Hepato Biliary Surgery Conference

1. Portal vein embolization and
colorectal liver metastases
Eric Vibert, MD, PhD
Centre Hépato-Biliaire

2. 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 ?

3. 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

4. No liver resection with a liver remnant volume < 0.5% of body weight ratio

5. 2011

6. MHV
RHV
Vcongestion
NCLR : 29%
NCLR : 20%
Vascular reconstruction
Mise et al. BJS 2011

7. The middle hepatic vein is between
the right and the left liver…
Be careful to liver resection that cut middle hepatic vein
« Morphological » Vol. ≠ « Functional » Vol.
Tanaka et al. Surgery 2010

8. ?
Pas de veine hépatique inf. droite
Foie gauche = 0,5%

9. Interhepatic vein anastomoses
e flow

10. 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

11. 2011
Gp A
Gp B
Gp C

12. Post-operative liver failure is the
consequence of macroscopic and
microscopic liver « desorganization »

13. Difference between fulminant
hepatitis and major hepatectomy
Fulminant hepatitis Major hepatectomy

14. « The liver is not a Brocoli, it is 2 Brocolis »
INFLOW OUTFLOW
Sano et al,, Ann Surg 2002

15. The liver function is related to vascular
surface between hepatocytes / sinusoids
Hoelme et al. PNAS 2010

16. Day 0 Day 4
Hepatocytes
proliferation
Endothelial
proliferation

17. 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

19. Patients and Methods
Portal 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

20. There is a correlation of PVP
with liver failure and 90-day mortality
YesNo
PosthepatectomyPVP(mmHg)
22.5 mmHg
15 mmHg
P < 0.001
Liver failure « 50-50 » criteria 90-day mortality
YesNo
15 mmHg
19 mmHg
P = 0.01

21. 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

22. 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%

23. 96
10
26
11
4
0
0
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

24. Maj + Min Mineure (<3 seg) Majeure (>2 seg) p
N=232 N=147 N=85
N(%) 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) 0,04
Ascite 17 (7) 3 (2) 14 (16) 0,0001
Pneumopathie 15 (6) 9 (6) 6 (6) 0,77
Confusion mentale 14 (6) 4 (3) 10 (11) 0,005
Infection urinaire 12 (5) 6 (4) 6 (7) 0,32
Collection péri-hépatique
infecté
9 (4) 2 (1)
7 (8) 0,009
Hémorragie 6 (2) 3 (2) 3 (3) 0,49
Thrombose portale 2 (1) 0 2 (2) 0,06
Hospit. en Réanimation (jours) 2,3±3,3 1,8±2,3 3,1±4,5 0,007
Hospitalisation globale (jours) 13,3±24 12,3±30,4 14,2±8,7 0,58

25. 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

27. C.H.B
J Am Coll Surg 1995; 181

28. C.H.B
Portal Puncture Under US Controle
Left Portal Branch

29. C.H.B
Right Portal Vein Embolization

30. C.H.B
Anatomical Hepatectomy after Fonctional Hepatectomy

31. 2007

32. 1 weeks

34. PVE allows to operate patient with finally the same overall result
2000

35. P=0.004

36. 1995

37. 2001

39. 2009

40. 2012

41. 87 pts with PVE and chemotherapy to be operated
47 Slow responders : > 12 cycles of chemo.
40 Fast responders : < 12 cycles of chemo.
2012

42. PVE and chemo…
2008

43. Injection de cellule tumorale en intra splénique ou systémique et procédure à J7
In the liver
In the chest

44. Subcapsular hepatoma in rat then
laparotomy, hep 30% or hep 60%
Evolution of the tumor ?

45. 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….

46. The Solution to prevent small remnant liver ?
Or a dangerous method to explore with caution ?

47. Conclusion
• Portal vein embolization allows to decrease to the risk of
po. Liver failure after major hepatectomy for colorectal liver
metastasis
• Portal vein embolization increases the growth of colorectal
liver 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

48. The future… Removable Adjustable
Vascular Ring around the portal vein