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Preoperative portal vein embolization

Author
Senthil Kumar, MS, FRCS (Ed), FRCS (Gen Surg)
Section Editor
Stanley W Ashley, MD
Deputy Editor
Kathryn A Collins, MD, PhD, FACS

INTRODUCTION

Liver resection has evolved into an oncologically effective treatment for primary hepatic malignancies (eg, hepatocellular carcinoma, cholangiocarcinoma) and for the treatment of metastatic liver tumors (eg, colorectal carcinoma, neuroendocrine tumor). In many clinical situations, liver resection, when possible, provides the best survival outcomes. However, the limits of liver resection are determined by the probability of leaving behind a safe volume of functional liver that has an adequate vascular inflow, venous outflow, and biliary drainage.

The generally accepted safe minimum threshold for the future liver remnant (FLR) varies from 20 to 25 percent for a normal liver to >40 percent for a cirrhotic liver [1-3]. If the FLR volume is deemed unsafe or marginal, adjunctive or alternative methods to ensure an adequate postresection liver volume may include: a staged resection, the associating liver partition and portal vein ligation for staged hepatectomy procedure, a hybrid procedure that combines liver resection with ablation techniques, and portal vein occlusion techniques such as preoperative portal vein ligation (PVL) or preoperative portal vein embolization (PVE).

Preoperative PVE is the elective obliteration of portal blood flow to a selected portion of the liver a few weeks prior to planned major liver resection. PVE initiates hypertrophy of the anticipated FLR. Preoperative PVE is a valuable adjunct to major liver resection, particularly for right-sided tumors, and it may allow a more extensive resection or staged bilateral resections [4-10]. The indications, contraindications, and techniques for PVE, and a comparison of PVE with other techniques, are reviewed here. (See "Overview of hepatic resection" and "Hepatic resection techniques".)

LIVER VOLUME AND FUNCTIONAL ASSESSMENT

In evaluating the need for preoperative portal vein embolization (PVE), the standardized future liver remnant (FLR) needs to be determined. (See "Overview of hepatic resection", section on 'Preoperative imaging'.)

A clear understanding and application of appropriate estimation of the volume and function of the liver is an important aspect of patient selection. Many methods are in clinical use and each has advantages and disadvantages. There is always a discrepancy between the measured or estimated volume and the actual weight, as demonstrated from graft weight measurements in living donor liver transplantation. The same applies to functional assessment as well.

                              

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Literature review current through: Nov 2016. | This topic last updated: Wed Oct 12 00:00:00 GMT+00:00 2016.
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