Sequential Portal Vein Embolization: a Technical Option for Hepatic Metastasis Resection
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SURGICAL TECHNIQUES AND INNOVATIONS
Sequential Portal Vein Embolization: a Technical Option for Hepatic Metastasis Resection Carmen Lama 1 & Carlos Parada 1 & Juan R. Artacho 2 & David Contreras 3 & Santiago Gil 3 Received: 24 May 2019 / Accepted: 13 March 2020 # Association of Surgeons of India 2020
Abstract We present the clinical case of a patient who, having been referred for surgery on two-stage hepatectomy, could not have a conventional portal embolization performed as an intermediate step in order to be able to resection the whole of the hepatic illness she was suffering. During right portal embolization (PE), the portography revealed minimal flow in the left portal vein, without thrombosis or stenosis. Given the risk of serious hepatic insufficiency, the embolization procedure was ruled out. Our option was to perform a portal embolization in two stages: initial PE of the right posterior branch, and subsequently, right anterior branch PE. After that, the liver resection could be completed. Keywords Portal vein embolization . Liver failure . Complications portal embolization
Introduction The surgical treatment of hepatic metastases (HM) is an elective treatment [1]. Nonetheless, only 30% of patients can be offered the surgery [1]. We present the clinical case of a patient who, having been referred for surgery on two-stage hepatectomy, could not have a conventional portal embolization performed as an intermediate step in order to be able to resection the whole of the hepatic illness she was suffering.
Clinical Case The patient was 67-years-old upon presentation, with a background of encephalitis in infancy, conditioning a slight right hemiparesis and arterial hypertension in
* Carmen Lama [email protected] 1
Department of Surgery, Hospital of Elda, Carretera de Sax s/n, 03600 Elda, Alicante, Spain
2
Department of Radiology, Hospital of Elda, Elda, Alicante, Spain
3
Department of Radiology, Hospital General de Alicante, Alicante, Spain
medical treatment. In December 2014, she was diagnosed with symptomatic sigmoid neoplasia with synchronous bilobar hepatic metastases by abdominal computer tomography (CT) (Fig. 1): segments II (25 mm), III (< 10 mm), IVa (17 mm), IVb (< 10 mm), VI (< 10 mm), VI–VII (12 mm), and VIII (20 mm). Left hemicolectomy was performed without morbidity. The histopathological result was a moderately differentiated adenocarcinoma, p-TNM T3N0 with MLH-1, MLH-2, and MLH-6 present. She began treatment with neoadjuvant chemotherapy (ChT) of the hepatic metastases, revealing a positive response according to RECIST criteria. Given the distribution of the lesions and an insufficient left hepatic lobe volume, she was considered for referral for surgery in two stages. She was operated on in March 2015, with resection of the left hepatic lobe lesions being performed. She was subsequently scheduled for right portal embolization (PE), with the portography revealing minimal flow in the left portal vein, without thrombosis or stenosis. Given the risk of serious hepatic insufficiency, the em
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