title: Analysis of the efficacy of portal vein embolization for patients with extensive liver malignancy and very low future liver remnant volume, including a comparison with the associating liver partition with portal vein ligation for staged hepatectomy approach.
abstract: BACKGROUND
  The primary reported indication for the associating liver partition with portal vein ligation for staged hepatectomy (ALPPS) technique is in patients with very low future liver remnant volumes. Given the elevated incidence of major morbidity (40%) and liver-related mortality (12%) with ALPPS, we sought to determine the safety and efficacy of percutaneous portal vein embolization (PVE) in a similar patient population.
  
  
  METHODS
  Tumor resectability and morbidity and mortality rates were reviewed for 144 consecutive liver tumor patients with future liver remnant to body weight ratios (LR/BW) less than 0.5%. All patients were referred for preoperative percutaneous right plus segment IV PVE using embolic microspheres, with planned reassessment of the LR/BW 30 days after PVE. Post-PVE outcomes were compared with reported outcomes for ALPPS.
  
  
  RESULTS
  Percutaneous PVE was successfully performed in 141 of the 144 study patients (97.9%). Adequate regeneration was observed in 139 patients (98.5%) with median post-PVE LR/BW rising from 0.33% to 0.52% (p < 0.0001), representing a per-patient median regeneration rate of 62% (range 0.3% to 379%). In total, 104 patients underwent extended right hepatectomy (n = 102) or right hepatectomy (n = 2). The remaining 40 patients (27.8%) were not resectable due to short-interval disease progression (27 patients, 18.5%), insufficient liver regeneration (5 patients, 3.5%), and medical comorbidities (8 patients, 5.6%). After resection, the following outcomes were observed: major morbidity: 33.0% (34 of 104), liver insufficiency: 12.5% (13 of 104), and 90-day liver-related mortality: 5.8% (6 of 104). These oncologic and technical results compare favorably with those of ALPPS.
  
  
  CONCLUSIONS
  Based on its ability to select oncologically resectable patients and superior safety and efficacy profiles, percutaneous right + segment IV PVE and interval surgery remains the standard of care for patients with very low future liver remnant volumes.
authors: Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA.
authors: Junichi
authors: J
authors: Shindoh
authors: Jean-Nicolas
authors: JN
authors: Vauthey
authors: Giuzeppe
authors: G
authors: Zimmitti
authors: Steven A
authors: SA
authors: Curley
authors: Steven Y
authors: SY
authors: Huang
authors: Armeen
authors: A
authors: Mahvash
authors: Sanjay
authors: S
authors: Gupta
authors: Michael J
authors: MJ
authors: Wallace
authors: Thomas A
authors: TA
authors: Aloia
mesh_terms: D000328:Adult; D000368:Aged; D004621:Embolization, Therapeutic / Q000295:instrumentation / Q000379:methods*; D005260:Female; D005500:Follow-Up Studies; D006498:Hepatectomy / Q000379:methods* / Q000401:mortality; D006801:Humans; D008026:Ligation; D008099:Liver / Q000098:blood supply / Q000254:growth & development* / Q000601:surgery; D008113:Liver Neoplasms / Q000401:mortality / Q000601:surgery* / Q000628:therapy; D008115:Liver Regeneration; D008297:Male; D008863:Microspheres; D008875:Middle Aged; D009929:Organ Size; D011169:Portal Vein / Q000601:surgery; D011300:Preoperative Care / Q000295:instrumentation / Q000379:methods*; D016019:Survival Analysis; D016896:Treatment Outcome
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