Vyas Soumil, Markar Sheraz, Partelli Stefano, Fotheringham Tim, Low Deborah, Imber Charles, Malago Massimo, Kocher Hemant M
Hepato-biliary and Pancreatic Surgery Unit, Royal Free Hospital, London, UK ; HPB and Liver Transplant Unit, Royal Free Hospital, Pond Street, London, NW3 2QG UK.
Hepato-biliary and Pancreatic Surgery Unit, Royal Free Hospital, London, UK.
Indian J Surg Oncol. 2014 Mar;5(1):30-42. doi: 10.1007/s13193-013-0279-y. Epub 2014 Jan 6.
Portal vein occlusion through embolization or ligation (PVE, PVL) offers the possibility of increasing the future liver remnant (FLR) and thus reducing the risk of hepatic failure after extended hepatectomy We reviewed the indications, scope and applicability of PVE/PVL in treatment of primary and secondary liver tumours. A thorough PubMED, Embase, Ovid and Cochrane database search was carried out for all original articles with 30 patients or more undergoing either PVE and any patient series with PVL, irrespective of number with outcome measure in at least one of the following parameters: FLR volume change, complications, length of stay, time to surgery, proportion resectable and survival data. PVE can be performed with a technical success in 98.9 % (95 % confidence interval 97-100) patients, with a mean morbidity of 3.13 % (95 % CI 1.21-5.04) and a median in-hospital stay of 2.1 (range 1-4) days (very few papers had data on length of stay following PVE). The mean increase in volume of the FLR following PVE was 39.75 % (95 % CI 30.8-48.6) facilitating extended liver resection after a mean of 37.13 days (95 % CI 28.51-45.74) with a resectability rate of 76.88 % (95 % CI 70.91-82.84). Morbidity and mortality following such extended liver resections after PVE is 26.58 % (95 % CI 19.20-33.95) and 2.59 % (95 % CI 1.34-3.83) respectively with an in-patient stay of 13.57 days (95 % CI 9.8-17.37). However following post-PVE liver hypertrophy 6.29 % (95 % CI 2.24-10.34) patients still have post-resection liver failure and up to 14.2 % (95 % CI -8.7 to 37) may have positive resection margins. Up to 4.80 % (95 % CI 2.07-7.52) have failure of hypertrophy after PVE and 17.46 % (95 % CI 11.89-23.02) may have disease progression during the interim awaiting hypertrophy and subsequent resection. PVL has a greater morbidity and duration of stay of 5.72 % (95 % CI 0-15.28) and 10.16 days (95 % CI 6.63-13.69) respectively; as compared to PVE. Duration to surgery following PVL was greater at 53.6 days (95 % CI 32.14-75.05). PVL induced FLR hypertrophy by a mean of 64.65 % (95 % CI 0-136.12) giving a resectability rate of 63.68 % (95 % CI 56.82-70.54). PVL failed to produce enough liver hypertrophy in 7.4 % of patients (95 % CI 0-16.12). Progression of disease following PVL was 29.29 (95%CI 15.69-42.88). PVE facilitates an extended hepatectomy in patients with limited or inadequate FLR, with good short and long-term outcomes. Patients need to be adequately counselled and consented for PVE and EH in light of these data. PVL would promote hypertrophy as well, but clearly PVE has advantages as compared to PVL on account of its inherent "minimally invasive" nature, fewer complications, length of stay and its feasibility to have shorter times to surgery.
通过栓塞或结扎实现门静脉闭塞（PVE，PVL）为增加未来肝残余量（FLR）从而降低扩大肝切除术后肝衰竭风险提供了可能。我们回顾了PVE/PVL在原发性和继发性肝肿瘤治疗中的适应证、范围及适用性。对PubMed、Embase、Ovid和Cochrane数据库进行了全面检索，纳入所有有30例及以上患者接受PVE的原始文章以及任何PVL患者系列，无论数量多少，且至少有以下参数之一的结局指标：FLR体积变化、并发症、住院时间、手术时间、可切除比例及生存数据。PVE技术成功率可达98.9%（95%置信区间97 - 100），平均发病率为3.13%（95% CI 1.21 - 5.04），中位住院时间为2.1天（范围1 - 4天）（关于PVE后住院时间的数据文章很少）。PVE后FLR平均体积增加39.75%（95% CI 30.8 - 48.6），平均37.13天后（95% CI 28.51 - 45.74）有利于进行扩大肝切除，可切除率为76.88%（95% CI 70.91 - 82.84）。PVE后进行此类扩大肝切除术后的发病率和死亡率分别为26.58%（95% CI 19.20 - 33.95）和2.59%（95% CI 1.34 - 3.83），住院时间为13.57天（95% CI 9.8 - 17.37）。然而，PVE后肝肥大的患者中6.29%（95% CI 2.24 - 10.34）仍会出现切除后肝衰竭，高达14.2%（95% CI - 8.7至37）可能有阳性切缘。PVE后高达4.80%（95% CI 2.07 - 7.52）出现肥大失败，17.46%（95% CI 11.89 - 23.02）可能在等待肥大及后续切除的期间出现疾病进展。PVL的发病率更高，为5.72%（95% CI 0 - 15.28），住院时间更长，为10.16天（95% CI 6.63 - 13.69）；与PVE相比。PVL后的手术时间更长，为53.6天（95% CI 32.14 - 75.05）。PVL使FLR平均肥大64.65%（95% CI 0 - 136.12），可切除率为63.68%（95% CI 56.82 - 70.54）。7.4%的患者（95% CI 0 - 16.12）PVL未能产生足够的肝肥大。PVL后疾病进展率为29.29（95% CI 15.69 - 42.88）。PVE有助于为FLR有限或不足的患者进行扩大肝切除，具有良好的短期和长期结局。鉴于这些数据，需要对患者进行充分的咨询并取得其对PVE和扩大肝切除的同意。PVL也会促进肥大，但显然PVE因其固有的“微创”性质、更少的并发症、住院时间以及更短的手术等待时间等优势，相比PVL更具优势。
