Simultaneous percutaneous right portal vein embolization and left liver tumor radiofrequency ablation prior to a major right hepatic resection for bilateral colorectal metastases

Background/Aims: Hepatic resection offers the best chance of survival for patients with liver metastases (LM) of colorectal origin. However, some patients are not eligible for surgery because of a too small future liver remnant (FLR) which carries a high risk of severe postoperative liver failure. The operability status of these patients can be favorably changed by selective right portal vein embolization (PVE) which induces compensatory growth of the left liver. However, during liver regeneration following right PVE, the left LM growth rate is faster than that of the non-embolized normal liver parenchyma. This study aimed at examining an approach for those patients in which there is bilateral LM potentially resectable following portal vein embolization, but in which there is a risk of rapid liver metastasis growth in the non-embolized liver. Methodology: Between October 1998 and January 2001, 5 patients underwent simultaneous right PVE and radiofrequency ablation (RFA) of a left LM, prior to a major right-sided hepatectomy for initially unresectable bilateral LM. All these patients had one LM in the left liver in addition with multiple LM in the right liver. Simultaneous right PVE and left RFA was performed percutaneously under intravenous sedation and analgesia. One month later, hepatectomy was undertaken. To allow histologic assessment of the RFA effectiveness, the previously treated left-sided tumor was also resected and analyzed. Results: Simultaneous PVE-RFA was successful in all patients. No tumor growth on the RFA site was observed during the interval between PVE-RFA and surgery. Histologic examination showed complete tumor sterilization of the RFA necrotic zone. In the postoperative course, I patient died of acute liver failure. For the 4 remaining patients, morbidity was minimal (transient bile leak in one patient). Conclusions: Simultaneous percutaneous right PVE and left RFA is feasible. This procedure allowed good left-sided tumor control during liver growth following PVE in all five patients. It is the most logical procedure for patients with bilateral colorectal LM needing right PVE before resection, if the left concomitant LM is small and accessible to percutaneous RFA. This procedure should be preferred because it eliminates the risk of left LM growth during the 1-month interval between PVE and surgery.