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Volume Regeneration of Segment 2+3 After Right Portal Vein Embolization in Patients Undergoing 2-Stage Hepatectomy
Yoshihiro Mise*, Thomas Aloia, Claudius Conrad, Steven Y. Huang, Michael J. Wallace, Jean-Nicolas Vauthey
MD Anderson cancer centor, Houston, TX
Background: Two-stage hepatectomy can offer a favorable prognosis in patients with advanced bilateral colorectal liver metastases. Right portal vein embolization (RPVE) following first-stage resection plays an important role in completing 2-stage hepatectomy by inducing hypertrophy of the left liver in patients with insufficient future liver remnant. The impact of first-stage resection on volume regeneration of segment 2+3 after RPVE has not been investigated.
Method: Volume data for segments 2 and 3 were compared between 45 patients undergoing 2-stage hepatectomy for colorectal liver metastases and 111 patients undergoing planned single-stage hepatectomy for colorectal liver metastases after RPVE or RPVE and embolization of segment 4 (RPVE+4). In patients undergoing 2-stage hepatectomy, baseline volume was calculated using images obtained after the first-stage resection.
Results: Baseline volume of segments 2 and 3 did not differ between the 2 groups. However, degree of hypertrophy (difference between standardized volume of segments 2 and 3 before and after RPVE) was significantly lower in patients undergoing 2-stage hepatectomy (median 6.8% vs 8.3%, p=0.03). Kinetic growth rate, defined as the degree of hypertrophy at initial volume assessment divided by the number of weeks elapsed after RPVE, was also significantly lower in the 2-stage hepatectomy group (1.4% vs 2.0%, p<0.001). Multivariate analysis of 156 patients revealed that independent predictors of lower degree of hypertrophy were sinusoidal injury (HR: 2.72, CI: 1.22-5.40, p=0.02), lack of segment 4 embolization (HR: 2.40, CI: 1.60-3.60, p<0.01), body surface area >2.0 m2(HR: 1.94, CI: 1.32-2.89, p<0.01), and 2-stage hepatectomy (HR: 1.81, CI: 1.21-2.67, p<0.01). In patients undergoing 2-stage hepatectomy after RPVE+4, degree of hypertrophy and kinetic growth rate were similar to those in patients undergoing single-stage hepatectomy (p=0.19 and p=0.07, respectively; Figure).
Conclusion: The first-stage resection impairs volume regeneration of segments 2 and 3 after RPVE in patients undergoing 2-stage hepatectomy. When 2-stage extended right hepatectomy is planned, additional embolization of segment 4 is needed to obtain volume hypertrophy similar to that in patients undergoing single-stage hepatectomy.
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