What is the clinical benefit of portal vein embolization before extended hepatectomy for biliary cancer?

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Abstract

BACKGROUND

The clinical impact of performing portal vein embolization (PVE) before extended hepatectomy in patients with biliary cancer is not well documented because of a lack of surgical cases.

OBJECTIVES

To evaluate the clinical impact of PVE before extended complex hepatectomy in patients with biliary cancer.

DESIGN AND INTERVENTION

This study included 240 consecutive patients with biliary cancer who were due to undergo extended hepatectomy. PVE was performed 2-3 weeks before hepatectomy in all patients who were expected to have a remnant liver volume <40% of total liver volume postsurgery. Patients with jaundice underwent percutaneous hepatic biliary drainage, and serum bilirubin levels had to be ≤5 mg/dl before PVE could be performed. Liver volume was calculated by CT imaging ≤3 weeks after PVE. Measurements taken to assess liver function included total serum bilirubin, aspartate transaminase, and alanine transaminase levels, and the plasma disappearance rate of indocyanine green (KICG), 1-3 days before and 11-13 days after PVE. Data were compared with those from a control group of patients with cholangiocarcinoma and a remnant liver volume of >50% without PVE.

OUTCOME MEASURES

The primary outcome measure was survival. Secondary outcome measures included the rate of postoperative complications.

RESULTS

In total, 240 consecutive patients (mean age 63±11 years [range 35-83 years]) with biliary cancer (150 with cholangiocarcinoma; 90 with gallbladder cancer) were enrolled. Of these, 193 underwent hepatectomy. The rate of unresectable cancer was higher in patients with gallbladder cancer than in patients with cholangiocarcinoma (32.2% versus 12.0%; P<0.005). Overall, 17 patients (8.8%) died from complications after hepatectomy. The postsurgery mortality rate was higher in patients with gallbladder cancer than in patients with cholangiocarcinoma (18.0% versus 4.5%; P<0.05). More patients with a future liver remnant KICG of <0.05 after PVE died postsurgery, compared with those with a future liver remnant KICG of ≥0.05 after PVE (28.6% versus 5.5%; P<0.001). The volume of the nonembolized lobe increased significantly after PVE from 361±119 cm3 (range 103-700 cm3) to 460±120 cm3 (range 239-747 cm3) (P<0.0001). The volume of the embolized lobe significantly decreased after PVE from 688±167 cm3 (range 341-1,172 cm3) to 581±149 cm3 (range 261-1,009 cm3) (P<0.0001). The rates of hypertrophy and atrophy in PVE-treated patients were 1.33-fold±0.24-fold (range 1.00-fold to 2.22-fold) and 0.85-fold±0.11-fold (range 0.55-fold to 1.15-fold) those at baseline, respectively. The 3-year and 5-year survival rates posthepatectomy were 41.7% and 26.8% in patients with cholangiocarcinoma, and 23.5% and 17.1% in patients with gallbladder cancer, respectively (P = 0.011). The mortality rate of patients with cholangiocarcinoma undergoing PVE before surgery was similar to that of patients who did not undergo PVE (4.5% versus 3.7%, respectively).

CONCLUSIONS

PVE is beneficial for patients with advanced biliary cancer who are about to undergo extended, complex hepatectomy.

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