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Extracorporeal Portal Vein Arterialization in Man After Extended Hepatectomy to Prevent Acute Liver Failure: A Case Report
Extracorporeal Portal Vein Arterialization in Man After Extended Hepatectomy to Prevent Acute Liver Failure: A Case Report B. Nardo, S. Vaccarisi, V. Pellegrino, M. Cannistrà, E. Barcellona, and G. Cavallari
ABSTRACT Experimental studies have shown that increasing the oxygen supply to the liver through portal vein arterialization (PVA) enhances liver regeneration after partial hepatectomy. Moreover, our previous study demonstrated a beneficial effect of an extracorporeal device to increase the oxygenated blood to the liver and to improve the survival rate of animals subjected to subtotal hepatectomy. Herein we have reported a case of PVA through an extracorporeal device to treat a man after extended hepatectomy leading to acute liver failure (ALF). An obese 69-year-old man (body mass index ⬎ 35) affected by multiple metastases from colorectal cancer underwent 80% liver resection; at laparotomy, a steatotic liver was evident due to adjuvant chemotherapy. Moreover, the liver experienced 20 minutes of hepatic ischemia during the resection. At the end of resection he underwent extracorporeal PVA treatment. Blood was withdrawn from the femoral artery and returned into the portal venous system through the umbilical vein. An extracorporeal device was interposed between the outflow and inflow to monitor hemodynamic parameters. Starting from operating room each of six treatments lasted 6 hours per day. Serum and liver samples were collected daily. The extracorporeal device was dismounted at the seventh postoperative day. The postoperative course was assessed at 1 month. The PVA-extracorporeal treatment yielded beneficial effects for subtotal hepatectomy by decreasing serum ammonia, transaminases, and total bilirubin concentration. The international normalized ratio recovered rapidly, remaining significantly lower during the entire postoperative period. The ten-day postoperative period was uneventful. The patient was discharged in good health. He is alive and well at the moment. The arterial blood supply in the portal system through the umbilical vein using an extracorporeal device was easily applicable, efficacious, safe, and cost-effective. It may represent a novel approach to treat patients with potential ALF after subtotal liver resection. XPERIMENTAL STUDIES have shown that increasing the oxygen supply to the liver through portal vein arterialization (PVA) enhances liver regeneration after partial hepatectomy1,2 or CCl4-induced massive liver necrosis in rats.3 In the clinical setting, it has been performed to raise portal oxygen pressure to protect the liver against massive necrosis due to obstruction of the hepatic artery after extended hepatopancreatobiliary surgery.4,5 Finally, some reports have shown that PVA can also be used in the case of hepatic artery thrombosis after liver transplantation in the presence of a normal portal venous system.6 – 8 Our group reported a patient with massive necrosis due to drug intoxication who was rescued by PVA, thus avoiding liver
E
transplantation.9 Moreover, a pilot experimental study was carried out to assess the efficacy and feasibility of a new device namely L.E.O.NARDO (which means Liver Extra-
From the Hepato-Biliary-Pancreatic and Transplant Organ Unit (B.N., S.V., V.P., M.C., E.B.), Annunziata Hospital of Cosenza, Cosenza, Italy, and Department of Surgery and Transplantation (B.N., G.C.), S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy. Address reprint requests to Professor Bruno Nardo, MD, PhD, Department of Surgery, Hepato-Biliary-Pancreatic and Transplant Organs Unit Annunziata Hospital, Via F. Migliori 1, 87100 Cosenza, Italy. E-mail: [email protected]
© 2011 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710
0041-1345/–see front matter doi:10.1016/j.transproceed.2011.02.052
Transplantation Proceedings, 43, 1193–1195 (2011)
1193
1194
corporeal Oxygen NARDO) in a subtotal hepatectomyinduced acute liver failure (ALF) swine model. Our results demonstrated a beneficial effect of the extracorporeal device to increase the physiologically oxygenated arterial blood to the liver through the portal system and to improve the survival rate of animals subjected to subtotal hepatectomy.10 Herein we have reported the first case of PVA through this extracorporeal device to treat a man after extended hepatectomy led to ALF.
CASE REPORT An obese 69-year old man (body mass index ⬎ 35) was affected by metastases from colorectal cancer in the right lobe. The patient underwent right hepatectomy extended to S4 plus wedge resection of S3 for small lesions diagnosed by intraoperative ultrasound. The remnant liver contained marked steatosis due to adjuvant chemotherapy. A total of 80% of liver parenchyma was resected with a 30-minute period of intermittent ischemia. At the end of the resection the patient underwent the extracorporeal PVA treatment (Fig 1). The extracorporeal device (Bellco S.r.I., Mirandola, Italy) was interposed between the outflow and the inflow to increase the oxygen supply to the liver by pumping and mixing the physiologically oxygenated arterial blood in the venous portal system, and to monitor hemodynamic parameters. Blood was withdrawn from the femoral artery and returned in the portal venous system through the umbilical vein. Starting from the operating room each of six treatments lasted 6 hours per day. Serum and liver samples were collected daily. The extracorporeal device was dismounted at the seventh postoperative day. The postoperative course was assessed at 1 month. No side effects were observed during the extracorporeal treatments. It yielded beneficial effects with decreased serum ammonia,
NARDO, VACCARISI, PELLEGRINO ET AL Table 1. Blood Test Parameters Before and After Extracorporeal PVA Treatment Parameters
Pre-PVA (day ⫺1)
Post-PVA (week ⫹1)
Post-PVA (month ⫹1)
AST (1–41 U/L) ALT (1–54 U/L) Total bilirubin (0.4–1.2 mg/dL) INR (0.7–1.1) Albumin (3.5–5.0 g/dL) Ammonia (16–60 mol/L) Creatinine (0.6–1.2 mg/dL) Platelets (150–450 ⫻ 103)
72 93 1.2 1.24 3.4 18 0.71 237
366 452 1.2 1.16 3.8 20 0.80 225
64 85 1.1 1.18 3.9 16 0.77 241
PVA, portal vein arterialization; AST, aspartate aminotransferase; ALT, alanine aminotransferase; INR, international normalized ratio.
transaminases, and total bilirubin concentrations (Table 1). International normalized ratio recovered rapidly remaining significantly lower during all the postoperative period. The ten-day postoperative period was ineventful. The patient was discharged in good health. He is alive and well at the moment.
DISCUSSION
Previous animal studies have shown that an increased oxygen supply to the liver enhances regeneration capacity after extended hepatectomy.1,2,10 The exact molecular mechanism of the effects on survival is not completely clear, but several acceptable hypotheses have been advanced.11 Herein we have reported the effectiveness of an extracorporeal device (L.E.O.NARDO) to treat a man with ALF after extended hepatectomy. The arterial blood supply through the umbilical vein to the extracorporeal device was easily, applicable, efficacious, safe, and cost-effective. This apparatus may represent a novel approach to treat patient with potential ALF induced by subtotal liver resection. It is clear that further investigations must be done to comprehend fully the potential of PVA as an approach to treat ALF.
REFERENCES
Fig 1. Extracorporeal portal vein arterialization treatment.
1. Shimizu Y, Miyazaki M, Shimizu H, et al: Beneficial effects of arterialization of the portal vein on extended hepatectomy. Br J Surg 87:784, 2000 2. Fan Y-D, Praet M, Van Huysse J, et al: Effects of portal vein arterialization on liver regeneration after partial hepatectomy in the rat. Liver Transpl 8:146, 2002 3. Nardo B, Caraceni P, Puviani L, et al: Successful treatment of CC14-induced acute liver failure with portal vein arterialization in the rat. J Surg Res 135:394, 2006 4. Iseki J, Youyama K, Noie T, et al: Partial arterialization for the prevention of massive necrosis following extended pancreatobiliary surgery: experience of two cases. Surg Today 22:568, 1992 5. Ozeki Y, Umemoto T, Tateyama K, et al: Partial portal arterialization in dearterialized liver after hepatectomy. Br J Surg 84:1011, 1997
EXTRACORPOREAL PORTAL VEIN ARTERIALIZATION 6. Tanabe G, Kawaida K, Hamanoue M, et al: Treatment of accidental occlusion of the hepatic artery after hepatic resection: report of two cases. Surg Today 29:268, 1999 7. Cavallari A, Nardo B, Caraceni P: Arterialization of the portal vein in a patient with a dearterialized liver graft and massive necrosis. N Engl J med 345:1352, 2001 8. Shimizu K, Tani T, Takamura H, et al: Partial portal arterialization in living-donor liver transplantation for hepatic artery occlusion. Transplantation 77:954, 2004
1195 9. Nardo B, Montalti R, Puviani L, et al: Portal vein arterialization in a patient with acute liver failure. Transplantation 79:851, 2005 10. Nardo B, Montalti R, Puviani L, et al: An experimental pilot study on controlled portal vein arterialization with an extracorporeal device in the swine model of partial liver resection and ischemia. Int J Artif Organs 29:912, 2006 11. Tsivian M, Neri F, Prezzi D, et al: Portal vein arterialization in hepatobiliary surgery and liver transplantation. Transplant Proc 39:1877, 2007
ABSTRACT Experimental studies have shown that increasing the oxygen supply to the liver through portal vein arterialization (PVA) enhances liver regeneration after partial hepatectomy. Moreover, our previous study demonstrated a beneficial effect of an extracorporeal device to increase the oxygenated blood to the liver and to improve the survival rate of animals subjected to subtotal hepatectomy. Herein we have reported a case of PVA through an extracorporeal device to treat a man after extended hepatectomy leading to acute liver failure (ALF). An obese 69-year-old man (body mass index ⬎ 35) affected by multiple metastases from colorectal cancer underwent 80% liver resection; at laparotomy, a steatotic liver was evident due to adjuvant chemotherapy. Moreover, the liver experienced 20 minutes of hepatic ischemia during the resection. At the end of resection he underwent extracorporeal PVA treatment. Blood was withdrawn from the femoral artery and returned into the portal venous system through the umbilical vein. An extracorporeal device was interposed between the outflow and inflow to monitor hemodynamic parameters. Starting from operating room each of six treatments lasted 6 hours per day. Serum and liver samples were collected daily. The extracorporeal device was dismounted at the seventh postoperative day. The postoperative course was assessed at 1 month. The PVA-extracorporeal treatment yielded beneficial effects for subtotal hepatectomy by decreasing serum ammonia, transaminases, and total bilirubin concentration. The international normalized ratio recovered rapidly, remaining significantly lower during the entire postoperative period. The ten-day postoperative period was uneventful. The patient was discharged in good health. He is alive and well at the moment. The arterial blood supply in the portal system through the umbilical vein using an extracorporeal device was easily applicable, efficacious, safe, and cost-effective. It may represent a novel approach to treat patients with potential ALF after subtotal liver resection. XPERIMENTAL STUDIES have shown that increasing the oxygen supply to the liver through portal vein arterialization (PVA) enhances liver regeneration after partial hepatectomy1,2 or CCl4-induced massive liver necrosis in rats.3 In the clinical setting, it has been performed to raise portal oxygen pressure to protect the liver against massive necrosis due to obstruction of the hepatic artery after extended hepatopancreatobiliary surgery.4,5 Finally, some reports have shown that PVA can also be used in the case of hepatic artery thrombosis after liver transplantation in the presence of a normal portal venous system.6 – 8 Our group reported a patient with massive necrosis due to drug intoxication who was rescued by PVA, thus avoiding liver
E
transplantation.9 Moreover, a pilot experimental study was carried out to assess the efficacy and feasibility of a new device namely L.E.O.NARDO (which means Liver Extra-
From the Hepato-Biliary-Pancreatic and Transplant Organ Unit (B.N., S.V., V.P., M.C., E.B.), Annunziata Hospital of Cosenza, Cosenza, Italy, and Department of Surgery and Transplantation (B.N., G.C.), S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy. Address reprint requests to Professor Bruno Nardo, MD, PhD, Department of Surgery, Hepato-Biliary-Pancreatic and Transplant Organs Unit Annunziata Hospital, Via F. Migliori 1, 87100 Cosenza, Italy. E-mail: [email protected]
© 2011 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710
0041-1345/–see front matter doi:10.1016/j.transproceed.2011.02.052
Transplantation Proceedings, 43, 1193–1195 (2011)
1193
1194
corporeal Oxygen NARDO) in a subtotal hepatectomyinduced acute liver failure (ALF) swine model. Our results demonstrated a beneficial effect of the extracorporeal device to increase the physiologically oxygenated arterial blood to the liver through the portal system and to improve the survival rate of animals subjected to subtotal hepatectomy.10 Herein we have reported the first case of PVA through this extracorporeal device to treat a man after extended hepatectomy led to ALF.
CASE REPORT An obese 69-year old man (body mass index ⬎ 35) was affected by metastases from colorectal cancer in the right lobe. The patient underwent right hepatectomy extended to S4 plus wedge resection of S3 for small lesions diagnosed by intraoperative ultrasound. The remnant liver contained marked steatosis due to adjuvant chemotherapy. A total of 80% of liver parenchyma was resected with a 30-minute period of intermittent ischemia. At the end of the resection the patient underwent the extracorporeal PVA treatment (Fig 1). The extracorporeal device (Bellco S.r.I., Mirandola, Italy) was interposed between the outflow and the inflow to increase the oxygen supply to the liver by pumping and mixing the physiologically oxygenated arterial blood in the venous portal system, and to monitor hemodynamic parameters. Blood was withdrawn from the femoral artery and returned in the portal venous system through the umbilical vein. Starting from the operating room each of six treatments lasted 6 hours per day. Serum and liver samples were collected daily. The extracorporeal device was dismounted at the seventh postoperative day. The postoperative course was assessed at 1 month. No side effects were observed during the extracorporeal treatments. It yielded beneficial effects with decreased serum ammonia,
NARDO, VACCARISI, PELLEGRINO ET AL Table 1. Blood Test Parameters Before and After Extracorporeal PVA Treatment Parameters
Pre-PVA (day ⫺1)
Post-PVA (week ⫹1)
Post-PVA (month ⫹1)
AST (1–41 U/L) ALT (1–54 U/L) Total bilirubin (0.4–1.2 mg/dL) INR (0.7–1.1) Albumin (3.5–5.0 g/dL) Ammonia (16–60 mol/L) Creatinine (0.6–1.2 mg/dL) Platelets (150–450 ⫻ 103)
72 93 1.2 1.24 3.4 18 0.71 237
366 452 1.2 1.16 3.8 20 0.80 225
64 85 1.1 1.18 3.9 16 0.77 241
PVA, portal vein arterialization; AST, aspartate aminotransferase; ALT, alanine aminotransferase; INR, international normalized ratio.
transaminases, and total bilirubin concentrations (Table 1). International normalized ratio recovered rapidly remaining significantly lower during all the postoperative period. The ten-day postoperative period was ineventful. The patient was discharged in good health. He is alive and well at the moment.
DISCUSSION
Previous animal studies have shown that an increased oxygen supply to the liver enhances regeneration capacity after extended hepatectomy.1,2,10 The exact molecular mechanism of the effects on survival is not completely clear, but several acceptable hypotheses have been advanced.11 Herein we have reported the effectiveness of an extracorporeal device (L.E.O.NARDO) to treat a man with ALF after extended hepatectomy. The arterial blood supply through the umbilical vein to the extracorporeal device was easily, applicable, efficacious, safe, and cost-effective. This apparatus may represent a novel approach to treat patient with potential ALF induced by subtotal liver resection. It is clear that further investigations must be done to comprehend fully the potential of PVA as an approach to treat ALF.
REFERENCES
Fig 1. Extracorporeal portal vein arterialization treatment.
1. Shimizu Y, Miyazaki M, Shimizu H, et al: Beneficial effects of arterialization of the portal vein on extended hepatectomy. Br J Surg 87:784, 2000 2. Fan Y-D, Praet M, Van Huysse J, et al: Effects of portal vein arterialization on liver regeneration after partial hepatectomy in the rat. Liver Transpl 8:146, 2002 3. Nardo B, Caraceni P, Puviani L, et al: Successful treatment of CC14-induced acute liver failure with portal vein arterialization in the rat. J Surg Res 135:394, 2006 4. Iseki J, Youyama K, Noie T, et al: Partial arterialization for the prevention of massive necrosis following extended pancreatobiliary surgery: experience of two cases. Surg Today 22:568, 1992 5. Ozeki Y, Umemoto T, Tateyama K, et al: Partial portal arterialization in dearterialized liver after hepatectomy. Br J Surg 84:1011, 1997
EXTRACORPOREAL PORTAL VEIN ARTERIALIZATION 6. Tanabe G, Kawaida K, Hamanoue M, et al: Treatment of accidental occlusion of the hepatic artery after hepatic resection: report of two cases. Surg Today 29:268, 1999 7. Cavallari A, Nardo B, Caraceni P: Arterialization of the portal vein in a patient with a dearterialized liver graft and massive necrosis. N Engl J med 345:1352, 2001 8. Shimizu K, Tani T, Takamura H, et al: Partial portal arterialization in living-donor liver transplantation for hepatic artery occlusion. Transplantation 77:954, 2004
1195 9. Nardo B, Montalti R, Puviani L, et al: Portal vein arterialization in a patient with acute liver failure. Transplantation 79:851, 2005 10. Nardo B, Montalti R, Puviani L, et al: An experimental pilot study on controlled portal vein arterialization with an extracorporeal device in the swine model of partial liver resection and ischemia. Int J Artif Organs 29:912, 2006 11. Tsivian M, Neri F, Prezzi D, et al: Portal vein arterialization in hepatobiliary surgery and liver transplantation. Transplant Proc 39:1877, 2007