metastases, HCC, and cholangiocellular carcinoma [22]. They also reported similar results to Nagino et al. with a 54% increase of the FLR volume and 6% posthepatectomy mortality