Evaluation of Liver Function and the Role of Biliary Drainage before Major Hepatic Resections

Visceral Medicine ◽

10.1159/000512439 ◽

2020 ◽

pp. 1-8

Author(s):

Yuzo Yamamoto

Keyword(s):

Liver Function ◽

Portal Vein ◽

Biliary Drainage ◽

Future Liver Remnant ◽

Volume Ratio ◽

Preoperative Biliary Drainage ◽

Perihilar Cholangiocarcinoma ◽

Portal Vein Ligation ◽

Liver Remnant

Background: Prevention of posthepatectomy liver failure is a prerequisite for improving the postoperative outcome of perihilar cholangiocarcinoma. From this perspective, appropriate assessment of future liver remnant (FLR) function and the optimized preparation are mandatory. Summary: FLR volume ratio using CT volumetry based on 3-dimensional vascular imaging is the current assessment yardstick and is sufficient for assessing a normal liver. However, in a liver with underling parenchymal disease such as fibrosis or prolonged jaundice, weighing up the degree of liver damage against the FLR volume ratio is necessary to know the real FLR function. For this purpose, the indocyanine green (ICG) clearance test, monoethylglycinexylidide (MEGX) test, liver maximum capacity (LiMAX) test, 99mTc-labeled galactosyl human serum albumin (99mTc-GSA) scintigraphy, albumin-bilirubin (ALBI) grade, and ALPlat (albumin × platelets) criterion are used. After the optimization of FLR function by means of portal vein embolization or associating liver partition and PVL (portal vein ligation) for staged hepatectomy (ALPPS), SPECT scintigraphy with either 99mTc-GSA or 99mTc-mebrofenin compensates for misestimation due to the regional heterogeneity of liver function. The role of preoperative biliary drainage has long been debated, with the associated complications having led to a lack of approval. However, the recent establishment of safety and an improvement in success rates of endoscopic biliary drainage seem to be changing the awareness of the importance of biliary drainage. Key Messages: Appropriate selection of an assessment method is of prime importance to predict the FLR function according to the preoperative condition of the liver. Preoperative biliary drainage in patients with perihilar cholangiocarcinoma is gaining support due to the increasing safety and success rate, especially in patients who need optimization of their liver function before hepatectomy.

Download Full-text

Biliary Drainage Before and After Liver Resection for Perihilar Cholangiocarcinoma

The American Surgeon ◽

10.1177/0003134820923287 ◽

2020 ◽

Vol 86 (6) ◽

pp. 628-634

Author(s):

Laura M. Enomoto ◽

Matthew E. B. Dixon ◽

Allene Burdette ◽

Niraj J. Gusani

Keyword(s):

Biliary Drainage ◽

Future Liver Remnant ◽

Preoperative Biliary Drainage ◽

Perihilar Cholangiocarcinoma ◽

Patient Specific ◽

Liver Remnant ◽

Biliary Sepsis ◽

Before And After

Perihilar cholangiocarcinoma (PHC) is a rare tumor that requires surgical resection for a potential cure. The role of preoperative biliary drainage has long been debated, given its treatment of biliary sepsis and decompression of the future liver remnant (FLR), but high procedure-specific morbidity. The indications, methods, and outcomes for preoperative biliary drainage are discussed to serve as a guide for perioperative management of patients with resectable PHC. Multiple studies from the literature related to perihilar cholangiocarcinoma, biliary drainage, and management of the FLR were reviewed. Commonly employed preoperative biliary drainage includes endoscopic biliary stenting and percutaneous transhepatic biliary drainage. Drainage of the FLR remains controversial, with most experts recommending drainage of the only in patients with an FLR <50%. Biliary drainage for resectable PHC requires a patient-specific approach with careful determination of the FLR and balancing of potential morbidity with the benefits of drainage.

Download Full-text

Folinic Acid Potentiates the Liver Regeneration Process after Selective Portal Vein Ligation in Rats

Cancers ◽

10.3390/cancers14020371 ◽

2022 ◽

Vol 14 (2) ◽

pp. 371

Author(s):

Jorge Gutiérrez Sáenz de Santa María ◽

Borja Herrero de la Parte ◽

Gaizka Gutiérrez-Sánchez ◽

Inmaculada Ruiz Montesinos ◽

Sira Iturrizaga Correcher ◽

...

Keyword(s):

Liver Function ◽

Portal Vein ◽

Liver Regeneration ◽

Folinic Acid ◽

Hepatic Metastases ◽

Future Liver Remnant ◽

Control Group ◽

Portal Vein Ligation ◽

Nuclear Area ◽

Liver Remnant

Liver resection remains the gold standard for hepatic metastases. The future liver remnant (FLR) and its functional status are two key points to consider before performing major liver resections, since patients with less than 25% FLR or a Child–Pugh B or C grade are not eligible for this procedure. Folinic acid (FA) is an essential agent in cell replication processes. Herein, we analyze the effect of FA as an enhancer of liver regeneration after selective portal vein ligation (PVL). Sixty-four male WAG/RijHsd rats were randomly distributed into eight groups: a control group and seven subjected to 50% PVL, by ligation of left portal branch. The treated animals received FA (2.5 m/kg), while the rest were given saline. After 36 h, 3 days or 7 days, liver tissue and blood samples were obtained. FA slightly but significantly increased FLR percentage (FLR%) on the 7th day (91.88 ± 0.61%) compared to control or saline-treated groups (86.72 ± 2.5 vs. 87 ± 3.33%; p < 0.01). The hepatocyte nuclear area was also increased both at 36 h and 7days with FA (61.55 ± 16.09 µm2, and 49.91 ± 15.38 µm2; p < 0.001). Finally, FA also improved liver function. In conclusion, FA has boosted liver regeneration assessed by FLR%, nuclear area size and restoration of liver function after PVL.

Download Full-text

Concurrent biliary drainage and portal vein embolization in preparation for extended hepatectomy in patients with biliary cancer

Acta Radiologica Open ◽

10.1177/2058460115579121 ◽

2015 ◽

Vol 4 (5) ◽

pp. 205846011557912

Author(s):

Jan Nilsson ◽

Sam Eriksson ◽

Peter Nørgaard Larsen ◽

Inger Keussen ◽

Susanne Christiansen Frevert ◽

...

Keyword(s):

Portal Vein ◽

Portal Vein Embolization ◽

Biliary Drainage ◽

Percutaneous Transhepatic Biliary Drainage ◽

Future Liver Remnant ◽

Preoperative Biliary Drainage ◽

Combined Approach ◽

Extended Hepatectomy ◽

Liver Remnant ◽

Transhepatic Biliary Drainage

Background Patients with perihilar cholangiocarcinoma and gallbladder cancer extending into the hilum often present with jaundice and a small future liver remnant (FLR). If resectable, preoperative biliary drainage and portal vein embolization (PVE) are indicated. Classically, these measures have been performed sequentially, separated by 4–6 weeks. Purpose To report on a new regime where percutaneous transhepatic biliary drainage (PTBD) and PVE are performed simultaneously, shortening the preoperative process. Material and Methods Six patients were treated with concurrent PTBD and PVE under general anesthesia. Results Surgical exploration followed the combined procedure after 35 days (range, 28–51 days). The FLR ratio increased from 22% to 32%. Three patients developed cholangitis after the procedure. Conclusion The combined approach of PTBD and PVE seems feasible, but more studies on morbidity are warranted.

Download Full-text

Surgical Removal of Inadvertent Portal Thrombosis by Rescue-ALPPS for Perihilar Cholangiocarcinoma

10.31487/j.ijscr.2019.01.06 ◽

2019 ◽

pp. 1-4

Author(s):

Jun Li

Keyword(s):

Portal Vein ◽

Treatment Options ◽

Future Liver Remnant ◽

Perihilar Cholangiocarcinoma ◽

Surgical Removal ◽

Portal Vein Ligation ◽

Technical Failure ◽

Portal Thrombosis ◽

Liver Remnant ◽

Type Iv

Introduction:Treatment of perihilar cholangiocarcinoma (PHC) usually requires extended resection after inducing hypertrophy of the future liver remnant (FLR). Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) can achieve rapid hypertrophy of the FLR. Though, due to significant morbidity and mortality, portal vein embolization (PVE) is considered gold standard. Despite remaining controversies, ALPPS might suit as reserve in patients who failed to achieve adequate hypertrophy of the FLR or suffered complications following PVE. We illustrate a rescue-ALPPS after inadvertent nontarget thrombosis of the FLR following PVE in a patient with PHC. Presentation of Case:A 67-year-old patient requiring right trisectionectomy for PHC Bismuth type IV suffered inadvertent nontarget portal thrombosis of the FLR following PVE. Subsequently, insufficient FLR hypertrophy prevented the planned surgical resection. ALPPS procedure with concomitant thrombectomy of the left portal vein was used as a rescue strategy for this patient. Discussion:Since ALPPS is associated with significant limitations, especially in patients with PHC, this approach remains controversial. However, surgery still remains the only curative option for patients with PHC and thus, in case of inadequate hypertrophy of the FLR or technical failure following PVE, these patients lack further treatment options. Recent technical refinements and methods of improved patient selection have the potential to emend outcomes of ALPPS in experienced centres. Conclusion:ALPPS should be considered as reasonable rescue strategy not only in case of insufficient hypertrophy of the FLR but also in the event of technical failure or complications following PVE, even in patients with PHC.

Download Full-text

The Contemporary Role of Resection and Ablation in Colorectal Cancer Liver Metastases

Digestive Disease Interventions ◽

10.1055/s-0040-1715816 ◽

2020 ◽

Vol 04 (03) ◽

pp. 291-302

Author(s):

Mariam F. Eskander ◽

Christopher T. Aquina ◽

Aslam Ejaz ◽

Timothy M. Pawlik

Keyword(s):

Colorectal Cancer ◽

Portal Vein ◽

Surgical Oncology ◽

Portal Vein Ligation ◽

Safe Alternative ◽

Colorectal Cancer Liver Metastases ◽

Liver Remnant ◽

New Era ◽

Ablation Therapy

AbstractAdvances in the field of surgical oncology have turned metastatic colorectal cancer of the liver from a lethal disease to a chronic disease and have ushered in a new era of multimodal therapy for this challenging illness. A better understanding of tumor behavior and more effective systemic therapy have led to the increased use of neoadjuvant therapy. Surgical resection remains the gold standard for treatment but without the size, distribution, and margin restrictions of the past. Lesions are considered resectable if they can safely be removed with tumor-free margins and a sufficient liver remnant. Minimally invasive liver resections are a safe alternative to open surgery and may offer some advantages. Techniques such as portal vein embolization, association of liver partition with portal vein ligation for staged hepatectomy, and radioembolization can be used to grow the liver remnant and allow for resection. If resection is not possible, nonresectional ablation therapy, including radiofrequency and microwave ablation, can be performed alone or in conjunction with resection. This article presents the most up-to-date literature on resection and ablation, with a discussion of current controversies and future directions.

Download Full-text