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Preoperative Portal Vein Embolization for Major Liver Resection: A Meta-Analysis

Abulkhir, Adel MD*; Limongelli, Paolo MD*; Healey, Andrew J. BSc(Hons), MRCSEd*; Damrah, Osama MD, FACS*; Tait, Paul ChM, FRCR; Jackson, James FRCR; Habib, Nagy ChM, FRCS*; Jiao, Long R. MD, FRCS*

doi: 10.1097/SLA.0b013e31815f6e5b

Introduction: Preoperative portal vein embolization (PVE) is used clinically to prevent postoperative liver insufficiency. The current study examined the impact of portal vein embolization on liver resection.

Method: A comprehensive Medline search to identify all registered literature in the English language on portal vein embolization. Meta-analysis was performed to assess the result of PVE and its impact on major liver resection.

Result: A total of 75 publications met the search criteria but only 37 provided data sufficiently enough for analysis involving 1088 patients. The overall morbidity rate for PVE was 2.2% without mortality. Four weeks following PVE, 85% patients underwent the planned hepatectomy (n = 930). Twenty-three patients had transient liver failure following resection after PVE (2.5%) but 7 patients developed acute liver failure and died (0.8%).

The reason for nonresection following PVE (n = 158, 15%) included inadequate hypertrophy of remnant liver (n = 18), severe progression of liver metastasis (n = 43), extrahepatic spread (n = 35), refusal to surgery (n = 1), poor general condition (n = 1), altered treatment to transcatheter artery embolization or chemotherapy (n = 24), complete remission after treatment with 3 cycles of fluoracil and interferon α in a patient with hepatocellular carcinoma (n = 1), incomplete pre- or postembolization scanning (n = 8). Of those who underwent laparotomy without resection, (n = 27) reasons included intraoperative finding of peritoneal dissemination (n = 15), portal node metastasis (n = 2), severe invasion of the tumor to the hepatic artery and portal vein (n = 1), and gross tumoral extension precluding curative resection (n = 9).

Two techniques were used for portal vein embolization: percutaneous transhepatic portal embolization, (PTPE) and transileocolic portal embolization, (TIPE). The increase in remnant liver volume was much greater in PTPE than TIPE group (11.9% vs. 9.7%; P = 0.00001). However, the proportion of patients who underwent resection following PVE was 97% in TIPE and 88% PTPE, respectively (P = <0.00001). Although there was no significant difference in patients who had major complications post-PVE, the rate for minor complications was significantly higher among patients who had PTPE (53.6% vs. 0%, P = <0.0001).

Conclusion: PVE is a safe and effective procedure in inducing liver hypertrophy to prevent postresection liver failure due to insufficient liver remnant.

The principle of portal vein embolization to increase the size of the contralateral lobe has been recognized for years. It has been used as a procedure to reduce the risk of postoperative liver insufficiency after major liver resection. This is a meta-analysis using publications between 1990 and 2005 to assess the impact of portal vein embolization on liver surgery worldwide.

From the *HPB Surgery, Division of Surgery, Oncology, Reproductive Biology and Anaesthetics, Imperial College of Science, Technology and Medicine, Hammersmith Hospital Campus, London, England; and †Department of Radiology, Hammersmith Hospital, London, England.

Reprints: Mr. L. R. Jiao, MD, FRCS, HPB Surgery, Hammersmith Hospital, Du Cane Road, London W12 0NN. Email:

© 2008 Lippincott Williams & Wilkins, Inc.