Portal Vein Embolization in Hilar Cholangiocarcinoma

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In patients with hilar cholangiocarcinoma, extended hepatectomy and caudate lobe resection are often performed to achieve an R0 resection. In patients whose standardized future liver remnant is less than or equal to 20% of total liver volume, portal vein embolization (PVE) should be performed. In patients with biliary dilatation of the future liver remnant, a biliary drainage catheter should be placed before PVE. If the planned surgery is an extended right hepatectomy, segment 4 branch embolization improves the hypertrophy of segments 2 and 3. In high-volume centers, PVE can be safely performed; it increases the resectability rate and results in the same survival rates as those in patients who undergo resection without PVE.

Section snippets

Approach

PVE can be performed by two different approaches: transileocolic and transhepatic.5, 6, 7, 8 The transileocolic approach is performed intraoperatively by introducing a catheter in the ileocolic vein and embolizing all the portal branches to be resected. It is important to embolize all branches to avoid recanalization of the portal vein by portal-portal shunts. Indications for this approach include the preference of the surgical group, the lack of availability of a radiologic team with skills in

Indications

Different factors should be taken into account before PVE is performed.

Complications

As with other hepatic percutaneous procedures, PVE is associated with different complications, such as subcapsular hematoma, hemoperitoneum, pseudoaneurysm, portal vein thrombosis, pneumothorax, and infection. In the largest series (240 patients) describing PVE for the treatment of biliary cancers, Nagino and colleagues33 reported only two major complications: one case of hypersplenism with splenomegaly successfully resected, and one extensive portal and mesenteric vein thrombosis unresected

Outcomes

PVE improves resectability and prevents postoperative hepatic dysfunction in patients with biliary tract cancers whose future liver remnant before extended hepatectomy is expected to be of inadequate size. PVE achieves this improvement without impairing postoperative outcome and survival.

In a recent meta-analysis, Abulkhir and colleagues34 examined 37 publications including 1088 patients who underwent PVE before liver resection for liver tumors. Cholangiocarcinoma was the primary tumor in 430

Summary

The only potentially curative treatment for biliary tract cancer is surgery. Extended right hepatectomy and caudate lobe resection is often performed to achieve a R0 resection. To minimize the risk of postoperative liver dysfunction, in patients with an estimated future liver remnant less than or equal to 20% PVE should be performed. If after PVE the estimated future liver remnant is less than or equal to 20% or the degree of hypertrophy is less than or equal to 5%, liver resection is

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  • Cited by (40)

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      2017, European Journal of Surgical Oncology
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      According to the results of this meta-analysis, the routine use of preoperative biliary drainage seem to be unjustified, because of the high risk of infective complications. With regards to the role of PBD in patients who had undergone PVE, there is a consensus about performing liver decompression to improve liver function and FLR hypertrophy.40–42 No recommendations have been reached with regards to the most appropriate drainage method.43

    • The role of portal vein embolization in the surgical management of primary hepatobiliary cancers. A systematic review

      2017, European Journal of Surgical Oncology
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      In order to increase hypertrophy rate using PVE in patients with small FLR there are two ways: Firstly the embolization of segment IV along with right PVE in patients who require extended right hepatectomy65 and second sequential embolization of the ipsilateral hepatic vein if FLR volume was <40% of TLV at 2–3 weeks following PVE.46 Furthermore, a new surgical technique, has been introduced recently, in order to gain rapid and profound hepatic hypertrophy in cases that the FLR is very small.66

    • Preoperative cholangitis and future liver remnant volume determine the risk of liver failure in patients undergoing resection for hilar cholangiocarcinoma

      2016, Journal of the American College of Surgeons
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      All patients included in the study underwent CT volumetry of the future liver remnant (FLR). When the estimated FLR was considered insufficient, preoperative PVE of the contralateral liver was performed.18-20 Liver resection was scheduled at least 4 weeks after PVE if sufficient hypertrophy was achieved.

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    Jean-Nicolas Vauthey, MD, is a consultant for Sanofi-aventis and Genentech. Dr. Vauthey received honoraria from sanofi-aventis and Genentech. Drs. Vauthey and Abdalla have received research funding from Sanofi-aventis.

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