The Role of Endovascular Methods in the Preparation of Patients with Metastatic Liver Tumors to Radical Surgical Treatment
Expanded liver resection is the only treatment offering a chance of long-term survival of patients with metastatic liver cancer. However, it can be performed in only 10 % of patients, because the future remnant liver is too small, risking severe postoperative liver failure. Preoperative portal vein embolization for these patients may to increase remnant liver volume and give them a chance to radical treatment.
Objective: to compare the immediate and long-term results of liver resection group of patients who underwent endovascular intervention as preoperative preparation and patient groups, which preoperative endovascular treatment was not performed. Contralateral or ipsilateral transhepatic portal accesses were applied, polyvinil particles and coils were used for portal branch occlusion.
Materials and Methods. Preoperative portal vein embolization was performed in 71 patients with the estimated residual liver volume less than 30 % of the intact liver parenchyma. The comparison group included 118 patients who were sufficient (> 30 %) residual liver volume and without preoperative endovascular interventions. Liver function tests including total bilirubin, aspartate aminotransferase, alanine aminotransferase and prothrombin time were performed before portal vein embolization, daily for 5 days thereafter, and before surgery. CT scan volumetric measurements were performed before PVE and before surgery.
Results and Discussion. As a preparation for large hepatic resection, preoperative portal embolization was feasible in all patients. There were no significant deaths. Patients prescribed antibiotics in prophylactic doses, analgesics, anti-inflammatory drugs. In all cases after preoperative portal vein embolization residual liver volume increasing in 56.6 ± 14.0 % was observed. It allowed to exclude 68 (95.7 %) patients from high-risk group and perform radical extensive hepatectomy in 63 (88.7 %) patients. The group of patients after endovascular intervention have less clinical and laboratory markers of postoperative liver failure, than in the comparison group. This is explained by the diversity of post-resection major damaging factors — reducing the volume of functioning liver parenchyma and portal hypertension induced reduction of portal perfusion. There was no significant difference in 1-, 3- and 5-year disease-free survival in both groups of patients: 82, 64, 40 % versus 88, 60, 39 %, respectively.
Conclusion. Preoperative portal vein embolization allows more patients with previously unresectable liver tumors to beneﬁt from resection. This approach preserves sufficient functioning liver parenchyma to prevent postoperative liver failure. By removing the contraindication of an insufficient remnant liver, PVE increases the resectability of colorectal liver metastases with a survival beneﬁt comparable to that obtained with primary liver resection. It can be considered a new neoadjuvant modality in the management of hepatic colorectal metastases. Long-term survival is comparable to that after resection without endovascular preparation.
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