N. Alzerwi, CH David Kwon, et al Safety & Feasibility Of Laparoscopic Major hepatectomy after Portal Vein Embolization, a Case Series N. Alzerwi, CH David Kwon, et al  Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea

Context Selective portal vein embolization ( PVE ) is an effective adjunct to increase resectability pool* However, PVE poses several technical challenges to laparoscopic approach for major hepatectomy ( LMH ): a thicker pedicle with surrounding inflammation difficult and bloody hilar dissection security and safety of pedicle transection with a stapler on top of coils? risk of spread of the remnant embolus or fragments to the contralateral pedicle! *Makuuchi M, et al. Surgery. 1990

Objective To demonstrate safety and feasibility of LMH after PVE.

Methodology Between May 2012 and September 2014 15 patients underwent LMH after PVE. Single surgeon Volumetry: CT Future Liver Remnant/Standard Liver Volume (FLR/SLV) Net increase FLR = (Pre-PVE FLR- Post-PVE FLR )/ SLV

PVE technique Contralateral approach Gelfoam distally, 2nd order branches Coils proximally, 2nd order branches Sparing 1st order branches P4b, P4a sparing

Operative Technique Inflow control: Temporary inflow control of glissonean pedicle “TICGL" technique Parenchymal transection: Ultrasonic dissector, advanced bipolar device, bipolar electrocautery No CUSA was used

*Ischemic heart disease Demographics Diagnosis Age Sex Etiology Comorbidities Stage (AJCC 2010) Tumor Burden Extent of Hepatectomy 10 HCC 1 CCC 2 HCC/CCC 2 CLM 58 (32-79) 13 M 2 F 8 HBV 2 HCV 6 DM 7 HTN 4 TB 1 HIV 1 IHD* 1 PE† 1 DVT 1 COPD 12 early stage I/II 1 stage IVa CCC 2 stage IV CLM No. Size 11 LRHH 4 LeRH 1 (1-3 ) 5 cm (1.8 – 8 cm ) *Ischemic heart disease † Pulmonary embolism

Parenchymal Functional Reserve Variables CTP ICG-R15 Albumin INR Bilirubin Ascites Hepatic encephalopathy Variceal Bleeding Median ( Range ) A5 (A5-A6 ) 12.5% (7.3-69.5%) 3.5 (2.7-4.5 ) 1.13 (0.98-1.3 ) 0.8 (0.2-2.3 )

Parenchymal Volumetrics Variables SLV ml Pre PVE FLR Post PVE FLR Net ↑ in FLR PVE-Surgery Interval (days) Vol mL Vol % Median ( range ) 1191 ( 982-1396) 282 ( 191-383 ) 24% ( 16-28% ) 483 ( 397-617 ) 42% ( 33-46% ) 212 ( 114-293 ) 71% ( 38-110% ) 21 ( 14-42 )

Operative Variables Variables Pringle’s EBL (mL) Op Time (mins) Stapler Color Code Margins LOS (days) No Duration ( mins ) Median ( Range ) 1 (0- 5 ) 30 ( 8 – 75 ) 100 (50-300 ) 324 (246 – 803 ) 11 tan* 2 tan + purple† 1 white‡ 1 blue# 1 cm (0.1-5 cm ) 9 (5-37 ) * (2-3 mm, Tristaple ) thickness † ( 3-4 mm, Tristaple ) thickness ‡ (2 mm ) thickness #( 3.5 mm ) thickness

Mortality & Morbidity Profile Cases Type of Complication ( Clavien-Dindo ) Relevant details/ risk factors/ management Case I Postoperative bleeding ( II ) Op time = 803 mins LeRHH White cartridge EBL < 300 ml Lack of sling maneuver of hilar structures LOS = 37 Conservatively Blood component therapy PTBD ERPD Bile leak Grade B, stricture ( IIIa ) Case II Upper limb DVT LOS = 14 days Anticoagulation Case III SSI: Superficial incisional Organ space (thoracic empyema ) Combined Colectomy Iatrogenic pneumothorax during trocar insertion ICD insertion LOS = 25 days IV Antibiotics Bedside Drainage IV antibiotics ICD Case IV Post hepatectomy Liver Insufficency ( Iva ) HBV HCC/CCC 55 y.o. ICG 70% Post-PVE FLR= 33% Net increase 38% PVE-surgery Interval = 42 days Pringles 3X ( 45 mins ) RHH LOS = 20 days Supportive ICU care Case V Brain air embolism ( V ) CVL insertion for TPN Care POD 35 Mortality rate = 6.6% ( 1/15 ) Morbidity rate = 33% ( 5/15 )

Conclusion LMH after PVE seems relatively safe and feasible with acceptable morbidity & mortality. Glissonian pedicle is thick post PVE, white cartridge ( 2 mm ) should be avoided, tan ( 2-3 mm, Tristaple ) seems safer.