Abstract
Background/Aim: Transileocolic portal vein embolization (TIPE) may reduce the risk of liver failure after massive hepatectomy. However, convincing evidence of its usefulness in this regard is yet to be reported. Therefore, this study aimed to investigate the use of TIPE after massive hepatectomy. Patients and Methods: Twelve patients who underwent TIPE were included. Pre- and postoperative liver volumetry was determined using a 3D simulator with computed tomography. Results: After TIPE, the percent change in total liver volume was 104.0%±13.1% (p=0.08). Conversely, the percent increase in remnant liver volume (ml)/total liver volume (ml) and remnant liver volume (ml)/standard liver volume (ml) was 122.9%±18.6% (p<0.001) and 132.2%±19.6% (p<0.001), respectively. TIPE operation time was 125±84.6 min, with minimal blood loss in all cases. Postoperative hospitalization duration during TIPE was 4.5±2.6 days. No TIPE-related complications occurred in any patient. Conclusion: TIPE is beneficial and safe when preoperative volumetry indicates that the remaining liver volume is inadequate and inoperable.
- Transileocolic portal vein embolization
- massive liver resection
- hepatomegaly
- hepatectomy
- portal vein
- liver failure
Massive hepatic resection is indicated for treating hepatic malignancies; however, it can be fatal due to liver failure after hepatic resection (1). Although advances in imaging technology have made it possible to predict the remnant liver volume (RLV) before surgery, patients are commonly determined as inoperable with an insufficient predicted RVL (2).
Various techniques have been developed to increase the remaining postoperative liver volume. A common method is to block the portal vein blood flow to the liver for resection via portal vein ligation, percutaneous transhepatic portal embolization (PTPE), transileocolic portal vein embolization (TIPE), or associated liver partition and portal vein embolization for staged hepatectomy (ALPPS). These techniques are aimed at ipsilateral atrophy and compensatory remnant hypertrophy. In particular, endovascular treatment applications, such as PTPE and TIPE, are relatively less invasive and have been reported to be useful for increasing remnant liver capacity (2, 3). However, the detailed timeframe, such as when hepatectomy should be performed after blocking portal vein blood flow, and the prospects for RLV increase have not been clarified. If the duration of hepatectomy is short, then the increase in RLV is insufficient; if it is long, then the possibility of tumor growth and distant metastasis increases (4). Therefore, in the present study, we investigated the use of TIPE for massive hepatectomies and identified prospects and issues that need to be resolved.
Patients and Methods
Patients. Twelve adults (>20 years old) who underwent TIPE for liver and/or cholangitis tumors at Matsuyama Red Cross Hospital between January 2018 and March 2023 were included in this retrospective study. The patients were scheduled to undergo a right lobectomy, right trisectomy, or left trisectomy. Medical charts were retrospectively reviewed to obtain patient data.
This study was approved by the Ethics Committee of the Matsuyama Red Cross Hospital (No. 1005). The study was performed in accordance with the 1975 Declaration of Helsinki. Informed consent was obtained from all participants.
Preoperative liver function evaluation. Preoperative evaluation of liver function included a complete blood count; coagulation tests, such as prothrombin time and activated partial thromboplastin time; and biochemical tests, such as albumin, bilirubin, aspartate aminotransferase, alanine transaminase, gamma-glutamyl transpeptidase, and indocyanine green retention rate at 15 min (ICG-R15) using Takasaki’s formula (5). Additionally, after imaging evaluation using computed tomography (CT), magnetic resonance imaging, positron emission tomography-CT, and confirmation of ascites, 3D-CT volumetry was performed. When liver function could not be assessed using ICGR-15 because of jaundice, technetium 99 m diethyl-enetriaminepentaacetic acid galactosyl human serum albumin scintigraphy was performed and evaluated using the formula described by Kawamura et al. (6).
Preoperative and postoperative liver volumetry. In 3D-CT volumetry, total liver volume (TLV) and RLV were calculated using the SYNAPSE VINCENT® system (Fujifilm Co., Ltd., Tokyo, Japan). Standard liver volume (SLV) was calculated using the formula SLV=706.2×body surface area+2.4 (ml) (7). We defined the limit of resectability as RLV/TLV or RLV/SLV >35%; however, patient age and liver function were ultimately considered when determining the indication for TIPE. Hepatectomy was scheduled ~1 month after TIPE. Contrast-enhanced CT was performed in all patients on day 7 after hepatectomy, and RLVs were calculated using volumetry.
TIPE technique. Under general anesthesia, the abdomen was opened with a short median incision (50-70 mm) below the umbilicus with the patient in supine position. Then, the ileum was withdrawn from the body. One of the mesenteric vein branches encircled the oral side, ~10 cm from the ileum. The distal side of the vein was ligated, and 5Fr Destination® (TERUMO Co., Ltd., Tokyo, Japan) was inserted from the stump of the mesenteric vein to the portal vein antegradely. Each selected portal vein branch was embolized with Gelpart® (2 mm, 80 mg; Nihonkayaku Co., Ltd., Tokyo, Japan) and coils. Gelpart® was minced and injected as a contrast agent. Coils (Interlock™ and IDC-coil™; Boston Scientific, Boston, MA, USA) sized 2-12 mm were selected depending on the diameter of the vessels. Embolization was performed until complete or near-occlusion of blood flow was achieved on angiography. The incised intestinal membrane was sutured, and the abdominal cavity was closed after Seprafilm® (Kaken Pharmaceutical Co., Ltd., Tokyo, Japan) was placed in the abdominal cavity.
Statistical analysis. All values are expressed as mean and standard deviation. Categorical variables were compared using χ2 tests. p<0.05 was considered significant. All statistical analyses were performed using the JMP 16 software (SAS Institute Japan, Tokyo, Japan).
Results
Patients’ backgrounds. The diagnoses included hilar bile duct cancer (four patients), metastatic liver cancer (three patients), hepatocellular carcinoma (two patients), gallbladder cancer (two patients), and intrahepatic bile duct carcinoma (one patient). The preoperative patient characteristics are shown in Table I. Two patients developed distant metastasis of the tumor after TIPE while waiting for hepatectomy, which prevented radical surgery.
Preoperative characteristics of patients.
Liver volume change after TIPE and hepatectomy. Comparison of TLV before and after TIPE revealed an increase of 104.0%±13.1% with no significant difference (p=0.08) (Figure 1A). RLV increased 132.2%±19.6% after TIPE. RLV/TLV before TIPE was 34.8%±3.7% and was significantly increased after TIPE to 45.4%±8.1% (p<0.001) (Figure 1B). When RLV/TLV before TIPE and after hepatectomy were compared, RLV/TLV after hepatectomy was significantly increased to 50.9%±20.7% (p<0.001) (Figure 1B). Conversely, RLV/SLV before TIPE was 34.6%±8.1% and after TIPE was 49.7%±8.8% (p<0.001) (Figure 1C). When RLV/SLV before TIPE and after hepatectomy were compared, RLV/SLV after hepatectomy significantly increased to 61.4%±12.2% (p<0.001) (Figure 1C).
Pre- and post-transileocolic portal vein embolization (TIPE) and post-operative liver volume changes. A) Pre- and post-TIPE total liver volume (TLV) changes. B) Pre- and post-TIPE and post-operative remnant liver volume (RLV)/TLV changes. C) Pre- and post-TIPE and post-operative RLV/standard liver volume (SLV) changes.
Perioperative factors associated with TIPE. The factors associated with TIPE are listed in Table II. The operating time was 125±85 min, blood loss was minimal in all cases, and the length of hospitalization for TIPE was 4.5±2.6 days. The hepatectomy procedures were right lobectomy (eight patients), right trisegmentectomy (one patient), and left trisegmentectomy (one patient). Two patients were scheduled for right lobectomy; however, hepatectomy was cancelled because of distant metastasis of the tumor.
Factors associated with transileocolic portal vein embolization (TIPE).
The time from TIPE to hepatectomy was 26±10.4 days, and the actual liver weight resected was 590±155.4 g. Postoperative liver failure was not observed in any of the patients, and postoperative ascites requiring treatment was observed in six patients. No mortality occurred within 30 days after hepatectomy.
Discussion
Liver failure after massive hepatectomy is a fatal complication, and various management approaches have been developed (8). Methods such as blocking the portal blood flow to the liver before hepatectomy to promote enlargement of the remnant liver and increasing the RLV after resection have been employed using various approaches. Portal ligation and ALPPS are two-stage procedures that increase RLV; however, they require hilar manipulation during the first stage of surgery, which leads to adhesions during the second stage of surgery making liver resection difficult (9). In contrast, in endovascular treatment, portal blood flow in the resected liver can be interrupted without touching the hilar hilum, thus having minimal impact on the second stage of surgery (10).
There are two main types of endovascular treatments: PTPE and TIPE (2, 11). PTPE is performed percutaneously, and TIPE is performed surgically. Although PTPE can be performed under local anesthesia, it is associated with complications, such as biliary fistulas and relatively high catheter manipulation difficulties (Figure 2A) (4). Embolization of the resected liver by puncture from the resected liver requires retrograde catheter manipulation, which is a highly skilled technique and is advantageous for the cannulation of the detailed portal vein branches and targeted branches. TIPE requires general anesthesia but allows for progressive catheterization and cannulation of the portal vein segments in relatively targeted locations (Figure 2B). Additionally, as the procedure can be performed through a midline abdominal incision of up to 7 cm, as we perform at our institution, it is relatively less invasive and is likely to have less influence on liver resection in combination with anti-adhesive solutions. Another advantage is that the addition of a scanning laparoscope during TIPE allows for intra-abdominal observation, allowing a preoperative search for peritoneal dissemination and other conditions. Furthermore, since the procedure is performed under general anesthesia, it can take a relatively long time to embolize the subsegmental or caudate lobe branches (Figure 3).
The schema of portal vein embolization. A) The schema of percutaneous transhepatic portal embolization (PTPE). B) The schema of transileocolic portal vein embolization (TIPE). The red arrow heads indicate the movement of catheters into the portal vein.
Transileocolic portal vein embolization (TIPE) performed at our institution. A) The fluoroscopic image before TIPE. B) The fluoroscopic image after coiling embolization.
In this study, RLV at the time of hepatectomy increased 132.2%±19.6% after TIPE. In contrast, previous reports have shown only a 108%-127% increase after PVE (2, 9, 11, 12). This result can be attributed in part to the collaboration between the vascular and hepatobiliary surgery teams at our institution, where real-time discussions, such as where the detailed portal vein branches should be embolized, where the portal vein should be embolized at the right and left main portions, and how deep the caudate lobe branches should be embolized, are conducted during the actual TIPE procedure. Collaboration with other teams in this manner would usually occur only in high-volume centers. The larger RLV after actual liver resection in the present study may reflect a bias in the intraoperative surgeon’s intention to increase the RLV as much as possible.
In our study, there were patients in whom the tumors had grown or developed distant metastases by the time liver resection was performed, making liver resection impossible. Indeed, two-stage surgery based on portal vein embolization is often regarded as problematic because the interval before hepatic resection can lead to tumor growth and the appearance of distant metastases (13, 14). However, in the present study, the interval period was approximately 1 month, and if the tumor had increased or metastasized in such a short period, then the surgical outcome would have been poor, even if a one-stage operation had been performed in the first place.
A limitation of the present study is that the perioperative residual liver was determined using CT volumetrics only. Korenblik et al. (15) suggested that remnant liver function assessment is more critical than RLV assessment to proceed with resection. Some previous reports have included liver function evaluation using technetium-99 m-mebrofenin hepatobiliary scintigraphy (12, 16, 17) and have indicated that there may be limitations to evaluating the remnant liver by volume alone. The small number of cases and the retrospective design of the study are further limitations that should be addressed in future studies.
Conclusion
TIPE is a useful technique that can increase RLV for massive hepatectomy, and real-time discussions between the TIPE surgeon and hepatectomy surgeon could help maintain a higher RLV.
Acknowledgements
The Authors would like to thank Editage (www.editage.jp) for English language editing.
Footnotes
Authors’ Contributions
Koichi Kimura: Conceptualization and Writing – original draft. Ryosuke Minagawa: Supervision. Terutoshi Yamaoka: Supervision. Takuma Izumi, Yu Takahashi, Mitsuru Nakanishi, Takayuki Tokunaga, Daisuke Matsuda, Yoshinari Nobuto, Hiroko Yano, Yuichiro Kajiwara, Kenichi Honma, Shigeyuki Nagata, Kazuhito Minami: Data curation. Takashi Nishizaki: Supervision.
Funding
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Conflicts of Interest
The Authors have no conflicts of interest to disclose in relation to this study.
- Received July 2, 2024.
- Revision received July 15, 2024.
- Accepted July 16, 2024.
- Copyright © 2024 The Author(s). Published by the International Institute of Anticancer Research.
This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY-NC-ND) 4.0 international license (https://creativecommons.org/licenses/by-nc-nd/4.0).
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