Evaluation of portal vein occlusion with or without parenchymal splitting in the management of irresectable liver tumors

Ammar, Khaled; Shoreem, Hany; Zakaria, Hazem; Alwarraky, Mohamed; Abdeldayem, Hesham; Ibrahim, Tarek M

doi:10.4103/ejs.ejs_202_18

Evaluation of portal vein occlusion with or without parenchymal splitting in the management of irresectable liver tumors

Authors

Abstract

Background
Portal vein embolization (PVE) has been developed with the principle of inducing hypertrophy of the future liver remnant (FLR) (10–50% after a period of 2–8 weeks). Tumor progression and insufficient hypertrophy of the FLR are the commonest causes that preclude definitive surgery in 10–30% of patients. Recently, associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) has been proposed, with the goal of achieving a faster and magnified hypertrophy (74–87.2% in 9–13 days) for patients with extensive colorectal liver metastases or hilar cholangiocarcinoma. However, introducing ALPPS for hepatocellular carcinoma (HCC) on top of cirrhosis has been questioned and not thoroughly investigated.
Patients and methods
A prospective observational study was conducted on patients who were admitted to the National Liver Institute from 2016 to 2018 with nonresectable liver tumors owing to insufficient FLR. Hypertrophy of the FLR, perioperative morbidity and mortality, overall survival, and other parameters were compared between patients who underwent ALPPS and patients who underwent PVE.
Results
Nineteen patients, of which 17 patients had HCC, underwent first-stage ALPPS, whereas 26 patients, of which 20 patients had HCC, underwent PVE. The mean of the percentage of hypertrophy at 2 weeks for ALPPS group was 41.62±39.7. The mean of hypertrophy after PVE at 2 weeks was 37±5.77%. Fourteen (73.6%) patients could be operated upon for definitive resection in the second stage of ALPPS. Fourteen (54%) patients underwent resection after PVE.
Conclusion
Despite the morbidity and outcomes of ALPPS in patients with cirrhosis, it still can be introduced with strict criteria. Although ALPPS produces more extensive hypertrophy than PVE and less likely progression of the tumor to the FLR, PVE has less overall morbidity and mortality.

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