Progress of transformational therapy in colorectal liver metastases

Colorectal cancer liver metastases （CLM） treatment is very important given the high incidence of colorectal cancer with liver metastases, which are primarily treated by surgical resection. Transformational therapy such as systemic chemotherapy, hepatic arterial infusion （HAl）, portal vein embolization （PVE）, ablation therapy, and targeted therapy, should be applied to CLM patients who are unable to undergo immediate surgery to improve patients＇ survival and quality of life.

Simultaneous portal and hepatic vein embolization is better than portal embolization or ALPPS for hypertrophy of future liver remnant before major hepatectomy: A systematic review and network meta-analysis

Background:Post-hepatectomy liver failure(PHLF)is the Achilles’heel of hepatic resection for colorectal liver metastases.The most commonly used procedure to generate hypertrophy of the functional liver remnant(FLR)is portal vein embolization(PVE),which does not always lead to successful hypertrophy.Associating liver partition and portal vein ligation for staged hepatectomy(ALPPS)has been proposed to overcome the limitations of PVE.Liver venous deprivation(LVD),a technique that includes simultaneous portal and hepatic vein embolization,has also been proposed as an alternative to ALPPS.The present study aimed to conduct a systematic review as the first network meta-analysis to compare the efficacy,effectiveness,and safety of the three regenerative techniques.Data sources:A systematic search for literature was conducted using the electronic databases Embase,PubMed(MEDLINE),Google Scholar and Cochrane.Results:The time to operation was significantly shorter in the ALPPS cohort than in the PVE and LVD cohorts by 27 and 22 days,respectively.Intraoperative parameters of blood loss and the Pringle maneuver demonstrated non-significant differences between the PVE and LVD cohorts.There was evidence of a significantly higher FLR hypertrophy rate in the ALPPS cohort when compared to the PVE cohort,but non-significant differences were observed when compared to the LVD cohort.Notably,the LVD cohort demonstrated a significantly better FLR/body weight(BW)ratio compared to both the ALPPS and PVE cohorts.Both the PVE and LVD cohorts demonstrated significantly lower major morbidity rates compared to the ALPPS cohort.The LVD cohort also demonstrated a significantly lower 90-day mortality rate compared to both the PVE and ALPPS cohorts.Conclusions:LVD in adequately selected patients may induce adequate and profound FLR hypertrophy before major hepatectomy.Present evidence demonstrated significantly lower major morbidity and mortality rates in the LVD cohort than in the ALPPS and PVE cohorts.

Non-target lung embolization during portal vein embolization due to an unrecognized portosystemic venous fistula:A case report

BACKGROUND Portal vein embolization(PVE)is an effective and relatively safe procedure performed prior to major hepatic resection to enhance future liver remnant.Nontarget embolization during PVE is rare,and if it occurs,it usually affects the future liver remnant.Intrahepatic portosystemic venous fistulas are extremely rare in non-cirrhotic livers.We report a case of non-targeted lung embolization during PVE due to an unrecognized intrahepatic portosystemic fistula.CASE SUMMARY A 60-year-old male presented with metastatic colon cancer of the liver.The patient underwent preoperative right PVE.During the embolization procedure,a small amount of glue and lipiodol emulsion was embolized to the heart and lungs through an unrecognized intrahepatic portosystemic fistula.The patient remained clinically stable and underwent the planned hepatic resection after 4 wk,with an uneventful postoperative course.CONCLUSION Conventional portograms and careful evaluation prior to PVE are advisable to avoid such complications.

Portal vein embolization for closure of marked arterioportal shunt of hepatocellular carcinoma to enable radioembolization:A case report

BACKGROUND Marked arterioportal shunt(APS)can be a contraindication for transarterial radioembolization(TARE)because of the risk of radiation-induced liver toxicity or pneumonitis.To date,the best method to close marked APS to reduce intrahepatic shunt(IHS)and hepatopulmonary shunt(HPS)before TARE has not been elucidated.CASE SUMMARY This case report describes a novel strategy of embolization of the portal venous outlet to reduce IHS and HPS caused by marked APS before TARE in a patient with advanced hepatocellular carcinoma(HCC).The patient had a significant intratumoral shunt from the tumor artery to the portal vein and had already been suspected based on pre-interventional magnetic resonance angiography,and digital subtraction angiography(DSA)confirmed the shunt.Selective right portal vein embolization(PVE)was performed to close the APS outlet and DSA confirmed complete closure.Technetium-99m macroaggregated albumin was administered and single photon emission computed tomography revealed a low HPS with 8.4%.Successful TARE was subsequently performed.No major procedurerelated complication occurred.CONCLUSION Closure of APS with PVE during mapping angiography of advanced-stage HCC to enable reduction of HPS and subsequent TARE is feasible.

Transarterial embolization and low-dose continuous hepatic arterial infusion chemotherapy with oxaliplatin and raltitrexed for hepatocellular carcinoma with major portal vein tumor thrombus

AIM To determine the efficacy and safety of transarterial embolization and low-dose continuous hepatic arterial infusion chemotherapy with oxaliplatin and raltitrexed in hepatocellular carcinoma(HCC) with major portal vein tumor thrombus(MPVTT).METHODS eighty-six patients with MPVTT accepted routine embolization. The catheter was kept in the hepatic artery and oxaliplatin(50 mg in 250 m L of glucose) was infused by pump for 4 h,followed by raltitrexed(2 mg in 100 m L of 0.9% saline) infusion by pump for the next 1 h. The efficacy and safety were evaluated afterthe transarterial chemoembolization(TACe).RESULTS Full or partial embolization was achieved in 86 cases,where all the cases received low dose continuous hepatic arterial infusion chemotherapy. Complete responses(CRs),partial responses(PRs),stable disease(SD),and disease progression(PD) for intrahepatic disease were observed in 0,45,20,and 21 patients,respectively. The 1-,2-and 3-year overall survival rates of the 86 patients were 40.7%,22.1%,and 8.1% respectively,and the median survival time was 8.7 mo. Complication was limited. CONCLUSION TACE with low dose continuous hepatic arterial infusion of oxaliplatin and raltitrexed could be an option in MPVTT patient; it was shown to be effective in patients with advanced HCC with MPVTT with less toxicity.

Hepatocellular Carcinoma with Tumor Thrombus in Portal Vein: Finding in Ultrasonography, Computed Tomography, Angiography and Chemoembolization

Transcatheter hepatic artery chemoembolization (TACE) was performed in 41 patients with hepatocellular carcinoma (HCC) accompanied with portal tumor thrombus (PTT). The primary tumors and the PTTs had been detected with ultrasonography (US), computed tomography (CT) and digital subtraction angiography (DSA) before TACE. The purpose of this article is to compare the sensitivity of these methods. Eighty cases of HCC without PTT detected by DSA during the same period were studied as a control group. The PTTs were found in 37 of 41 (90.2%) cases with DSA, whereas the detection rate was 81.1% with US and 41.0% with CT. The internal left lobe of liver was invaded by tumor in 23 of 41 (56.1%) patients with PTT, but it is only 26.3% in the control group (P<001). The primary tumor located in the internal left lobe was significantly smaller than that in the right lobe (P<001). No serious dysfunction of the liver occurred during the treatment. It is concluded that DSA and US are more sensitive than CT to the detection of PTT, that tumor in the internal left lobe of the liver more easily invades the portal vein, and that TACE should be performed as actively as possible even if the portal vein has been invaded.

Portal vein embolization induces compensatory hypertrophy of remnant liver

AIM： To evaluate the effectiveness and safety of different portal vein branch embolization agents in inducing compensatory hypertrophy of the remnant liver and to offer a theoretic basis for clinical portal vein branch embolization. METHODS： Forty-one adult dogs were included in the experiment and divided into four groups. Five dogs served as a control group, 12 as a gelfoam group, 12 as a coil-gelfoam group and 12 as an absolute ethanol group. Left portal vein embolization was performed in each group. The results from the embolization in each group using different embolic agents were compared. The safety of portal vein embolization （PVE） was evaluated by liver function test, computed tomography （CT） and digital subtraction angiography （DSA） of liver and portal veins. Statistical test of variance was performed to analyze the results. RESULTS： Gelfoam used for PVE was inefficient in recanalization of portal vein branch 4 wk after the procedure. The liver volume in groups of coil-gelfoam and absolute ethanol increased 25.1% and 33.18%, respectively. There was no evidence of recanalization of embolized portal vein, hepatic dysfunction, and portal hypertension in coil-gelfoam group and absolute ethanol group. CONCOUSION： Portal vein branch embolization using absolute ethanol and coil-gelfoam could induce atrophy of the embolized lobes and compensatory hypertrophy of the remnant liver. Gelfoam is an inefficient agent.

Portal vein embolization by fine needle ethanol injection :experimental and clinicalstudies

AIM To improve the technique of intraportal embolization (PVE) therapy, a new embolic method, was devised and the safety, effectiveness and feasibility were evaluated. METHODS PVE with intraportal ethanol injection via a fine needle was performed in 28 normal dogs, 22 SD rats, and 24 cirrhotic SD rats. After PVE, portography, histological and functional alteration of the liver were evaluated in dogs and rats, and the changes in portal hemodynamics as well as hepatic anatomy were observed in rats. In the clinical study, PVE by ethanol injection was performed in 61 patients with hepatocellular carcinoma under the guidance of portoechography with intraportal injection of CO 2. The effect of PVE was evaluated by ultrasonography and laparotomy. RESULTS The effectiveness and toxicity were dependent on the dose of ethanol. In the dogs, 0 25*!mg/*!kg of ethanol caused incomplete embolization with least liver damage, while 1 0*!mg/*!kg induced complete embolization with a high mortality of 57 1% (4/*!7) due to respiratory arrest. The dose of 0 5*!mg/*!kg resulted in complete embolization with slight toxicity to the liver. In the rats, the survival rate was 100% in normal group but 40 9% in cirrhotic models after ethanol injection by dose of 0 05*!mg/*!100*!g . PVE for cirrhotic rats with 0 03*!mg/*!100*!g of ethanol induced satisfactory embolization with significant hypertrophy in nonembolized lobes, and only slight damage to the hepatic parenchyma, and transient alteration in liver function, portal pressure and portal flow. In the clinical study, 12 cases with reverse portal flow were excluded judged by portoechography. Satisfactory embolization was gained in 90 2% (55/*!61) of the remaining patients determined by ultrasonography and surgery. All cases ran an uneventful postembolization course with no aberrant embolization. CONCLUSION PVE with intraportal ethanol injection of appropriate dosage via a fine needle is safe and effective and has several advantages comparing with transcatheter method. Portoechography is a mandatory approach for the prevention of aberrant embolization.

Rescue associating liver partition and portal vein ligation for staged hepatectomy after portal embolization: Our experience and literature review

AIM To report a single-center experience in rescue associating liver partition and portal vein ligation for staged hepatectomy(ALPPS), after failure of previous portal embolization. We also performed a literature review.METHODS Between January 2014 and December 2015, every patient who underwent a rescue ALPPS procedure in Toulouse Rangueil University Hospital, France, was included. Every patient included had a project of major hepatectomy and a previous portal vein embolization(PVE) with insufficient future liver remnant to body weight ratio after the procedure. The ALPPS procedure was performed in two steps(ALPPS-1 and ALPPS-2), separated by an interval phase. ALPPS-2 was done within 7 to 9 d after ALPPS-1. To estimate the FLR, a computed tomography scan examination was performed 3 to 6 wk after the PVE procedure and 6 to 8 d after ALPPS-1. A transcystic stent was placed during ALPPS-1 and remained opened duringthe interval phase, in order to avoid biliary complications. Postoperative liver failure was defined using the 50-50 criteria. Postoperative complications were assessed according to the Dindo-Clavien Classification.RESULTS From January 2014 to December 2015, 7 patients underwent a rescue ALPPS procedure. Median FLR before PVE, ALPPS-1 and ALPPS-2 were respectively 263 cc(221-380), 450 cc(372-506), and 660 cc(575-776). Median FLR/BWR before PVE, ALPPS-1 and ALPPS-2 were respectively 0.4%(0.3-0.5), 0.6%(0.5-0.8), and 1%(0.8-1.2). Median volume growth of FLR was 69%(18-92) after PVE, and 45%(36-82) after ALPPS-1. The combination of PVE and ALPPS induced a growth of median initial FLR of +408 cc(254-513), leading to an increase of +149%(68-199). After ALPPS-2, 4 patients had stage Ⅰ-Ⅱ complications. Three patients had more severe complications(one stage Ⅲ, one stage Ⅳ and one death due to bowel perforation). Two patients suffered from postoperative liver failure according to the 50/50 criteria. None of our patients developed any biliary complication during the ALPPS procedure.CONCLUSION Rescue ALPPS may be an alternative after unsuccessful PVE and could allow previously unresectable patients to reach surgery. Biliary drainage seems to reduce biliary complications.

Portal vein embolization effect on colorectal cancer liver metastasis progression:Lessons learned

Colorectal liver metastasis(CRLM) is the major cause of death in patients diagnosed with colorectal cancer. The gold standard treatment of CRLM is surgical rese-ction. Yet, in the past, more than half of these patients were deemed unresectable due to the inadequate future liver remnant(FLR). The introduction of efficient portal vein embolization(PVE) preoperatively allowed more resections of metastasis in CRLM patients by stimulating adequate liver hypertrophy. However, several exp-erimental and clinical studies reported tumor progression after PVE which critically influences the subsequent management of these patients. The underlying path-ophysiological mechanism of tumor progression post-PVE is still not fully understood. In spite of the adverse effects of PVE, it remains a potentially curative procedure in patients who would remain otherwise unresectable because of the insufficient FLR. Currently, the challenge is to halt tumor proliferation following PVE in patients who require this technique. This could potentially be achieved by either attempting to suppress the underlying oncologic stimulus or by inhibiting tumor growth once observed after PVE, without jeopardizing liver regeneration. More research is still required to better identify patients at risk of experiencing tumor growth post-PVE.

Preoperative portal vein embolization for hepatocellular carcinoma: consensus and controversy

Thirty years have passed since the first report of portal vein embolization(PVE),and this procedure is widely adopted as a preoperative treatment procedure for patients with a small future liver remnant(FLR).PVE has been shown to be useful in patients with hepatocellular carcinoma(HCC)and chronic liver disease.However,special caution is needed when PVE is applied prior to subsequent major hepatic resection in cases with cirrhotic livers,and volumetric analysis of the liver segments in addition to evaluation of the liver functional reserve before PVE is mandatory in such cases.Advances in the embolic material and selection of the treatment approach,and combined use of PVE and transcatheter arterial embolization/chemoembolization have yielded improved outcomes after PVE and major hepatic resections.A novel procedure termed the associating liver partition and portal vein ligation for staged hepatectomy has been gaining attention because of the rapid hypertrophy of the FLR observed in patients undergoing this procedure,however,application of this technique in HCC patients requires special caution,as it has been shown to be associated with a high morbidity and mortality even in cases with essentially healthy livers.

Sequential transcatheter arterial chemoembolization and portal vein embolization before right hemihepatectomy in patients with hepatocellular carcinoma

Background:Recent studies showed that sequential selective transcatheter arterial chemoembolization(TACE)and portal vein embolization(PVE)provided better future liver remnant(FLR)regeneration rate and disease-free survival following surgery compared with PVE alone.The present study aimed to clarify whether preoperative sequential TACE and PVE before right hemihepatectomy can reduce postoperative hepatocellular carcinoma(HCC)recurrence and improve long-term disease-free and overall survival.Methods:Recurrence and survival outcomes were retrospectively evaluated in 205 patients with HCC who underwent right hemihepatectomy by a single surgeon from November 1993 to November 2017.Patients were divided into four groups according to the procedure performed before the surgery:sequential TACE and PVE(TACE-PVE),PVE-only,TACE-only,or na?ve control groups.The baseline patient and tumor characteristics,postoperative outcomes,recurrence-free survival and overall survival were analyzed.Results:Baseline patient and tumor characteristics upon diagnosis were similar in all four groups,while sequential TACE and PVE were well tolerated.The TACE-PVE group had a higher mean increase in percentage FLR volume compared with that of the PVE-only group(17.46%±6.63%vs.12.14%±5.93%;P=0.001).The TACE-PVE group had significantly better overall and disease-free survival rates compared with the other groups(both P<0.001).Conclusions:Sequential TACE and PVE prior to surgery can be an effective therapeutic strategy for patients with HCC scheduled for major hepatic resection.The active application of preoperative sequential TACE and PVE for HCC would allow more patients with marginal FLR volume to become candidates for major hepatic resection by promoting compensatory FLR hypertrophy without the deterioration of basal hepatic functional reserve or tumor progression.

No difference in mortality among ALPPS,two-staged hepatectomy,and portal vein embolization/ligation:A systematic review by updated traditional and network meta-analyses

Background:There is an ongoing debate on the feasibility,safety,and oncological efficacy of the associating liver partition and portal vein ligation for staged hepatectomy(ALPPS)technique.The aim of this study was to compare ALPPS,two-staged hepatectomy(TSH),and portal vein embolization(PVE)/ligation(PVL)using updated traditional meta-analysis and network meta-analysis(NMA).Data sources:Electronic databases were used in a systematic literature search.Updated traditional metaanalysis and NMA were performed and compared.Mortality and major morbidity were selected as primary outcomes.Results:Nineteen studies including 1200 patients were selected from the pool of 436 studies.Of these patients,315(31%)and 702(69%)underwent ALPPS and portal vein occlusion(PVO),respectively.Ninetyday mortality based on updated traditional meta-analysis,subgroup analysis of the randomized controlled trials(RCTs),and both Bayesian and frequentist NMA did not demonstrate significant differences between the ALPPS cohort and the PVE,PVL,and TSH cohorts.Moreover,analysis of RCTs did not demonstrate significant differences of major morbidity between the ALPPS and PVO cohorts.The ALPPS cohort demonstrated significantly more favorable outcomes in hypertrophy parameters,time to operation,definitive hepatectomy,and R0 margins rates compared with the PVO cohort.In contrast,1-year disease-free survival was significantly higher in the PVO cohort compared to the ALPPS cohort.Conclusions:This study is the first to use updated traditional meta-analysis and both Bayesian and frequentist NMA and demonstrated no significant differences in 90-day mortality between the ALPPS and other hepatic hypertrophy approaches.Furthermore,two high quality RCTs including 147 patients demonstrated no significant differences in major morbidity between the ALPPS and PVO cohorts.

Transhepatic catheter-directed thrombolysis for portal vein thrombosis after partial splenic embolization in combination with balloon-occluded retrograde transvenous obliteration of splenorenal shunt

A 66-year-old woman underwent partial splenic embolization （PSE） for hypersplenisrn with idiopathic portal hypertension （IPH）. One week later, contrast-enhanced CT revealed extensive portal vein thrombosis （PVT） and dilated portosystemic shunts. The PVT was not dissolved by the intravenous administration of urokinase. The right portal vein was canulated via the percutaneous transhepatic route under ultrasonic guidance and a 4 Fr. straight catheter was advanced into the portal vein through the thrombus. Transhepatic catheter-directed thrombolysis was performed to dissolve the PVT and a splenorenal shunt was concurrently occluded to increase portal blood flow, using balloon-occluded retrograde transvenous obliteration （BRTO） technique. Subsequent contrast-enhanced CT showed good patency of the portal vein and thrombosed splenorenal shunt. Transhepatic catheter-directed thrombolysis combined with BRTO is feasible and effective for PVT with portosystemic shunts.

Portal vein embolization before major hepatectomy

To discuss the rationale, techniques and the unsolved issues regarding preoperative portal vein embolization (PVE) before major hepatectomy. After a systematic search of Pubmed, we reviewed and retrieved literature related to PVE. Preoperative PVE is an approach that is gaining increasing acceptance in the preoperative treatment of selected patients prior to major hepatic resection. Induction of selective hypertrophy of the nondiseased portion of the liver with PVE in patients with either primary or secondary hepatobiliary, malignancy with small estimated future liver remnants (FLR) may result in fewer complications and shorter hospital stays following resection. Additionally, PVE performed in patients initially considered unsuitable for resection due to lack of sufficient remaining normal parenchyma may add to the pool of candidates for surgical treatment. The results suggest that PVE is recomm-endable in treating the cirrhotic patients before major liver resection.

Simultaneous transcatheter arterial chemoembolization and portal vein embolization for patients with large hepatocellular carcinoma before major hepatectomy

BACKGROUND Sequential transarterial chemoembolization(TACE)and portal vein embolization(PVE)are associated with long time interval that can allow tumor growth and nullify treatments'benefits.AIM To evaluate the effect of simultaneous TACE and PVE for patients with large hepatocellular carcinoma(HCC)prior to elective major hepatectomy.METHODS Fifty-one patients with large HCC who underwent PVE combined with or without TACE prior to hepatectomy were included in this study,with 13 patients in the simultaneous TACE+PVE group,17 patients in the sequential TACE+PVE group,and 21 patients in the PVE-only group.The outcomes of the procedures were compared and analyzed.RESULTS All patients underwent embolization.The mean interval from embolization to surgery,the kinetic growth rate of the future liver remnant(FLR),the degree of tumor size reduction,and complete tumor necrosis were significantly better in the simultaneous TACE+PVE group than in the other groups.Although the patients in the simultaneous TACE+PVE group had a higher transaminase levels after PVE and TACE,they recovered to comparable levels with the other two groups before surgery.The intraoperative course and the complication and mortality rates were similar among the three groups.The overall survival and disease-free survival were higher in the simultaneous TACE+PVE group than in the other two groups.CONCLUSION Simultaneous TACE and PVE is a safe and effective approach to increase FLR volume for patients with large HCC before major hepatectomy.

A study of portal vein embolization with absolute ethanol injection in cirrhotic rats

AIM To investigate the effects of portal vein embolization (PVE) with absolute ethanol injection on the cirrhotic livers.METHODS Absolute ethanol was injected intraportally into normal and cirrhotic SD rats and the changes of the animals in anatomy, pathology, liver function as well as portal hemodynamics were observed.RESULTS At a dose of 0.05mL/100g of ethanol, the survival rate was 100% in normal rats compared with 40.9% in cirrhotic rats. PVE in the cirrhotic rats with 0.03mL/100g of ethanol, caused significant hypertrophy in non-embolized lobes, mild or moderate damage to the hepatic parenchyma, slight and transient alterations in liver function, portal pressure and portal flow.CONCLUSION PVE with absolute ethanol injection in the setting of liver cirrhosis could be safe at an appropriate dose, and precautions aimed at preserving liver function were preferable.INTRODUCTIONPortal vein embolization (PVE) plays an important role in the management of hepatocellular carcinoma (HCC). We modified the conventional method of transcatheter embolization and developed a new PVE technique with ethanol injection via a fine needle in experimental study[1] and subsequent clinical application under guidance of portoechography[2]. To further elucidate the therapeutic basis of this technique, particularly its effects on the cirrhotic liver, we observed the alterations in liver anatomy, pathology, biochemistry and portal hemodynamics in cirrhotic rats undergoing PVE with ethanol injection.

Embolization of splenorenal shunt associated to portal vein thrombosis and hepatic encephalopathy

Hepatic encephalopathy(HE)is a cognitive disturbance characterized by neuropsychiatric alterations.It occurs in acute and chronic hepatic disease and also in patients with portosystemic shunts.The presence of these portosystemic shunts allows the passage of nitrogenous substances from the intestines through systemic veins without liver depuration.Therefore,the embolization of these shunts has been performed tocontrol HE manifestations,but the presence of portal vein thrombosis is considered a contraindication.In this presentation we show a cirrhotic patient with severe HE and portal vein thrombosis who was submitted to embolization of a large portosystemic shunt.Case report:a 57 years-old cirrhotic patient who had been hospitalized many times for persistent HE and hepatic coma,even without precipitant factors.She had a wide portosystemic shunt and also portal vein thrombosis.The abdominal angiography confirmed the splenorenal shunt and showed other shunts.The larger shunt was embolized through placement of microcoils,and the patient had no recurrence of overt HE.There was a little increase of esophageal and gastric varices,but no endoscopic treatment was needed.Since portosystemic shunts are frequent causes of recurrent HE in cirrhotic patients,portal vein thrombosis should be considered a relative contraindication to perform a shunt embolization.However,in particular cases with many shunts and severe HE,we found that one of these shunts can be safely embolized and this procedure can be sufficient to obtain a good HE recovery.In conclusion,we reported a case of persistent HE due to a wide portosystemic shunt associated with portal vein thrombosis.As the patient had other shunts,she was successfully treated by embolization of the larger shunt.

Treatment of gastric varices with partial splenic embolization in a patient with portal vein thrombosis and a myeloproliferative disorder

Therapeutic options for gastric variceal bleeding in the presence of extensive portal vein thrombosis associated with a myeloproliferative disorder are limited.We report a case of a young woman who presented with gastric variceal bleeding secondary to extensive splanchnic venous thrombosis due to a Janus kinase 2 mutation associated myeloproliferative disorder that was managed effectively with partial splenic embolization.

Portal vein embolization for induction of selective hepatic hypertrophy prior to major hepatectomy: rationale,techniques, outcomes and future directions

The ability to modulate the future liver remnant(FLR) is a key component of modern oncologic hepatobiliary surgery practice and has extended surgical candidacy for patients who may have been previously thought unable to survive liver resection. Multiple techniques have been developed to augment the FLR including portal vein embolization(PVE), associating liver partition and portal vein ligation(ALPPS), and the recently reported transhepatic liver venous deprivation(LVD). PVE is a well-established means to improve the safety of liver resection by redirecting blood flow to the FLR in an effort to selectively hypertrophy and ultimately improve functional reserve of the FLR. This article discusses the current practice of PVE with focus on summarizing the large number of published reports from which outcomes based practices have been developed. Both technical aspects of PVE including volumetry, approaches, and embolization agents; and clinical aspects of PVE including data supporting indications, and its role in conjunction with chemotherapy and transarterial embolization will be highlighted. PVE remains an important aspect of oncologic care; in large part due to the substantial foundation of information available demonstrating its clear clinical benefit for hepatic resection candidates with small anticipated FLRs.