Tsuruga Yosuke, Kamiyama Toshiya, Kamachi Hirofumi, Orimo Tatsuya, Shimada Shingo, Nagatsu Akihisa, Asahi Yoh, Sakamoto Yuzuru, Kakisaka Tatsuhiko, Taketomi Akinobu
Department of Gastroenterological Surgery I, Hokkaido University Graduate School of Medicine, Sapporo 060-8638, Japan.
World J Gastrointest Surg. 2021 Feb 27;13(2):153-163. doi: 10.4240/wjgs.v13.i2.153.
Preoperative portal vein embolization (PVE) is a widely used strategy to enable major hepatectomy in patients with insufficient liver remnant. PVE induces hypertrophy of the future liver remnant (FLR) and a shift of the functional reserve to the FLR. However, whether the increase of the FLR volume (FLRV) corresponds to the functional transition after PVE remains unclear.
To investigate the sequential relationship between the increase in FLRV and functional transition after preoperative PVE using 3-dimensional (3D) computed tomography (CT) and Tc-galactosyl-human serum albumin (Tc-GSA) single-photon emission computed tomography (SPECT) fusion images.
Thirty-three patients who underwent major hepatectomy following PVE at the Department of Gastroenterological Surgery I, Hokkaido University Hospital between October 2013 and March 2018 were enrolled. Three-phase dynamic multidetector CT and Tc-GSA SPECT scintigraphy were performed at pre-PVE, and at 1 and 2 wk after PVE; 3D Tc-GSA SPECT CT-fused images were constructed from the Digital Imaging and Communications in Medicine data using 3D image analysis system. Functional FLRV (FFLRV) was defined as the total liver volume × (FLR volume counts/total liver volume counts) on the 3D Tc-GSA SPECT CT-fused images. The calculated FFLRV was compared with FLRV.
FFLRV increased by a significantly larger extent than FLRV at 1 and 2 wk after PVE ( < 0.01). The increase in FFLRV and FLRV was 55.1% ± 41.6% and 26.7% ± 17.8% ( < 0.001), respectively, at 1 wk after PVE, and 64.2% ± 33.3% and 36.8% ± 18.9% ( < 0.001), respectively, at 2 wk after PVE. In 3 of the 33 patients, FFLRV levels decreased below FLRV at 2 wk. One of the three patients showed rapidly progressive fatty changes in FLR. The biopsy at 4 wk after PVE showed macro- and micro-vesicular steatosis of more than 40%, which improved to 10%. Radical resection was performed at 13 wk after PVE. The patient recovered uneventfully without any symptoms of pos-toperative liver failure.
The functional transition lagged behind the increase in FLRV after PVE in some cases. Evaluating both volume and function is needed to determine the optimal timing of hepatectomy after PVE.
术前门静脉栓塞术（PVE）是一种广泛应用的策略，用于使肝剩余量不足的患者能够接受肝大部切除术。PVE可诱导未来肝剩余（FLR）肥大，并使功能储备向FLR转移。然而，PVE后FLR体积（FLRV）的增加是否与功能转变相对应仍不清楚。
使用三维（3D）计算机断层扫描（CT）和锝标记半乳糖基人血清白蛋白（Tc-GSA）单光子发射计算机断层扫描（SPECT）融合图像，研究术前PVE后FLRV增加与功能转变之间的先后关系。
纳入2013年10月至2018年3月在北海道大学医院第一消化外科接受PVE后行肝大部切除术的33例患者。在PVE前、PVE后1周和2周进行三期动态多排CT和Tc-GSA SPECT闪烁扫描；使用3D图像分析系统从医学数字成像和通信数据构建3D Tc-GSA SPECT CT融合图像。功能性FLRV（FFLRV）定义为3D Tc-GSA SPECT CT融合图像上的肝脏总体积×（FLR体积计数/肝脏总体积计数）。将计算出的FFLRV与FLRV进行比较。
PVE后1周和2周，FFLRV的增加幅度明显大于FLRV（<0.01）。PVE后1周，FFLRV和FLRV的增加分别为55.1%±41.6%和26.7%±17.8%（<0.001），PVE后2周分别为64.2%±33.3%和36.8%±18.9%（<0.001）。33例患者中有3例在2周时FFLRV水平降至FLRV以下。其中1例患者FLR出现快速进展性脂肪变。PVE后4周的活检显示大泡性和小泡性脂肪变超过40%，改善至10%。PVE后13周进行根治性切除。患者恢复顺利，无任何术后肝衰竭症状。
在某些情况下，PVE后功能转变滞后于FLRV的增加。评估体积和功能两者对于确定PVE后肝切除的最佳时机是必要的。
