title: Preoperative Sequential Portal and Hepatic Vein Embolization in Patients with Hepatobiliary Malignancy.
abstract: BACKGROUND
  Preoperative portal vein embolization (PVE) induces shrinkage of the embolized lobe and compensatory regeneration in the non-embolized lobe, but does not always induce sufficient regeneration of the future remnant liver (FRL). We previously developed preoperative sequential PVE-hepatic vein embolization (HVE), and here we present our experience of treating 42 patients with sequential PVE-HVE.
  
  
  METHODS
  During 8-year study period, preoperative PVE-HVE was performed on 42 patients with hepatobiliary malignancies.
  
  
  RESULTS
  Primary diseases were bile duct cancers [perihilar cholangiocarcinoma (n = 33) and diffuse bile duct cancer (n = 1)], hepatocellular carcinomas (n = 4), and intrahepatic tumors [intrahepatic cholangiocarcinoma (n = 3) and gallbladder cancer liver invasion (n = 1)]. These patients demonstrated insufficient FRL regeneration following PVE, thus HVE was performed to induce further regeneration. No PVE-HVE procedure-associated complications occurred. In the bile duct cancer group, FRL volume was 33.9 ± 2.2 % before PVE, 38.4 ± 1.5 % before HVE, 43.7 ± 2.1 % at surgery, and 73.6 ± 8.3 % at 2 weeks after right hepatectomy. The degree of FRL hypertrophy was 13.3 % after PVE, 28.9 % after PHV-HVE, and 117.1 % at 2 weeks after right hepatectomy. All patients except one recovered uneventfully after surgery, and the 3-year patient survival rate was 45.1 %. In the HCC group, transarterial chemoembolization was initially performed and FRL regeneration following PVE-HVE occurred very slowly. Active FRL regeneration occurred in the liver tumor group, but rapid tumor growth was observed in 1 of 4 patients.
  
  
  CONCLUSIONS
  The sequential application of HVE following PVE safely and effectively induces further FRL regeneration in non-cirrhotic livers. Further validation using larger patient population and multicenter studies is needed to reliably widen the indications.
authors: Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea. shwang@amc.seoul.kr.
authors: Shin
authors: S
authors: Hwang
authors: Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
authors: Tae-Yong
authors: TY
authors: Ha
authors: Department of Diagnostic Imaging, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
authors: Gi-Young
authors: GY
authors: Ko
authors: Department of Diagnostic Imaging, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
authors: Dong-Il
authors: DI
authors: Kwon
authors: Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
authors: Gi-Won
authors: GW
authors: Song
authors: Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
authors: Dong-Hwan
authors: DH
authors: Jung
authors: Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
authors: Myung-Hwan
authors: MH
authors: Kim
authors: Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
authors: Sung-Koo
authors: SK
authors: Lee
authors: Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
authors: Sung-Gyu
authors: SG
authors: Lee
mesh_terms: D000328:Adult; D000368:Aged; D001650:Bile Duct Neoplasms / Q000601:surgery / Q000628:therapy*; D006528:Carcinoma, Hepatocellular / Q000601:surgery / Q000628:therapy*; D018281:Cholangiocarcinoma / Q000601:surgery; D004621:Embolization, Therapeutic; D005260:Female; D005706:Gallbladder Neoplasms / Q000473:pathology / Q000601:surgery / Q000628:therapy*; D006498:Hepatectomy; D006503:Hepatic Veins; D006801:Humans; D006984:Hypertrophy; D018285:Klatskin Tumor / Q000601:surgery / Q000628:therapy*; D008099:Liver / Q000473:pathology* / Q000502:physiology; D008113:Liver Neoplasms / Q000601:surgery / Q000628:therapy*; D008115:Liver Regeneration; D008297:Male; D008875:Middle Aged; D011169:Portal Vein; D011300:Preoperative Care; D015996:Survival Rate; D016896:Treatment Outcome