PBC and PSC
Authors: Nizar Zein, Ibrahim Hanouneh, Paul Bishop, Maggie Samaan, Cristiano Quintini, Charles Miller, Lisa Yerian, Ryan Klatte, Takumi Fukumoto, Kaori Kuramitsu, Masahiro Kido, Atsushi Takebe, Motofumi Tanaka, Hisoka Kinoshita, Shohei Komatsu, Yonson Ku, Kenichi Harada, Yasuni Nakanuma, Christian Rupp, Kilian Friedrich, Andreas Wannhoff, Karl Weiss, Peter Sauer, Wolfgang Stremmel, Daniel Gotthardt, Weiwei Wang, Stan Indik, Shawn Wasilenko, Eric Carpenter, Gane Wong, Andrew Mason, Kazuhito Kawata, Masanobu Tsuda, Guo-Xiang Yang, Hajime Tanaka, Weici Zhang, Yoshimasa Kobayashi, Koichi Tsuneyama, Patrick Leung, Stuart Knechtle, Ross Cop- Pel, Aftab Ansari, M Gershwin, Elias Spyrou, Lars Komorowski, Christian Probst, Eirini Rigopoulou, Dimitrios Bogdanos, George Dalekos
Journal: Hepatology (2013)

Background) We have previously reported the efficacy of dual treatment, which is consisted of reductive hepatectomy and percutaneous isolated hepatic perfusion (PIHP), for patients with advanced HCC.However these patients are frequently complicated with Vp4 portal vein tumor thrombus (PVTT), and conventional en bloc resection is not always feasible.To overcome this situation, we have developed back flow thrombectomy (BFT) technique.For right hemihepatectomy with Vp4 PVTT, which reached to the contralateral left second portal branch, the portal trunk should be at first clamped at the superior border of the pancreas.After one transverse venotomy at an appropriate site of the right portal branch, tumor thrombus is extracted by forceps and scissors using suction devices.Of particular note, the vascular clamp at the left first portal branch should be avoided because it may split PVTT and enhance portal vein embolization with fragmented tumor thrombus.Instead, back flow pressure in the portal system generated by BFT technique should be kept throughout the thrombectomy procedure.This pressure eases effective extraction of both micro-and macroscopic cancer nests liberated to the blood stream and avoid the migration into the future remnant liver.(Methods) Until the end of 2011, 43 multiple bilobular HCC patients with Vp4 were performed reductive hepatectomy with tumor thrombectomy.In 22 of 43 patients, BFT techniques were used.Sixteen of 23 patients had PVTT in the contralateral second portal branch.Seventeen of 43 patients were not performed PIHP because of economical reason, extrahepatic metastases, aggressive tumor progression, hepatic dysfunction, infectious complications or unfavorable conditions after surgery.(Results) Patency of portal vein at thrombectomy site of all/BFT patients 3 and 6 months after hepatectomy were 92%/90% and 87%/86%, respectively.The median OS of all 43 patients was 14 months and the 1 and 3-year OS rate was 55.5% and 19.1% respectively.In 26 patients who could undergo PIHP as second treatment, the median OS was 17 months and the 1 and 3-year OS rate was 69.2% and 23.1% respectively.(Conclusions) Tumor thrombectomy by BFT technique allows multi-disciplinary treatment for patients with PVTT.An impressively increased survival rate achieved by additional PIHP supports the dual treatment strategy for multiple bilobular HCC patients with Vp4 PVTT.