Natural history of portal vein embolization before liver resection: a 23-year analysis of intention-to-treat results

Abstract Background Portal vein embolization (PVE) use is nowadays debated due to the risk of technical or biological unresectability after the period of time needed to achieve future liver remnant (FLR) hypertrophy. We evaluated the safety and efficacy of PVE in a single high-volume hepatobiliary center, with emphasis in the feasibility to achieve tumor resection. Methods Patients undergoing PVE before major hepatectomy at our institution between 1993 and 2015 were retrospectively analyzed. Results A total of 431 patients formed the study population. Morbidity and mortality rates of PVE were 16.7% and 0.2% respectively. Morbidity was similar between percutaneous and ileocolic approaches or between histoacryl and ethanol as embolization materials ( P  > 0.05). On the contrary, the percutaneous ipsilateral approach was associated with significantly less complications than the contralateral approach (10.3% vs 19.4%; P  = 0.024). Almost all patients (96%) achieved sufficient FLR volume after embolization, but only 66% finally underwent planned liver resection. Disease progression was the most common cause of unresectability (67%). Patients with extrahepatic biliary tumors experienced significantly higher unresectability rates compared to other entities (45.1% vs 31.4%; P  = 0.019). Conclusion PVE was not followed by hepatectomy in 34% of our patients. Biliary tumors displayed the higher dropout rates after PVE and the higher chances of tumor progression preventing curative resection. Although PVE may be performed with acceptable morbidity, PVE-related complications prevented curative resection in 5% of patients. Careful multidisciplinary selection is crucial to avoid PVE overuse in technically resectable patients who will experience a not negligible risk of futile use and non-therapeutic laparotomy.