portal vein embolization and colorectal liver met
DESCRIPTION
Hepato Biliary Surgery ConferenceTRANSCRIPT
Portal vein embolization and colorectal liver metastases
Eric Vibert, MD, PhD
Centre Hépato-Biliaire
Plan
• Why we perform Portal Vein Occlusion ?
• How we perform Portal Vein Occlusion ?
• What are the consequences of PVE on
– Fonction ?
– Volume ?
– Histology of the liver ?
– Tumor ?
• Alternative to PVE ?
To avoid post-operative liver failure
< 20% of standard liver volume or 0.5% body weight
Liver SP Liver SP
Truant et al. JACS 2008Ribeiro, Vauthey et al. BJS 2007
No liver resection with a liver remnant volume < 0.5% of body weight ratio
2011
MHV
RHV
Vcongestion
NCLR : 29%
NCLR : 20%
Vascular reconstructionMise et al. BJS 2011
The middle hepatic vein is betweenthe right and the left liver…
Be careful to liver resection that cut middle hepatic vein
« Morphological » Vol. ≠ « Functional » Vol.
Tanaka et al. Surgery 2010
?
Pas de veine hépatique inf. droite
Foie gauche = 0,5%
Interhepatic vein anastomoses
e flow
Post-hepatectomy liver failure
At D3 et/ou D5 : Bilirubine > 50 µMol/L and TP < 50% 50 à 63% of 1 month mortality
50
J5
De J1 et J90 : Bilirubine > 120 µMol/L 70% of 3 month mortality
Balzan…Belghit et al. Ann Surg 2005 Paugam…Belghit et al. Ann Surg 2009 Mullen…Vauthey et al. JACS 2007
And /Or
n=1057 majors hepatectomies
in non cirrhotic liver
n=870 then n=436
hepatectomies
2011
Gp A
Gp B
Gp C
Post-operative liver failure is the consequence of macroscopic and
microscopic liver « desorganization »
Difference between fulminant hepatitis and major hepatectomy
Fulminant hepatitis Major hepatectomy
« The liver is not a Brocoli, it is 2 Brocolis »
INFLOW OUTFLOW
Sano et al,, Ann Surg 2002
The liver function is related to vascular surface between hepatocytes / sinusoids
Hoelme et al. PNAS 2010
Day 0 Day 4
Hepatocytes
proliferationEndothelial
proliferation
Before hepatectomy
Day 0 to Day 4 / major hepatectomy
Hepatocytes multiplication +++
Œdema Increase of portal pressure
Decrease of exchange surface between endoth. cell and hepatocytes Poor liver function
After Day 4 / major hepatectomy
Improve of « liver permeability »
Endothelial prolifération +++
Enlargment of surface exchange between LSEC and Hep. Function
PV
CLVHepatocytes
Endothelial Cell
Biliary cell
Patients and MethodsPortal Vein Pressure measurement
• When? 30 min to 1 hour after liver transection just before abdominal closure
• How? Transducer connected to a 25 gauge needle inserted into the portal trunk
There is a correlation of PVP with liver failure and 90-day mortality
YesNoPost
hep
atec
tom
y P
VP
(m
mH
g)
22.5 mmHg
15 mmHg
P < 0.001
Liver failure « 50-50 » criteria 90-day mortality
YesNo
15 mmHg
19 mmHg
P = 0.01
Optimal cutoff of PVP for each liver failure definition
« 50-50 » criteria Peak of serum bilirubin > 7 mg/dL
ISGLS grade 3 definition
22 mmHg 22 mmHg21 mmHg
Incidence of POLF after
hepatectomy for CRLM
Auteur Date Période Hépatectomie Mortalité po Hep.Maj Ins.Hep Ins.Hep/Maj.
N. % N. % %
Figueras et al. 2001 1991-2000 256 4,0 145 0,8 1,4
Tamandl et al. 2007 2001-2004 276 0,0 27 0,7 7,4
Finch et al. 2007 1993-2003 484 3,5 349 0,4 0,6
Gold 2008 1992-2003 443 2,9 380 0,5 0,5
Mehta 2008 2003-2005 173 4,0 127 1,2 1,6
Welsh et al. 2008 1987-2005 911 1,5 0,2
Kesmodel 2008 2004-2006 125 1,6 (3 mois) 77 1,6 2,6
Konopke 2009 1993-2008 107 0,9 49 1,9 4,1
Ferrero 2010 2002-2004 80 0,0 39 2,5 5,1
Schiesser 2008 1992-2005 197 2,5 126 1,0 1,6
Karanjia et al. 2008 1996-2006 283 2,1 151 0,7 1,3
2,1% 1% 2,6%
96
10
26
114
00
20
40
60
80
100
120
Grade 0 Grade 1 Grade 2 Grade 3 Grade 4 Grade 5
34
6
22
14
7
2
0
5
10
15
20
25
30
35
40
Grade 0 Grade 1 Grade 2 Grade 3 Grade 4 Grade 5
147 Hépatectomies mineures
85 Hépatectomies majeures
32% Gr 1-2 27% Gr 3-4-5
24% Gr 1-2 11% Gr 3-4-5
Morbidité 33% Mortalité 0%
Morbidité 59% Mortalité 2%
Morbidité grave
Morbidité grave
Maj + Min Mineure (<3 seg) Majeure (>2 seg) p
N=232 N=147 N=85N(%) or Moy±SD N(%) or Moy±SD N(%) or Moy±SD
Insuff. hép. post hep. 7 (3%) 1 (0,8%) 6 (7%) 0,002
Fistule Biliaire 19 (8) 11 (7) 8 (9) 0,04Ascite 17 (7) 3 (2) 14 (16) 0,0001Pneumopathie 15 (6) 9 (6) 6 (6) 0,77Confusion mentale 14 (6) 4 (3) 10 (11) 0,005Infection urinaire 12 (5) 6 (4) 6 (7) 0,32Collection péri-hépatique infecté
9 (4) 2 (1)7 (8) 0,009
Hémorragie 6 (2) 3 (2) 3 (3) 0,49Thrombose portale 2 (1) 0 2 (2) 0,06
Hospit. en Réanimation (jours) 2,3±3,3 1,8±2,3 3,1±4,5 0,007Hospitalisation globale (jours) 13,3±24 12,3±30,4 14,2±8,7 0,58
Toutes Hépatectomies(N=232)
Hépatectomies majeures (N=85)
RR (95% CI) p RR (95% CI) p
PO. Liver Failure 3,84 (1,01 – 14,4) 0,04 4,14 (1,29 – 14,8) 0,01
Mental Confusion 3,11 (1,37 – 7,14) 0,006 3,66 (1,18 – 12,5) 0,02
Infected Collection 2,87 (1,24 – 6,62) 0,01 -
Intraop Transf. 2,27 (1,21 – 4,09) 0,009 -
1er pronostic factor of long
term mortality after hep. for
colorectal liver met.
PO. Liver FailureSuivi moy. > 36 mois
C.H.B
J Am Coll Surg 1995; 181
C.H.B
Portal Puncture Under US Controle
Left Portal Branch
C.H.B
Right Portal Vein Embolization
C.H.B
Anatomical Hepatectomy after Fonctional Hepatectomy
2007
1 weeks
PVE allows to operate patient with finally the same overall result
2000
P=0.004
1995
2001
2009
2012
87 pts with PVE and chemotherapy to be operated
47 Slow responders : > 12 cycles of chemo.
40 Fast responders : < 12 cycles of chemo.
2012
PVE and chemo…
2008
Injection de cellule tumorale en intra splénique ou systémique et procédure à J7
In the liverIn the chest
Subcapsular hepatoma in rat thenlaparotomy, hep 30% or hep 60%
Evolution of the tumor ?
PV Ligation + In situ Splitting
« ALPPS » for Associated Liver Partition and Portal ligation for Staged hepatectomy
+ 72% in 9 days…
N=25
2012
To win time and volume….
The Solution to prevent small remnant liver ?
Or a dangerous method to explore with caution ?
Conclusion
• Portal vein embolization allows to decrease to the risk ofpo. Liver failure after major hepatectomy for colorectal livermetastasis
• Portal vein embolization increases the growth of colorectalliver metastases– Short term period between PVE / Hepatectomy– PVE and chemotherapy
• Alternative to PVE must be explored…– Major hepactomy seems did not increased malignancy– Portal flow modulation to prevent po. Failure with PVE
The future… Removable AdjustableVascular Ring around the portal vein