MINI-ALPPS achieves adequate future liver remnant (FLR) hypertrophy to allow safe two stage liver resection

Abstract Background Solitary fibrous tumor is an unusual fibroblastic mesenchymal neoplasm typically described in the pleura. It may appear anywhere with a varied anatomic distribution and essentially it can develop from any soft tissue or visceral location. Its course is usually indolent and it rarely causes distant metastases, so it has a prolonged survival rate. It sometimes presents itself as a disseminate disease being the liver the most frequently involved location. In these occasions, the management should be discussed in a multidisciplinary tumor committee formed by surgeons, oncologists and radiologists. Surgery remains the gold standard for treatment. Case representation We present the case of a woman with a tumor in the left abdominal wall and bilobar massive liver metastases, both locations histologically diagnosed as solitary fibrous tumor. She receives biological treatment for a severe case of Crohn´s disease. Evaluated in a multidisciplinary committee, surgery was recommended for both the primary lesion and the liver metastases. The hepatobiliary surgeons considered a two-stage hepatectomy with portal vein embolization (PVE) as the best strategy. After the first procedure consisting in cleaning the left hepatic lobe followed by PVE the future liver remnant volume (FLRV) was considered inadequate, so the patient was also treated with right transarterial radioembolizacion with yttrium 90 (TARE-Y90) intending a double goal: to treat the tumor and to increased the FLRV. Furthermore, a severe flare of Crohn´s disease forced us to intensify the patient’s treatment with the addition of biological agents (infliximab and adalimumab) until complete remission of the symptoms. The second stage of the liver surgery had to be postponed for more than 6 months and could finally be carried out without complications, achieving an R0 resection. The postoperative course was uneventful and the follow up has showed no recurrence to date. Conclusion Solitary fibrous tumours with extensive liver metastases are infrequent but when they appear modern surgical strategies like two stage hepatectomy are the treatment of choice and must be carried out by specialised units. The therapeutic decisions should be guided by a multidisciplinary committee.

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Expanded Makuuchi's criteria using estimated indocyanine green clearance rate of future liver remnant as a safety limit for maximum extent of liver resection

HPB ◽

10.1016/j.hpb.2018.12.001 ◽

2019 ◽

Vol 21 (8) ◽

pp. 990-997 ◽

Cited By ~ 4

Author(s):

Yuta Kobayashi ◽

Yoshitaka Kiya ◽

Toshitaka Sugawara ◽

Yujiro Nishioka ◽

Masaji Hashimoto ◽

...

Keyword(s):

Liver Resection ◽

Indocyanine Green ◽

Clearance Rate ◽

Future Liver Remnant ◽

Liver Remnant ◽

Indocyanine Green Clearance ◽

Maximum Extent ◽

Safety Limit

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Portal Vein Embolization is Associated with Reduced Liver Failure and Mortality in High-Risk Resections for Perihilar Cholangiocarcinoma

Annals of Surgical Oncology ◽

10.1245/s10434-020-08258-3 ◽

2020 ◽

Vol 27 (7) ◽

pp. 2311-2318 ◽

Cited By ~ 2

Author(s):

Pim B. Olthof ◽

◽

Luca Aldrighetti ◽

Ruslan Alikhanov ◽

Matteo Cescon ◽

...

Keyword(s):

Liver Resection ◽

Portal Vein ◽

Liver Failure ◽

Portal Vein Embolization ◽

Future Liver Remnant ◽

International Study ◽

Perihilar Cholangiocarcinoma ◽

Major Liver Resection ◽

Biliary Leakage ◽

Liver Remnant

Abstract Background Preoperative portal vein embolization (PVE) is frequently used to improve future liver remnant volume (FLRV) and to reduce the risk of liver failure after major liver resection. Objective This paper aimed to assess postoperative outcomes after PVE and resection for suspected perihilar cholangiocarcinoma (PHC) in an international, multicentric cohort. Methods Patients undergoing resection for suspected PHC across 20 centers worldwide, from the year 2000, were included. Liver failure, biliary leakage, and hemorrhage were classified according to the respective International Study Group of Liver Surgery criteria. Using propensity scoring, two equal cohorts were generated using matching parameters, i.e. age, sex, American Society of Anesthesiologists classification, jaundice, type of biliary drainage, baseline FLRV, resection type, and portal vein resection. Results A total of 1667 patients were treated for suspected PHC during the study period. In 298 patients who underwent preoperative PVE, the overall incidence of liver failure and 90-day mortality was 27% and 18%, respectively, as opposed to 14% and 12%, respectively, in patients without PVE (p < 0.001 and p = 0.005). After propensity score matching, 98 patients were enrolled in each cohort, resulting in similar baseline and operative characteristics. Liver failure was lower in the PVE group (8% vs. 36%, p < 0.001), as was biliary leakage (10% vs. 35%, p < 0.01), intra-abdominal abscesses (19% vs. 34%, p = 0.01), and 90-day mortality (7% vs. 18%, p = 0.03). Conclusion PVE before major liver resection for PHC is associated with a lower incidence of liver failure, biliary leakage, abscess formation, and mortality. These results demonstrate the importance of PVE as an integral component in the surgical treatment of PHC.

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Hepatectomy using a combination of extrafascial extrahepatic (Takasaki approach) and extrafascial intrahepatic pedicle approaches (Ton That Tung approach)

Journal of Surgical Case Reports ◽

10.1093/jscr/rjab419 ◽

2021 ◽

Vol 2021 (10) ◽

Author(s):

Quyet Van Ha ◽

Toan Huy Nguyen ◽

Huong Van Nguyen ◽

Xuan Anh Le ◽

Kinh Huy Tran

Keyword(s):

Liver Resection ◽

Future Liver Remnant ◽

Liver Parenchyma ◽

Liver Remnant ◽

Ischemic Time ◽

Precise Knowledge ◽

Safe Technique ◽

Glissonean Pedicle ◽

A New Technique ◽

Anatomical Liver Resection

Abstract Selective pedicle control and anatomical liver resection are considered standard techniques in hepatectomy for hepatocellular carcinoma. In 1963, Ton That Tung made significant improvements in hepatectomy techniques with the principle of locating and ligation of Glissonean pedicle in the liver parenchyma based on precise knowledge of vascular and biliary anatomy (Tung TT, Quang ND. A new technique for operating on the liver. Lancet 1963;281:192–3). In 1986, the extrafascial Glissonean dissection was first introduced by Takasaki in 1986. This is a simple and safe technique that helps to identify the exact borders between liver sections for anatomic liver resection (Takasaki K. Glissonean pedicle transection method for hepatic resection: a new concept of liver segmentation. J Hepatobiliary Pancreat Surg 1998;5:286–91). The combination of two techniques helps minimize complications, reduce ischemic time of future liver remnant, intraoperative blood loss and avoid migration of cancer cells into other segments.

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A Comparison of Portal Vein Embolization With Poly(2-hydroxyethylmethacrylate) and a Histoacryl/Lipiodol Mixture in Patients Scheduled for Extended Right Hepatectomy

Physiological Research ◽

10.33549/physiolres.932992 ◽

2015 ◽

pp. 841-848 ◽

Cited By ~ 1

Author(s):

J. H. PEREGRIN ◽

R. JANOUŠEK ◽

D. KAUTZNEROVÁ ◽

M. OLIVERIUS ◽

E. STICOVÁ ◽

...

Keyword(s):

Portal Vein ◽

Portal Vein Embolization ◽

Future Liver Remnant ◽

Right Hepatectomy ◽

Portal Vein Branch ◽

Liver Remnant ◽

Extended Right Hepatectomy ◽

The Right ◽

Transhepatic Access ◽

Flr Hypertrophy

ght hepatectomy and whether it is as effective as the currently used agent (a histoacryl/lipiodol mixture). Two groups of nine patients each scheduled for extended right hepatectomy for primary or secondary hepatic tumor, had right portal vein embolization in an effort to induce future liver remnant (FLR) hypertrophy. One group had embolization with PHEMA, the other one with the histoacryl/lipiodol mixture. In all patients, embolization was performed using the right retrograde transhepatic access. Embolization was technically successful in all 18 patients, with no complication related to the embolization agent. Eight patients of either group developed FLR hypertrophy allowing extended right hepatectomy. Likewise, one patient in each group had recanalization of a portal vein branch. Histology showed that both embolization agents reach the periphery of portal vein branches, with PHEMA penetrating somewhat deeper into the periphery. PHEMA has been shown to be an agent suitable for embolization in the portal venous system comparable with existing embolization agent (histoacryl/lipiodol mixture).

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Radiation Lobectomy: An Overview of Concept and Applications, Technical Considerations, Outcomes

Seminars in Interventional Radiology ◽

10.1055/s-0041-1735530 ◽

2021 ◽

Vol 38 (04) ◽

pp. 419-424

Author(s):

Pouya Entezari ◽

Ahmed Gabr ◽

Kristie Kennedy ◽

Riad Salem ◽

Robert J. Lewandowski

Keyword(s):

Early Stage ◽

Future Liver Remnant ◽

High Dose ◽

Hepatic Malignancy ◽

Curative Intent ◽

Liver Remnant ◽

Y90 Radioembolization ◽

Flr Hypertrophy ◽

Hepatic Malignancies ◽

Technical Considerations

AbstractSurgical resection has long been considered curative for patients with early-stage hepatocellular carcinoma (HCC). However, inadequate future liver remnant (FLR) renders many patients not amenable to surgery. Recently, lobar administration of yttrium-90 (Y90) radioembolization has been utilized to induce FLR hypertrophy while providing disease control, eventually facilitating resection in patients with hepatic malignancy. This has been termed “radiation lobectomy (RL).” The concept is evolving, with modified approaches combining RL and high-dose curative-intent radioembolization (radiation segmentectomy) to achieve tumor ablation. This article provides an overview of the concept and applications of RL, including technical considerations and outcomes in patients with hepatic malignancies.

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