Background: Preoperative portal vein embolization (PVE) is performed to enhance the future remnant liver function (FRLF) and volume (FRLV). However, the volume of the nonembolized liver does not increase enough in some patients, which results in an insufficient FRLF. The aim of this study was to evaluate the predictors of insufficient FRLF after PVE for extended hepatectomy. Methods: This retrospective study included 172 patients (107 patients with cholangiocarcinoma, 40 patients with metastatic liver cancer and 25 patients with hepatocellular carcinoma) who underwent PVE before extended hepatectomy. The total liver function was evaluated by measuring the indocyanine green plasma clearance rate (KICG). Computed tomography volumetry was conducted to evaluate the total liver volume and FRLV. The KICG of the future remnant liver (remK) was calculated using the following formula: KICG × FRLV/total liver volume. The safety margin for hepatectomy was set at remK after PVE (post-PVE remK) ≥0.05. Results: One hundred and twenty-three patients with a post-PVE remK level of >0.05 underwent hepatectomy without postoperative liver failure [sufficient liver regeneration (SLR) group], and 9 patients with a post-PVE remK level of <0.05 did not due to insufficient FRLF [insufficient liver regeneration (ILR) group]. In the SLR group, the KICG values did not change after PVE (median, 0.144-0.146, p = 0.523); however, the %FRLV and remK increased significantly (35.0-44.3%, p < 0.001 and 0.0488-0.0610, p < 0001, respectively). In contrast, in the ILR group, the KICG values decreased significantly (0.128-0.108, p = 0.021) and the %FRLV increased marginally (27.4-32.6%, p = 0.051). As a result, the remK did not increase significantly (0.0351-0.0365, p = 0.213). A receiver operating characteristic curve demonstrated an remK value of 0.04 obtained before PVE (pre-PVE remK) to be the optimal cutoff point for defective liver regeneration. The univariate and multivariate analyses revealed that a pre-PVE remK value of <0.04 was a factor for ILR. It was also correlated with postoperative liver failure in the analysis of the patients who underwent hepatectomy. Conclusions: The patients in the ILR group did not achieve SLR after PVE due to a significant decrease in the KICG and an insufficient increase in %FRLV. A pre-PVE remK value of <0.04 is a useful predictor of insufficient regeneration of the nonembolized liver, even after PVE.

Makuuchi M, Thai BL, Takayasu K, Takayama T, Kosuge T, Gunven P, et al: Preoperative portal embolization to increase safety of major hepatectomy for hilar bile duct carcinoma: a preliminary report. Surgery 1990;107:521-527.
Kinoshita H, Sakai K, Hirohashi K, Igawa S, Yamasaki O, Kubo S: Preoperative portal vein embolization for hepatocellular carcinoma. World J Surg 1986;10:803-808.
Farges O, Belghiti J, Kianmanesh R, Regimbeau JM, Santoro R, Vilgrain V, et al: Portal vein embolization before right hepatectomy: prospective clinical trial. Ann Surg 2003;237:208-217.
Abdalla EK, Barnett CC, Doherty D, Curley SA, Vauthey JN: Extended hepatectomy in patients with hepatobiliary malignancies with and without preoperative portal vein embolization. Arch Surg 2002;137:675-680, discussion 680-681.
Wakabayashi H, Ishimura K, Okano K, Karasawa Y, Goda F, Maeba T, et al: Application of preoperative portal vein embolization before major hepatic resection in patients with normal or abnormal liver parenchyma. Surgery 2002;131:26-33.
Ribero D, Abdalla EK, Madoff DC, Donadon M, Loyer EM, Vauthey JN: Portal vein embolization before major hepatectomy and its effects on regeneration, resectability and outcome. Br J Surg 2007;94:1386-1394.
Hemming AW, Reed AI, Howard RJ, Fujita S, Hochwald SN, Caridi JG, et al: Preoperative portal vein embolization for extended hepatectomy. Ann Surg 2003;237:686-691, discussion 691-693.
Yokoyama Y, Nishio H, Ebata T, Igami T, Sugawara G, Nagino M: Value of indocyanine green clearance of the future liver remnant in predicting outcome after resection for biliary cancer. Br J Surg 2010;97:1260-1268.
Vauthey JN, Chaoui A, Do KA, Bilimoria MM, Fenstermacher MJ, Charnsangavej C, et al: Standardized measurement of the future liver remnant prior to extended liver resection: methodology and clinical associations. Surgery 2000;127:512-519.
Nagino M, Kamiya J, Nishio H, Ebata T, Arai T, Nimura Y: Two hundred forty consecutive portal vein embolizations before extended hepatectomy for biliary cancer: surgical outcome and long-term follow-up. Ann Surg 2006;243:364-372.
Nagino M, Nimura Y, Kamiya J, Kondo S, Kanai M: Selective percutaneous transhepatic embolization of the portal vein in preparation for extensive liver resection: the ipsilateral approach. Radiology 1996;200:559-563.
Nagino M, Kamiya J, Kanai M, Uesaka K, Sano T, Yamamoto H, et al: Right trisegment portal vein embolization for biliary tract carcinoma: technique and clinical utility. Surgery 2000;127:155-160.
Balzan S, Belghiti J, Farges O, Ogata S, Sauvanet A, Delefosse D, et al: The ‘50-50 criteria' on postoperative day 5: an accurate predictor of liver failure and death after hepatectomy. Ann Surg 2005;242:824-828, discussion 828-829.
Clavien PA, Sanabria JR, Strasberg SM: Proposed classification of complications of surgery with examples of utility in cholecystectomy. Surgery 1992;111:518-526.
Dindo D, Demartines N, Clavien PA: Classification of surgical complications: a new proposal with evaluation in a cohort of 6,336 patients and results of a survey. Ann Surg 2004;240:205-213.
Shindoh J, Truty MJ, Aloia TA, Curley SA, Zimmitti G, Huang SY, et al: Kinetic growth rate after portal vein embolization predicts posthepatectomy outcomes: toward zero liver-related mortality in patients with colorectal liver metastases and small future liver remnant. J Am Coll Surg 2013;216:201-209.
Abulkhir A, Limongelli P, Healey AJ, Damrah O, Tait P, Jackson J, et al: Preoperative portal vein embolization for major liver resection: a meta-analysis. Ann Surg 2008;247:49-57.
Hoekstra LT, van Lienden KP, Doets A, Busch OR, Gouma DJ, van Gulik TM: Tumor progression after preoperative portal vein embolization. Ann Surg 2012;256:812-817, discussion 817-818.
Wack KE, Ross MA, Zegarra V, Sysko LR, Watkins SC, Stolz DB: Sinusoidal ultrastructure evaluated during the revascularization of regenerating rat liver. Hepatology 2001;33:363-378.
Ross MA, Sander CM, Kleeb TB, Watkins SC, Stolz DB: Spatiotemporal expression of angiogenesis growth factor receptors during the revascularization of regenerating rat liver. Hepatology 2001;34:1135-1148.
Belghiti J, Liddo G, Raut V, Zappa M, Dokmak S, Vilgrain V, et al: ‘Inherent limitations' in donors: control matched study of consequences following a right hepatectomy for living donation and benign liver lesions. Ann Surg 2012;255:528-533.
Shirabe K, Shimada M, Gion T, Hasegawa H, Takenaka K, Utsunomiya T, et al: Postoperative liver failure after major hepatic resection for hepatocellular carcinoma in the modern era with special reference to remnant liver volume. J Am Coll Surg 1999;188:304-309.
Tsao JI, Loftus JP, Nagorney DM, Adson MA, Ilstrup DM: Trends in morbidity and mortality of hepatic resection for malignancy. A matched comparative analysis. Ann Surg 1994;220:199-205.
Gruttadauria S, Luca A, Mandala L, Miraglia R, Gridelli B: Sequential preoperative ipsilateral portal and arterial embolization in patients with colorectal liver metastases. World J Surg 2006;30:576-578.
Hwang S, Lee SG, Ko GY, Kim BS, Sung KB, Kim MH, et al: Sequential preoperative ipsilateral hepatic vein embolization after portal vein embolization to induce further liver regeneration in patients with hepatobiliary malignancy. Ann Surg 2009;249:608-616.
Ninomiya M, Shirabe K, Terashi T, Ijichi H, Yonemura Y, Harada N, et al: Deceleration of regenerative response improves the outcome of rat with massive hepatectomy. Am J Transplant 2010;10:1580-1587.
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