Portal vein embolization and
colorectal liver metastases
Eric Vibert, MD, PhD
Centre Hépato-Biliaire
Plan
• Why we perform Portal Vein Occlusion ?
• How we perform Portal Vein Occlusion ?
• What are the consequences of PVE ...
To avoid post-operative liver failure
< 20% of standard liver volume or 0.5% body weight
Liver SP Liver SP
Truant et al. J...
No liver resection with a liver remnant volume < 0.5% of body weight ratio
2011
MHV
RHV
Vcongestion
NCLR : 29%
NCLR : 20%
Vascular reconstruction
Mise et al. BJS 2011
The middle hepatic vein is between
the right and the left liver…
Be careful to liver resection that cut middle hepatic vei...
?
Pas de veine hépatique inf. droite
Foie gauche = 0,5%
Interhepatic vein anastomoses
e flow
Post-hepatectomy liver failure
At D3 et/ou D5 : Bilirubine > 50 µMol/L and TP < 50%  50 à 63% of 1 month mortality
50
J5
...
2011
Gp A
Gp B
Gp C
Post-operative liver failure is the
consequence of macroscopic and
microscopic liver « desorganization »
Difference between fulminant
hepatitis and major hepatectomy
Fulminant hepatitis Major hepatectomy
« The liver is not a Brocoli, it is 2 Brocolis »
INFLOW OUTFLOW
Sano et al,, Ann Surg 2002
The liver function is related to vascular
surface between hepatocytes / sinusoids
Hoelme et al. PNAS 2010
Day 0 Day 4
Hepatocytes
proliferation
Endothelial
proliferation
Before hepatectomy
Day 0 to Day 4 / major hepatectomy
Hepatocytes multiplication +++
Œdema Increase of portal pressure
De...
Patients and Methods
Portal Vein Pressure measurement
• When? 30 min to 1 hour after liver transection just
before abdomin...
There is a correlation of PVP
with liver failure and 90-day mortality
YesNo
PosthepatectomyPVP(mmHg)
22.5 mmHg
15 mmHg
P <...
Optimal cutoff of PVP for
each liver failure definition
« 50-50 » criteria Peak of serum
bilirubin > 7 mg/dL
ISGLS grade 3...
Incidence of POLF after
hepatectomy for CRLM
Auteur Date Période Hépatectomie Mortalité po Hep.Maj Ins.Hep Ins.Hep/Maj.
N....
96
10
26
11
4
0
0
20
40
60
80
100
120
Grade 0 Grade 1 Grade 2 Grade 3 Grade 4 Grade 5
34
6
22
14
7
2
0
5
10
15
20
25
30
35...
Maj + Min Mineure (<3 seg) Majeure (>2 seg) p
N=232 N=147 N=85
N(%) or Moy±SD N(%) or Moy±SD N(%) or Moy±SD
Insuff. hép. p...
Toutes Hépatectomies
(N=232)
Hépatectomies majeures
(N=85)
RR (95% CI) p RR (95% CI) p
PO. Liver Failure 3,84 (1,01 – 14,4...
C.H.B
J Am Coll Surg 1995; 181
C.H.B
Portal Puncture Under US Controle
Left Portal Branch
C.H.B
Right Portal Vein Embolization
C.H.B
Anatomical Hepatectomy after Fonctional Hepatectomy
2007
1 weeks
PVE allows to operate patient with finally the same overall result
2000
P=0.004
1995
2001
2009
2012
87 pts with PVE and chemotherapy to be operated
47 Slow responders : > 12 cycles of chemo.
40 Fast responders : < 12 cycle...
PVE and chemo…
2008
Injection de cellule tumorale en intra splénique ou systémique et procédure à J7
In the liver
In the chest
Subcapsular hepatoma in rat then
laparotomy, hep 30% or hep 60%
Evolution of the tumor ?
PV Ligation + In situ Splitting
« ALPPS » for Associated Liver Partition and Portal ligation for Staged hepatectomy
+ 72% ...
The Solution to prevent small remnant liver ?
Or a dangerous method to explore with caution ?
Conclusion
• Portal vein embolization allows to decrease to the risk of
po. Liver failure after major hepatectomy for colo...
The future… Removable Adjustable
Vascular Ring around the portal vein
Portal Vein Embolization and colorectal liver met
Portal Vein Embolization and colorectal liver met
Portal Vein Embolization and colorectal liver met
Portal Vein Embolization and colorectal liver met
of 48

Portal Vein Embolization and colorectal liver met

Hepato Biliary Surgery Conference
Published on: Mar 4, 2016
Published in: Science      
Source: www.slideshare.net


Transcripts - Portal Vein Embolization and colorectal liver met

  • 1. Portal vein embolization and colorectal liver metastases Eric Vibert, MD, PhD Centre Hépato-Biliaire
  • 2. Plan • Why we perform Portal Vein Occlusion ? • How we perform Portal Vein Occlusion ? • What are the consequences of PVE on – Fonction ? – Volume ? – Histology of the liver ? – Tumor ? • Alternative to PVE ?
  • 3. To avoid post-operative liver failure < 20% of standard liver volume or 0.5% body weight Liver SP Liver SP Truant et al. JACS 2008Ribeiro, Vauthey et al. BJS 2007
  • 4. No liver resection with a liver remnant volume < 0.5% of body weight ratio
  • 5. 2011
  • 6. MHV RHV Vcongestion NCLR : 29% NCLR : 20% Vascular reconstruction Mise et al. BJS 2011
  • 7. The middle hepatic vein is between the right and the left liver… Be careful to liver resection that cut middle hepatic vein « Morphological » Vol. ≠ « Functional » Vol. Tanaka et al. Surgery 2010
  • 8. ? Pas de veine hépatique inf. droite Foie gauche = 0,5%
  • 9. Interhepatic vein anastomoses e flow
  • 10. Post-hepatectomy liver failure At D3 et/ou D5 : Bilirubine > 50 µMol/L and TP < 50%  50 à 63% of 1 month mortality 50 J5 De J1 et J90 : Bilirubine > 120 µMol/L  70% of 3 month mortality Balzan…Belghit et al. Ann Surg 2005 Paugam…Belghit et al. Ann Surg 2009 Mullen…Vauthey et al. JACS 2007 And /Or n=1057 majors hepatectomies in non cirrhotic liver n=870 then n=436 hepatectomies
  • 11. 2011 Gp A Gp B Gp C
  • 12. Post-operative liver failure is the consequence of macroscopic and microscopic liver « desorganization »
  • 13. Difference between fulminant hepatitis and major hepatectomy Fulminant hepatitis Major hepatectomy
  • 14. « The liver is not a Brocoli, it is 2 Brocolis » INFLOW OUTFLOW Sano et al,, Ann Surg 2002
  • 15. The liver function is related to vascular surface between hepatocytes / sinusoids Hoelme et al. PNAS 2010
  • 16. Day 0 Day 4 Hepatocytes proliferation Endothelial proliferation
  • 17. Before hepatectomy Day 0 to Day 4 / major hepatectomy Hepatocytes multiplication +++ Œdema Increase of portal pressure Decrease of exchange surface between endoth. cell and hepatocytes  Poor liver function After Day 4 / major hepatectomy Improve of « liver permeability » Endothelial prolifération +++ Enlargment of surface exchange between LSEC and Hep.  Function PV CLVHepatocytes Endothelial Cell Biliary cell
  • 18. Patients and Methods Portal Vein Pressure measurement • When? 30 min to 1 hour after liver transection just before abdominal closure • How? Transducer connected to a 25 gauge needle inserted into the portal trunk
  • 19. There is a correlation of PVP with liver failure and 90-day mortality YesNo PosthepatectomyPVP(mmHg) 22.5 mmHg 15 mmHg P < 0.001 Liver failure « 50-50 » criteria 90-day mortality YesNo 15 mmHg 19 mmHg P = 0.01
  • 20. Optimal cutoff of PVP for each liver failure definition « 50-50 » criteria Peak of serum bilirubin > 7 mg/dL ISGLS grade 3 definition 22 mmHg 22 mmHg21 mmHg
  • 21. Incidence of POLF after hepatectomy for CRLM Auteur Date Période Hépatectomie Mortalité po Hep.Maj Ins.Hep Ins.Hep/Maj. N. % N. % % Figueras et al. 2001 1991-2000 256 4,0 145 0,8 1,4 Tamandl et al. 2007 2001-2004 276 0,0 27 0,7 7,4 Finch et al. 2007 1993-2003 484 3,5 349 0,4 0,6 Gold 2008 1992-2003 443 2,9 380 0,5 0,5 Mehta 2008 2003-2005 173 4,0 127 1,2 1,6 Welsh et al. 2008 1987-2005 911 1,5 0,2 Kesmodel 2008 2004-2006 125 1,6 (3 mois) 77 1,6 2,6 Konopke 2009 1993-2008 107 0,9 49 1,9 4,1 Ferrero 2010 2002-2004 80 0,0 39 2,5 5,1 Schiesser 2008 1992-2005 197 2,5 126 1,0 1,6 Karanjia et al. 2008 1996-2006 283 2,1 151 0,7 1,3 2,1% 1% 2,6%
  • 22. 96 10 26 11 4 0 0 20 40 60 80 100 120 Grade 0 Grade 1 Grade 2 Grade 3 Grade 4 Grade 5 34 6 22 14 7 2 0 5 10 15 20 25 30 35 40 Grade 0 Grade 1 Grade 2 Grade 3 Grade 4 Grade 5 147 Hépatectomies mineures 85 Hépatectomies majeures 32% Gr 1-2 27% Gr 3-4-5 24% Gr 1-2 11% Gr 3-4-5 Morbidité 33%  Mortalité 0% Morbidité 59%  Mortalité 2% Morbidité grave Morbidité grave
  • 23. Maj + Min Mineure (<3 seg) Majeure (>2 seg) p N=232 N=147 N=85 N(%) or Moy±SD N(%) or Moy±SD N(%) or Moy±SD Insuff. hép. post hep. 7 (3%) 1 (0,8%) 6 (7%) 0,002 Fistule Biliaire 19 (8) 11 (7) 8 (9) 0,04 Ascite 17 (7) 3 (2) 14 (16) 0,0001 Pneumopathie 15 (6) 9 (6) 6 (6) 0,77 Confusion mentale 14 (6) 4 (3) 10 (11) 0,005 Infection urinaire 12 (5) 6 (4) 6 (7) 0,32 Collection péri-hépatique infecté 9 (4) 2 (1) 7 (8) 0,009 Hémorragie 6 (2) 3 (2) 3 (3) 0,49 Thrombose portale 2 (1) 0 2 (2) 0,06 Hospit. en Réanimation (jours) 2,3±3,3 1,8±2,3 3,1±4,5 0,007 Hospitalisation globale (jours) 13,3±24 12,3±30,4 14,2±8,7 0,58
  • 24. Toutes Hépatectomies (N=232) Hépatectomies majeures (N=85) RR (95% CI) p RR (95% CI) p PO. Liver Failure 3,84 (1,01 – 14,4) 0,04 4,14 (1,29 – 14,8) 0,01 Mental Confusion 3,11 (1,37 – 7,14) 0,006 3,66 (1,18 – 12,5) 0,02 Infected Collection 2,87 (1,24 – 6,62) 0,01 - Intraop Transf. 2,27 (1,21 – 4,09) 0,009 - 1er pronostic factor of long term mortality after hep. for colorectal liver met. PO. Liver FailureSuivi moy. > 36 mois
  • 25. C.H.B J Am Coll Surg 1995; 181
  • 26. C.H.B Portal Puncture Under US Controle Left Portal Branch
  • 27. C.H.B Right Portal Vein Embolization
  • 28. C.H.B Anatomical Hepatectomy after Fonctional Hepatectomy
  • 29. 2007
  • 30. 1 weeks
  • 31. PVE allows to operate patient with finally the same overall result 2000
  • 32. P=0.004
  • 33. 1995
  • 34. 2001
  • 35. 2009
  • 36. 2012
  • 37. 87 pts with PVE and chemotherapy to be operated 47 Slow responders : > 12 cycles of chemo. 40 Fast responders : < 12 cycles of chemo. 2012
  • 38. PVE and chemo… 2008
  • 39. Injection de cellule tumorale en intra splénique ou systémique et procédure à J7 In the liver In the chest
  • 40. Subcapsular hepatoma in rat then laparotomy, hep 30% or hep 60% Evolution of the tumor ?
  • 41. PV Ligation + In situ Splitting « ALPPS » for Associated Liver Partition and Portal ligation for Staged hepatectomy + 72% in 9 days… N=25 2012 To win time and volume….
  • 42. The Solution to prevent small remnant liver ? Or a dangerous method to explore with caution ?
  • 43. Conclusion • Portal vein embolization allows to decrease to the risk of po. Liver failure after major hepatectomy for colorectal liver metastasis • Portal vein embolization increases the growth of colorectal liver metastases – Short term period between PVE / Hepatectomy – PVE and chemotherapy • Alternative to PVE must be explored… – Major hepactomy seems did not increased malignancy – Portal flow modulation to prevent po. Failure with PVE
  • 44. The future… Removable Adjustable Vascular Ring around the portal vein

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