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Cheng J, Hong DF, Zhang CW, Fan XM, Luo ZY, Yao WF, Jin LM. Transcatheter arterial chemoembolization after percutaneous microwave ablation and portal vein embolization for advanced hepatocellular carcinoma. Hepatobiliary Pancreat Dis Int 2023; 22:213-216. [PMID: 35780016 DOI: 10.1016/j.hbpd.2022.06.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 06/23/2022] [Indexed: 02/05/2023]
Affiliation(s)
- Jian Cheng
- General Surgery, Cancer Center, Department of Hepatobiliary & Pancreatic Surgery and Minimally Invasive Surgery, Zhejiang Provincial People's Hospital, Affiliated People's Hospital of Hangzhou Medical College, Hangzhou 310014, China
| | - De-Fei Hong
- Department of General Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou 310020, China
| | - Cheng-Wu Zhang
- General Surgery, Cancer Center, Department of Hepatobiliary & Pancreatic Surgery and Minimally Invasive Surgery, Zhejiang Provincial People's Hospital, Affiliated People's Hospital of Hangzhou Medical College, Hangzhou 310014, China
| | - Xiao-Ming Fan
- General Surgery, Cancer Center, Department of Hepatobiliary & Pancreatic Surgery and Minimally Invasive Surgery, Zhejiang Provincial People's Hospital, Affiliated People's Hospital of Hangzhou Medical College, Hangzhou 310014, China
| | - Zu-Yan Luo
- General Surgery, Cancer Center, Department of Hepatobiliary & Pancreatic Surgery and Minimally Invasive Surgery, Zhejiang Provincial People's Hospital, Affiliated People's Hospital of Hangzhou Medical College, Hangzhou 310014, China
| | - Wei-Feng Yao
- General Surgery, Cancer Center, Department of Hepatobiliary & Pancreatic Surgery and Minimally Invasive Surgery, Zhejiang Provincial People's Hospital, Affiliated People's Hospital of Hangzhou Medical College, Hangzhou 310014, China
| | - Li-Ming Jin
- General Surgery, Cancer Center, Department of Hepatobiliary & Pancreatic Surgery and Minimally Invasive Surgery, Zhejiang Provincial People's Hospital, Affiliated People's Hospital of Hangzhou Medical College, Hangzhou 310014, China.
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Rey Chaves CE, Conde D, Tapias L, Roa I, Sabogal Olarte JC. Associating liver partition and portal vein ligation (ALPPS): A two staged procedure, in Bogotá Colombia. Case report and literature review. Int J Surg Case Rep 2021; 89:106560. [PMID: 34808445 PMCID: PMC8607210 DOI: 10.1016/j.ijscr.2021.106560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 10/08/2021] [Accepted: 10/30/2021] [Indexed: 02/07/2023] Open
Abstract
Introduction For liver tumors (primary or metastases), surgery combined with neoadjuvant, or adjuvant chemotherapy is the treatment of choice, offering long term survival time and disease-free time period (Alvarez et al., 2012) Associating liver partition and portal vein ligation, or ALPPS, it's a surgical technique that increases the future liver remnant in a short period of time, trying to avoid postoperative liver failure (PLF), and achieving R0 resections in liver malignant tumors (Alvarez et al., 2012). Presentation of the case A 43 years old woman with colorectal liver metastases in both lobes. Colorectal surgical procedure was performed 1 year previous the liver intervention, followed by adjuvant chemotherapy. Decision of a tri-segmental hepatectomy was made to resolve the metastases. Into the surgical procedure, we evaluated the liver parenchyma, and the future liver remnant tissue was insufficient, for that reason we decided to perform ALPPS procedure. Discussion Colorectal liver metastases (CLRM) are considered the most common indication for ALPPS procedure according to the international registry. Compared with the portal vein ligation, resection rate varies from 50 to 80%, and the non-resectability disease was explained by tumor progression. Postoperative mortality rate was 5.1% in young patients (<60 years old), and 8% in general for CRLM. Oncologic outcomes represent an increased disease-free survival period and overall survival time compared with non-surgical approach. Conclusion The ALPPS procedure it's an interesting approach to patients with not enough liver remnant tissue, with good oncologic results in terms of disease-free survival time, and overall survival. Appropriate selection of the patient, careful postoperative management, and a multidisciplinary approach are related with good postoperative outcomes.
ALPPS should be in the surgical armamentarium in liver metastases from colorectal neoplasms, as well hepatocarcinoma and cholangiocarcinoma. Multidisciplinary approach in liver metastases impact in postoperative outcomes Adequate selection of patient reflects in postoperative outcomes and prolonged disease-free survival and overall survival period. This case report, it’s the first one published in Colombia.
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Affiliation(s)
| | - Danny Conde
- Hospital Universitario Mayor Méderi, Colombia
| | - Laura Tapias
- School of Medicine, Universidad el Rosario, Colombia
| | - Isabella Roa
- School of Medicine, Universidad el Rosario, Colombia
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Kogure M, Arai T, Momose H, Matsuki R, Suzuki Y, Sakamoto Y. Rescue Partial ALPPS for Left Hemihepatectomy with Reconstruction of the Middle Hepatic Vein. Dig Surg 2021; 38:325-329. [PMID: 34753129 DOI: 10.1159/000520695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2021] [Accepted: 11/03/2021] [Indexed: 12/10/2022]
Abstract
Major hepatectomy in patients with insufficient future liver remnant (FLR) volume and impaired liver functional reserve has considerable risks for posthepatectomy liver failure (PHLF). The patient was a male in his 70s with an intrahepatic cholangiocarcinoma in left hemiliver, involving the middle hepatic vein (MHV). Although FLR volume after left hemihepatectomy was estimated to be 64.4% of the total liver volume, an indocyanine green retention rate at 15 min (ICG-R15) value was 24.2%, thus the patient underwent left portal vein embolization. The FLR volume increased to 71.3%; however, the noncongestive FLR volume was re-estimated as 45.8% after resection of the MHV, the ICG-R15 value was 29.0%, and ICG-Krem was calculated as 0.037. We performed partial rescue Associating Liver Partition and Portal vein occlusion for Staged hepatectomy (ALPPS) for left hemihepatectomy with the MHV reconstruction. On the first stage, partial liver partition was done along Rex-Cantlie's line, preserving the MHV and sacrificing the remaining branches to segment 8. The FLR volume increased to 77.4% on day 14. The ICG-R15 value was 29.6%, but ICG-Krem after MHV reconstruction was estimated to be 0.059. The second-stage operation on day 21 was left hemihepatectomy with the MHV reconstruction using the left superficial femoral vein graft. The usage of rescue partial ALPPS may contribute to preventing PHLF by introducing occlusion of the portal and/or venous branches in the left hemiliver before curative hepatectomy.
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Affiliation(s)
- Masaharu Kogure
- Department of Hepato-Biliary-Pancreatic Surgery, Kyorin University Hospital, Mitaka-City, Japan
| | - Takaaki Arai
- Department of Hepato-Biliary-Pancreatic Surgery, Kyorin University Hospital, Mitaka-City, Japan
| | - Hirokazu Momose
- Department of Hepato-Biliary-Pancreatic Surgery, Kyorin University Hospital, Mitaka-City, Japan
| | - Ryota Matsuki
- Department of Hepato-Biliary-Pancreatic Surgery, Kyorin University Hospital, Mitaka-City, Japan
| | - Yutaka Suzuki
- Department of Hepato-Biliary-Pancreatic Surgery, Kyorin University Hospital, Mitaka-City, Japan
| | - Yoshihiro Sakamoto
- Department of Hepato-Biliary-Pancreatic Surgery, Kyorin University Hospital, Mitaka-City, Japan
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Qin JM. Conversion therapy for primary liver cancer: Indications and selective strategies. Shijie Huaren Xiaohua Zazhi 2021; 29:501-510. [DOI: 10.11569/wcjd.v29.i10.501] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Primary liver cancer has an insidious onset and no specific symptoms at early stage. Most patients are in the middle or advanced stage when diagnosed, and only 20%-40% of patients meet the criteria for radical resection. At present, surgical resection is still the main radical treatment for primary liver cancer, but factors such as liver function decompensation, too large tumor volume, too small future liver remnant, intrahepatic multiple metastasis, tumor thrombus invading the large vessels or bile duct, and distant metastasis limit the application of surgical resection or liver transplantation. In recent years, with the advances of basic research of primary liver cancer, the development of surgical techniques and equipment, as well as the development of new molecular targeted drugs and immunotherapy drugs, a part of unresectable patients with primary liver cancer can receive conversion therapy to improve liver function, minimize tumor volume, minimize or inactivate tumor thrombus, and increase the residual liver volume. Following conversion therapy, patients with primary liver cancer can undergo surgical resection or liver transplantation, which greatly improve the therapeutic efficacy and patient survival.
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Affiliation(s)
- Jian-Min Qin
- Department of General Surgery, the Third Hospital Affiliated to Naval Military Medical University, Shanghai 201805, China
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Wanis KN, Linecker M, Madenci AL, Müller PC, Nüssler N, Brusadin R, Robles-Campos R, Hahn O, Serenari M, Jovine E, Lehwald N, Knoefel WT, Reese T, Oldhafer K, de Santibañes M, Ardiles V, Lurje G, Capelli R, Enne M, Ratti F, Aldrighetti L, Zhurbin AS, Voskanyan S, Machado M, Kitano Y, Adam R, Chardarov N, Skipenko O, Ferri V, Vicente E, Tomiyama K, Hernandez-Alejandro R. Variation in complications and mortality following ALPPS at early-adopting centers. HPB (Oxford) 2021; 23:46-55. [PMID: 32456975 PMCID: PMC7680722 DOI: 10.1016/j.hpb.2020.04.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2019] [Accepted: 04/13/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Various, often conflicting, estimates for post-operative morbidity and mortality following ALPPS have been reported in the literature, suggesting that considerable center-level variation exists. Some of this variation may be related to center volume and experience. METHODS Using data from seventeen centers who were early adopters of the ALPPS technique, we estimated the variation, by center, in standardized 90-day mortality and comprehensive complication index (CCI) for patients treated between 2012 and 2018. RESULTS We estimated that center-specific 90-day mortality following treatment with ALPPS varied from 4.2% (95% CI: 0.8, 9.9) to 29.1% (95% CI: 13.9, 50.9), and that center-specific CCI following treatment with ALPPS varied from 17.0 (95% CI: 7.5, 26.5) to 49.8 (95% CI: 38.1, 61.8). Declines in estimated 90-day mortality and CCI were observed over time, and almost all individual centers followed this trend. Patients treated at centers with a higher number of ALPPS cases performed over the prior year had a lower risk of post-operative mortality. CONCLUSION Despite considerable center-level variation in ALPPS outcomes, perioperative outcomes following ALPPS have improved over time and treatment at higher volume centers results in a lower risk of 90-day mortality. Morbidity and mortality remain concerningly high at some centers.
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Affiliation(s)
- Kerollos N Wanis
- Department of Surgery, Western University, Ontario, Canada; Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA.
| | - Michael Linecker
- Department of Surgery and Transplantation, University Hospital Zurich, Switzerland
| | - Arin L Madenci
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Philip C Müller
- Department of Surgery and Transplantation, University Hospital Zurich, Switzerland
| | - Natascha Nüssler
- Department of Surgery, Klinikum Neuperlach, Städtisches Klinikum München, Munich, Germany
| | - Roberto Brusadin
- Department of Surgery and Liver and Pancreas Transplantation, Virgen de la Arrixaca Clinic and University Hospital, Murcia, Spain
| | - Ricardo Robles-Campos
- Department of Surgery and Liver and Pancreas Transplantation, Virgen de la Arrixaca Clinic and University Hospital, Murcia, Spain
| | - Oszkar Hahn
- Hepato-Pancreatico-Biliary (HPB) Surgical Research Center Hungary, 1st Department of Surgery, Semmelweis University, Budapest, Hungary
| | - Matteo Serenari
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Elio Jovine
- Department of Surgery, C. A. Pizzardi Maggiore Hospital, Bologna, Italy
| | - Nadja Lehwald
- Department of General, Visceral and Pediatric Surgery, Medical Faculty, University of Duesseldorf, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Wolfram T Knoefel
- Department of General, Visceral and Pediatric Surgery, Medical Faculty, University of Duesseldorf, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Tim Reese
- Department of General, Visceral and Oncological Surgery, Asklepios Klinik Barmbek, Hamburg, Germany
| | - Karl Oldhafer
- Department of General, Visceral and Oncological Surgery, Asklepios Klinik Barmbek, Hamburg, Germany
| | | | - Victoria Ardiles
- Department of Surgery, Hospital Italiano, Buenos Aires, Argentina
| | - Georg Lurje
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Germany; Department of Surgery, Charité Universitätsmedizin Berlin, Campus Charité Mitte I Campus Virchow Klinikum, Augustenburger Platz 1, 13353 Berlin, Germany
| | - Rafaela Capelli
- Hepatobiliary Surgery, Ipanema Federal Hospital, Health Ministry, Rio de Janeiro, Brazil
| | - Marcelo Enne
- Hepatobiliary Surgery, Ipanema Federal Hospital, Health Ministry, Rio de Janeiro, Brazil
| | | | | | - Alexey S Zhurbin
- Department of Surgery, A.I. Burnazyan FMBC Russian State Scientific Center of FMBA, Moscow, Russia
| | - Sergey Voskanyan
- Department of Surgery, A.I. Burnazyan FMBC Russian State Scientific Center of FMBA, Moscow, Russia
| | - Marcel Machado
- Department of Surgery, University of São Paulo, São Paulo, Brazil
| | - Yuki Kitano
- Hepato-Biliary Center, AP-HP Paul Brousse Hospital, University of Paris-Sud, Inserm U776, Villejuif, France
| | - René Adam
- Hepato-Biliary Center, AP-HP Paul Brousse Hospital, University of Paris-Sud, Inserm U776, Villejuif, France
| | - Nikita Chardarov
- Research Center of Surgery, Russian Academy of Medical Science, Moscow, Russia
| | - Oleg Skipenko
- Research Center of Surgery, Russian Academy of Medical Science, Moscow, Russia
| | - Valentina Ferri
- Department of General Surgery, HM Sanchinarro Hospital, Madrid, Spain
| | - Emilio Vicente
- Department of General Surgery, HM Sanchinarro Hospital, Madrid, Spain
| | - Koji Tomiyama
- Division of Transplantation/Hepatobiliary Surgery, Department of Surgery, University of Rochester, NY, USA
| | - Roberto Hernandez-Alejandro
- Department of Surgery, Western University, Ontario, Canada; Division of Transplantation/Hepatobiliary Surgery, Department of Surgery, University of Rochester, NY, USA
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Chan KS, Low JK, Shelat VG. Associated liver partition and portal vein ligation for staged hepatectomy: a review. Transl Gastroenterol Hepatol 2020; 5:37. [PMID: 32632388 PMCID: PMC7063517 DOI: 10.21037/tgh.2019.12.01] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Accepted: 11/30/2019] [Indexed: 02/05/2023] Open
Abstract
Outcomes of liver resection have improved with advances in surgical techniques, improvements in critical care and expansion of resectability criteria. However, morbidity and mortality following liver resection continue to plague surgeons. Post-hepatectomy liver failure (PHLF) due to inadequate future liver remnant (FLR) is an important cause of morbidity and mortality following liver resection. Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) is a novel two-staged procedure described in 2012, which aims to induce rapid hypertrophy of the FLR unlike conventional two-stage hepatectomy, which require a longer time for FLR hypertrophy. Careful patient selection and modifications in surgical technique has improved morbidity and mortality rates in ALPPS. Colorectal liver metastases (CRLM) confers the best outcomes post-ALPPS. Patients <60 years old and low-grade fibrosis with underlying hepatocellular carcinoma (HCC) are also eligible for ALPPS. Evidence for other types of cancers is less promising. Current studies, though limited, demonstrate that ALPPS has comparable oncological outcomes with conventional two-stage hepatectomy. Modifications such as partial-ALPPS and mini-ALPPS have shown improved morbidity and mortality compared to classic ALPPS. ALPPS may be superior to conventional two-stage hepatectomy in carefully selected groups of patients and has a promising outlook in liver surgery.
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Affiliation(s)
- Kai Siang Chan
- Department of Medicine, Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | - Jee Keem Low
- Department of General Surgery, Tan Tock Seng Hospital, Singapore
| | - Vishal G. Shelat
- Department of General Surgery, Tan Tock Seng Hospital, Singapore
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Lehwald-Tywuschik N, Vaghiri S, Schulte Am Esch J, Alaghmand S, Klosterkemper Y, Schimmöller L, Lachenmayer A, Ashmawy H, Krieg A, Topp SA, Rehders A, Knoefel WT. In situ split plus portal vein ligation (ISLT) - a salvage procedure following inefficient portal vein embolization to gain adequate future liver remnant volume prior to extended liver resection. BMC Surg 2020; 20:63. [PMID: 32252737 PMCID: PMC7333278 DOI: 10.1186/s12893-020-00721-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Accepted: 03/23/2020] [Indexed: 02/07/2023] Open
Abstract
Background Right extended liver resection is frequently required to achieve tumor-free margins. Portal venous embolization (PVE) of the prospective resected hepatic segments for conditioning segments II/III does not always induce adequate hypertrophy in segments II and III (future liver remnant volume (FLRV)) for extended right-resection. Here, we present the technique of in situ split dissection along segments II/III plus portal disruption to segments IV-VIII (ISLT) as a salvage procedure to overcome inadequate gain of FLRV after PVE. Methods In eight patients, FLRV was further pre-conditioned following failed PVE prior to hepatectomy (ISLT-group). We compared FLRV changes in the ISLT group with patients receiving extended right hepatectomy following sufficient PVE (PVEres-group). Survival of the ISLT-group was compared to PVEres patients and PVE patients with insufficient FLRV gain or tumor progress who did not receive further surgery (PVEnores-group). Results Patient characteristics and surgical outcome were comparable in both groups. The mean FLRV-to-body-weight ratio in the ISLT group was smaller than in the PVEres-group pre- and post-PVE. One intraoperative mortality due to a coronary infarction was observed for an ISLT patient. ISLT was successfully completed in the remaining seven ISLT patients. Liver function and 2-year survival of ~ 50% was comparable to patients with extended right hepatectomy after efficient PVE. Patients who received a PVE but who were not subsequently resected (PVEnores) demonstrated no survival beyond 4 months. Conclusion Despite extended embolization of segments I and IV-VIII, ISLT should be considered if hypertrophy was not adequate. Liver function and overall survival after ISLT was comparable to patients with trisectionectomy after efficient PVE.
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Affiliation(s)
- Nadja Lehwald-Tywuschik
- Department of Surgery A, University Hospital Duesseldorf, Duesseldorf, Germany.,Department of General, Visceral, Thorax and Pediatric Surgery,Heinrich-Heine-University Hospital, Moorenstr. 5, 40225, Duesseldorf, Germany
| | - Sascha Vaghiri
- Department of Surgery A, University Hospital Duesseldorf, Duesseldorf, Germany.,Department of General, Visceral, Thorax and Pediatric Surgery,Heinrich-Heine-University Hospital, Moorenstr. 5, 40225, Duesseldorf, Germany
| | - Jan Schulte Am Esch
- Present address: Center of Visceral Medicine, Department of Visceral Surgery, Protestant Hospital of Bethel Foundation, Bielefeld, Germany
| | - Salman Alaghmand
- Department of Surgery A, University Hospital Duesseldorf, Duesseldorf, Germany
| | - Yan Klosterkemper
- Department of Diagnostic and Interventional Radiology, University Hospital Duesseldorf, Duesseldorf, Germany
| | - Lars Schimmöller
- Department of Diagnostic and Interventional Radiology, University Hospital Duesseldorf, Duesseldorf, Germany
| | - Anja Lachenmayer
- Present ccaddress: Department of Visceral Surgery and Medicine, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Hany Ashmawy
- Department of Surgery A, University Hospital Duesseldorf, Duesseldorf, Germany.,Department of General, Visceral, Thorax and Pediatric Surgery,Heinrich-Heine-University Hospital, Moorenstr. 5, 40225, Duesseldorf, Germany
| | - Andreas Krieg
- Department of Surgery A, University Hospital Duesseldorf, Duesseldorf, Germany.,Department of General, Visceral, Thorax and Pediatric Surgery,Heinrich-Heine-University Hospital, Moorenstr. 5, 40225, Duesseldorf, Germany
| | - Stefan A Topp
- Present address: Department of Surgery, Ameos Hospital, Bremerhaven, Germany
| | - Alexander Rehders
- Department of Surgery A, University Hospital Duesseldorf, Duesseldorf, Germany.,Department of General, Visceral, Thorax and Pediatric Surgery,Heinrich-Heine-University Hospital, Moorenstr. 5, 40225, Duesseldorf, Germany
| | - Wolfram Trudo Knoefel
- Department of Surgery A, University Hospital Duesseldorf, Duesseldorf, Germany. .,Department of General, Visceral, Thorax and Pediatric Surgery,Heinrich-Heine-University Hospital, Moorenstr. 5, 40225, Duesseldorf, Germany.
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Au KP, Chan ACY. Current status of associating liver partition with portal vein ligation for staged hepatectomy: Comparison with two-stage hepatectomy and strategies for better outcomes. World J Gastroenterol 2019; 25:6373-6385. [PMID: 31798275 PMCID: PMC6881507 DOI: 10.3748/wjg.v25.i43.6373] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2019] [Revised: 07/31/2019] [Accepted: 08/07/2019] [Indexed: 02/06/2023] Open
Abstract
Since its introduction in 2012, associating liver partition with portal vein ligation for staged hepatectomy (ALPPS) has significantly expanded the pool of candidates for liver resection. It offers patients with insufficient liver function a chance of a cure. ALPPS is most controversial when its high morbidity and mortality is concerned. Operative mortality is usually a result of post-hepatectomy liver failure and can be minimized with careful patient selection. Elderly patients have limited reserve for tolerating the demanding operation. Patients with colorectal liver metastasis have normal liver and are ideal candidates. ALPPS for cholangiocarcinoma is technically challenging and associated with fair outcomes. Patients with hepatocellular carcinoma have chronic liver disease and limited parenchymal hypertrophy. However, in selected patients with limited hepatic fibrosis satisfactory outcomes have been produced. During the inter-stage period, serum bilirubin and creatinine level and presence of surgical complication predict mortality after stage II. Kinetic growth rate and hepatobiliary scintigraphy also guide the decision whether to postpone or omit stage II surgery. The outcomes of ALPPS have been improved by a combination of technical modifications. In patients with challenging anatomy, partial ALPPS potentially reduces morbidity, but remnant hypertrophy may compare unfavorably to a complete split. When compared to conventional two-stage hepatectomy with portal vein embolization or portal vein ligation, ALPPS offers a higher resection rate for colorectal liver metastasis without increased morbidity or mortality. While ALPPS has obvious theoretical oncological advantages over two-stage hepatectomy, the long-term outcomes are yet to be determined.
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Affiliation(s)
- Kin Pan Au
- Department of Surgery, Queen Mary Hospital, Hong Kong, China
| | - Albert Chi Yan Chan
- Department of Surgery and State Key Laboratory for Liver Research, The University of Hong Kong, Hong Kong, China
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9
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Abstract
The complete resection offers the best long-term survival for advanced hepatocellular carcinoma patients. ALPPS as a choice of resection, how is its outcome compared to one-stage resection, liver transplantation and TACE? This retrospective study included 20 ALPPS patients. To minimize the effect of confounding influences of measured covariates, PSM was performed. The overall survival (OS), morbidity, mortality and the increasing rate, KGR were analyzed. The OS in ALPPS group is 27.4 (±3.8 months) moths and the TACE group is 13.5(±1.2 months) (P < .001), LT group is 41.3 (±3.2 months) (P = .048), Resection group is 31.8 (±2.6 months) (P = .368). And the medium increasing volume is 209.5 cm (±61.5 cm) with the increasing ratio 52.4% (+26.9%). The ALPPS is a feasible treatment for HCC patients and it provides a better long-term survival than TACE and it is similar to Resection, less than LT.
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10
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Albati NA, Korairi AA, Al Hasan I, Almodhaiberi HK, Algarni AA. Outcomes of staged hepatectomies for liver malignancy. World J Hepatol 2019; 11:513-521. [PMID: 31293719 PMCID: PMC6603508 DOI: 10.4254/wjh.v11.i6.513] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2019] [Revised: 05/27/2019] [Accepted: 06/18/2019] [Indexed: 02/06/2023] Open
Abstract
Liver malignancies are the fifth most common cause of death worldwide. Surgical intervention with curative intent is the treatment of choice for liver tumors as it provides long-term survival. However, only 20% of patients with metastatic liver lesions can be managed by curative liver resection. In most of the cases, hepatectomy is not feasible because of insufficient future liver remnant (FLR). Two-stage hepatectomy is advocated to achieve liver resection in a patient who is considered to not be a candidate for resection. Procedures of staged hepatectomy include conventional two-stage hepatectomy, portal vein embolization, and associating liver partition and portal vein ligation for a staged hepatectomy. Technical success is high for each of these procedures but variable between them. All the procedures have been reported as being effective in achieving a satisfactory FLR and completing the second-stage resection. Moreover, the overall survival and disease-free survival rates have improved significantly for patients who were otherwise considered nonresectable; yet, an increase in the morbidity and mortality rates has been observed. We suggest that this type of procedure should be carried out in high-flow centers and through a multidisciplinary approach. An experienced surgeon is key to the success of those interventions.
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Affiliation(s)
- Naif A Albati
- Hepatobiliary and Liver Transplant Unit, Department of General Surgery, Prince Sultan Military Medical City, Riyadh 11159, Saudi Arabia
| | - Ali A Korairi
- Hepatobiliary and Liver Transplant Unit, Department of General Surgery, Prince Sultan Military Medical City, Riyadh 11159, Saudi Arabia
| | - Ibrahim Al Hasan
- Hepatobiliary and Liver Transplant Unit, Department of General Surgery, Prince Sultan Military Medical City, Riyadh 11159, Saudi Arabia
| | - Helayel K Almodhaiberi
- Hepatobiliary and Liver Transplant Unit, Department of General Surgery, Prince Sultan Military Medical City, Riyadh 11159, Saudi Arabia
| | - Abdullah A Algarni
- Hepatobiliary and Liver Transplant Unit, Department of General Surgery, Prince Sultan Military Medical City, Riyadh 11159, Saudi Arabia
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11
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Aljumaiah S, Alarfaj L, Almahozi AI, Tabbal M, Alqahtani MS. Experience of associated liver partition and portal vein ligation for staged hepatectomy as first published case report in Saudi Arabia. Clin Case Rep 2019; 7:1083-1086. [PMID: 31110750 PMCID: PMC6509894 DOI: 10.1002/ccr3.2146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Revised: 12/14/2018] [Accepted: 01/06/2019] [Indexed: 11/20/2022] Open
Abstract
This case is the first published associated liver partition and portal vein ligation for staged hepatectomy procedure done successfully in Saudi Arabia, with excellent hypertrophic response to the liver remnant. This is a milestone in liver resection techniques in the country and the region.
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Affiliation(s)
- Shaikhah Aljumaiah
- Hepatobiliary Surgery Section, Department of SurgeryKing Fahd Specialist Hospital DammamDammamSaudi Arabia
| | - Leenah Alarfaj
- Hepatobiliary Surgery Section, Department of SurgeryKing Fahd Specialist Hospital DammamDammamSaudi Arabia
| | - Ahmad I. Almahozi
- Hepatobiliary Surgery Section, Department of SurgeryKing Fahd Specialist Hospital DammamDammamSaudi Arabia
| | - Mahmoud Tabbal
- Hepatobiliary Surgery Section, Department of SurgeryKing Fahd Specialist Hospital DammamDammamSaudi Arabia
| | - Mohammed S. Alqahtani
- Hepatobiliary Surgery Section, Department of SurgeryKing Fahd Specialist Hospital DammamDammamSaudi Arabia
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Zhang ZF, Luo YJ, Lu Q, Dai SX, Sha WH. Conversion therapy and suitable timing for subsequent salvage surgery for initially unresectable hepatocellular carcinoma: What is new? World J Clin Cases 2018; 6:259-273. [PMID: 30211206 PMCID: PMC6134280 DOI: 10.12998/wjcc.v6.i9.259] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Revised: 07/18/2018] [Accepted: 08/07/2018] [Indexed: 02/05/2023] Open
Abstract
AIM To review the conversion therapy for initially unresectable hepatocellular carcinoma (HCC) patients and the suitable timing for subsequent salvage surgery.
METHODS A PubMed search was undertaken from 1987 to 2017 to identify articles using the keywords including “unresectable” “hepatocellular carcinoma”, ”hepatectomy”, ”conversion therapy”, “resection”, “salvage surgery” and “downstaging”. Additional studies were investigated through a manual search of the references from the articles. The exclusion criteria were duplicates, case reports, case series, videos, contents unrelated to the topic, comments, and editorial essays. The main and widely used conversion therapies and the suitable timing for subsequent salvage surgery were discussed in detail. Two members of our group independently performed the literature search and data extraction.
RESULTS Liver volume measurements [future liver remnant (FLR)/total liver volume or residual liver volume/bodyweight ratio] and function tests (scoring systems and liver stiffness) were often performed in order to justify whether patients were suitable candidates for surgery. Successful conversion therapy was usually defined as downstaging the tumor, increasing FLR and providing subsequent salvage surgery, without increasing complications, morbidity or mortality. The requirements for performing salvage surgery after transcatheter arterial chemoembolization were the achievement of a partial remission in radiology, the disappearance of the portal vein thrombosis, and the lack of extrahepatic metastasis. Patients with a standardized FLR (sFLR) > 20% were good candidates for surgery after portal vein embolization, while other predictive parameters like growth rate, kinetic growth rate were treated as an effective supplementary. There was probably not enough evidence to provide a standard operation time after associating liver partition and portal vein ligation for staged hepatectomy or yttrium-90 microsphere radioembolization. The indications of any combinations of conversion therapies and the subsequent salvage surgery time still need to be carefully and comprehensively evaluated.
CONCLUSION Conversion therapy is recommended for the treatment of initially unresectable HCC, and the suitable subsequent salvage surgery time should be reappraised and is closely related to its previous therapeutic effect.
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Affiliation(s)
- Ze-Feng Zhang
- Department of Gastroenterology and Hepatology, Guangdong Geriatrics Institute, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, Guangdong Province, China
| | - Yu-Jun Luo
- Department of Gastroenterology and Hepatology, Guangdong Geriatrics Institute, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, Guangdong Province, China
| | - Quan Lu
- Department of Gastroenterology and Hepatology, Guangdong Geriatrics Institute, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, Guangdong Province, China
| | - Shi-Xue Dai
- Department of Gastroenterology and Hepatology, Guangdong Geriatrics Institute, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, Guangdong Province, China
| | - Wei-Hong Sha
- Department of Gastroenterology and Hepatology, Guangdong Geriatrics Institute, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, Guangdong Province, China
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Uribe M, Uribe-Echevarría S, Mandiola C, Zapata MI, Riquelme F, Romanque P. Insight on ALPPS - Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy - mechanisms: activation of mTOR pathway. HPB (Oxford) 2018; 20:729-738. [PMID: 29571618 DOI: 10.1016/j.hpb.2018.02.636] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2017] [Revised: 02/21/2018] [Accepted: 02/24/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND ALPPS procedure has been introduced to increase the volume of future liver remnant. The mechanisms underlying the accelerated regeneration observed with ALPPS are unknown. It was hypothesized that AMPK/mTOR is activated as an integrating pathway for metabolic signals leading to proliferation and cell growth. Our aim was to analyze increase in liver volume, proliferation parameters and expression of AMPK/mTOR pathway-related molecules in patients undergoing ALPPS. METHODS A single center prospective study of patients undergoing ALPPS was performed from 2013 to 2015. Liver and serum samples, clinical laboratory results and CT-scan data were obtained. ELISA, Ki-67 immunostaining and qRT-PCR were performed in deportalized and remnant liver tissue in both stages of the procedure. RESULTS 11 patients were enrolled. Remnant liver volume increased 112 ± 63% (p < 0.05) in 9.1 ± 1.6 days. Proliferation-related cytokines IL-6, TNF-α, HGF and EGF significantly increased, while higher Ki-67 immunostaining and cyclin D expression were observed in remnant livers after ALPPS. mTOR, S6K1, 4E-BP1, TSC1 and TSC2 expression were significantly increased in remnant livers at second stage, while AMPK and Akt increased only in deportalized liver samples. CONCLUSION Rapid liver regeneration with ALPPS might be associated with hepatocyte proliferation induced by mTOR pathway activation.
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Affiliation(s)
- Mario Uribe
- Department of Surgery, Hospital del Salvador, Faculty of Medicine, Universidad de Chile, Santiago, Chile
| | - Sebastián Uribe-Echevarría
- Department of Surgery, Hospital del Salvador, Faculty of Medicine, Universidad de Chile, Santiago, Chile
| | - Carlos Mandiola
- Biomedical Sciences Institute, Faculty of Medicine, Universidad de Chile, Santiago, Chile
| | - María I Zapata
- Biomedical Sciences Institute, Faculty of Medicine, Universidad de Chile, Santiago, Chile
| | - Francisco Riquelme
- Department of Surgery, Hospital del Salvador, Faculty of Medicine, Universidad de Chile, Santiago, Chile
| | - Pamela Romanque
- Biomedical Sciences Institute, Faculty of Medicine, Universidad de Chile, Santiago, Chile.
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López-López V, Robles-Campos R, Brusadin R, López-Conesa A, Navarro Á, Arevalo-Perez J, Gil PJ, Parrilla P. Tourniquet-ALPPS is a promising treatment for very large hepatocellular carcinoma and intrahepatic cholangiocarcinoma. Oncotarget 2018; 9:28267-28280. [PMID: 29963276 PMCID: PMC6021344 DOI: 10.18632/oncotarget.25538] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Accepted: 05/12/2018] [Indexed: 02/06/2023] Open
Abstract
When very large hepatocellular carcinomas (HCCs) and intrahepatic cholangiocarcinoma (IHCCs) with insufficient future liver remnants are treated using associating liver partition and portal vein ligation for staged hepatectomy (ALPPS), the outcome is often poor. We therefore tested the efficacy of a modified version of that technique, tourniquet-ALPPS. A review of the literature examining outcomes of HCC and IHCC patients treated with ALPPS revealed the incidences of morbidity ≥ III and postoperative mortality to be respectively 20.7% and 16.1% among HCC patients and 50% and 45.4% among IHCC patients. In the present case series, in which HCC and IHCC patients were treated with tourniquet-ALPPS, median tumor size was 100 mm (range: 70-200 mm). After surgical stage I, there was no morbidity, no mortality and the median future liver remnant had increased at day 7 by 76%. In surgical stage II, 100% of tumors were resectable (8 right trisectionectomies, 5 with inferior vena cava resection). Two patients experienced serious morbidity ≥ IIIB and 1 patient died (11%). One- and 3-year overall survival was 75% and 60%, respectively. Thus tourniquet-ALPPS appears to be an effective alternative to classical ALPPS for the treatment of patients with HCC or IHCC.
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Affiliation(s)
- Victor López-López
- Virgen de la Arrixaca Clinic and University Hospital, IMIB, Murcia, Spain
| | | | - Robeto Brusadin
- Virgen de la Arrixaca Clinic and University Hospital, IMIB, Murcia, Spain
| | | | - Álvaro Navarro
- Virgen de la Arrixaca Clinic and University Hospital, IMIB, Murcia, Spain
| | - Julio Arevalo-Perez
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Pedro Jose Gil
- Virgen de la Arrixaca Clinic and University Hospital, IMIB, Murcia, Spain
| | - Pascual Parrilla
- Virgen de la Arrixaca Clinic and University Hospital, IMIB, Murcia, Spain
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Wanis KN, Ardiles V, Alvarez FA, Tun-Abraham ME, Linehan D, de Santibañes E, Hernandez-Alejandro R. Intermediate-term survival and quality of life outcomes in patients with advanced colorectal liver metastases undergoing associating liver partition and portal vein ligation for staged hepatectomy. Surgery 2017; 163:691-697. [PMID: 29203284 DOI: 10.1016/j.surg.2017.09.044] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Revised: 08/13/2017] [Accepted: 09/13/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) is an innovative, 2-staged hepatectomy which has elicited controversy within the international hepatobiliary community. Uptake of ALPPS has been limited due to concerns related to evidence of high morbidity and mortality, and scant oncologic and outcome data on quality of life (Qol). Demonstrating reasonable long-term benefits with a short-term risk is necessary to support more widespread endorsement of ALPPS. Our aim was to describe the intermediate-term survival and patient-reported quality of life outcomes after an ALPPS. METHODS Prospectively collected data from 2 high-volume ALPPS centers, who were pioneers with the technique, were combined and analyzed for disease-free and overall survival from date of the ALLPS. Only patients treated for colorectal liver metastases with >6 month postoperative follow-up were included. All patients had bilateral colorectal liver metastases with an initially unresectable tumor load, and received preoperative chemotherapy. Information concerning the demographics of the patients, characteristics of the tumor, and treatment were analyzed. The well-validated European Organization for Research and Treatment for Cancer Quality of Life Core Questionnaire version 3.0 questionnaire was used to assess patient quality of life. RESULTS A total of 58 patients underwent ALPPS for colorectal liver metastases, and 47 patients met our inclusion criteria. There were no perioperative mortalities, and the rate of severe complications was 21%. At 3 years post-ALPPS, the overall survival was 50%, while the disease-free survival was 13%. The commonest site of first recurrence was the liver alone (38%). Patient-reported quality of life after ALPPS was similar to reference values for general population. CONCLUSION In select patients operated at experienced centers, ALPPS results in low perioperative risk, satisfactory overall survival, and excellent quality of life. Hepatic recurrence and not systemic recurrence is the most common site of relapse after ALPPS.
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Affiliation(s)
- Kerollos Nashat Wanis
- Department of Surgery, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
| | - Victoria Ardiles
- Department of Surgery, Division of HPB Surgery, Liver Transplant Unit, Italian Hospital Buenos Aires, Buenos Aires, Argentina
| | - Fernando A Alvarez
- Department of Surgery, Division of HPB Surgery, Liver Transplant Unit, Italian Hospital Buenos Aires, Buenos Aires, Argentina
| | - Mauro Enrique Tun-Abraham
- Department of Surgery, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
| | - David Linehan
- Department of Surgery, University of Rochester, Rochester, NY
| | - Eduardo de Santibañes
- Department of Surgery, Division of HPB Surgery, Liver Transplant Unit, Italian Hospital Buenos Aires, Buenos Aires, Argentina
| | - Roberto Hernandez-Alejandro
- Division of Transplantation/Hepatobiliary Surgery, Department of Surgery, University of Rochester, Rochester, NY.
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16
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Kang D, Schadde E. Hypertrophy and Liver Function in ALPPS: Correlation with Morbidity and Mortality. Visc Med 2017; 33:426-433. [PMID: 29344516 DOI: 10.1159/000479477] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Background ALPPS (associating liver partition and portal vein ligation for staged hepatectomy) was introduced with the promise to reduce posthepatectomy liver failure (PHLF) in extended hepatectomies but has higher morbidity and mortality rates compared to conventional methods of volume enhancement. There are few studies of the incidence of PHLF after ALPPS and little information on how to avoid PHLF by functional testing. It remains unclear what causes the compromise in liver function despite rapid volume gain and if any of the modifications proposed reduce the incidence of PHLF. This review summarizes published data on this topic. Methods This is a systematic review that studies literature on the incidence of liver failure and assessment of liver function following ALPPS as well as modifications of the existing technique. Articles were searched in PubMed, evaluated, selected, and tabulated. Results The literature search revealed 326 articles that met the selection criteria. PHLF criteria as defined by the International Study Group of Liver Surgery (ISGLS) were the most commonly used criteria, but PHLF was frequently not defined. PHLF occurred most frequently after stage 2 of ALPPS at around 30% in most larger studies. Hepatobiliary scintigraphy showed a discrepancy between volume and functional growth of the liver. Function increase was only 50% compared to volume increase. Mechanistic explanations using histologic analyses have been given to explain the immaturity of the liver after rapid hypertrophy. Modifications of ALPPS showed a comparable volumetric gain when compared to classic ALPPS, but data were lacking to assess PHLF. Conclusion ALPPS has relatively high rates of PHLF, morbidity, and mortality. This may be explained by data demonstrating functional growth when compared to volume growth. ALPPS should not be performed without functional assessment and with caution.
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Affiliation(s)
- Danby Kang
- Department of Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Erik Schadde
- Department of Surgery, Rush University Medical Center, Chicago, IL, USA.,Cantonal Hospital Winterthur, Winterthur, Switzerland.,Institute of Physiology, Center for Integrative Human Physiology, University of Zurich, Zurich, Switzerland
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Stavrou GA, Donati M, Fard-Aghaie MH, Zeile M, Huber TM, Stang A, Oldhafer KJ. Did the International ALPPS Meeting 2015 Have an Impact on Daily Practice? The Hamburg Barmbek Experience of 58 Cases. Visc Med 2017; 33:456-461. [PMID: 29344520 PMCID: PMC5757589 DOI: 10.1159/000479476] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND ALPPS (associating liver partition and portal vein ligation for staged hepatectomy) was introduced only 10 years ago and has gained wide acceptance as a variation of staged procedures in liver surgery. It has been criticized for its high morbidity and mortality, which all centers reported in their initial series. METHODS After a world expert meeting in Hamburg in 2015 where all experts in the field met to discuss this method, caveats were extracted and formulated. We researched our complete prospective ALPPS database to see if the recommendations had any impact on outcome. RESULTS In total, we performed 58 ALPPS procedures in our center. 33 patients were operated on before, 25 after the meeting. Results in terms of morbidity and mortality were significantly better after the meeting, as were patient selection and strategy. CONCLUSION In our own center's experience, the implementation of the meetings' recommendations and the information gathered through this valuable exchange had a dramatic impact on results. Having performed 58 ALPPS procedures in total, we can now conclude that ALPPS has become much safer in our hands since the 2015 meeting and that morbidity and mortality are no longer the issue to be discussed. Future research must focus on oncologic outcomes in these patients.
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Affiliation(s)
- Gregor A. Stavrou
- General and Visceral Surgery, Surgical Oncology, Asklepios Hospital Barmbek, Hamburg, Germany
- Semmelweis Medical Faculty, Campus Hamburg, Hamburg, Germany
| | - Marcello Donati
- General and Visceral Surgery, Surgical Oncology, Asklepios Hospital Barmbek, Hamburg, Germany
- Department of Surgery, Vittorio-Emanuele University Hospital Catania, Catania, Italy
| | - Mohammad H. Fard-Aghaie
- General and Visceral Surgery, Surgical Oncology, Asklepios Hospital Barmbek, Hamburg, Germany
| | - Martin Zeile
- Semmelweis Medical Faculty, Campus Hamburg, Hamburg, Germany
- Diagnostic and Interventional Radiology, Asklepios Hospital Barmbek, Hamburg, Germany
| | - Tessa M. Huber
- General and Visceral Surgery, Surgical Oncology, Asklepios Hospital Barmbek, Hamburg, Germany
| | - Axel Stang
- Semmelweis Medical Faculty, Campus Hamburg, Hamburg, Germany
- Medical Oncology, Asklepios Hospital Barmbek, Hamburg, Germany
| | - Karl J. Oldhafer
- General and Visceral Surgery, Surgical Oncology, Asklepios Hospital Barmbek, Hamburg, Germany
- Semmelweis Medical Faculty, Campus Hamburg, Hamburg, Germany
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Lau WY, Lai EC. Modifications of ALPPS - from complex to more complex or from complex to less complex operations. Hepatobiliary Pancreat Dis Int 2017; 16:346-352. [PMID: 28823363 DOI: 10.1016/s1499-3872(17)60034-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Accepted: 05/12/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) has recently been developed to induce rapid liver hypertrophy to reduce the chance of post-hepatectomy liver failure in patients with borderline or insufficient future liver remnant. ALPPS is still in an early developmental stage and its techniques have not been standardized. This study aimed to review the technical modifications of the conventional ALPPS procedure. DATA SOURCES Studies were identified by searching MEDLINE and PubMed for articles published from January 2007 to December 2016 using the keywords "associating liver partition and portal vein ligation for staged hepatectomy" and "ALPPS". Additional articles were identified by a manual search of references from key articles. RESULTS There have been a lot of modifications of the conventional ALPPS. These are classified as: (1) modifications aiming to improve surgical results; (2) modifications aiming to expand surgical indications; (3) salvage ALPPS; (4) ALPPS using the minimally invasive approach. Some of these modifications have made the conventional ALPPS procedure to become even more complex, although there have also been other attempts to make the procedure less complex. The results of most of these modifications have been reported in small case series or case reports. We need better well-designed studies to establish the true roles of these modifications. However, it is interesting to see how this conventional ALPPS procedure has evolved since its introduction. CONCLUSIONS There is a trend for the use of minimally invasive procedure in the phase 1 or 2 of the conventional ALPPS procedure. Some of these modifications have expanded the use of ALPPS in patients who have been considered to have unresectable liver tumors. The long-term oncological outcomes of these modifications are still unknown.
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Affiliation(s)
- Wan Yee Lau
- Faculty of Medicine, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong SAR, China.
| | - Eric Ch Lai
- Faculty of Medicine, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong SAR, China; Department of Surgery, Pamela Youde Nethersole Eastern Hospital, Hong Kong SAR, China
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Truant S, Baillet C, Deshorgue AC, El Amrani M, Huglo D, Pruvot FR. Contribution of hepatobiliary scintigraphy in assessing ALPPS most suited timing. Updates Surg 2017; 69:411-419. [PMID: 28795384 DOI: 10.1007/s13304-017-0481-5] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2016] [Accepted: 07/12/2017] [Indexed: 12/12/2022]
Abstract
To reduce post-hepatectomy liver failure (PHLF), associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) has been recently developed for patients with a limited future remnant liver (FRL). Nevertheless, high morbi-mortality rates have been reported . The current study aimed to analyze the kinetics of FRL function in patients who were offered ALPPS. Serial SPECT (99 m)Tc-mebrofenin hepatobiliary scintigraphy (HBS) was performed in all patients before and after surgery as well as at inter-stage to quantitatively assess hepatic function [total liver (TL) and FRL]. Patients were offered ALPPS for colorectal liver metastases (CLMs) (n = 6) and gallbladder carcinoma (n = 1). The data of delta of function or volume, expressed as (postoperative FRL - preoperative FRL/preoperative FRL) were compared to those derived from HBS of patients referred to the university hospital of Lille for one-stage major hepatectomy (n = 93). Additionally, the intrinsic liver function (i.e. function per unit of volume) was used to assess the regeneration rate. All but one patient had an anticipated FRL to body weight ratio (FRLBWR) ≤0.5%. Inter-stages HBS showed a progressive attenuation of the functional value of the excluded hepatic segments in favour of the FRL for all patients. Overall, there was a drop of total liver function contrasting with subnormal passive biochemical tests. Notably, the increase in FRL function between ALPPS stages [+12.5% (4.2-28.6%)] was lower than the volumetric gain [+42.6% (18.3-110.2%)] and inferior to that observed after one-stage major hepatectomy [+41.7% (-38.6 to +158.33%)]. This resulted in a drop of the FRL intrinsic liver function in ALPPS patients, of whom one died from PHLF. Our study enhances the importance of assessing liver function along with volume during ALPPS procedure and supports HBS as a suitable and reliable method, including a valuable contribution to determine most appropriate stage 2 surgical timing.
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Affiliation(s)
- Stéphanie Truant
- Department of Digestive Surgery and Transplantation, Hôpital HURIEZ, Rue M. Polonovski, CHU, Univ Nord de France, 59000, Lille, France.
| | - Clio Baillet
- Department of Nuclear Medicine, Hôpital HURIEZ, Lille, France
| | - Anne Claire Deshorgue
- Department of Digestive Surgery and Transplantation, Hôpital HURIEZ, Rue M. Polonovski, CHU, Univ Nord de France, 59000, Lille, France
| | - Mehdi El Amrani
- Department of Digestive Surgery and Transplantation, Hôpital HURIEZ, Rue M. Polonovski, CHU, Univ Nord de France, 59000, Lille, France
| | - Damien Huglo
- Department of Nuclear Medicine, Hôpital HURIEZ, Lille, France
| | - François-René Pruvot
- Department of Digestive Surgery and Transplantation, Hôpital HURIEZ, Rue M. Polonovski, CHU, Univ Nord de France, 59000, Lille, France
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Peng SY, Wang XA, Huang CY, Zhang YY, Li JT, Hong DF, Cai XJ. Evolution of associating liver partition and portal vein ligation for staged hepatectomy: Simpler, safer and equally effective methods. World J Gastroenterol 2017; 23:4140-4145. [PMID: 28694654 PMCID: PMC5483488 DOI: 10.3748/wjg.v23.i23.4140] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2017] [Revised: 04/03/2017] [Accepted: 05/04/2017] [Indexed: 02/06/2023] Open
Abstract
Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) has been recently demonstrated as a method to induce rapid and extensive hypertrophy within a short time and has been employed for a variety of primary and metastatic liver tumors. However, controversies remain due to its high morbidity and mortality. To enable safer surgery, liver surgeons have searched for better technical modifications, such as partial ALPPS, mini-ALPPS, minimally invasive ALPPS, and Terminal branches portal vein Embolization Liver Partition for Planned hepatectomy (TELPP). It seems that TELPP is very promising, because it has the main advantage of ALPPS - the rapid increase of future liver remnant volume, but the morbidity and mortality are much lower because only one surgical operation is required.
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Abstract
OBJECTIVE We describe a modified procedure associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) including portal pedicle preservation during parenchymal division, thus avoiding necrosis. BACKGROUND Although ALPPS recently has been advocated for treating advanced liver tumors, sepsis originating from the ischemic area produced by parenchymal division increases mortality, accounting for one-third of postoperative deaths. METHODS Our procedure differs from the original ALPPS technique by sparing portal pedicles at the transection plane, thus maintaining blood supply. The preserved pedicles are segment 4 (S4) in right lobectomy plus right portal vein ligation (PVL), S1 in extended right hepatectomy (extended to S1) plus right PVL, lateral portal pedicles of the right paramedian sector (RPS) in extended right lateral sectoriectomy plus lateral PVL, and both portal pedicles of the lateral RPS and S1 in extended right lateral sectoriectomy with S1 resection plus lateral PVL. RESULTS These procedures were performed in 5 patients. Morbidity rates at first- and second-stage operations were 0% and 80%, without mortality. Mean hypertrophy of the future liver remnant was 1.638 ± 0.384 a week after the first-stage procedure. CONCLUSIONS Our technique stimulates rapid hypertrophy and may improve safety in ALPPS.
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Zerial M, Lorenzin D, Risaliti A, Zuiani C, Girometti R. Abdominal cross-sectional imaging of the associating liver partition and portal vein ligation for staged hepatectomy procedure. World J Hepatol 2017; 9:733-745. [PMID: 28652892 PMCID: PMC5468342 DOI: 10.4254/wjh.v9.i16.733] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2017] [Revised: 03/22/2017] [Accepted: 04/10/2017] [Indexed: 02/06/2023] Open
Abstract
Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) is a recently introduced technique aimed to perform two-stage hepatectomy in patients with a variety of primary or secondary neoplastic lesions. ALPSS is based on a preliminary liver resection associated with ligation of the portal branch directed to the diseased hemiliver (DH), followed by hepatectomy after an interval of time in which the future liver remnant (FLR) hypertrophied adequately (partly because of preserved arterialization of the DH). Multidetector computed tomography (MDCT) and magnetic resonance imaging (MRI) play a pivotal role in patients’ selection and FLR assessment before and after the procedure, as well as in monitoring early and late complications, as we aim to review in this paper. Moreover, we illustrate main abdominal MDCT and MRI findings related to ALPPS.
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Modified ALPPS procedures: more safety through less invasive surgery. Langenbecks Arch Surg 2017; 402:563-574. [PMID: 28493147 DOI: 10.1007/s00423-017-1588-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Accepted: 05/04/2017] [Indexed: 02/06/2023]
Abstract
PURPOSE Although associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) has been advocated for treating advanced liver tumors, increased morbidity and mortality remain serious problems. Many modified procedures have been devised to improve patient safety, but some confusion persists as to benefits and risks. METHODS Modifications to ALPPS as originally reported were reviewed to clarify their contributions to safety and their clinical relevance. RESULTS A variety of modifications are explained and considered. Modifications mainly aim to reduce adhesions, prevent tumor spread, avoid devascularization during liver splitting, and reduce surgical severity. Such changes aiming to increase safety and reduce invasiveness are needed to avoid high morbidity and mortality rates with this innovative procedure. However, these modified procedures still require more meaningful statistical comparisons of outcome. CONCLUSIONS Prospective controlled studies are needed to confirm which modified procedures should be adopted in a standardized manner as an alternative to the original ALPPS. Further, we need to further explore mechanisms of liver regeneration, functional recovery, histopathologic changes of hepatocytes, and blood distribution during ALPPS simultaneously to developing and evaluating modifications of the procedure.
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Sanei B, Sheikhbahaei S, Sanei MH, Bahreini A, Jafari HR. Associating liver partition and portal vein ligation for staged hepatectomy: A surgical technique for liver resections. JOURNAL OF RESEARCH IN MEDICAL SCIENCES 2017; 22:52. [PMID: 28567071 PMCID: PMC5426088 DOI: 10.4103/jrms.jrms_829_16] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/18/2016] [Revised: 01/02/2017] [Accepted: 01/29/2017] [Indexed: 12/27/2022]
Abstract
Background: Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) is a novel surgical technique liver resection in traditionally nonresectable primary intrahepatic tumors or colorectal liver metastases. Materials and Methods: From June 2013 to March 2014, patients with primary tumor of liver or colorectal tumors with liver metastasis were selected to evaluate whether they met the initial criteria for ALPPS procedure. Results: Nine patients enrolled in the study with primary diagnoses of colon and rectosigmoid cancer, carcinoid tumor, gastrointestinal stromal tumor of small intestine, hepatocellular carcinoma, and pancreatic neuroendocrine tumor (PNET). Four candidates excluded from the study prior or during the first step operation due to fatty liver, hepatic fibrosis, peritoneal seeding, and multiple small intestine metastases. Five patients underwent two stages of ALPPS with the interval of about 1 week. Liver hypertrophy was 100% among our candidates after the initial step. One postoperative death happened because of massive pulmonary thromboembolism Recurrence of liver metastasis was seen in one patient. Hepatic failure Class B and A were observed in two patients which did not progress during follow-up period. One patient developed an enterocutaneous fistula. Discussion: We recommend to use 2 organ bags, one for wrapping right lobe and the other one for covering visceral organs and also do liver biopsy in suspicious cases of damaged liver parenchyma and laparoscopic exploration of abdomen for seeding and multiple metastases prior to laparotomy. Conclusion: As the procedure has not been well established and verified by oncologists yet, further studies are required to define the exact indications of ALPPS.
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Affiliation(s)
- Behnam Sanei
- Department of Liver Transplant and Hepatobiliary and Pancreatic Surgery, Isfahan, Iran.,Department of General Surgery, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Saba Sheikhbahaei
- Acquired Immunodeficiency Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | | | - Amin Bahreini
- Department of Liver Transplant and Hepatobiliary and Pancreatic Surgery, Ahvaz, Iran.,Department of General Surgery, Jundishapour University of Medical Sciences, Ahvaz, Iran
| | - Hamid Reza Jafari
- Department of General Surgery, Isfahan University of Medical Sciences, Isfahan, Iran
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Olthof PB, Huiskens J, Wicherts DA, Huespe PE, Ardiles V, Robles-Campos R, Adam R, Linecker M, Clavien PA, Koopman M, Verhoef C, Punt CJA, van Gulik TM, de Santibanes E. Survival after associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) for advanced colorectal liver metastases: A case-matched comparison with palliative systemic therapy. Surgery 2017; 161:909-919. [PMID: 28038862 DOI: 10.1016/j.surg.2016.10.032] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2016] [Revised: 10/06/2016] [Accepted: 10/19/2016] [Indexed: 12/17/2022]
Abstract
BACKGROUND Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) allows the resection of colorectal liver metastases with curative intent which would otherwise be unresectable and only eligible for palliative systemic therapy. This study aimed to compare outcomes of ALPPS in patients with otherwise unresectable colorectal liver metastases with matched historic controls treated with palliative systemic treatment. METHODS All patients with colorectal liver metastases from the international ALPPS registry were identified and analyzed. Survival data were compared according to the extent of disease. Otherwise unresectable ALPPS patients were defined by at least 2 of the following criteria: ≥6 metastasis, ≥2 future remnant liver metastasis, ≥6 involved segments excluding segment 1. These patients were matched with patients included in 2, phase 3, metastatic, colorectal cancer trials (CAIRO and CAIRO2) using propensity scoring in order to compare survival. RESULTS Of 295 patients with colorectal liver metastases in the ALPPS registry, 70 patients had otherwise unresectable disease defined by the proposed criteria. Two-year overall survival was 49% and 72% for patients with ≥2 and <2 criteria, respectively (P = .002). Median disease-free survival was 6 months compared to 12 months (P < .001) in the ≥2 and <2 criteria groups, respectively. Median overall survival was comparable between ALPPS patients with ≥2 criteria and case-matched patients who received palliative treatment (24.0 vs 17.6 months, P = .088). CONCLUSION Early oncologic outcomes of patients with advanced liver metastases undergoing ALPPS were not superior to results of matched patients receiving systemic treatment with palliative intent. Careful patient selection is essential in order to improve outcomes.
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Affiliation(s)
- Pim B Olthof
- Department of Surgery, Academic Medical Center, Amsterdam, the Netherlands.
| | - Joost Huiskens
- Department of Surgery, Academic Medical Center, Amsterdam, the Netherlands
| | - Dennis A Wicherts
- Department of Surgery, Academic Medical Center, Amsterdam, the Netherlands
| | - Pablo E Huespe
- Department of Surgery, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Victoria Ardiles
- Department of Surgery, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Ricardo Robles-Campos
- Servicio de Cirugía General y Aparato Digestivo, Virgen de la Arrixaca University Hospital, Murcia, Spain
| | - René Adam
- Centre Hépato-Biliaire, Hôpital Paul Brousse, Villejuif, France
| | - Michael Linecker
- Department of Surgery and Transplantation, Swiss HPB Centre, University Hospital Zurich, Switzerland
| | - Pierre-Alain Clavien
- Department of Surgery and Transplantation, Swiss HPB Centre, University Hospital Zurich, Switzerland
| | - Miriam Koopman
- Department of Medical Oncology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Cornelis Verhoef
- Department of Surgical Oncology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Cornelis J A Punt
- Department of Medical Oncology, Academic Medical Center, Amsterdam, the Netherlands
| | - Thomas M van Gulik
- Department of Surgery, Academic Medical Center, Amsterdam, the Netherlands
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Liao M, Zhang T, Wang H, Liu Y, Lu M, Huang J, Zeng Y. Rabbit model provides new insights in liver regeneration after transection with portal vein ligation. J Surg Res 2017; 209:242-251. [DOI: 10.1016/j.jss.2016.10.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Revised: 09/28/2016] [Accepted: 10/26/2016] [Indexed: 02/07/2023]
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Lau WY, Lai EC, Lau SH. Associating liver partition and portal vein ligation for staged hepatectomy: the current role and development. Hepatobiliary Pancreat Dis Int 2017; 16:17-26. [PMID: 28119254 DOI: 10.1016/s1499-3872(16)60174-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) has recently been developed to induce rapid liver hypertrophy and reduce post-hepatectomy liver failure in patients with insufficient future liver remnant (FLR). ALPPS is still considered to be in an early developmental phase because surgical indications and techniques have not been standardized. This article aimed to review the current role and future developments of ALPPS. DATA SOURCES Studies were identified by searching MEDLINE and PubMed for articles from January 2007 to October 2016 using the keywords "associating liver partition and portal vein ligation for staged hepatectomy" and "ALPPS". Additional papers were identified by a manual search of references from key articles. RESULTS ALPPS induces more hypertrophy of the FLR in less time than portal vein embolization or portal vein ligation. The benefits of ALPPS include rapid hypertrophy 47%-110% of the liver over a median of 6-16.4 days, and 95%-100% completion rate of the second stage of ALPPS. The main criticisms of ALPPS are centered on its high morbidity and mortality rates. Morbidity rates after ALPPS have been reported to be 15.3%-100%, with ≥ the Clavien-Dindo grade III morbidity of 13.6%-44%. Mortality rates have been reported to be 0%-29%. The important questions to ask even if oncologic long-term results are acceptable are: whether the gain in quality and quantity of life can be off balance by the substantial risks of morbidity and mortality, and whether stimulation of rapid liver hypertrophy also accelerates rapid tumor progression and spread. Up till now, the documentations of the ALPPS procedure come mainly from case series, and most of these series include heterogeneous groups of malignancies. The numbers are also too small to separately evaluate survival for different tumor etiologies. CONCLUSIONS Currently, knowledge on ALPPS is limited, and prospective randomized studies are lacking. From the reported preliminary results, safety of the ALPPS procedure remains questionable. ALPPS should only be used in experienced, high-volume hepatobiliary centers.
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Affiliation(s)
- Wan Yee Lau
- Faculty of Medicine, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong, China.
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28
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Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) in colorectal liver metastasis: the radiologist's perspective. Abdom Radiol (NY) 2016; 41:2150-2160. [PMID: 27377899 DOI: 10.1007/s00261-016-0832-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE Hepatic resection is the only potentially curative treatment for patients with colorectal liver metastasis (CRLM). Many multidisciplinary approaches, including the associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) procedure, have been proposed to increase the resectability rate in these patients. ALPPS is the most recently described staged liver resection technique, representing an advantageous strategy to induce a rapid and marked increase in the future liver remnant (FLR) volume. The aim of this article is to describe the radiological evaluation of this procedure and its variation. METHODS This retrospective study included 9 patients with CRLM who underwent the ALPPS procedure. Abdominal imaging studies were reviewed, with an emphasis on a rational radiological approach. The number of liver metastases, the FLR volume (pre- and postportal vein ligation), anatomical variations, potential pitfalls related to disease progression, and postoperative complications were evaluated. RESULTS The types of hepatic resection included 4 classical ALPPS cases, 3 right ALPPS variations, and 2 left ALPPS variations. The mean FLR volume calculated in the initial evaluation was 453 mL (213-790 mL). Following the first surgery, the mean FLR volume increased to 634 mL (410-957 mL), which indicated a mean volume increase of 181.1 mL (95% CI 149.7-212.5 mL; p < 0.001) and a mean absolute volume increase of 48% (19%-88%). CONCLUSION The ALPPS procedure is an emerging form of two-stage hepatectomy. In this context, radiologists should provide crucial preoperative and perioperative information that may change surgical planning and contribute to an improvement in the oncologic outcome.
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Cai YL, Song PP, Tang W, Cheng NS. An updated systematic review of the evolution of ALPPS and evaluation of its advantages and disadvantages in accordance with current evidence. Medicine (Baltimore) 2016; 95:e3941. [PMID: 27311006 PMCID: PMC4998492 DOI: 10.1097/md.0000000000003941] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
The main obstacle to achieving an R0 resection after a major hepatectomy is inability to preserve an adequate future liver remnant (FLR) to avoid postoperative liver failure (PLF). Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) is a novel technique for resecting tumors that were previously considered unresectable, and this technique results in a vast increase in the volume of the FLR in a short period of time. However, this technique continues to provoke heated debate because of its high mortality and morbidity.The evolution of ALPPS and its advantages and disadvantages have been systematically reviewed and evaluated in accordance with current evidence. Electronic databases (PubMed and Medline) were searched for potentially relevant articles from January 2007 to January 2016.ALPPS has evolved into various modified forms. Some of these modified techniques have reduced the difficulty of the procedure and enhanced its safety. Current evidence indicates that the advantages of ALPPS are rapid hypertrophy of the FLR, the feasibility of the procedure, and a higher rate of R0 resection in comparison to other techniques. However, ALPPS is associated with worse major complications, more deaths, and early tumor recurrence.Hepatobiliary surgeons should carefully consider whether to perform ALPPS. Some modified forms of ALPPS have reduced the mortality and morbidity of the procedure, but they cannot be recommended over the original procedure currently. Portal vein embolization (PVE) is still the procedure of choice for patients with a tumor-free FLR, and ALPPS could be used as a salvage procedure when PVE fails. More persuasive evidence needs to be assembled to determine whether ALPPS or two-stage hepatectomy (TSH) is better for patients with a tumor involving the FLR. Evidence with regard to long-term oncological outcomes is still limited. More meticulous comparative studies and studies of the 5-year survival rate of ALPPS could ultimately help to determine the usefulness of ALPPS. Indications and patient selection for the procedure need to be determined.
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Affiliation(s)
- Yu-Long Cai
- Department of Bile Duct Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Pei-Pei Song
- Graduate School of Frontier Sciences, The University of Tokyo, Kashiwa-shi, Chiba, Japan
| | - Wei Tang
- Department of Bile Duct Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Nan-Sheng Cheng
- Department of Bile Duct Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
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Buac S, Schadde E, Schnitzbauer AA, Vogt K, Hernandez-Alejandro R. The many faces of ALPPS: surgical indications and techniques among surgeons collaborating in the international registry. HPB (Oxford) 2016; 18:442-8. [PMID: 27154808 PMCID: PMC4857070 DOI: 10.1016/j.hpb.2016.01.547] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2015] [Accepted: 01/14/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND ALPPS was developed to induce accelerated future liver remnant (FLR) hypertrophy in order to increase hepatic tumour resectability and reduce the risk of post-operative liver failure. While early studies demonstrated concerning complication rates, others reported favourable results. This inconsistency may be due to variability in surgical indications and technique. METHODS A web-based survey was sent to surgeons participating in the International ALPPS Registry in September of 2014. Questions addressed surgeon demographics and training, surgical indications and technique, and clinical management approaches. RESULTS Fifty six out of 85 surgeons from 78 centers responded (66%) and half (n = 30) had training in liver transplantation. Forty seven (84%) did not reserve ALPPS solely for colorectal liver metastases (CRLM) and 30 (54%) would perform ALPPS for an FLR over 30%. Neoadjuvant chemotherapy for CRLM was recommended by 37 (66%) respondents. Surgical approaches varied considerably, with 30% not preserving outflow to the middle hepatic vein and 39% believing it necessary to skeletonize the hepatoduodenal ligament. Twenty five (45%) surgeons have observed segment 4 necrosis. CONCLUSION There is considerable variability in how ALPPS is performed internationally. This heterogeneity in practice patterns may explain the current incongruity in published outcomes, and highlights the need for standardization.
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Affiliation(s)
- Suzana Buac
- Dept. of Surgery, Western University, London, ON, Canada
| | - Erik Schadde
- Division of Transplantation, Dept. of Surgery, Rush University Medical Center, Chicago, IL, United States,Cantonal Hospital Winterthur, Winterthur, Canton Zurich, Switzerland
| | | | - Kelly Vogt
- Dept. of Surgery, Western University, London, ON, Canada
| | - Roberto Hernandez-Alejandro
- Dept. of Surgery, Western University, London, ON, Canada,Correspondence Roberto Hernandez-Alejandro, Western University, University Hospital LHSC, 339 Windermere Rd, London, ON N6A 5A5, Canada. Tel: +1 519 663 2904. Fax: +1 519 663 3858.
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31
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Edmondson MJ, Sodergren MH, Pucher PH, Darzi A, Li J, Petrowsky H, Campos RR, Serrablo A, Jiao LR. Variations and adaptations of associated liver partition and portal vein ligation for staged hepatectomy (ALPPS): Many routes to the summit. Surgery 2016; 159:1058-1072. [PMID: 26747229 DOI: 10.1016/j.surg.2015.11.013] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Revised: 10/19/2015] [Accepted: 11/11/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND Our aim was to review variations from the originally described associated liver partition and portal vein ligation for staged hepatectomy (ALPPS) procedure and relevant clinical outcomes. METHODS A systematic review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (ie, PRISMA) guidelines. A search of PubMed and Google Scholar was conducted until March 2015. Inclusion criteria were any publications reporting technical variations and descriptions of ALPPS. Exclusion criteria were insufficient technical description, data repeated elsewhere, or data that could not be accessed in English. RESULTS Initial search results returned 790 results; 46 studies were included in the final qualitative analysis. There were several alternatives described to the first stage of complete parenchymal split. Variations included partial ALPPS (partial split; hypertrophy of future liver remnant [FLR] 80-90%), radiofrequency-assisted liver partition and portal vein ligation (mean FLR hypertrophy 62%), laparoscopic microwave ablation and portal vein ligation (FLR hypertrophy 78-90%), associating liver tourniquet and portal ligation for staged hepatectomy (median FLR hypertrophy 61%), and sequential associating liver tourniquet and portal ligation for staged hepatectomy (FLR hypertrophy 77%) with a potential decrease in morbidity particularly after stage I. We analyzed several other variations, including considerations for segment IV, operative maneuvers, use of laparoscopy, identification of biliary complications, and liver containment. CONCLUSION The current literature demonstrates a large variability in techniques of ALPPS that limits meaningful statistical comparisons of outcomes. Not physically splitting the liver at the first stage may decrease morbidity; however, randomized controlled trials are needed to determine benefits in technical variations.
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Affiliation(s)
- Matthew J Edmondson
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom
| | - Mikael H Sodergren
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom.
| | - Philip H Pucher
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom
| | - Ara Darzi
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom
| | - Jun Li
- Department of Hepatobiliary Surgery and Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Henrik Petrowsky
- Swiss HPB and Transplant Center, University Hospital Zurich, Zurich, Switzerland
| | - Ricardo Robles Campos
- Department of General Surgery, Liver Transplant Unit, Virgen De La Arrixaca University Hospital, Murcia, Spain
| | | | - Long R Jiao
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom
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Wei W, Zhang T, Zafarnia S, Schenk A, Xie C, Kan C, Dirsch O, Settmacher U, Dahmen U. Establishment of a rat model: Associating liver partition with portal vein ligation for staged hepatectomy. Surgery 2016; 159:1299-307. [PMID: 26879073 DOI: 10.1016/j.surg.2015.12.005] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2015] [Revised: 12/08/2015] [Accepted: 12/09/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND We adapted the anatomically oriented parenchyma-preserving resection technique for associating liver partition with portal vein ligation (PVL) for staged hepatectomy (ALPPS) in rats and examined the role of revascularization in intrahepatic size regulation. METHODS We performed the procedures based on anatomic study. The ALPPS procedure consisted of a 70% PVL (occluding the left median, left lateral, and right lobes), parenchymal transection (median lobe) and partial (10%) hepatectomy (PHx; caudate lobe). The transection effect was evaluated by measuring the extent of hepatic atrophy or regeneration of individual liver lobes in the ALPPS and control groups (70% PVL and 10% PHx without transection). The survival rates after stage II resection and collateral formation within the portal vein system was examined. RESULTS Anatomic study revealed a close spatial relationship between the demarcation line and the middle median hepatic vein. This enabled placing the transection plane without injuring the hepatic vein. Transection was achieved via stepwise clamping, followed by 2-3 parenchyma-preserving piercing sutures on both sides of the clamp. Ligated liver lobes atrophy was significantly enhanced after ALPPS compared with the control group. In contrast, both a significantly greater relative weight of the regenerated lobe and proliferation index on the first postoperative day were observed. All animals tolerated stage II-resection without complications. Portoportal collaterals were only observed in the control group. CONCLUSION We developed an anatomically precise technique for parenchymal transection. The lack of a dense vascular network between the portalized and deportalized lobes may play an important role in accelerating regeneration and atrophy augmentation.
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Affiliation(s)
- Weiwei Wei
- Experimental Transplantation Surgery, Department of General, Visceral and Vascular Surgery, Jena University Hospital, Jena, Germany
| | - Tianjiao Zhang
- Experimental Transplantation Surgery, Department of General, Visceral and Vascular Surgery, Jena University Hospital, Jena, Germany
| | - Sara Zafarnia
- Department of Experimental Molecular Imaging, RWTH Aachen University, Aachen, Germany
| | - Andrea Schenk
- Fraunhofer Institute for Medical Image Computing MEVIS, Bremen, Germany
| | - Chichi Xie
- Experimental Transplantation Surgery, Department of General, Visceral and Vascular Surgery, Jena University Hospital, Jena, Germany
| | - Chunyi Kan
- Experimental Transplantation Surgery, Department of General, Visceral and Vascular Surgery, Jena University Hospital, Jena, Germany
| | - Olaf Dirsch
- Institute of Pathology, Chemnitz Hospital, Chemnitz, Germany
| | - Utz Settmacher
- Experimental Transplantation Surgery, Department of General, Visceral and Vascular Surgery, Jena University Hospital, Jena, Germany
| | - Uta Dahmen
- Experimental Transplantation Surgery, Department of General, Visceral and Vascular Surgery, Jena University Hospital, Jena, Germany.
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Matsuo K, Murakami T, Kawaguchi D, Hiroshima Y, Koda K, Yamazaki K, Ishida Y, Tanaka K. Histologic features after surgery associating liver partition and portal vein ligation for staged hepatectomy versus those after hepatectomy with portal vein embolization. Surgery 2016; 159:1289-98. [PMID: 26775576 DOI: 10.1016/j.surg.2015.12.004] [Citation(s) in RCA: 73] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2015] [Revised: 11/17/2015] [Accepted: 12/06/2015] [Indexed: 12/28/2022]
Abstract
OBJECTIVE We compared histologic findings in nonneoplastic portions of liver resected during surgery associating liver partition with portal vein ligation for staged hepatectomy (ALPPS) with those from hepatectomy after portal vein embolization (PVE). SUMMARY BACKGROUND DATA Effects of congestion and ischemia in ALPPS on hepatocyte regeneration are incompletely understood, as are those on hepatocyte maturity. METHODS Specimens obtained from 8 patients treated with ALPPS and from 14 patients treated with hepatectomy after PVE were examined by light and electron microscopy. RESULTS Extrapolated kinetic growth of the future liver remnant (FLR) for ALPPS was 14.4 ± 4.8 mL/d, which was faster than for PVE (3.6 ± 2.2 mL/d; P < .001). Microscopically, the FLR showed greater hepatocyte cell density and smaller hepatocyte size in ALPPS than in PVE (P < .01 for each). Bright-appearing hepatocytes and sinusoidal narrowing were more frequent in ALPPS (50% and 50%) than in PVE (0% and 8.3%; P = .025 for each). In the deportalized ventral aspect of the anterior section, hepatocyte atrophy, hepatocyte degeneration or necrosis, sinusoidal dilation, fibrosis, and congestion were more frequent in ALPPS than in PVE (P = .001, P = .002, P < .001, and P < .001, respectively). Electron microscopy frequently showed vacant-appearing hepatocytic cytoplasm filled with glycogen granules in the FLR in ALPPS. Fewer cytoplasmic organelles and lipofuscin granules were observed in ALPPS than in PVE. CONCLUSION In the FLR, regenerative hepatocytes in ALPPS were morphologically immature compared with PVE. ALPPS should be performed with caution, considering limited functional increase in the FLR reflecting immaturity of the regenerative hepatocytes.
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Affiliation(s)
- Kenichi Matsuo
- Department of Surgery, Teikyo University Chiba Medical Center, Chiba, Japan
| | - Takashi Murakami
- Department of Surgery, Teikyo University Chiba Medical Center, Chiba, Japan
| | - Daisuke Kawaguchi
- Department of Surgery, Teikyo University Chiba Medical Center, Chiba, Japan
| | - Yukihiko Hiroshima
- Department of Surgery, Teikyo University Chiba Medical Center, Chiba, Japan
| | - Keiji Koda
- Department of Surgery, Teikyo University Chiba Medical Center, Chiba, Japan
| | - Kazuto Yamazaki
- Division of Diagnostic Pathology, Teikyo University Chiba Medical Center, Chiba, Japan
| | - Yasuo Ishida
- Division of Diagnostic Pathology, Teikyo University Chiba Medical Center, Chiba, Japan
| | - Kuniya Tanaka
- Department of Surgery, Teikyo University Chiba Medical Center, Chiba, Japan.
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Vivarelli M, Vincenzi P, Montalti R, Fava G, Tavio M, Coletta M, Vecchi A, Nicolini D, Agostini A, Ali Ahmed E, Giovagnoni A, Mocchegiani F. ALPPS Procedure for Extended Liver Resections: A Single Centre Experience and a Systematic Review. PLoS One 2015; 10:e0144019. [PMID: 26700646 PMCID: PMC4689524 DOI: 10.1371/journal.pone.0144019] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2015] [Accepted: 11/12/2015] [Indexed: 02/06/2023] Open
Abstract
AIM To report a single-centre experience with the novel Associating Liver Partition and Portal vein ligation for Staged hepatectomy (ALPPS) technique and systematically review the related literature. METHODS Since January 2013, patients with extended primary or secondary liver tumors whose future liver remnant (FLR) was considered too small to allow hepatic resection were prospectively assessed for the ALPPS procedure. A systematic literature search was performed using PubMed, Scopus and the Cochrane Library Central. RESULTS Until July 2014 ALPPS was completed in 9 patients whose mean age was 60 ± 8 years. Indications for surgical resection were metastases from colorectal cancer in 3 cases, perihilar cholangiocarcinoma in 3 cases, intrahepatic cholangiocarcinoma in 2 cases and hepatocellular carcinoma without chronic liver disease in 1 case. The calculated FLR volume was 289 ± 122 mL (21.1 ± 5.5%) before ALPPS-1 and 528 ± 121 mL (32.2 ± 5.7%) before ALLPS-2 (p < 0.001). The increase in FLR between the two procedures was 96 ± 47% (range: 24-160%, p < 0.001). Additional interventions were performed in 4 cases: 3 patients underwent Roux-en-Y hepaticojejunostomy, and one case underwent wedge resection of a residual tumor in the FLR. The average time between the first and second step of the procedure was 10.8 ± 2.9 days. The average hospital stay was 24.1 ± 13.3 days. There was 1 postoperative death due to hepatic failure in the oldest patient of this series who had a perihilar cholangiocarcinoma and concomitant liver fibrosis; 11 complications occurred in 6 patients, 4 of whom had grade III or above disease. After a mean follow-up of 17.1 ± 8.5 months, the overall survival was 89% at 3-6 and 12 months. The recurrence-free survival was 100%, 87.5% and 75% at 3-6-12 months respectively. The literature search yielded 148 articles, of which 22 articles published between 2012 and 2015 were included in this systematic review. CONCLUSION The ALPPS technique effectively increased the resectability of otherwise inoperable liver tumors. The postoperative morbidity in our series was high in accordance with the data from the systematic review. Age, liver fibrosis and presence of biliary stenting were predisposing factors for postoperative morbidity and mortality.
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Affiliation(s)
- Marco Vivarelli
- Hepatobiliary and Abdominal Transplantation Surgery, Department of Experimental and Clinical Medicine, Polytechnic University of Marche, Ancona, Italy
| | - Paolo Vincenzi
- Hepatobiliary and Abdominal Transplantation Surgery, Department of Experimental and Clinical Medicine, Polytechnic University of Marche, Ancona, Italy
| | - Roberto Montalti
- Hepatobiliary and Abdominal Transplantation Surgery, Department of Experimental and Clinical Medicine, Polytechnic University of Marche, Ancona, Italy
| | - Giammarco Fava
- Department of Gastroenterology, Polytechnic University of Marche, Ancona, Italy
| | - Marcello Tavio
- Unit of Emerging and Immunosuppressed Infectious Diseases, Department of Gastroenterology and Transplantation, Polytechnic University of Marche, Ancona, Italy
| | - Martina Coletta
- Hepatobiliary and Abdominal Transplantation Surgery, Department of Experimental and Clinical Medicine, Polytechnic University of Marche, Ancona, Italy
| | - Andrea Vecchi
- Hepatobiliary and Abdominal Transplantation Surgery, Department of Experimental and Clinical Medicine, Polytechnic University of Marche, Ancona, Italy
| | - Daniele Nicolini
- Hepatobiliary and Abdominal Transplantation Surgery, Department of Experimental and Clinical Medicine, Polytechnic University of Marche, Ancona, Italy
| | - Andrea Agostini
- Unit of General and Paediatric Radiology, Department of Radiology, Polytechnic University of Marche, Ancona, Italy
| | - Emad Ali Ahmed
- Hepatobiliary and Abdominal Transplantation Surgery, Department of Experimental and Clinical Medicine, Polytechnic University of Marche, Ancona, Italy
- Department of Gastroenterology, Polytechnic University of Marche, Ancona, Italy
- Unit of Emerging and Immunosuppressed Infectious Diseases, Department of Gastroenterology and Transplantation, Polytechnic University of Marche, Ancona, Italy
- Unit of General and Paediatric Radiology, Department of Radiology, Polytechnic University of Marche, Ancona, Italy
- Hepatobiliary and Pancreatic Surgery Unit, Department of General Surgery, Faculty of Medicine, Sohag University, Sohag, Egypt
| | - Andrea Giovagnoni
- Unit of General and Paediatric Radiology, Department of Radiology, Polytechnic University of Marche, Ancona, Italy
| | - Federico Mocchegiani
- Hepatobiliary and Abdominal Transplantation Surgery, Department of Experimental and Clinical Medicine, Polytechnic University of Marche, Ancona, Italy
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Croome KP, Mao SA, Glorioso JM, Krishna M, Nyberg SL, Nagorney DM. Characterization of a porcine model for associating liver partition and portal vein ligation for a staged hepatectomy. HPB (Oxford) 2015; 17:1130-6. [PMID: 26234167 PMCID: PMC4644366 DOI: 10.1111/hpb.12465] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2015] [Accepted: 06/01/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND Publications using the ALPPS (associating liver partition and portal vein ligation for a staged hepatectomy) procedure have demonstrated a future liver remnant growth of 40-160% in only 6-9 days. The present study aimed to develop and describe the first large animal model of ALPPS that can be used for future studies. METHODS A total of 13 female domestic pigs underwent ALPPS stage 1 (portal vein division and parenchymal transection) followed by ALPPS stage 2 (completion left-extended hepatectomy) 7 days later. An abdominal computed tomography (CT) scan was performed immediately prior to ALPPS stage 1 surgery and again 7 days later to assess hypertrophy immediately prior to ALPPS stage 2 surgery. Blood samples, as well as tissue analysis for Ki-67, were performed. RESULTS On CT volumetric analysis, the mean size of the future liver remnant (FLR) prior to ALPPS stage 1 was 21 ± 2% and 40 ± 6% prior to ALPPS stage 2. The median degree of growth was 75% with a mean kinetic growth rate of 11% per day. Liver weights at autopsy correlated well with CT volumetric analysis (r = 0.87). There was no significant difference in mean lab values [asparate aminotransferase (AST), alanine aminotransferase (ALT), ammonia, International Normalized Ratio (INR) or bilirubin] from baseline until immediately prior to ALPPS stage 2. Post ALPPS stage 2 there was a significant increase in INR from baseline 1.1 to 1.6 (P = 0.012). No post-operative deaths secondary to liver failure were observed. CONCLUSION The present study describes the first reproducible large animal model of the ALPPS procedure. The degree of liver growth and the kinetic rate of growth were similar to that which has been demonstrated in human publications. This model will be valuable as future laboratory studies are performed.
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Affiliation(s)
- Kristopher P Croome
- Division of Gastroenterologic and General Surgery, Mayo ClinicRochester, MN, USA,Department of Transplantation, Mayo Clinic FloridaJacksonville, FL, USA
| | - Shennen A Mao
- Division of Gastroenterologic and General Surgery, Mayo ClinicRochester, MN, USA
| | - Jaime M Glorioso
- Division of Gastroenterologic and General Surgery, Mayo ClinicRochester, MN, USA
| | - Murli Krishna
- Division of Pathology, Mayo ClinicJacksonville, FL, USA
| | - Scott L Nyberg
- Division of Transplantation Surgery and Mayo Clinic William J. von Liebig Transplant Center, Mayo ClinicRochester, MN, USA
| | - David M Nagorney
- Division of Gastroenterologic and General Surgery, Mayo ClinicRochester, MN, USA
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Vyas SJ, Davies N, Grant L, Imber CJ, Sharma D, Davidson BR, Malago M, Fusai G. Failure of portal venous embolization. ALPPS as salvage enabling successful resection of bilobar liver metastases. J Gastrointest Cancer 2015; 45 Suppl 1:233-6. [PMID: 25081490 DOI: 10.1007/s12029-014-9643-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Soumil J Vyas
- Division of HPB and Liver Transplant Surgery, Royal Free Hospital and Medical School, Pond Street, London, NW3 2QG, UK,
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Cai X, Duan L, Wang Y, Jiang W, Liang X, Yu H, Cai L. Laparoscopic hepatectomy by curettage and aspiration: a report of 855 cases. Surg Endosc 2015; 30:2904-13. [PMID: 26487222 DOI: 10.1007/s00464-015-4576-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Accepted: 09/19/2015] [Indexed: 12/13/2022]
Abstract
BACKGROUND In 1998, the technique of laparoscopic hepatectomy by curettage and aspiration was developed and a special instrument, laparoscopic multifunctional operative dissector (LPMOD), was designed for this procedure. In the past 17 years, this procedure was developed gradually and had become the routine procedure for laparoscopic hepatectomy in local area. This paper is to report results of 17-year practice of this procedure. METHODS Patients who underwent laparoscopic hepatectomy from August 1998 to March 2015 were reviewed. Hepatectomies were performed using the technique of laparoscopic hepatectomy by curettage and aspiration. By using the LPMOD, liver parenchyma was crashed and aspirated immediately and the intrahepatic ducts and small vessels were preserved and were safely dissected for ligation. Laparoscopic selective hepatic flow occlusion was performed routinely for hemi-hepatectomies to control intraoperative blood loss. RESULTS A total of 855 cases underwent laparoscopic hepatectomy by curettage and aspiration. No perioperative death, 105 patients were converted to open operation, and 84 of them were converted before liver transection without any emergency. Postoperative bleeding occurred in three patients (0.4 %), and bile leakage occurred in seven patients (0.8 %). CONCLUSION Laparoscopic hepatectomy by curettage and aspiration is a safe procedure for liver resection with acceptable morbidity and mortality.
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Affiliation(s)
- XiuJun Cai
- Department of General Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, 3, East Qingchun Road, Hangzhou, 310016, China.
| | - Lian Duan
- Department of General Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, 3, East Qingchun Road, Hangzhou, 310016, China
| | - YiFan Wang
- Department of General Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, 3, East Qingchun Road, Hangzhou, 310016, China
| | - Wenbin Jiang
- Department of General Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, 3, East Qingchun Road, Hangzhou, 310016, China
| | - Xiao Liang
- Department of General Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, 3, East Qingchun Road, Hangzhou, 310016, China
| | - Hong Yu
- Department of General Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, 3, East Qingchun Road, Hangzhou, 310016, China
| | - LiuXin Cai
- Department of General Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, 3, East Qingchun Road, Hangzhou, 310016, China
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Kremer M, Manzini G, Hristov B, Polychronidis G, Mokry T, Sommer CM, Mehrabi A, Weitz J, Büchler MW, Schemmer P. Impact of Neoadjuvant Chemotherapy on Hypertrophy of the Future Liver Remnant after Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy. J Am Coll Surg 2015; 221:717-728.e1. [PMID: 26232303 DOI: 10.1016/j.jamcollsurg.2015.05.017] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2015] [Revised: 05/13/2015] [Accepted: 05/19/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) has been demonstrated as a feasible procedure in extended liver resections as a means of successfully increasing the volume of the future liver remnant (FLR). Neoadjuvant chemotherapy (CTx) is toxic to the organ and may impair hepatic regeneration. This study was performed to assess the procedure's effect on hypertrophy of the FLR, including the short-term survival. STUDY DESIGN We analyzed 19 consecutive ALPPS patients, of whom 58% (n = 11) received neoadjuvant CTx because of colorectal liver metastasis (CRM). Patients presented with multifocal CRM (n = 11, 58%); cholangiocarcinoma (n = 7, 37%), of which 5 were in the Klatskin position; and gallbladder carcinoma (n = 1, 5%). Hepatectomy was performed within 6 to 13 days after hepatic partition. Volumetry was performed before both liver partitioning and hepatectomy. A survival analysis was performed. RESULTS Liver partition and portal vein ligation induced sufficient hypertrophy of the FLR, with an increased volume of 74% ± 35%. Patients underwent hepatectomy after a median of 8 days; in all cases R0 resection was achieved. Neoadjuvant CTx was shown to significantly impair hypertrophy. The volume of the FLR in non-CTx patients increased by 98% ± 35%; an increase of 59% ± 22% was observed in patients who underwent CTx (p = 0.027). Chemotherapy did not have an impact on either morbidity or in-hospital mortality, which were 68% and 16%, respectively. One-year overall survival was 53%, with a 1-year survival of 67% in CRM patients and 38% in non-CRM patients (p > 0.05). CONCLUSIONS Data presented here demonstrate for the first time that neoadjuvant CTx significantly impairs hypertrophy of the FLR after ALPPS.
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Affiliation(s)
- Michael Kremer
- Department of General, Visceral and Transplant Surgery, University Hospital Heidelberg, Germany
| | - Giulia Manzini
- Department of General, Visceral and Transplant Surgery, University Hospital Heidelberg, Germany
| | - Branimir Hristov
- Department of General, Visceral and Transplant Surgery, University Hospital Heidelberg, Germany
| | - Georg Polychronidis
- Department of General, Visceral and Transplant Surgery, University Hospital Heidelberg, Germany
| | - Theresa Mokry
- Department of Diagnostic and Interventional Radiology, University Hospital Heidelberg, Germany
| | - Christoph M Sommer
- Department of Diagnostic and Interventional Radiology, University Hospital Heidelberg, Germany
| | - Arianeb Mehrabi
- Department of General, Visceral and Transplant Surgery, University Hospital Heidelberg, Germany
| | - Jürgen Weitz
- Department of General, Visceral and Transplant Surgery, University Hospital Heidelberg, Germany
| | - Markus W Büchler
- Department of General, Visceral and Transplant Surgery, University Hospital Heidelberg, Germany
| | - Peter Schemmer
- Department of General, Visceral and Transplant Surgery, University Hospital Heidelberg, Germany.
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Zhang Y, Yang H, Chen Y, Zhu S, Lu T, Jun X. Totally Laparoscopic Associating Liver Tourniquet and Portal Ligation for Staged Hepatectomy via Anterior Approach for Cirrhotic Hepatocellular Carcinoma. J Am Coll Surg 2015; 221:e43-e48. [PMID: 26206661 DOI: 10.1016/j.jamcollsurg.2015.04.016] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2015] [Revised: 04/19/2015] [Accepted: 04/20/2015] [Indexed: 02/07/2023]
Affiliation(s)
- Yu Zhang
- Third Department of Hepatobiliary Surgery, Sichuan Academy of Medical Sciences (Sichuan Provincial People's Hospital), Chinese Academy of Sciences, Chengdu, China
| | - Hongji Yang
- Third Department of Hepatobiliary Surgery, Sichuan Academy of Medical Sciences (Sichuan Provincial People's Hospital), Chinese Academy of Sciences, Chengdu, China.
| | - Yunfei Chen
- Third Department of Hepatobiliary Surgery, Sichuan Academy of Medical Sciences (Sichuan Provincial People's Hospital), Chinese Academy of Sciences, Chengdu, China
| | - Shikai Zhu
- Third Department of Hepatobiliary Surgery, Sichuan Academy of Medical Sciences (Sichuan Provincial People's Hospital), Chinese Academy of Sciences, Chengdu, China
| | - Tao Lu
- Third Department of Hepatobiliary Surgery, Sichuan Academy of Medical Sciences (Sichuan Provincial People's Hospital), Chinese Academy of Sciences, Chengdu, China
| | - Xu Jun
- Third Department of Hepatobiliary Surgery, Sichuan Academy of Medical Sciences (Sichuan Provincial People's Hospital), Chinese Academy of Sciences, Chengdu, China
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Croome KP, Hernandez-Alejandro R, Parker M, Heimbach J, Rosen C, Nagorney DM. Is the liver kinetic growth rate in ALPPS unprecedented when compared with PVE and living donor liver transplant? A multicentre analysis. HPB (Oxford) 2015; 17:477-84. [PMID: 25728543 PMCID: PMC4430776 DOI: 10.1111/hpb.12386] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2014] [Accepted: 12/12/2014] [Indexed: 12/12/2022]
Abstract
BACKGROUND The clinical perspective on hepatic growth is limited. The goal of the present study was to compare hepatic hypertrophy and the kinetic growth rate(KGR) in patients after the ALPPS (Associating Liver Partition with Portal Vein Ligation for Staged Hepatectomy) procedure, portal vein embolization (PVE) and living donor liver transplantation. METHODS Volumetry and KGR of the future liver remnant (FLR) were compared from (15) patients undergoing ALPPS, (53) patients undergoing PVE, (90) recipients of living donor liver grafts and (93) donors of living donor liver grafts. RESULTS The degree of hypertrophy was significantly greater after ALPPS (84.3 ± 7.8%) than after PVE (36.0 ± 27.2%) (P < 0.001). The KGR was also significantly greater for ALPPS [32.7 ± 13.6 cubic centimetres (cc)/day] (10.8 ± 4.5%/day) compared with PVE (4.4 ± 3.2 cc/day) (0.98 ± 0.75%/day) (P < 0.001). The FLR of living donor donors had the greatest degree of hypertrophy (107.5 ± 39.2%) and was greater than after ALPPS (P = 0.02), PVE (P < 0.001) and in living donor-recipient grafts (P < 0.001). KGR (cc/day) was greater in FLR of living donor donors compared with both ALPPS (P < 0.001) and PVE (P < 0.001). The KGR in patients undergoing ALPPS and living donor liver transplantation had a linear relationship with the size of FLR. CONCLUSION FLR hypertrophy and KGR were greater after ALPPS than PVE. However, the degree of hypertrophy after ALPPS is not unprecedented, as KGR in the FLR from living donor donors is equal to or greater than after ALPPS. The KGR of the FLR in patients after ALPPS and living donor donors correlates directly with the size of the FLR.
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Affiliation(s)
- Kristopher P Croome
- Divisions of Gastroenterologic and General Surgery, Mayo ClinicRochester, MN, USA
- Department of Transplantation, Mayo ClinicJacksonville, FL, USA
| | | | - Maile Parker
- Divisions of Gastroenterologic and General Surgery, Mayo ClinicRochester, MN, USA
| | - Julie Heimbach
- Division of Transplantation Surgery and Mayo Clinic William J. von Liebig Transplant Center, Mayo ClinicRochester, MN, USA
| | - Charles Rosen
- Division of Transplantation Surgery and Mayo Clinic William J. von Liebig Transplant Center, Mayo ClinicRochester, MN, USA
| | - David M Nagorney
- Divisions of Gastroenterologic and General Surgery, Mayo ClinicRochester, MN, USA
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Lang SA, Loss M, Benseler V, Glockzin G, Schlitt HJ. Long-term results after in-situ split (ISS) liver resection. Langenbecks Arch Surg 2015; 400:361-9. [PMID: 25854503 DOI: 10.1007/s00423-015-1285-z] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2014] [Accepted: 02/08/2015] [Indexed: 02/07/2023]
Abstract
PURPOSE In-situ split (ISS) liver resection is a novel method to induce rapid hypertrophy of the contralateral liver lobe in patients at risk for postoperative liver failure due to insufficient liver remnant. So far, no data about oncological long-term survival after ISS liver resection is available. METHODS We retrospectively analyzed our patients treated with ISS liver resection at the Department of Surgery of the University of Regensburg, the first center worldwide to perform ISS. RESULTS Between 2007 and 2014, ISS liver resection was performed in 16 patients. Two patients (12.5 %) were lost in early postoperative phase (90 days) and one was lost to follow-up. Thirteen patients with a follow-up period of more than 3 months were included into oncologically focused analyses. Median follow-up was 26.4 months (range 3.2-54.6). Seven patients had suffered from colorectal liver metastases (CRLM) and six from various other liver malignancies (non-CRLM). The ISS procedure had led to a median increase of 86.3 % of the left lateral liver lobe after a median of 9 days (range 4-28 days). Median disease-free survival (DFS) was 14.6 months and median overall survival (OS) was 41.7 months (26.4 months when including 90-days mortality). Three-year survival was calculated with 56.4 and 48.9 % when including perioperative mortality, respectively (CRLM 64.3 % vs. non-CRLM 50 %). CONCLUSION ISS liver resection can provide long-term survival of selected patients with advanced liver malignancies that otherwise are not eligible for liver resection due to insufficient liver remnant.
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Affiliation(s)
- Sven A Lang
- Department of Surgery, University Hospital Regensburg, Franz-Josef-Strauss Allee 11, 93053, Regensburg, Germany,
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Tanaka K, Matsuo K, Murakami T, Kawaguchi D, Hiroshima Y, Koda K, Endo I, Ichikawa Y, Taguri M, Tanabe M. Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS): short-term outcome, functional changes in the future liver remnant, and tumor growth activity. Eur J Surg Oncol 2015; 41:506-12. [PMID: 25704556 DOI: 10.1016/j.ejso.2015.01.031] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2014] [Revised: 01/20/2015] [Accepted: 01/23/2015] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND We compared clinical outcomes of associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) against those of classical 2-stage hepatectomy in treating metastatic liver disease. METHODS Short-term outcomes, serial changes in volume of the future liver remnant (FLR), functional FLR volume, and tumor growth activity during the treatment period, were compared between our first 11 consecutive patients treated with ALPPS and 54 patients treated with classical 2-stage hepatectomy. RESULTS Mortality in the ALPPS group (9%) tended to be higher than in the classical 2-stage group (2%, P = 0.341). The FLR hypertrophy ratio (FLR volume after vs. before the procedure) 1 week after the first operation in the ALPPS group (1.54 ± 0.18) exceeded that in the classical 2-stage group (1.19 ± 0.29, P = 0.005), being similar to the ratio at 3 weeks after the first procedure in the classical 2-stage group (1.40 ± 0.43). However, functional volume of the FLR in the ALPPS group 1 week after the first procedure (52.1%) tended to be smaller than that in the classical group 3 weeks after the first procedure (59.2%). CONCLUSIONS ALPPS should be used with extreme caution, giving special attention to postoperative complications and grade of functional liver regeneration.
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Affiliation(s)
- K Tanaka
- Department of Surgery, Teikyo University Chiba Medical Center, Chiba, Japan.
| | - K Matsuo
- Department of Surgery, Teikyo University Chiba Medical Center, Chiba, Japan
| | - T Murakami
- Department of Surgery, Teikyo University Chiba Medical Center, Chiba, Japan
| | - D Kawaguchi
- Department of Surgery, Teikyo University Chiba Medical Center, Chiba, Japan
| | - Y Hiroshima
- Department of Surgery, Teikyo University Chiba Medical Center, Chiba, Japan
| | - K Koda
- Department of Surgery, Teikyo University Chiba Medical Center, Chiba, Japan
| | - I Endo
- Department of Gastroenterological Surgery, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Y Ichikawa
- Department of Clinical Oncology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - M Taguri
- Department of Biostatistics and Epidemiology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - M Tanabe
- Division of Diagnostic Pathology, Yokohama City University Medical Center, Yokohama, Japan
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Commentary on “Can we improve the morbidity and mortality associated with the associating liver partition with portal vein ligation for staged hepatectomy (ALPPS) procedure in the management of colorectal liver metastases?”. Surgery 2015; 157:207-10. [DOI: 10.1016/j.surg.2014.08.093] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2014] [Accepted: 08/27/2014] [Indexed: 11/23/2022]
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Truant S, Scatton O, Dokmak S, Regimbeau JM, Lucidi V, Laurent A, Gauzolino R, Castro Benitez C, Pequignot A, Donckier V, Lim C, Blanleuil ML, Brustia R, Le Treut YP, Soubrane O, Azoulay D, Farges O, Adam R, Pruvot FR. Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS): impact of the inter-stages course on morbi-mortality and implications for management. Eur J Surg Oncol 2015; 41:674-82. [PMID: 25630689 DOI: 10.1016/j.ejso.2015.01.004] [Citation(s) in RCA: 105] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2014] [Revised: 12/09/2014] [Accepted: 01/07/2015] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) was recently developed to induce rapid hypertrophy and reduce post-hepatectomy liver failure in patients with insufficient remnant liver volume (RLV). However, mortality rates >12% have been reported. This study aimed to analyze the perioperative course of ALPPS and to identify factors associated with morbi-mortality. METHODS Between April 2011 and September 2013, 62 patients operated in 9 Franco-Belgian hepatobiliary centres underwent ALPPS for colorectal metastases (N = 50) or primary tumors, following chemotherapy (N = 50) and/or portal vein embolization (PVE; N = 9). RESULTS Most patients had right (N = 31) or right extended hepatectomy (N = 25) (median RLV/body weight ratio of 0.54% [0.21-0.77%]). RLV increased by 48.6% [-15.3 to 192%] 7.8 ± 4.5 days after stage1, but the hypertrophy decelerated beyond 7 days. Stage2 was cancelled in 3 patients (4.8%) for insufficient hypertrophy, portal vein thrombosis or death and delayed to ≥9 days in 32 (54.2%). Overall, 25 patients (40.3%) had major complication(s) and 8 (12.9%) died. Fourteen patients (22.6%) had post-stage1 complication of whom 5 (35.7%) died after stage2. Factors associated with major morbi-mortality were obesity, post-stage1 biliary fistula or ascites, and infected and/or bilious peritoneal fluid at stage2. The latter was the only predictor of Clavien ≥3 by multivariate analysis (OR: 4.9; 95% CI: 1.227-19.97; p = 0.025). PVE did not impact the morbi-mortality rates but prevented major cytolysis that was associated with poor outcome. CONCLUSIONS The inter-stages course was crucial in determining ALPPS outcome. The factors of high morbi-mortality rates associated with ALPPS are linked to the technique complexity.
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Affiliation(s)
- S Truant
- Department of Digestive Surgery and Transplantation, CHU, Univ Nord de France, Lille, France.
| | - O Scatton
- Department of Hepatobiliary Surgery and Liver Transplant, St Antoine Hospital, France
| | - S Dokmak
- Department of Hepatopancreatobiliary Surgery and Liver Transplantation, Beaujon Hospital, Clichy, France
| | - J-M Regimbeau
- Department of Digestive Surgery, Amiens University Medical Centre, Amiens, France
| | - V Lucidi
- Department of Abdominal Surgery and Transplantation, Hospital Erasme, Brussels University, Belgium
| | - A Laurent
- Department of Digestive and Hepatobiliary Surgery, AP-HP, Henri Mondor University Hospital, Créteil, France
| | - R Gauzolino
- Department of General and Visceral Surgery, University Hospital of Poitiers, France
| | - C Castro Benitez
- Hepatobiliary Centre, Paul Brousse Hospital, AP-HP, Univ Paris-Sud, Villejuif, France
| | - A Pequignot
- Department of Digestive Surgery, Amiens University Medical Centre, Amiens, France
| | - V Donckier
- Department of Abdominal Surgery and Transplantation, Hospital Erasme, Brussels University, Belgium
| | - C Lim
- Department of Digestive and Hepatobiliary Surgery, AP-HP, Henri Mondor University Hospital, Créteil, France
| | - M-L Blanleuil
- Department of General and Visceral Surgery, University Hospital of Poitiers, France
| | - R Brustia
- Department of Hepatobiliary Surgery and Liver Transplant, St Antoine Hospital, France
| | - Y-P Le Treut
- Department of Digestive Surgery and Liver Transplantation, AP-HM, La Conception Hospital, Aix-Marseille University, France
| | - O Soubrane
- Department of Hepatobiliary Surgery and Liver Transplant, St Antoine Hospital, France
| | - D Azoulay
- Department of Digestive and Hepatobiliary Surgery, AP-HP, Henri Mondor University Hospital, Créteil, France
| | - O Farges
- Department of Hepatopancreatobiliary Surgery and Liver Transplantation, Beaujon Hospital, Clichy, France
| | - R Adam
- Hepatobiliary Centre, Paul Brousse Hospital, AP-HP, Univ Paris-Sud, Villejuif, France
| | - F-R Pruvot
- Department of Digestive Surgery and Transplantation, CHU, Univ Nord de France, Lille, France
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Schadde E, Ardiles V, Slankamenac K, Tschuor C, Sergeant G, Amacker N, Baumgart J, Croome K, Hernandez-Alejandro R, Lang H, de Santibaňes E, Clavien PA. ALPPS offers a better chance of complete resection in patients with primarily unresectable liver tumors compared with conventional-staged hepatectomies: results of a multicenter analysis. World J Surg 2015; 38:1510-9. [PMID: 24748319 DOI: 10.1007/s00268-014-2513-3] [Citation(s) in RCA: 205] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Portal vein occlusion to increase the size of the future liver remnant (FLR) is well established, using portal vein ligation (PVL) or embolization (PVE) followed by resection 4-8 weeks later. Associating liver partition with portal vein ligation for staged hepatectomy (ALPPS) combines PVL and complete parenchymal transection, followed by hepatectomy within 1-2 weeks. ALPPS has been recently introduced but remains controversial. We compare the ability of ALPPS versus PVE or PVL for complete tumor resection. METHODS A retrospective review of all patients undergoing ALPPS or conventional staged hepatectomies using PVL or PVE at four high-volume HPB centres between 2003 and 2012 was performed. Patients with primary liver tumors and liver metastases were included. Primary endpoint was complete tumor resection. Secondary endpoints include 90-day mortality, complications, FLR increase, time to resection, and tumor recurrence. RESULTS Forty-eight patients with ALPPS were compared with 83 patients with conventional-staged hepatectomies. Eighty-three percent (40/48 patients) of ALPPS patients achieved complete resection compared with 66 % (55/83 patients) in PVE/PVL (odds ratio 3.34, p = 0.027). Ninety-day mortality in ALPPS and PVE/PVL was 15 and 6 %, respectively (p = 0.2). Extrapolated growth rate was 11 times higher in ALPPS (34.8 cc/day; interquartile range (IQR) 26-49) compared with PVE/PVL (3 cc/day; IQR2-6; p = 0.001). Tumor recurrence at 1 year was 54 versus 52 % for ALPPS and PVE/PVL, respectively (p = 0.7). CONCLUSIONS This study provides evidence that ALPPS offers a better chance of complete resection in patients with primarily unresectable liver tumors at the cost of a high mortality. The technique is promising but should currently not be used outside of studies and registries.
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Affiliation(s)
- Erik Schadde
- Department of Surgery and Transplantation, Swiss HPB Center, University Hospital Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
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Bertens KA, Hawel J, Lung K, Buac S, Pineda-Solis K, Hernandez-Alejandro R. ALPPS: challenging the concept of unresectability--a systematic review. Int J Surg 2014; 13:280-287. [PMID: 25496851 DOI: 10.1016/j.ijsu.2014.12.008] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2014] [Accepted: 12/07/2014] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Hepatic resection for malignancy is limited by the amount of liver parenchyma left behind. As a result, two-staged hepatectomy and portal vein occlusion (PVO) have become part of the treatment algorithm. Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) has been recently described as a method to stimulate rapid and profound hypertrophy. MATERIALS AND METHODS A systematic review of the literature pertaining to ALPPS was undertaken. Peer-reviewed articles relating to portal vein ligation (PVL) and in situ split (ISS) of the parenchyma were included. RESULTS To date, ALPPS has been employed for a variety of primary and metastatic liver tumors. In early case series, the perioperative morbidity and mortality was unacceptably high. However with careful patient selection and improved technique, many centers have reported a 0% 90-day mortality. The benefits of ALPPS include hypertrophy of 61-93% over a median 9-14 days, 95-100% completion of the second stage, and high likelihood of R0 resection (86-100%). DISCUSSION ALPPS is only indicated when a two-stage hepatectomy is necessary and the future liver remnant (FLR) is deemed inadequate (<30%). Use in patients with poor functional status, or advanced age (>70 years) is cautioned. Discretion should be used when considering this in patients with pathology other than colorectal liver metastases (CRLM), especially hilar tumors requiring biliary reconstruction. Biliary ligation during the first stage and routine lymphadenectomy of the hepatoduodenal ligament should be avoided. CONCLUSIONS A consensus on the indications and contraindications for ALPPS and a standardized operative protocol are needed.
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Affiliation(s)
- Kimberly A Bertens
- Department of Surgery, Schulich School of Medicine & Dentistry, University of Western Ontario, 339 Windermere Road, London, ON, Canada N6A 5A5
| | - Jeffrey Hawel
- Department of Surgery, Schulich School of Medicine & Dentistry, University of Western Ontario, 339 Windermere Road, London, ON, Canada N6A 5A5
| | - Kalvin Lung
- Department of Surgery, Schulich School of Medicine & Dentistry, University of Western Ontario, 339 Windermere Road, London, ON, Canada N6A 5A5
| | - Suzana Buac
- Department of Surgery, Schulich School of Medicine & Dentistry, University of Western Ontario, 339 Windermere Road, London, ON, Canada N6A 5A5
| | - Karen Pineda-Solis
- Department of Surgery, Schulich School of Medicine & Dentistry, University of Western Ontario, 339 Windermere Road, London, ON, Canada N6A 5A5; Multi-Organ Transplant Program, London Health Sciences Centre, 339 Windermere Road, London, ON, Canada N6A 5A5
| | - Roberto Hernandez-Alejandro
- Department of Surgery, Schulich School of Medicine & Dentistry, University of Western Ontario, 339 Windermere Road, London, ON, Canada N6A 5A5; Multi-Organ Transplant Program, London Health Sciences Centre, 339 Windermere Road, London, ON, Canada N6A 5A5.
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Schadde E, Schnitzbauer AA, Tschuor C, Raptis DA, Bechstein WO, Clavien PA. Systematic review and meta-analysis of feasibility, safety, and efficacy of a novel procedure: associating liver partition and portal vein ligation for staged hepatectomy. Ann Surg Oncol 2014; 22:3109-20. [PMID: 25448799 DOI: 10.1245/s10434-014-4213-5] [Citation(s) in RCA: 93] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2014] [Indexed: 02/06/2023]
Abstract
BACKGROUND Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) is a novel strategy to resect liver tumors despite the small size of the liver remnant. It is an hepatectomy in two stages, with PVL and parenchymal transection during the first stage, which induces rapid growth of the remnant liver exceeding any other technique. Despite high postoperative morbidity and mortality in most reports, the technique was adopted by a number of surgeons. MATERIALS AND METHODS This systematic review explores current data regarding the feasibility, safety, and oncologic efficacy of ALPPS; the search strategy has been published online. A meta-analysis of hypertrophy, feasibility (ALPPS stage 2 performed), mortality, complications, and R0 (complete) resection was performed. RESULTS A literature search revealed a total of 13 publications that met the search criteria, reporting data from 295 patients. Evidence levels were low, with the highest Oxford evidence level being 2c. The most common indication was colorectal liver metastasis in 203 patients. Hypertrophy in the meta-analysis was 84 %, feasibility (ALPPS stage 2 performed) 97 % (CI 94-99 %), 90-day mortality 11 % (CI 8-16 %), and complications grade IIIa or higher occured in 44 % (CI 38-50 %) of patients. A standardized reporting format for complications is lacking despite the widespread use of the Clavien-Dindo classification. Oncological outcome is not well-documented. The most common topics in the selected studies published were technical feasibility and indications for the procedures. Publication bias due to case-series and single-center reports is common. CONCLUSION A systematic exploration of this novel operation with a rigid methodology, such as registry analyses and a randomized controlled trial, is highly advised.
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Affiliation(s)
- Erik Schadde
- Department of Surgery, Swiss HPB and Transplant Center, University Hospital Zurich, Zurich, Switzerland
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Alonso Casado O, González Moreno S, Encinas García S, Rubio González E, Ortega Pérez G. Two-stage right hepatic trisectionectomy with interval portal embolization: another alternative for advanced liver disease with large tumour volume in segment IV and small residual volume. Cir Esp 2014; 93:253-6. [PMID: 25433422 DOI: 10.1016/j.ciresp.2014.09.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2014] [Revised: 09/03/2014] [Accepted: 09/29/2014] [Indexed: 02/07/2023]
Affiliation(s)
- Oscar Alonso Casado
- Unidad de Oncología Quirúrgica Digestiva, MD Anderson Cancer Center Madrid, Madrid, España.
| | | | - Sara Encinas García
- Unidad de Oncología Médica Digestiva, MD Anderson Cancer Center Madrid, Madrid, España
| | - Eduardo Rubio González
- Unidad de Oncología Quirúrgica Digestiva, MD Anderson Cancer Center Madrid, Madrid, España
| | - Gloria Ortega Pérez
- Unidad de Oncología Quirúrgica Digestiva, MD Anderson Cancer Center Madrid, Madrid, España
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