Preoperative portal vein embolization: the technical and clinical considerations / 介入放射学杂志

Preoperative portal vein embolization(PVE)has become an important tool in the management of selected patients with hepatic cancer before the major hepatic resection is carried out.PVE can redirect the portal flow to the intended future remnant liver tissue in order to induce the hypertrophy of the non-diseased portion of the liver and thereby may reduce the occurrence of complications and shorten the hospitalization days after surgery.This article aims to review the technical and clinical considerations in performing PVE and to discuss the PVE-related practical points,including the relevant anatomy,the access approach,the choosing of embolic agents and the pathophysioiogy of PVE.In addition,the indications and contraindications for performing PVE,the use of combination therapies and the concern for tumor growth after PVE are also discussed.

Saftey and Long-term Outcome following Major Hepatectomy for Hepatocellular Carcinoma Combined with Compensated Liver Cirrhosis

PURPOSE: Hepatic resection has been considered as the standard treatment method for hepatocellular carcinoma, but the majority of patients have underlying liver cirrhosis that limits the extent of hepatic resection. However, the saftey and long-term results of major hepatic resection for the HCC patient with compensated cirrhosis has not yet been fully evaluated. So, we conducted this study to evaluate the perioperative outcomes and long-term survival following major hepatic resection for hepatocelluar carcinoma (HCC) in the patients with compensated cirrhosis. METHODS: We carried out retrospective analysis on the clinicopathological data of 132 HCC patients with histologically proven liver cirrhosis who underwent hepatic resection for HCC from Sep 1987 to Aug 2003. Among them, 49 HCC patients received major hepatic resection (group A). The perioperative outcomes and long-term survival of group A were compared with those of 83 patients who underwent minor hepatic resection (group B). RESULTS: Group A had significantly better liver function, a wider resection margin, a larger sized tumor, more frequent multiple lesions, and more total and minor complications than group B. However, the two groups showed similar results for the hospital stay, the perioperative blood transfusion and the major complication rate. The only prognostic factor for determining the occurrence of major complication was the transfusion. Both groups did not show statistical differences with regards to 5 year overall and disease free survival rate (67.8% vs 61%, 45.7% vs 35.5%, respectively). CONCLUSION: Major hepatic resection for the hepatocellular carcinoma patient with compensated liver cirrhosis is an effective and safe treatment option with acceptable mortality and major complications rates.

Effectiveness of Continuing Low Central Venous Pressure during Major Hepatic Resection / 한국간담췌외과학회지

BACKGROUND/AIMS: Blood loss and blood transfusion are extremely important determinants of morbidity and mortality following hepatic resection. This is attributed to increased risks of coagulopathy, acute respiratory distress syndrome and multiorgan failure. The hypothesis is that a low pressure in the central veins would be accompanied by a low pressure in the hepatic veins and sinusoids, thereby decreasing blood loss during hepatic resection. This study evaluates the effectiveness of continuing low central venous pressure comparing with high central venous pressure during major hepatic resection. METHODS: 20 consecutive major hepatic resections between March 2000 and August 2000 were studied prospectively concerning central venous pressure which was analysed for 10 cases with a central venous pressure less than 10 mmHg, and greater than or equal to 10 mmHg. The central venous pressure was monitored continuously using a Narkomed Anaesthetic Component Monitoring System (Drager Inc., USA). RESULTS: Low central venous pressure allowed a smaller intraoperative blood loss ( or =10 mmHg: 1770+/-916.5 ml, p or =10 mmHg: 807+/-799.2 ml, p or =10 mmHg: 293.0+/-123.2 IU/L, p or =10 mmHg: 193.2+/-103.5 IU/L, p or =10 mmHg: 8.7+/-1.6 days, p<0.05) in comparison to high central venous pressure. There was no postoperative mortality in both group. CONCLUSIONS: Maintaining a low central venous pressure throughout major hepatic resection reduced blood loss, blood transfusion requirements and enzyme recovery periods. Lowering the central venous pressure is a simple and effective way during hepatic resection.

Prognosis for a Hepatocellular Carcinoma Smaller Than 5 cm in Relation to Hepatic Resection: Major Resection vs Limited Resection

BACKGROUND: A hepatocellular carcinoma (HCC) is an awesome malignancy; survival time is usually less than 1 year once symptoms and signs appear, irrespective of treatment. Screening tools are now available that make it possible to detect a preclinical HCC, which is usually small and surgically resectable. We studied the prognosis after hepatic resections of HCCs smaller than 5 cm and tried to clarify which effective treatments correlated with high survival rates by comparing the outcomes of major hepatic resections with those of limited hepatic resections. METHODS: Of the 105 cases treated from January 1, 1990, to December 31, 1998, at Asan Medical Center, all proved surgically to be small HCCs and pathologically to be HCC types. There were two categories of patients: those receiving a major hepatic resection (n=48) and those receiving a limited hepatic resection (n=57). RESULTS: The median age was 53 (range, 33-69), and the male:female ratio was 42:6 in the major resection group. The median tumor size was 3.4 cm, and the median resection margin was 2.6 cm. Major resections were done in 48 cases, including right lobectomies (32 cases), left lobectomies (9 cases), central bisegmentectomies (3 cases), extended left lobectomies (3 cases) and extended right lobectomy (1 case). The median age was 52 (range, 30-76), and the male:female ratio was 46:11 in the limited resection group. The median tumor size was 3.2 cm, and the median resection margin was 1.2 cm. Limited resections were done in 57 cases, including left lateral segmentectomies (12 cases), right posterior segmentectomies (10 cases), #6 subsegmentectomies (7 cases), left medial segmentectomies (7 cases), right anterior segmentectomies (6 cases), nonanatomical partial hepatectomies (5 cases), #5 #6 subsegmentec-tomies (2 cases), #8 subsegmentectomies (2 cases), caudate lobectomies (2 cases), #5 subsegmentectomies (2 cases), #5 subsegmentectomy caudate lobectomy(1 case), and #2 subsegmentectomy (1 case). The cumulative 5-year survival rate of the two groups was 69%. The cumulative 5-year disease-free survival rate of the major resection group was better than that of the limited resection group (80% vs 53%, p=0.01). CONCLUSIONS: Problems, including the relatively high recurrence rate after a limited hepatic resection, remain to be solved. It is necessary to perform adjuvant therapy to prevent recurrence in patients receiving a limited hepatic resection. We advocate a major hepatic resection for primary small hepatocellular carcinomas in order to prevent recurrence. Preoperative portal vein embolization can be a good modality in patients who will undergo major hepatic resections.