Asencio José M, García-Sabrido José L, López-Baena José A, Olmedilla Luis, Peligros Isabel, Lozano Pablo, Morales-Taboada Álvaro, Fernández-Mena Carolina, Steiner Miguel A, Sola Emma, Perez-Peña José M, Herrero Miriam, Laso Juan, Lisbona Cristina, Bañares Rafael, Casanova Javier, Vaquero Javier
Servicio de Cirugía General III, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Madrid, Spain; Facultad de Medicina, Univ. Complutense de Madrid, Madrid, Spain.
Servicio de Cirugía General III, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Madrid, Spain; Facultad de Medicina, Univ. Complutense de Madrid, Madrid, Spain.
Surgery. 2017 Jun;161(6):1489-1501. doi: 10.1016/j.surg.2016.12.003. Epub 2017 Jan 20.
Portal vein embolization is performed weeks before extended hepatic resections to increase the future liver remnant and prevent posthepatectomy liver failure. Portal vein embolization performed closer to the operation also could be protective, but worsening of portal hyper-perfusion is a major concern. We determined the hepatic hemodynamic effects of a portal vein embolization performed 24 hours prior to hepatic operation.
An extended (90%) hepatectomy was performed in swine undergoing (portal vein embolization) or not undergoing (control) a portal vein embolization 24 hours earlier (n = 10/group). Blood tests, hepatic and systemic hemodynamics, hepatic function (plasma disappearance rate of indocyanine green), liver histology, and volumetry (computed tomographic scanning) were assessed before and after the hepatectomy. Hepatocyte proliferating cell nuclear antigen expression and hepatic gene expression also were evaluated.
Swine in the control and portal vein embolization groups maintained stable systemic hemodynamics and developed similar increases of portal blood flow (302 ± 72% vs 486 ± 92%, P = .13). Portal pressure drastically increased in Controls (from 9.4 ± 1.3 mm Hg to 20.9 ± 1.4 mm Hg, P < .001), while being markedly attenuated in the portal vein embolization group (from 11.4 ± 1.5 mm Hg to 16.1 ± 1.3 mm Hg, P = .061). The procedure also improved the preservation of the hepatic artery blood flow, liver function, and periportal edema. These effects occurred in the absence of hepatocyte proliferation or hepatic growth and were associated with the induction of the vasoprotective gene Klf2.
Portal vein embolization preconditioning represents a potential hepato-protective strategy for extended hepatic resections. Further preclinical studies should assess its medium-term effects, including survival. Our study also supports the relevance of hepatic hemodynamics as the main pathogenetic factor of post-hepatectomy liver failure.
在扩大肝切除术前数周进行门静脉栓塞，以增加未来肝脏残余量并预防肝切除术后肝衰竭。在更接近手术时进行门静脉栓塞也可能具有保护作用，但门静脉高灌注恶化是一个主要问题。我们确定了在肝脏手术前24小时进行门静脉栓塞对肝脏血流动力学的影响。
对在24小时前接受（门静脉栓塞）或未接受（对照）门静脉栓塞的猪进行扩大（90%）肝切除术（每组n = 10）。在肝切除术前和术后评估血液检查、肝脏和全身血流动力学、肝功能（吲哚菁绿血浆消失率）、肝脏组织学和容积测量（计算机断层扫描）。还评估了肝细胞增殖细胞核抗原表达和肝脏基因表达。
对照组和门静脉栓塞组的猪维持稳定的全身血流动力学，门静脉血流增加相似（302±72%对486±92%，P = 0.13）。对照组门静脉压力急剧升高（从9.4±1.3 mmHg升至20.9±1.4 mmHg，P < 0.001），而门静脉栓塞组明显减弱（从11.4±1.5 mmHg升至16.1±1.3 mmHg，P = 0.061）。该操作还改善了肝动脉血流的保存、肝功能和门静脉周围水肿。这些效应在没有肝细胞增殖或肝脏生长的情况下发生，并与血管保护基因Klf2的诱导有关。
门静脉栓塞预处理是扩大肝切除术的一种潜在肝保护策略。进一步的临床前研究应评估其中期效果，包括生存率。我们的研究还支持肝脏血流动力学作为肝切除术后肝衰竭主要发病因素的相关性。
