Hepatobiliary surgery and nutrition · 2025
When is enough enough?-predicting adequacy of portal vein embolization for hypertrophy of the future liver remnant in the age of liver venous deprivation.
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Haddad Antony, Ayabe Reed I, Newton Andrew D, Maki Harufumi, Lendoire Mateo, Chun Yun Shin, Tzeng Ching-Wei D, Odisio Bruno C, Huang Steven Y, Vauthey Jean-Nicolas, Newhook Timothy E, Tran Cao Hop S
Аннотация
BACKGROUND: Insufficient future liver remnant (FLR) increases the risk of postoperative hepatic insufficiency and death. Liver venous deprivation (LVD) is associated with greater FLR hypertrophy than portal vein embolization (PVE) but may incur additional cost and risk. Our aim was to determine the factors predictive of insufficient FLR hypertrophy after PVE and inform selection for LVD.
METHODS: Consecutive patients who underwent right PVE from January 1998 through December 2020 were identified. Clinicopathologic and treatment-related variables were evaluated for associations with post-PVE standardized FLR (sFLR) ≥30%, kinetic growth rate (KGR) ≥2% per week, or a composite endpoint of sFLR ≥30% or KGR ≥2% per week. In addition, the procedure duration and costs of PVE and LVD were compared in a contemporary cohort [2019-2024].
RESULTS: During 1998-2020, 477 patients underwent PVE. The median (interquartile range) pre-PVE sFLR was 22% (16-29%). Out of 477 patients, 284 (60%) achieved sFLR ≥30%, 271 (57%) achieved KGR ≥2% per week, and 364 (76%) achieved at least one of the two. After PVE, 360 (75%) underwent their planned operation. Multiple logistic regression showed that higher pre-PVE sFLR [odds ratio (OR), 1.4; 95% confidence interval (CI): 1.31-1.49] and extended PVE (OR, 0.47; 95% CI: 0.25-0.87) were predictive of post-PVE sFLR ≥30%. Receiver operating characteristic curve analysis revealed that pre-PVE sFLR >19% was 89% sensitive and 75% specific for post-PVE sFLR ≥30% (area under the curve, 0.914). Conversely, 97% of patients with pre-PVE sFLR >26% achieved sFLR ≥30%. Weight gain after PVE (OR, 0.50; 95% CI: 0.31-0.82), extended PVE (OR, 0.60; 95% CI: 0.40-0.91) and planned staged resection (OR, 0.41; 95% CI: 0.27-0.62) were independently predictive of failure to achieve KGR ≥2% per week. During 2019-2024, 63 patients underwent PVE, and 22 patients underwent LVD. Procedure duration was significantly higher in patients undergoing LVD compared to PVE (median 247 vs. 169 minutes, P<0.001). The average procedural and total costs were 1.22 and 1.44 times greater for LVD, respectively.
CONCLUSIONS: Patients with baseline sFLR <19% and those with baseline sFLR 19-26% and gross liver abnormalities or planned to undergo staged or extended right hepatectomy are unlikely to achieve adequate liver remnant hypertrophy with PVE. LVD may be the preferred approach for these patients as it is known to induce augmented hypertrophy. Healthy weight maintenance should be encouraged after PVE to optimize liver regeneration.
METHODS: Consecutive patients who underwent right PVE from January 1998 through December 2020 were identified. Clinicopathologic and treatment-related variables were evaluated for associations with post-PVE standardized FLR (sFLR) ≥30%, kinetic growth rate (KGR) ≥2% per week, or a composite endpoint of sFLR ≥30% or KGR ≥2% per week. In addition, the procedure duration and costs of PVE and LVD were compared in a contemporary cohort [2019-2024].
RESULTS: During 1998-2020, 477 patients underwent PVE. The median (interquartile range) pre-PVE sFLR was 22% (16-29%). Out of 477 patients, 284 (60%) achieved sFLR ≥30%, 271 (57%) achieved KGR ≥2% per week, and 364 (76%) achieved at least one of the two. After PVE, 360 (75%) underwent their planned operation. Multiple logistic regression showed that higher pre-PVE sFLR [odds ratio (OR), 1.4; 95% confidence interval (CI): 1.31-1.49] and extended PVE (OR, 0.47; 95% CI: 0.25-0.87) were predictive of post-PVE sFLR ≥30%. Receiver operating characteristic curve analysis revealed that pre-PVE sFLR >19% was 89% sensitive and 75% specific for post-PVE sFLR ≥30% (area under the curve, 0.914). Conversely, 97% of patients with pre-PVE sFLR >26% achieved sFLR ≥30%. Weight gain after PVE (OR, 0.50; 95% CI: 0.31-0.82), extended PVE (OR, 0.60; 95% CI: 0.40-0.91) and planned staged resection (OR, 0.41; 95% CI: 0.27-0.62) were independently predictive of failure to achieve KGR ≥2% per week. During 2019-2024, 63 patients underwent PVE, and 22 patients underwent LVD. Procedure duration was significantly higher in patients undergoing LVD compared to PVE (median 247 vs. 169 minutes, P<0.001). The average procedural and total costs were 1.22 and 1.44 times greater for LVD, respectively.
CONCLUSIONS: Patients with baseline sFLR <19% and those with baseline sFLR 19-26% and gross liver abnormalities or planned to undergo staged or extended right hepatectomy are unlikely to achieve adequate liver remnant hypertrophy with PVE. LVD may be the preferred approach for these patients as it is known to induce augmented hypertrophy. Healthy weight maintenance should be encouraged after PVE to optimize liver regeneration.