Journal Article

Effect of structured use of preoperative portal vein embolization on outcomes after liver resection of perihilar cholangiocarcinoma

Gulik, T. M., Rassam, F., Bennink, R. J., Erdmann, J. I., van Lienden, K. P., Olthof, P. B., Besselink, M. G., Busch, O. R., Franken, L. C.

2020

Overview

Background Portal vein embolization (PVE) is performed to reduce the risk of liver failure and subsequent mortality after major liver resection. Although a cut‐off value of 2·7 per cent per min per m2 has been used with hepatobiliary scintigraphy (HBS) for future remnant liver function (FRLF), patients with perihilar cholangiocarcinoma (PHC) potentially benefit from an additional cut‐off of 8·5 per cent/min (not corrected for body surface area). Since January 2016 a more liberal approach to PVE has been adopted, including this additional cut‐off for HBS of 8·5 per cent/min. The aim of this study was to assess the effect of this approach on liver failure and mortality. Methods This was a single‐centre retrospective study in which consecutive patients undergoing liver resection under suspicion of PHC in 2000–2015 were compared with patients treated in 2016–2019, after implementation of the more liberal approach. Primary outcomes were postoperative liver failure (International Study Group of Liver Surgery grade B/C) and 90‐day mortality. Results Some 191 patients with PHC underwent liver resection. PVE was performed in 6·4 per cent (9 of 141) of the patients treated in 2000–2015 and in 32 per cent (16 of 50) of those treated in 2016–2019. The 90‐day mortality rate decreased from 16·3 per cent (23 of 141) to 2 per cent (1 of 50) (P = 0·009), together with a decrease in the rate of liver failure from 19·9 per cent (28 of 141) to 4 per cent (2 of 50) (P = 0·008). In 2016–2019, 24 patients had a FRLF greater than 8·5 per cent/min and no liver failure or death occurred, suggesting that 8·5 per cent/min is a reliable cut‐off for patients with suspected PHC. Conclusion The major decrease in liver failure and mortality rates in recent years and the simultaneous increased use of PVE suggests an important role for PVE in reducing adverse outcomes after surgery for PHC. Antecedentes La embolización de la vena porta (portal vein embolization, PVE) se realiza para reducir el riesgo de insuficiencia hepática y de mortalidad asociada después de una resección hepática mayor. Aunque con la gammagrafía hepato‐biliar (hepato‐biliary scintigraphy, HBS) se ha utilizado un punto de corte de 2,7%/min/m2 para la función hepática remanente futura (future remnant liver function, FRLF), los pacientes con colangiocarcinoma perihilar (perihilar cholangiocarcinoma, PHC) se beneficiarían potencialmente de un punto de corte adicional de 8,5%/min (no corregido para el área de superficie corporal). Desde enero de 2016, se adoptó un enfoque más liberal para la PVE, incluyendo este punto de corte adicional para la HBS de 8,5%/min. El objetivo de este estudio fue evaluar el efecto de este enfoque sobre la insuficiencia hepática y la mortalidad. Métodos Se trata de un estudio retrospectivo de un solo centro, en el que los pacientes consecutivos sometidos a resección hepática por sospecha de PHC entre 2000‐2016 se compararon con los pacientes tratados entre 2016‐2019, después de la implementación de un enfoque más liberal. Los objetivos primarios fueron la insuficiencia hepática postoperatoria (ISGLS grado B/C) y la mortalidad a los 90 días. Resultados Un total de 191 pacientes con PHC se sometieron a resección hepática. Se realizó PVE en el 6% (9/141) de los pacientes antes de 2016 y en el 32% (16/50) de los pacientes después de 2016. La mortalidad disminuyó del 16% (23/141) al 2% (1/50) (P = 0,009), junto con una disminución de la insuficiencia hepática del 20% (28/141) al 4% (2/50) (P = 0,008). Después de 2016, 20 pacientes tuvieron un FRLF > 8,5%/min y no se produjo insuficiencia hepática o mortalidad, lo que sugiere que el 8,5%/min es un punto de corte fiable para los pacientes con sospecha de PHC. Conclusión La disminución marcada de la insuficiencia hepática y de la mortalidad en los últimos años y el aumento simultáneo del uso de la PVE, sugiere que la PVE ha jugado un importante papel en el descenso de los resultados adversos después de la cirugía para el PHC. The use of portal vein embolization (PVE) in patients undergoing major liver resection for perihilar cholangiocarcinoma at the authors' centre increased from 6·4 per cent in 2000–2015 to 32 per cent in 2016–2019. This increased use of PVE coincided with a major decrease in the postoperative liver failure rate, from 19·9 to 4 per cent, and a decrease in the 90‐day mortality rate, from 16·3 to 2 per cent. Using hepatobiliary scintigraphy, an additional cut‐off for future remnant liver function of 8·5 per cent/min (not corrected for body surface area) correlated with safe liver resection in patients with suspected perihilar cholangiocarcinoma. Portal vein embolization decreases rates of liver failure and mortality

• Publisher: John Wiley & Sons, Ltd,Oxford University Press
• Subject: Cholangiocarcinoma / Embolization / Endoscopy / Hepatectomy / HPB / Liver / Liver failure / Mortality / Original / Patients / Postoperative period / Surgery / Values