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Chen Z, Chen X, Hu H, Chen K, Xiao H, Du C, Lan X. The combination of extra-Glissonian pedicle ligation of the tumor-bearing area and traditional ALPPS: a novel modified ALPPS method. J Gastrointest Oncol 2025; 16:317-326. [PMID: 40115932 PMCID: PMC11921378 DOI: 10.21037/jgo-24-691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2024] [Accepted: 01/17/2025] [Indexed: 03/23/2025] Open
Abstract
Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) can provide patients with large liver tumors the opportunity to undergo radical resection. However, tumor progression between the surgical stages and unsatisfactory hyperplasia of the residual liver reduces the second-stage resection rate and limit the application of ALPPS. We reported a novel modified ALPPS method that can accelerate tumor necrosis and hyperplasia of the residual liver and increase the second-stage resection rate. The data of patients who underwent the novel modified ALPPS procedure in our hospital between September 2021 and April 2024 were retrospectively analyzed. In addition to ligation of the right hepatic portal vein and liver partition during the first stage, we transected all the Glissonian pedicles of the tumor-bearing area to accelerate tumor necrosis. Ultimately, three patients underwent this novel modified ALPPS procedure. Second-stage resection was successfully performed in all these patients. Satisfactory hyperplasia was obtained in the residual liver before the second stage of surgery. The tumor-bearing area showed obvious necrosis and atrophy. The residual liver volumes of the three patients increased by 83%, 23%, and 49%, respectively. No postoperative complications or tumor recurrence was observed. This novel modified approach is safe and effective. This approach can prevent tumor progression between the surgical stages and promote compensatory liver proliferation.
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Affiliation(s)
- Zhu Chen
- Department of Hepatobiliary Surgery, The First Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Xingyu Chen
- Department of Hepatobiliary Surgery, The First Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Haiyang Hu
- Department of Hepatobiliary Surgery, The First Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Kai Chen
- Department of Hepatobiliary Surgery, The First Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Heng Xiao
- Department of Hepatobiliary Surgery, The First Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Chengyou Du
- Department of Hepatobiliary Surgery, The First Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Xiang Lan
- Department of Hepatobiliary Surgery, The First Affiliated Hospital, Chongqing Medical University, Chongqing, China
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Lederer AK, Görrissen N, Nguyen TT, Kreutz C, Rasel H, Bartsch F, Lang H, Endres K. Exploring the effects of gut microbiota on cholangiocarcinoma progression by patient-derived organoids. J Transl Med 2025; 23:34. [PMID: 39789543 PMCID: PMC11716211 DOI: 10.1186/s12967-024-06012-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2024] [Accepted: 12/19/2024] [Indexed: 01/12/2025] Open
Abstract
BACKGROUND Recent research indicates a role of gut microbiota in development and progression of life-threatening diseases such as cancer. Carcinomas of the biliary ducts, the so-called cholangiocarcinomas, are known for their aggressive tumor biology, implying poor prognosis of affected patients. An impact of the gut microbiota on cholangiocarcinoma development and progression is plausible due to the enterohepatic circulation and is therefore the subject of scientific debate, however evidence is still lacking. This review aimed to discuss the suitability of complex cell culture models to investigate the role of gut microbiota in cholangiocarcinoma progression. MAIN BODY Clinical research in this area is challenging due to poor comparability of patients and feasibility reasons, which is why translational models are needed to understand the basis of tumor progression in cholangiocarcinoma. A promising approach to investigate the influence of gut microbiota could be an organoid model. Organoids are 3D cell models cultivated in a modifiable and controlled condition, which can be grown from tumor tissue. 3D cell models are able to imitate physiological and pathological processes in the human body and thus contribute to a better understanding of health and disease. CONCLUSION The use of complex cell cultures such as organoids and organoid co-cultures might be powerful and valuable tools to study not only the growth behavior and growth of cholangiocarcinoma cells, but also the interaction with the tumor microenvironment and with components of the gut microbiota.
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Affiliation(s)
- Ann-Kathrin Lederer
- Department of General, Visceral and Transplantation Surgery, University Medical Center Mainz, 55131, Mainz, Germany.
- Center for Complementary Medicine, Department of Medicine II, Faculty of Medicine, Medical Center-University of Freiburg, University of Freiburg, 79106, Freiburg, Germany.
| | - Nele Görrissen
- Department of General, Visceral and Transplantation Surgery, University Medical Center Mainz, 55131, Mainz, Germany
| | - Tinh Thi Nguyen
- Department of Psychiatry and Psychotherapy, University Medical Center Mainz, 55131, Mainz, Germany
- Institute of Molecular Biology (IMB), 55128, Mainz, Germany
| | - Clemens Kreutz
- Institute of Medical Biometry and Statistics (IMBI), Faculty of Medicine and Medical Center, 79106, Freiburg, Germany
| | - Hannah Rasel
- Department of General, Visceral and Transplantation Surgery, University Medical Center Mainz, 55131, Mainz, Germany
| | - Fabian Bartsch
- Department of General, Visceral and Transplantation Surgery, University Medical Center Mainz, 55131, Mainz, Germany
| | - Hauke Lang
- Department of General, Visceral and Transplantation Surgery, University Medical Center Mainz, 55131, Mainz, Germany
| | - Kristina Endres
- Department of Psychiatry and Psychotherapy, University Medical Center Mainz, 55131, Mainz, Germany
- Faculty of Computer Sciences and Microsystems Technology, University of Applied Sciences Kaiserslautern, 66482, Zweibrücken, Germany
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Kimura K, Minagawa R, Yamaoka T, Izumi T, Takahashi YU, Nakanishi M, Tokunaga T, Matsuda D, Nobuto Y, Yano H, Kajiwara Y, Honma K, Nagata S, Minami K, Nishizaki T. Transileocolic Portal Vein Embolization Increases Remnant Liver Volume After Major Hepatectomy. In Vivo 2024; 38:2761-2766. [PMID: 39477424 PMCID: PMC11535930 DOI: 10.21873/invivo.13755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2024] [Revised: 07/15/2024] [Accepted: 07/16/2024] [Indexed: 11/07/2024]
Abstract
BACKGROUND/AIM Transileocolic portal vein embolization (TIPE) may reduce the risk of liver failure after massive hepatectomy. However, convincing evidence of its usefulness in this regard is yet to be reported. Therefore, this study aimed to investigate the use of TIPE after massive hepatectomy. PATIENTS AND METHODS Twelve patients who underwent TIPE were included. Pre- and postoperative liver volumetry was determined using a 3D simulator with computed tomography. RESULTS After TIPE, the percent change in total liver volume was 104.0%±13.1% (p=0.08). Conversely, the percent increase in remnant liver volume (ml)/total liver volume (ml) and remnant liver volume (ml)/standard liver volume (ml) was 122.9%±18.6% (p<0.001) and 132.2%±19.6% (p<0.001), respectively. TIPE operation time was 125±84.6 min, with minimal blood loss in all cases. Postoperative hospitalization duration during TIPE was 4.5±2.6 days. No TIPE-related complications occurred in any patient. CONCLUSION TIPE is beneficial and safe when preoperative volumetry indicates that the remaining liver volume is inadequate and inoperable.
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Affiliation(s)
- Koichi Kimura
- Department of Surgery, Matsuyama Red Cross Hospital, Matsuyama, Japan;
| | - Ryosuke Minagawa
- Department of Surgery, Matsuyama Red Cross Hospital, Matsuyama, Japan
| | - Terutoshi Yamaoka
- Department of Vascular Surgery, Matsuyama Red Cross Hospital, Matsuyama, Japan
| | - Takuma Izumi
- Department of Surgery, Matsuyama Red Cross Hospital, Matsuyama, Japan
| | - Y U Takahashi
- Department of Surgery, Matsuyama Red Cross Hospital, Matsuyama, Japan
| | - Mitsuru Nakanishi
- Department of Surgery, Matsuyama Red Cross Hospital, Matsuyama, Japan
| | - Takayuki Tokunaga
- Department of Surgery, Matsuyama Red Cross Hospital, Matsuyama, Japan
| | - Daisuke Matsuda
- Department of Vascular Surgery, Matsuyama Red Cross Hospital, Matsuyama, Japan
| | - Yoshinari Nobuto
- Department of Surgery, Matsuyama Red Cross Hospital, Matsuyama, Japan
| | - Hiroko Yano
- Department of Surgery, Matsuyama Red Cross Hospital, Matsuyama, Japan
| | - Yuichiro Kajiwara
- Department of Surgery, Matsuyama Red Cross Hospital, Matsuyama, Japan
| | - Kenichi Honma
- Department of Vascular Surgery, Matsuyama Red Cross Hospital, Matsuyama, Japan
| | - Shigeyuki Nagata
- Department of Surgery, Matsuyama Red Cross Hospital, Matsuyama, Japan
| | - Kazuhito Minami
- Department of Surgery, Matsuyama Red Cross Hospital, Matsuyama, Japan
| | - Takashi Nishizaki
- Department of Surgery, Matsuyama Red Cross Hospital, Matsuyama, Japan
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Golriz M, Ramouz A, Hammad A, Aminizadeh E, Sabetkish N, Khajeh E, Ghamarnejad O, Carvalho C, Rio-Tinto H, Chang DH, Joao AA, Goncalves G, Mehrabi A. Promising Results of Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy for Perihilar Cholangiocarcinoma in a Systematic Review and Single-Arm Meta-Analysis. Cancers (Basel) 2024; 16:771. [PMID: 38398162 PMCID: PMC10887221 DOI: 10.3390/cancers16040771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Revised: 01/31/2024] [Accepted: 02/07/2024] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND ALPPS popularity is increasing among surgeons worldwide and its indications are expanding to cure patients with primarily unresectable liver tumors. Few reports recommended limitations or even contraindications of ALPPS in perihilar cholangiocarcinoma (phCC). Here, we discuss the results of ALPPS in patients with phCC in a systematic review as well as a pooled data analysis. METHODS MEDLINE and Web of Science databases were systematically searched for relevant literature up to December 2023. All studies reporting ALPPS in the management of phCC were included. A single-arm meta-analysis of proportions was carried out to estimate the overall rate of outcomes. RESULTS After obtaining 207 articles from the primary search, data of 18 studies containing 112 phCC patients were included in our systematic review. Rates of major morbidity and mortality were calculated to be 43% and 22%, respectively. The meta-analysis revealed a PHLF rate of 23%. One-year disease-free survival was 65% and one-year overall survival was 69%. CONCLUSIONS ALPPS provides a good chance of cure for patients with phCC in comparison to alternative treatment options, but at the expense of debatable morbidity and mortality. With refinement of the surgical technique and better perioperative patient management, the results of ALPPS in patients with phCC were improved.
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Affiliation(s)
- Mohammad Golriz
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, 69120 Heidelberg, Germany; (M.G.); (A.R.); (A.H.); (E.A.); (N.S.); (E.K.); (O.G.)
- Liver Cancer Centre Heidelberg (LCCH), University Hospital Heidelberg, 69120 Heidelberg, Germany;
- Clinic of General and Visceral Surgery, Diakonie in Südwestfallen, 57076 Siegen, Germany
| | - Ali Ramouz
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, 69120 Heidelberg, Germany; (M.G.); (A.R.); (A.H.); (E.A.); (N.S.); (E.K.); (O.G.)
| | - Ahmed Hammad
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, 69120 Heidelberg, Germany; (M.G.); (A.R.); (A.H.); (E.A.); (N.S.); (E.K.); (O.G.)
| | - Ehsan Aminizadeh
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, 69120 Heidelberg, Germany; (M.G.); (A.R.); (A.H.); (E.A.); (N.S.); (E.K.); (O.G.)
| | - Nastaran Sabetkish
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, 69120 Heidelberg, Germany; (M.G.); (A.R.); (A.H.); (E.A.); (N.S.); (E.K.); (O.G.)
| | - Elias Khajeh
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, 69120 Heidelberg, Germany; (M.G.); (A.R.); (A.H.); (E.A.); (N.S.); (E.K.); (O.G.)
| | - Omid Ghamarnejad
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, 69120 Heidelberg, Germany; (M.G.); (A.R.); (A.H.); (E.A.); (N.S.); (E.K.); (O.G.)
| | - Carlos Carvalho
- Digestive Oncology Unit, Champalimaud Foundation, 1400-038 Lisbon, Portugal;
| | - Hugo Rio-Tinto
- Department of Radiology, Champalimaud Foundation, 1400-038 Lisbon, Portugal;
| | - De-Hua Chang
- Liver Cancer Centre Heidelberg (LCCH), University Hospital Heidelberg, 69120 Heidelberg, Germany;
- Department of Diagnostic and Interventional Radiology, University Hospital Heidelberg, 69120 Heidelberg, Germany
| | - Ana Alagoa Joao
- Hepato-Pancreato-Biliary Surgery Unit, Department of Digestive Surgery, Champalimaud Foundation, 1400-038 Lisbon, Portugal; (A.A.J.); (G.G.)
| | - Gil Goncalves
- Hepato-Pancreato-Biliary Surgery Unit, Department of Digestive Surgery, Champalimaud Foundation, 1400-038 Lisbon, Portugal; (A.A.J.); (G.G.)
| | - Arianeb Mehrabi
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, 69120 Heidelberg, Germany; (M.G.); (A.R.); (A.H.); (E.A.); (N.S.); (E.K.); (O.G.)
- Liver Cancer Centre Heidelberg (LCCH), University Hospital Heidelberg, 69120 Heidelberg, Germany;
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Lopez-Lopez V, Linecker M, Caballero-Llanes A, Reese T, Oldhafer KJ, Hernandez-Alejandro R, Tun-Abraham M, Li J, Fard-Aghaie M, Petrowsky H, Brusadin R, Lopez-Conesa A, Ratti F, Aldrighetti L, Ramouz A, Mehrabi A, Autran Machado M, Ardiles V, De Santibañes E, Marichez A, Adam R, Truant S, Pruvot FR, Olthof PB, Van Gulick TM, Montalti R, Troisi RI, Kron P, Lodge P, Kambakamba P, Hoti E, Martinez-Caceres C, de la Peña-Moral J, Clavien PA, Robles-Campos R. Liver Histology Predicts Liver Regeneration and Outcome in ALPPS: Novel Findings From A Multicenter Study. Ann Surg 2024; 279:306-313. [PMID: 37487004 DOI: 10.1097/sla.0000000000006024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/26/2023]
Abstract
BACKGROUND AND AIMS Alterations in liver histology influence the liver's capacity to regenerate, but the relevance of each of the different changes in rapid liver growth induction is unknown. This study aimed to analyze the influence of the degree of histological alterations during the first and second stages on the ability of the liver to regenerate. METHODS This cohort study included data obtained from the International ALPPS Registry between November 2011 and October 2020. Only patients with colorectal liver metastases were included in the study. We developed a histological risk score based on histological changes (stages 1 and 2) and a tumor pathology score based on the histological factors associated with poor tumor prognosis. RESULTS In total, 395 patients were included. The time to reach stage 2 was shorter in patients with a low histological risk stage 1 (13 vs 17 days, P ˂0.01), low histological risk stage 2 (13 vs 15 days, P <0.01), and low pathological tumor risk (13 vs 15 days, P <0.01). Regarding interval stage, there was a higher inverse correlation in high histological risk stage 1 group compared to low histological risk 1 group in relation with future liver remnant body weight ( r =-0.1 and r =-0.08, respectively), and future liver remnant ( r =-0.15 and r =-0.06, respectively). CONCLUSIONS ALPPS is associated with increased histological alterations in the liver parenchyma. It seems that the more histological alterations present and the higher the number of poor prognostic factors in the tumor histology, the longer the time to reach the second stage.
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Affiliation(s)
- Victor Lopez-Lopez
- Department of Surgery and Liver and Pancreas transplantation, Virgen de la Arrixaca Clinic and University Hospital, IMIB, Murcia, Spain
| | - Michael Linecker
- Department of Surgery and Transplantation, University Medical Center Schleswig-Holstein, Campus Kiel, Germany
| | - Albert Caballero-Llanes
- Department of Pathology, Virgen de la Arrixaca Clinic and University Hospital, IMIB, Murcia, Spain
| | - Tim Reese
- Department of Surgery, Division of Liver, Bileduct and Pancreatic Surgery, Asklepios Hospital Barmbek, Hamburg, Germany
| | - Karl J Oldhafer
- Department of Surgery, Division of Liver, Bileduct and Pancreatic Surgery, Asklepios Hospital Barmbek, Hamburg, Germany
| | | | - Mauro Tun-Abraham
- Department of Surgery, Western University, London, Ontario, Canada
- Division of Transplantation/Hepatobiliary Surgery, Department of Surgery, University of Rochester, NY
| | - Jun Li
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Mohammad Fard-Aghaie
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Henrik Petrowsky
- Department of Surgery and Transplantation, Swiss HPB and Transplant Center, University Hospital Zurich, Zurich, Switzerland
| | - Roberto Brusadin
- Department of Surgery and Liver and Pancreas transplantation, Virgen de la Arrixaca Clinic and University Hospital, IMIB, Murcia, Spain
| | - Asuncion Lopez-Conesa
- Department of Surgery and Liver and Pancreas transplantation, Virgen de la Arrixaca Clinic and University Hospital, IMIB, Murcia, Spain
| | - Francesca Ratti
- Department of Surgery, Hepatobiliary Surgery Division, IRCCS San Raffaele Hospital, School of Medicine, Milan, Italy
| | - Luca Aldrighetti
- Department of Surgery, Hepatobiliary Surgery Division, IRCCS San Raffaele Hospital, School of Medicine, Milan, Italy
| | - Ali Ramouz
- Department of General, Visceral and Transplant Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Arianeb Mehrabi
- Department of General, Visceral and Transplant Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | | | - Victoria Ardiles
- Department of Surgery, Division of HPB Surgery, Liver Transplant Unit, Italian Hospital Buenos Aires, Argentina
| | - Eduardo De Santibañes
- Department of Surgery, Division of HPB Surgery, Liver Transplant Unit, Italian Hospital Buenos Aires, Argentina
| | - Arthur Marichez
- Centre Hépato-Biliaire, Hôpital Paul Brousse, Villejuif, France
| | - René Adam
- Centre Hépato-Biliaire, Hôpital Paul Brousse, Villejuif, France
| | - Stéphanie Truant
- Department of Digestive Surgery and Transplantation, University Hospital, Lille, France
| | - Francois-René Pruvot
- Department of Digestive Surgery and Transplantation, University Hospital, Lille, France
| | - Pim B Olthof
- Department of Surgery, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Thomas M Van Gulick
- Department of Surgery, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Roberto Montalti
- Department of Clinical Medicine and Surgery, Federico II University Hospital Naples, Napoli, Italy
| | - Roberto I Troisi
- Department of Clinical Medicine and Surgery, Federico II University Hospital Naples, Napoli, Italy
| | - Philipp Kron
- HPB and Transplant Unit, St. James's University Hospital, Leeds, UK
| | - Peter Lodge
- HPB and Transplant Unit, St. James's University Hospital, Leeds, UK
| | - Patryk Kambakamba
- Department of Hepatobiliary Surgery and Liver Transplantation, St. Vincent's University Hospital, Dublin, Ireland
| | - Emir Hoti
- Department of Hepatobiliary Surgery and Liver Transplantation, St. Vincent's University Hospital, Dublin, Ireland
| | | | - Jesus de la Peña-Moral
- Department of Pathology, Virgen de la Arrixaca Clinic and University Hospital, IMIB, Murcia, Spain
| | - Pierre-Alain Clavien
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Ricardo Robles-Campos
- Department of Surgery and Liver and Pancreas transplantation, Virgen de la Arrixaca Clinic and University Hospital, IMIB, Murcia, Spain
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Selmani R, Karadzov Z, Begovic G, Rushiti Q, Memeti S, Dimitrova MG, Spirovska T, Atanasova M, Selmani A. ALPPS Procedure for the Treatment of Bilobar Multiple Liver Metastasis from Colorectal Cancer: First Case in RN Macedonia. Pril (Makedon Akad Nauk Umet Odd Med Nauki) 2023; 44:97-106. [PMID: 38109444 DOI: 10.2478/prilozi-2023-0053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2023]
Abstract
Introduction: ALPPS (Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy), is a recently developed procedure, first performed by HJ Schlitt in Regensburg, Germany. The technique developed two stages of hepatectomy. The ALPPS procedure has been introduced to increase the volume of future liver remnant, much more than the other technique, such as PVE (portal vein embolization). The first ALPPS in our country was introduced and performed by our team on May 15th, 2018. Results: The 60-year-old patient was previously operated on for rectal cancer in 2017 at another institution. The operation was performed with anterior resection and the patient was in long term adjuvant chemotherapy. One year after surgery, the patient has multiple bilobar liver metastases and increased tumor markers that led to instant admission to our institution for liver resection. In the first stage, we performed four metastasectomies on the left lobe with right portal vein ligation and transection on the Cantlie line. The second stage was performed after a CT evaluation on the eighth day, with significant hypertrophy on the left lobe. Pathological findings reported ten metastases on the right lobe with a diameter 1-3 cm. The patient was on the long-term chemotherapy, and after one year he had other MS in the IVa segment of the liver. We also performed a metastasectomy. The patient died 32 months after ALPPS. Conclusion: ALPPS is a safe and feasible procedure for the treatment of bilobar liver metastasis from colorectal cancer. It could provide long-term survival for patients.
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Affiliation(s)
- Rexhep Selmani
- 1University Clinic for Digestive Surgery, Medical faculty, University Ss. Cyril and Methodius" Skopje
| | - Zoran Karadzov
- 1University Clinic for Digestive Surgery, Medical faculty, University Ss. Cyril and Methodius" Skopje
| | - Goran Begovic
- 1University Clinic for Digestive Surgery, Medical faculty, University Ss. Cyril and Methodius" Skopje
| | - Qemal Rushiti
- 1University Clinic for Digestive Surgery, Medical faculty, University Ss. Cyril and Methodius" Skopje
| | - Shaban Memeti
- 2University Clinic of Pediatric Surgery, Medical Faculty, University Ss. Cyril and Methodius" Skopje
| | - Magdalena G Dimitrova
- 3University Clinic of Gasteroenterohepatology, Medical Faculty, University Ss. Cyril and Methodius" Skopje
| | - Tanja Spirovska
- 4University Clinic of Anesthesiology and Reanimatology and intensive care, Medical Faculty, University Ss. Cyril and Methodius" Skopje
| | | | - Arian Selmani
- 6University Clinic of Cardiovascular surgery, Medical Faculty, University Ss. Cyril and Methodius" Skopje
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7
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Mehrabi A, Golriz M, Ramouz A, Khajeh E, Hammad A, Hackert T, Müller-Stich B, Strobel O, Ali-Hasan-Al-Saegh S, Ghamarnejad O, Al-Saeedi M, Springfeld C, Rupp C, Mayer P, Mieth M, Goeppert B, Hoffmann K, Büchler MW. Promising Outcomes of Modified ALPPS for Staged Hepatectomy in Cholangiocarcinoma. Cancers (Basel) 2023; 15:5613. [PMID: 38067316 PMCID: PMC10705795 DOI: 10.3390/cancers15235613] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Revised: 11/13/2023] [Accepted: 11/22/2023] [Indexed: 09/14/2024] Open
Abstract
Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) is a two-stage procedure that can potentially cure patients with large cholangiocarcinoma. The current study evaluates the impact of modifications on the outcomes of ALPPS in patients with cholangiocarcinoma. In this single-center study, a series of 30 consecutive patients with cholangiocarcinoma (22 extrahepatic and 8 intrahepatic) who underwent ALPPS between 2011 and 2021 was evaluated. The ALPPS procedure in our center was modified in 2016 by minimizing the first stage of the surgical procedure through biliary externalization after the first stage, antibiotic administration during the interstage phase, and performing biliary reconstructions during the second stage. The rate of postoperative major morbidity and 90-day mortality, as well as the one- and three-year disease-free and overall survival rates were calculated and compared between patients operated before and after 2016. The ALPPS risk score before the second stage of the procedure was lower in patients who were operated on after 2016 (before 2016: median 6.4; after 2016: median 4.4; p = 0.010). Major morbidity decreased from 42.9% before 2016 to 31.3% after 2016, and the 90-day mortality rate decreased from 35.7% before 2016 to 12.5% after 2016. The three-year survival rate increased from 40.8% before 2016 to 73.4% after 2016. Our modified ALPPS procedure improved perioperative and postoperative outcomes in patients with extrahepatic and intrahepatic cholangiocarcinoma. Minimizing the first step of the ALPPS procedure was key to these improvements.
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Affiliation(s)
- Arianeb Mehrabi
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, 69120 Heidelberg, Germany
- Liver Cancer Center Heidelberg (LCCH), Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Mohammad Golriz
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, 69120 Heidelberg, Germany
- Liver Cancer Center Heidelberg (LCCH), Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Ali Ramouz
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, 69120 Heidelberg, Germany
| | - Elias Khajeh
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, 69120 Heidelberg, Germany
| | - Ahmed Hammad
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, 69120 Heidelberg, Germany
| | - Thilo Hackert
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, 69120 Heidelberg, Germany
- Liver Cancer Center Heidelberg (LCCH), Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Beat Müller-Stich
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, 69120 Heidelberg, Germany
- Liver Cancer Center Heidelberg (LCCH), Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Oliver Strobel
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, 69120 Heidelberg, Germany
- Liver Cancer Center Heidelberg (LCCH), Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Sadeq Ali-Hasan-Al-Saegh
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, 69120 Heidelberg, Germany
| | - Omid Ghamarnejad
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, 69120 Heidelberg, Germany
| | - Mohammed Al-Saeedi
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, 69120 Heidelberg, Germany
| | - Christoph Springfeld
- Liver Cancer Center Heidelberg (LCCH), Heidelberg University Hospital, 69120 Heidelberg, Germany
- Department of Medical Oncology, National Center for Tumor Diseases, Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Christian Rupp
- Department of Internal Medicine, Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Philipp Mayer
- Department of Interventional Radiology, Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Markus Mieth
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, 69120 Heidelberg, Germany
| | - Benjamin Goeppert
- Liver Cancer Center Heidelberg (LCCH), Heidelberg University Hospital, 69120 Heidelberg, Germany
- Institute of Pathology, Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Katrin Hoffmann
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, 69120 Heidelberg, Germany
- Liver Cancer Center Heidelberg (LCCH), Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Markus W. Büchler
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, 69120 Heidelberg, Germany
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8
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Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) in colorectal liver metastases: review of the literature. Clin Exp Hepatol 2021; 7:125-133. [PMID: 34295978 PMCID: PMC8284168 DOI: 10.5114/ceh.2021.106521] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Accepted: 02/26/2021] [Indexed: 02/08/2023] Open
Abstract
The liver is considered as one of the most common sites of metastasis and a key determining factor of survival in patients with isolated colorectal liver metastasis (CRLM). For longer survival of patients, surgical resection is the only available option. Especially in CRLM bilobar patients, to achieve R0 resection, maintaining an adequate volume of the future liver remnant (FLR) is the main technical challenge to avoid post-hepatectomy liver failure (PHLF). As standard procedures in the treatment of patients with severe metastatic liver disease, techniques such as portal vein embolization/portal vein ligation (PVE/PVL) accompanied by two-stage hepatectomy (TSH) have been introduced. These methods, however, have drawbacks depending on the severity of the disease and the capacity of the patient to expand the liver remnant. Eventually, implementation of the novel ALPPS technique ignited excitement among the community of hepatobiliary surgeons because ALPPS challenged the idea of unrespectability and extended the limit of liver surgery and it was reported that FLR hypertrophy of up to 80% was induced in a shorter time than PVL or PVE. Nonetheless, ALPPS techniques caused serious concerns due to the associated high morbidity and mortality levels of up to 40% and 15% respectively, and PHLF and bile leak are critical morbidity- and mortality-related factors. Carefully establishing the associated risk factors of ALPPS has opened up a new dimension in the field of ALPPS technique for improved surgical outcome by carefully choosing patients. The benefit of ALPPS technique is enhanced when performed for young patients with very borderline remnant volume. Adopting ALPPS technical modifications such as middle hepatic vein preservation, surgical management of the hepatoduodenal ligament, the anterior approach and partial ALPPS may lead to the improvement of ALPPS surgical performance. Research findings to validate the translatability of ALPPS’ theoretical advantages into real survival benefits are scarce.
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9
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Ahmed A, Stauffer JA, LeGout JD, Burns J, Croome K, Paz-Fumagalli R, Frey G, Toskich B. The use of neoadjuvant lobar radioembolization prior to major hepatic resection for malignancy results in a low rate of post hepatectomy liver failure. J Gastrointest Oncol 2021; 12:751-761. [PMID: 34012663 DOI: 10.21037/jgo-20-507] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Background Neoadjuvant yttrium-90 transarterial radioembolization (TARE) is increasingly being used as a strategy to facilitate resection of otherwise unresectable tumors due to its ability to generate both tumor response and remnant liver hypertrophy. Perioperative outcomes after the use of neoadjuvant lobar TARE remain underinvestigated. Methods A single center retrospective review of patients who underwent lobar TARE prior to major hepatectomy for primary or metastatic liver cancer between 2007 and 2018 was conducted. Baseline demographics, radioembolization parameters, pre- and post-radioembolization volumetrics, intra-operative surgical data, adverse events, and post-operative outcomes were analyzed. Results Twenty-six patients underwent major hepatectomy after neoadjuvant lobar TARE. The mean age was 58.3 years (17-88 years). 62% of patients (n=16) had primary liver malignancies while the remainder had metastatic disease. Liver resection included right hepatectomy or trisegmentectomy, left or extended left hepatectomy, and sectorectomy/segmentectomy in 77% (n=20), 8% (n=2), and 15% (n=4) of patients, respectively. The mean length of stay was 8.3 days (range, 3-33 days) and there were no grade IV morbidities or 90-day mortalities. The incidence of post hepatectomy liver failure (PHLF) was 3.8% (n=1). The median time to progression after resection was 4.5 months (range, 3.3-10 months). Twenty-three percent (n=6) of patients had no recurrence. The median survival was 28.9 months (range, 16.9-46.8 months) from major hepatectomy and 37.6 months (range, 25.2-53.1 months) from TARE. Conclusions Major hepatectomy after neoadjuvant lobar radioembolization is safe with a low incidence of PHLF.
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Affiliation(s)
- Altan Ahmed
- Department of Radiology, Mayo Clinic, Jacksonville, FL, USA.,Department of Radiology, Moffitt Cancer Center, Tampa, FL, USA
| | | | | | - Justin Burns
- Department of Transplantation, Mayo Clinic, Jacksonville, FL, USA
| | | | | | - Gregory Frey
- Department of Radiology, Mayo Clinic, Jacksonville, FL, USA
| | - Beau Toskich
- Department of Radiology, Mayo Clinic, Jacksonville, FL, USA
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10
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Kwan J, Pua U. Review of Intra-Arterial Therapies for Colorectal Cancer Liver Metastasis. Cancers (Basel) 2021; 13:cancers13061371. [PMID: 33803606 PMCID: PMC8003062 DOI: 10.3390/cancers13061371] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 03/14/2021] [Accepted: 03/15/2021] [Indexed: 12/12/2022] Open
Abstract
Simple Summary Colorectal cancer liver metastasis occurs in more than 50% of patients with colorectal cancer and is thought to be the most common cause of death from this cancer. The mainstay of treatment for inoperable liver metastasis has been combination systemic chemotherapy with or without the addition of biological targeted therapy with a goal for disease downstaging, for potential curative resection, or more frequently, for disease control. For patients with dominant liver metastatic disease or limited extrahepatic disease, liver-directed intra-arterial therapies including hepatic arterial chemotherapy infusion, chemoembolization and radioembolization are alternative treatment strategies that have shown promising results, most commonly in the salvage setting in patients with chemo-refractory disease. In recent years, their role in the first-line setting in conjunction with concurrent systemic chemotherapy has also been explored. This review aims to provide an update on the current evidence regarding liver-directed intra-arterial treatment strategies and to discuss potential trends for the future. Abstract The liver is frequently the most common site of metastasis in patients with colorectal cancer, occurring in more than 50% of patients. While surgical resection remains the only potential curative option, it is only eligible in 15–20% of patients at presentation. In the past two decades, major advances in modern chemotherapy and personalized biological agents have improved overall survival in patients with unresectable liver metastasis. For patients with dominant liver metastatic disease or limited extrahepatic disease, liver-directed intra-arterial therapies such as hepatic arterial chemotherapy infusion, chemoembolization and radioembolization are treatment strategies which are increasingly being considered to improve local tumor response and to reduce systemic side effects. Currently, these therapies are mostly used in the salvage setting in patients with chemo-refractory disease. However, their use in the first-line setting in conjunction with systemic chemotherapy as well as to a lesser degree, in a neoadjuvant setting, for downstaging to resection have also been investigated. Furthermore, some clinicians have considered these therapies as a temporizing tool for local disease control in patients undergoing a chemotherapy ‘holiday’ or acting as a bridge in patients between different lines of systemic treatment. This review aims to provide an update on the current evidence regarding liver-directed intra-arterial treatment strategies and to discuss potential trends for the future.
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11
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Ke L, Shen R, Fan W, Hu W, Shen S, Li S, Kuang M, Liang L, Li J, Peng B, Hua Y. The role of associating liver partition and portal vein ligation for staged hepatectomy in unresectable hepatitis B virus-related hepatocellular carcinoma. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:1402. [PMID: 33313147 PMCID: PMC7723523 DOI: 10.21037/atm-20-2420] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Background The role of associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) for hepatocellular carcinoma (HCC) remains controversial. Methods The records of 23 consecutive patients with hepatitis B virus (HBV)-related HCC who underwent ALPPS at our center between November 2013 and June 2018 were retrospectively reviewed. Oncological results were compared between patients who received ALPPS and those that received transarterial chemoembolization (TACE) using propensity score matching (PSM) analysis. Results In patients with a single tumor (n=12) the median tumor diameter was 13.0 (range: 5.1–20.0) cm, whereas in patients with multiple tumors (n=11) the median total tumor diameter was 6.3 (range: 2.3–26.0) cm. After the stage-1 ALPPS, the median future liver remnant (FLR) increased by 50.0%. The stage-2 ALPPS was completed in 20 patients (87.0%) after a median of 12 days. The 90-day mortality rate was 13% (3/23). The overall survival (OS) rates at 1-, 2-, and 5-year were 61.1%, 34.9%, and 8.7%, respectively, whereas the disease-free survival (DFS) rates at 1-, 2-, and 5-year were 27.8%, 27.8%, and 0.0%, respectively. PSM analysis showed no difference in OS between patients who underwent ALPPS and those that received TACE [P=0.178, Barcelona Clinic Liver Cancer (BCLC) stage A–C patients; P=0.241, BCLC stage B and C patients]. Conclusions ALPPS is a safe and effective treatment option for unresectable HBV-related HCC. However, for HBV-related intermediate and advanced HCC patients, ALPPS may not be superior to TACE.
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Affiliation(s)
- Lixin Ke
- Department of Liver Surgery, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Rui Shen
- Department of Liver Surgery, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Wenzhe Fan
- Department of Interventional Oncology, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Wenjie Hu
- Department of Liver Surgery, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Shunli Shen
- Department of Liver Surgery, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Shaoqiang Li
- Department of Liver Surgery, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Ming Kuang
- Department of Liver Surgery, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Lijian Liang
- Department of Liver Surgery, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Jiaping Li
- Department of Interventional Oncology, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Baogang Peng
- Department of Liver Surgery, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Yunpeng Hua
- Department of Liver Surgery, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
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12
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Hepatobiliary scintigraphy and kinetic growth rate predict liver failure after ALPPS: a multi-institutional study. HPB (Oxford) 2020; 22:1420-1428. [PMID: 32057681 DOI: 10.1016/j.hpb.2020.01.010] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Revised: 01/14/2020] [Accepted: 01/19/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Post hepatectomy liver failure (PHLF) after ALPPS has been related to the discrepancy between liver volume and function. Pre-operative hepatobiliary scintigraphy (HBS) can predict post-operative liver function and guide when it is safe to proceed with major hepatectomy. Aim of this study was to evaluate the role of HBS in predicting PHLF after ALPPS, defining a safe cut-off. METHODS A multicenter retrospective study was approved by the ALPPS Registry. All patients selected for ALPPS between 2012 and 2018, were evaluated. Every patient underwent HBS during ALPPS evaluation. PHLF was reported according to ISGLS definition, considering grade B or C as clinically significant. RESULTS 98 patients were included. Thirteen patients experienced PHLF grade B or C (14%) following ALPPS-2. The HBS and the daily gain in volume (KGRFLR) of the future liver remnant (FLR) were significantly lower in PHLF B and C (p = .004 and .041 respectively). ROC curves indicated safe cut-offs of 4.1%/day (AUC = 0.68) for KGRFLR, and of 2.7 %/min/m2 (AUC = 0.75) for HBSFLR. Multivariate analysis confirmed these cut-offs as variables predicting PHLF after ALPPS-2. CONCLUSION Patients presenting a KGRFLR ≤4.1%/day and a HBSFLR ≤2.7%/min/m2 are at high risk of PHLF and their second stage should be re-discussed.
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13
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Takahashi K, Liang C, Oda T, Ohkohchi N. Platelet and liver regeneration after liver surgery. Surg Today 2020; 50:974-983. [PMID: 31720801 DOI: 10.1007/s00595-019-01890-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Accepted: 08/03/2019] [Indexed: 02/06/2023]
Abstract
The success of liver surgery, including resection and transplantation, is largely dependent on the ability of the liver to regenerate. Despite substantial improvement in surgical techniques and perioperative care, one of the main concerns is post-hepatectomy liver failure and early allograft dysfunction, both of which are associated with impaired liver regeneration. Recent studies have demonstrated the positive role of platelets in promoting liver regeneration and protecting hepatocytes; however, the underlying mechanisms responsible for these effects are not fully understood. In this review, we updated the accumulated evidence of the role of platelets in promoting liver regeneration, with a focus on liver resection and liver transplantation. The goal of these studies was to support the clinical implementation of platelet agents, such as thrombopoietin receptor agonists, to augment liver regeneration after liver surgery. This "platelet therapy" may become a treatment choice for post-hepatectomy liver failure and early allograft dysfunction.
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Affiliation(s)
- Kazuhiro Takahashi
- Department of Surgery, University of Tsukuba, 1-1-1, Tennoudai, Tsukuba, Ibaraki, 305-8575, Japan
- Department of Surgery, Mito Central Hospital, 1136-1, Rokutanda-cho, Mito, 311-1135, Japan
| | - Chen Liang
- Department of Surgery, University of Tsukuba, 1-1-1, Tennoudai, Tsukuba, Ibaraki, 305-8575, Japan
- Department of Surgery, Mito Central Hospital, 1136-1, Rokutanda-cho, Mito, 311-1135, Japan
| | - Tatsuya Oda
- Department of Surgery, University of Tsukuba, 1-1-1, Tennoudai, Tsukuba, Ibaraki, 305-8575, Japan
- Department of Surgery, Mito Central Hospital, 1136-1, Rokutanda-cho, Mito, 311-1135, Japan
| | - Nobuhiro Ohkohchi
- Department of Surgery, University of Tsukuba, 1-1-1, Tennoudai, Tsukuba, Ibaraki, 305-8575, Japan.
- Department of Surgery, Mito Central Hospital, 1136-1, Rokutanda-cho, Mito, 311-1135, Japan.
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14
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Agostini A, Borgheresi A, Floridi C, Carotti M, Grazzini G, Pagnini F, Guerrini S, Palumbo P, Pradella S, Carrafiello G, Vivarelli M, Giovagnoni A. The role of imaging in surgical planning for liver resection: what the radiologist need to know. ACTA BIO-MEDICA : ATENEI PARMENSIS 2020; 91:18-26. [PMID: 32945275 PMCID: PMC7944681 DOI: 10.23750/abm.v91i8-s.9938] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Accepted: 06/11/2020] [Indexed: 12/18/2022]
Abstract
The management of patients undergoing surgical resection for liver malignancies requires a multidisciplinary team, including a dedicated radiologist. In the preoperative workup, the radiologist has to provide precise, relevant information to the surgeon. This requires the radiologist to know the basics of surgical techniques as well as liver surgical anatomy in order to help to avoid unexpected surgical scenarios and complications. Moreover, virtual resections and volumetries on radiological images will be discussed, and basic concepts of postoperative liver failure, regeneration, and methods for hypertrophy induction will be provided.
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Affiliation(s)
- Andrea Agostini
- Department of Clinical, Special and Dental Sciences, University Politecnica delle Marche, Ancona, AN, Italy; Division of Special and Pediatric Radiology, Department of Radiology, University Hospital "Umberto I - Lancisi - Salesi", Ancona, AN, Italy.
| | - Alessandra Borgheresi
- Division of Special and Pediatric Radiology, Department of Radiology, University Hospital "Umberto I - Lancisi - Salesi", Ancona, AN, Italy.
| | - Chiara Floridi
- Department of Clinical, Special and Dental Sciences, University Politecnica delle Marche, Ancona, AN, Italy; Division of Special and Pediatric Radiology, Department of Radiology, University Hospital "Umberto I - Lancisi - Salesi", Ancona, AN, Italy.
| | - Marina Carotti
- Division of Special and Pediatric Radiology, Department of Radiology, University Hospital "Umberto I - Lancisi - Salesi", Ancona, AN, Italy.
| | - Giulia Grazzini
- Department of Radiology, Careggi University Hospital, Florence, Italy.
| | - Francesco Pagnini
- Department of Medicine and Surgery, Unit of Radiology, University of Parma, Parma, Italy.
| | - Susanna Guerrini
- Unit of Diagnostic Imaging, Department of Radiological Sciences, University of Siena, Azienda Ospedaliero-Universitaria Senese, Siena, Italy.
| | - Pierpaolo Palumbo
- Department of Biotechnology and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy.
| | - Silvia Pradella
- Department of Radiology, Careggi University Hospital, Florence, Italy.
| | - Gianpaolo Carrafiello
- Radiology Department, Fondazione IRCSS Ca Granda, Ospedale Maggiore Policlinico and Department of Health Sciences, Università degli Studi di Milano, Milan, Italy.
| | - Marco Vivarelli
- University Politecnica delle Marche, School of Medicine and University Hospital "Umberto I - Lancisi - Salesi", Division of Hepatobiliary and Transplant Surgery, Ancona, Italy.
| | - Andrea Giovagnoni
- Department of Clinical, Special and Dental Sciences, University Politecnica delle Marche, Ancona, AN, Italy; Division of Special and Pediatric Radiology, Department of Radiology, University Hospital "Umberto I - Lancisi - Salesi", Ancona, AN, Italy.
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15
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Jeyarajah DR, Doyle MBM, Espat NJ, Hansen PD, Iannitti DA, Kim J, Thambi-Pillai T, Visser BC. Role of yttrium-90 selective internal radiation therapy in the treatment of liver-dominant metastatic colorectal cancer: an evidence-based expert consensus algorithm. J Gastrointest Oncol 2020; 11:443-460. [PMID: 32399284 DOI: 10.21037/jgo.2020.01.09] [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] [Indexed: 12/11/2022] Open
Abstract
Surgical resection of colorectal liver metastases is associated with greater survival compared with non-surgical treatment, and a meaningful possibility of cure. However, the majority of patients are not eligible for resection and may require other non-surgical interventions, such as liver-directed therapies, to be converted to surgical eligibility. Given the number of available therapies, a general framework is needed that outlines the specific roles of chemotherapy, surgery, and locoregional treatments [including selective internal radiation therapy (SIRT) with Y-90 microspheres]. Using a data-driven, modified Delphi process, an expert panel of surgical oncologists, transplant surgeons, and hepatopancreatobiliary (HPB) surgeons convened to create a comprehensive, evidence-based treatment algorithm that includes appropriate treatment options for patients stratified by their eligibility for surgical treatment. The group coined a novel, more inclusive phrase for targeted locoregional tumor treatment (a blanket term for resection, ablation, and other emerging locoregional treatments): local parenchymal tumor destruction therapy. The expert panel proposed new nomenclature for 3 distinct disease categories of liver-dominant metastatic colorectal cancer that is consistent with other tumor types: (I) surgically treatable (resectable); (II) surgically untreatable (borderline resectable); (III) advanced surgically untreatable (unresectable) disease. Patients may present at any point in the algorithm and move between categories depending on their response to therapy. The broad intent of therapy is to transition patients toward individualized treatments where possible, given the survival advantage that resection offers in the context of a comprehensive treatment plan. This article reviews what is known about the role of SIRT with Y-90 as neoadjuvant, definitive, or palliative therapy in these different clinical situations and provides insight into when treatment with SIRT with Y-90 may be appropriate and useful, organized into distinct treatment algorithm steps.
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Affiliation(s)
| | | | - N Joseph Espat
- Department of Surgery, Roger Williams Medical Center, Boston University School of Medicine, Providence, RI, USA
| | - Paul D Hansen
- HPB Surgery, Providence Portland Center, Portland, OR, USA
| | - David A Iannitti
- HPB Surgery, Atrium Health, Carolinas Medical Center, Charlotte, NC, USA
| | - Joseph Kim
- Department of Surgery, University of Kentucky, Lexington, KY, USA
| | - Thavam Thambi-Pillai
- Department of Surgery, University of South Dakota Sanford School of Medicine, Sioux Falls, SD, USA
| | - Brendan C Visser
- Department of Surgery, Stanford University Medical Center, CA, USA
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Wang Z, Peng Y, Hu J, Wang X, Sun H, Sun J, Shi Y, Xiao Y, Ding Z, Yang X, Tang M, Tang Z, Wang J, Lau WY, Fan J, Zhou J. Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy for Unresectable Hepatitis B Virus-related Hepatocellular Carcinoma: A Single Center Study of 45 Patients. Ann Surg 2020; 271:534-541. [PMID: 29995681 DOI: 10.1097/sla.0000000000002942] [Citation(s) in RCA: 59] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE The aim of the study is to assess the efficacy and safety of associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) in patients with hepatitis B virus-related hepatocellular carcinoma (HCC). BACKGROUND ALPSS allows curative resection of conventionally-unresectable liver tumors. However, its role in HCC is largely unknown. METHODS Consecutive HCC patients who underwent ALPPS at our center between April 2013 and September 2017 were retrospectively studied. The oncological results were compared with patients receiving transcatheter arterial chemoembolization (TACE), and patients undergoing one-stage resection by using propensity score matching (PSM) analysis. RESULTS The median tumor diameter was 13 cm (range: 6-22 cm) in patients with a single tumor (n = 28), whereas the median total tumor diameter was 12 cm (range: 9-31 cm) in patients with multiple tumors (n = 17). After stage-1 ALPPS, the median future liver remnant (FLR) increased by 56.8%. The stage-2 ALPPS was completed in 41 patients (91.1%) after a median of 12 days. The 90-day mortality rate was 11.1% (5/45). The overall survival (OS) rates at 1- and 3-year were 64.2% and 60.2%, whereas the disease-free survival (DFS) rates at 1 and 3 years were 47.6% and 43.9%, respectively. On PSM analysis, the long-term survival of patients undergoing ALPPS was significantly better than those receiving TACE (OS, P = 0.004; DFS, P < 0.0001) and similar to those subjected to one-stage liver resection (OS, P = 0.514; DFS, P = 0.849). CONCLUSIONS The long-term survival after ALPPS was significantly better than TACE, and similar to those after one-stage liver resection. ALPPS is a viable treatment option for patients with unresectable HCC in selected patients.
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Affiliation(s)
- Zheng Wang
- Department of Liver Surgery and Transplantation, Liver Cancer Institute, Zhongshan Hospital, Fudan University, Key Laboratory of Carcinogenesis and Cancer Invasion, Ministry of Education, Fudan University, Shanghai, China
| | - Yuanfei Peng
- Department of Liver Surgery and Transplantation, Liver Cancer Institute, Zhongshan Hospital, Fudan University, Key Laboratory of Carcinogenesis and Cancer Invasion, Ministry of Education, Fudan University, Shanghai, China
| | - Jingwu Hu
- Department of Liver Surgery and Transplantation, Liver Cancer Institute, Zhongshan Hospital, Fudan University, Key Laboratory of Carcinogenesis and Cancer Invasion, Ministry of Education, Fudan University, Shanghai, China
| | - Xiaoying Wang
- Department of Liver Surgery and Transplantation, Liver Cancer Institute, Zhongshan Hospital, Fudan University, Key Laboratory of Carcinogenesis and Cancer Invasion, Ministry of Education, Fudan University, Shanghai, China
| | - Huichuan Sun
- Department of Liver Surgery and Transplantation, Liver Cancer Institute, Zhongshan Hospital, Fudan University, Key Laboratory of Carcinogenesis and Cancer Invasion, Ministry of Education, Fudan University, Shanghai, China
| | - Jian Sun
- Department of Liver Surgery and Transplantation, Liver Cancer Institute, Zhongshan Hospital, Fudan University, Key Laboratory of Carcinogenesis and Cancer Invasion, Ministry of Education, Fudan University, Shanghai, China
| | - Yinghong Shi
- Department of Liver Surgery and Transplantation, Liver Cancer Institute, Zhongshan Hospital, Fudan University, Key Laboratory of Carcinogenesis and Cancer Invasion, Ministry of Education, Fudan University, Shanghai, China
| | - Yongsheng Xiao
- Department of Liver Surgery and Transplantation, Liver Cancer Institute, Zhongshan Hospital, Fudan University, Key Laboratory of Carcinogenesis and Cancer Invasion, Ministry of Education, Fudan University, Shanghai, China
| | - Zhenbing Ding
- Department of Liver Surgery and Transplantation, Liver Cancer Institute, Zhongshan Hospital, Fudan University, Key Laboratory of Carcinogenesis and Cancer Invasion, Ministry of Education, Fudan University, Shanghai, China
| | - Xinrong Yang
- Department of Liver Surgery and Transplantation, Liver Cancer Institute, Zhongshan Hospital, Fudan University, Key Laboratory of Carcinogenesis and Cancer Invasion, Ministry of Education, Fudan University, Shanghai, China
| | - Min Tang
- Department of Radiology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Zhaoyou Tang
- Department of Liver Surgery and Transplantation, Liver Cancer Institute, Zhongshan Hospital, Fudan University, Key Laboratory of Carcinogenesis and Cancer Invasion, Ministry of Education, Fudan University, Shanghai, China
| | - Jiping Wang
- Hepatobiliary Cancer Division of Surgical Oncology, Brigham and Women's Hospital, Boston, MA
| | - Wan Y Lau
- Faculty of Medicine, The Chinese University of Hong Kong, Prince of Wales Hospital, Sha Tin, Honk King, China
| | - Jia Fan
- Department of Liver Surgery and Transplantation, Liver Cancer Institute, Zhongshan Hospital, Fudan University, Key Laboratory of Carcinogenesis and Cancer Invasion, Ministry of Education, Fudan University, Shanghai, China
- Institute of Biomedical Sciences, Fudan University, Shanghai, China
- State Key Laboratory of Genetic Engineering and Collaborative Innovation Center for Genetics and Development, School of Life Sciences, Fudan University, Shanghai, China
- Shanghai Key Laboratory of Organ Transplantation, Shanghai, China
| | - Jian Zhou
- Department of Liver Surgery and Transplantation, Liver Cancer Institute, Zhongshan Hospital, Fudan University, Key Laboratory of Carcinogenesis and Cancer Invasion, Ministry of Education, Fudan University, Shanghai, China
- Institute of Biomedical Sciences, Fudan University, Shanghai, China
- State Key Laboratory of Genetic Engineering and Collaborative Innovation Center for Genetics and Development, School of Life Sciences, Fudan University, Shanghai, China
- Shanghai Key Laboratory of Organ Transplantation, Shanghai, China
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17
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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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Golriz M, Lemekhova A, Khajeh E, Ghamarnejad O, Al-Saeedi M, Strobel O, Hackert T, Müller-Stich B, Schneider M, Berchtold C, Tinoush P, Mayer P, Chang DH, Weiss KH, Hoffmann K, Mehrabi A. Evaluation of the role of transhepatic flow in postoperative outcomes following major hepatectomy (THEFLOW): study protocol for a single-centre, non-interventional cohort study. BMJ Open 2019; 9:e029618. [PMID: 31604785 PMCID: PMC6797302 DOI: 10.1136/bmjopen-2019-029618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Liver resection is the only curative treatment for primary and secondary hepatic tumours. Improvements in perioperative preparation of patients and new surgical developments have made complex liver resections possible. However, small for size and flow syndrome (SFSF) is still a challenging issue, rendering patients inoperable and causing postoperative morbidity and mortality. Although the role of transhepatic flow in the postoperative outcome has been shown in small partial liver transplantation and experimental studies of SFSF, this has never been studied in the clinical setting following liver resection. The aim of this study is to systematically evaluate transhepatic flow changes following major liver resection and its correlation with postoperative outcomes. METHODS AND ANALYSIS The TransHEpatic FLOW (THEFLOW) study is a single-centre, non-interventional cohort study, and aims to enrol 50 patients undergoing major hepatectomy (defined as hemihepatectomy or extended hepatectomy based on the Brisbane classification) with or without prior chemotherapy. The portal venous flow, hepatic artery flow and portal venous pressure are measured before and after each resection. All patients are followed-up for 3 months after the operation. During each evaluation, standard clinical data, posthepatectomy liver failure and overall morbidity and mortality will be recorded. THEFLOW study was initiated on 25 March 2018 and is expected to progress for 2 years. ETHICS AND DISSEMINATION This protocol study received approval from the Ethics Committee of the University of Heidelberg (registration number: S576/2017). The results of this study will be published in a peer-reviewed journal, and will also be presented at medical meetings. TRIAL REGISTRATION NUMBER NCT03762876.
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Affiliation(s)
- Mohammad Golriz
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
- Liver Cancer Center Heidelberg, University of Heidelberg, Heidelberg, Germany
- Division of Liver Surgery at Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Anastasia Lemekhova
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
- Liver Cancer Center Heidelberg, University of Heidelberg, Heidelberg, Germany
- Division of Liver Surgery at Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Elias Khajeh
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
- Division of Liver Surgery at Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Omid Ghamarnejad
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
- Division of Liver Surgery at Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Mohammed Al-Saeedi
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Oliver Strobel
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
- Liver Cancer Center Heidelberg, University of Heidelberg, Heidelberg, Germany
| | - Thilo Hackert
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
- Liver Cancer Center Heidelberg, University of Heidelberg, Heidelberg, Germany
| | - Beat Müller-Stich
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Martin Schneider
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
- Liver Cancer Center Heidelberg, University of Heidelberg, Heidelberg, Germany
| | - Christoph Berchtold
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Parham Tinoush
- Department of Diagnostic and Interventional Radiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Philipp Mayer
- Department of Diagnostic and Interventional Radiology, University Hospital Heidelberg, Heidelberg, Germany
| | - De-Hua Chang
- Liver Cancer Center Heidelberg, University of Heidelberg, Heidelberg, Germany
- Department of Diagnostic and Interventional Radiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Karl Heinz Weiss
- Liver Cancer Center Heidelberg, University of Heidelberg, Heidelberg, Germany
- Department of Gastroenterology and Hepatology, University of Heidelberg, Heidelberg, Germany
| | - Katrin Hoffmann
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
- Liver Cancer Center Heidelberg, University of Heidelberg, Heidelberg, Germany
- Division of Liver Surgery at Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Arianeb Mehrabi
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
- Liver Cancer Center Heidelberg, University of Heidelberg, Heidelberg, Germany
- Division of Liver Surgery at Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
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Bevilacqua A, D'Amuri FV, Pagnini F, Sabatino V, Russo U, Maggialetti N, Palumbo P, Pradella S, Giovagnoni A, Miele V, De Filippo M. Percutaneous needle biopsy of retroperitoneal lesions: technical developments. ACTA BIO-MEDICA : ATENEI PARMENSIS 2019; 90:62-67. [PMID: 31085974 PMCID: PMC6625572 DOI: 10.23750/abm.v90i5-s.8331] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Indexed: 02/08/2023]
Abstract
Percutaneous Needle Biopsy (PNB) is the insertion of a needle into a suspected lesion or an organ with the aim to obtain cells or tissue for diagnosis. It’s a relatively non-invasive procedure and is performed by radiologist under guidance of imaging techniques such as ultrasound (US), computed tomography (CT), fluoroscopy, magnetic resonance imaging (MRI), and positron emission tomography CT (PET-CT). The choice of imaging technique depends on the evaluation of the target lesion and patient compliance. PNB includes two categories: fine-needle aspiration biopsy (FNAB) that is the use of a thin needle (18-25 gauge) to extract cells for cytological evaluation; and core needle biopsy (CNB) that is the use of a larger needle (9-20 gauge) to extract a piece of tissue for histological evaluation. The indications for biopsy are the characterization of nature (benign or malignant) of a lesion, diagnosis and staging of tumor, and biological or immunohistochemical/genetic analisys on tissue. Success of PNB is the procurement of sufficient material to characterize lesions and to guide the patient outcome. Major complications are rare. PNB became a useful technique in diagnosis and study of retroperitoneal lesions, because of a more suitable access to specific intra-abdominal structures, lowering the risk of injury of interposed structures (such as bowel, great vessels). (www.actabiomedica.it)
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Affiliation(s)
- Andrea Bevilacqua
- Department of Medicine and Surgery, Unit of Radiologic Science, University of Parma, Maggiore Hospital, Parma, Italy.
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Lanzetta MM, Masserelli A, Addeo G, Cozzi D, Maggialetti N, Danti G, Bartolini L, Pradella S, Giovagnoni A, Miele V. Internal hernias: a difficult diagnostic challenge. Review of CT signs and clinical findings. ACTA BIO-MEDICA : ATENEI PARMENSIS 2019; 90:20-37. [PMID: 31085971 PMCID: PMC6625567 DOI: 10.23750/abm.v90i5-s.8344] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Indexed: 12/16/2022]
Abstract
Although internal hernias are uncommon, they must be beared in mind in the differential diagnosis in cases of intestinal obstruction, especially in patients with no history of previous surgery or trauma. Because of the high possibility of strangulation and ischemia of the affected loops, internal hernias represent a potentially life-threatening condition and surgical emergency that needs to be quickly recognized and managed promptly. Imaging plays a leading role in the diagnosis and in particular multidetector computed tomography (MDCT), with its thin-section and high-resolution multiplanar reformatted (MPR) images, represents the first line image technique in these patients. The purpose of the present paper is to illustrate the characteristic anatomic location, the clinical findings and the CT appearance associated with main types of internal hernia, including paraduodenal, foramen of Winslow, pericecal, sigmoid-mesocolon- and trans-mesenteric-related, transomental, supravesical and pelvic hernias. (www.actabiomedica.it)
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De Filippo M, Brunese L, Reginelli A. Advances in diagnostic and interventional radiology. ACTA BIO-MEDICA : ATENEI PARMENSIS 2019; 90:5-8. [PMID: 31085969 PMCID: PMC6625574 DOI: 10.23750/abm.v90i5-s.8327] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Indexed: 11/23/2022]
Affiliation(s)
- Massimo De Filippo
- Department of Medicine and Surgery, Unit of Radiologic Science, University of Parma, Maggiore Hospital, Parma, Italy.
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22
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Ouyang G, Liu J, Wang P, Ren Y, Yi P, Zhou Q, Chen J, Xiang B, Zhang Y, Zhang Z, Li L. Multiple factors affect the regeneration of liver. ACTA ACUST UNITED AC 2019; 64:791-798. [PMID: 30672999 DOI: 10.1590/1806-9282.64.09.791] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Accepted: 01/20/2018] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To study factors affecting the liver regeneration after hepatectomy. METHODS With 3D reconstitution technology, liver regeneration ability of 117 patients was analysed, and relative factors were studied. RESULTS There was no statistically difference between the volume of simulated liver resection and the actual liver resection. All livers had different degrees of regeneration after surgery. Age, gender and blood indicators had no impact on liver regeneration, while surgery time, intraoperative blood loss, blood flow blocking time and different ways of liver resection had a significant impact on liver regeneration; In addition, the patients' own pathological status, including, hepatitis and liver fibrosis all had a significant impact on liver regeneration. CONCLUSION 3D reconstitution model is a good model to calculate liver volume. Age, gender, blood indicators and biochemistry indicators have no impact on liver regeneration, but surgery indicators and patients' own pathological status have influence on liver regeneration.
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Affiliation(s)
- Gaoxiong Ouyang
- . Department of Hepatobiliary Surgery, Affiliated Cancer Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Jianyong Liu
- . Department of Hepatobiliary Surgery, Affiliated Cancer Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Peng Wang
- . Department of Radiology, Affiliated Cancer Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Yuan Ren
- . Department of Hepatobiliary Surgery, Affiliated Cancer Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Ping Yi
- . Department of Hepatobiliary Surgery, Affiliated Cancer Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Quan Zhou
- . Department of Hepatobiliary Surgery, Affiliated Cancer Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Jun Chen
- . Department of Pathology, Affiliated Cancer Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Bangde Xiang
- . Department of Hepatobiliary Surgery, Affiliated Cancer Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Yumei Zhang
- . Department of Hepatobiliary Surgery, Affiliated Cancer Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Zhiming Zhang
- . Department of Hepatobiliary Surgery, Affiliated Cancer Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Lequn Li
- . Department of Hepatobiliary Surgery, Affiliated Cancer Hospital of Guangxi Medical University, Nanning, Guangxi, China
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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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Akbulut S, Cicek E, Kolu M, Sahin TT, Yilmaz S. Associating liver partition and portal vein ligation for staged hepatectomy for extensive alveolar echinococcosis: First case report in the literature. World J Gastrointest Surg 2018; 10:1-5. [PMID: 29391928 PMCID: PMC5785687 DOI: 10.4240/wjgs.v10.i1.1] [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: 10/31/2017] [Revised: 12/04/2017] [Accepted: 12/13/2017] [Indexed: 02/06/2023] Open
Abstract
Alveolar echinococcosis (AE) is a zoonotic disease that is caused by Echinococcus multilocularis that affects liver and a variety of organs and tissues. It differs from other echinococcal disease because it shows tumor like behavior in the affected organ and tissues. The treatment of choice is concomitant medical therapy and resection with negative margins. Nevertheless, resection with the intent of negative margins (R0) may lead to serious complications such as liver failure. In the present case report, we used Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy (ALPPS) procedure, which was defined in 2012 by Schnitzbauer et al, in a 28-year-old male patient to avoid complications of major liver resection in order to treat alveolar echinococcosis. Until now, we have not encountered any study using ALPPS procedure for the treatment of alveolar echinococcosis. In the present case report we aimed to show that ALPPS procedure can be safely performed for margin-negative resection of primary or recurrent AE that shows a tumor like behavior. It is our opinion that this procedure should be performed in centers that have expertise and sufficient technical capacity to perform liver transplantation and advanced liver surgery.
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Affiliation(s)
- Sami Akbulut
- Department of Surgery and Liver Transplant Institute, Inonu University Faculty of Medicine, Malatya 44280, Turkey
| | - Egemen Cicek
- Department of Surgery and Liver Transplant Institute, Inonu University Faculty of Medicine, Malatya 44280, Turkey
| | - Mehmet Kolu
- Department of Radiology, Inonu University Faculty of Medicine, Malatya 44280, Turkey
| | - Tevfik Tolga Sahin
- Department of Surgery and Liver Transplant Institute, Inonu University Faculty of Medicine, Malatya 44280, Turkey
| | - Sezai Yilmaz
- Department of Surgery and Liver Transplant Institute, Inonu University Faculty of Medicine, Malatya 44280, Turkey
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He Z, Chen G, Ouyang B, Zhang H, Chen H, Wang Y, Yan S, Pan W. Conformal Radiation Therapy or Stereotactic Body Radiation Therapy: Institutional Experience in the Management of Colorectal Liver Metastases by Radiation Therapy. Technol Cancer Res Treat 2018. [PMCID: PMC6295685 DOI: 10.1177/1533033818816080] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Aim: Methods: Results: Conclusions:
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Affiliation(s)
- Zemin He
- Department of General Surgery, The Affiliated Jiangning Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Gang Chen
- Department of Oncology, The Affiliated Jiangning Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Bo Ouyang
- Department of General Surgery, The Affiliated Jiangning Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Haoyue Zhang
- Department of General Surgery, The Affiliated Jiangning Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Hui Chen
- Department of Radiation Oncology, The Affiliated Jiangning Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Yehuang Wang
- National Chinese Medical Center of Colorectal Diseases, The Third Affiliated Hospital of Nanjing University of Traditional Chinese Medicine, Nanjing, Jiangsu, China
| | - Shushan Yan
- Department of Gastrointestinal and Anal Diseases Surgery, The Affiliated Hospital of Weifang Medical University, Weifang, Shandong, China
| | - Wei Pan
- Department of Radiation Oncology, The Affiliated Jiangning Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
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Zhou Z, Xu M, Lin N, Pan C, Zhou B, Zhong Y, Xu R. Associating liver partition and portal vein ligation for staged hepatectomy versus conventional two-stage hepatectomy: a systematic review and meta-analysis. World J Surg Oncol 2017; 15:227. [PMID: 29258518 PMCID: PMC5738171 DOI: 10.1186/s12957-017-1295-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Accepted: 12/08/2017] [Indexed: 02/08/2023] Open
Abstract
Background It is generally accepted that an insufficient future liver remnant is a major limitation of large-scale hepatectomy for patients with primary hepatocellular carcinoma. Conventional two-stage hepatectomy (TSH) is commonly considered to accelerate future liver regeneration despite its low regeneration rate. Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS), which is characterized by a rapid regeneration, has brought new opportunities. Methods Relevant studies were identified by searching the selected databases up to September 2017. Then, a meta-analysis of regeneration efficiency, complication rate, R0 resection ratio, and short-term outcomes was performed. Results Ten studies, comprising 719 patients, were included. The overall analysis showed that ALPPS was associated with a larger hyperplastic volume and a shorter time interval (P < 0.00001) than TSH. ALPPS also exhibited a higher completion rate for second-stage operations (odds ratio, OR 9.50; P < 0.0001) and a slightly higher rate of R0 resection (OR 1.90; P = 0.11). Interestingly, there was no significant difference in 90-day mortality between the two treatments (OR 1.44; P = 0.35). Conclusions These results indicate that compared with TSH, ALPPS possesses a stronger regenerative ability and better facilitates second-stage operations. However, the safety, patient outcomes, and patient selection for ALPPS require further study. Electronic supplementary material The online version of this article (10.1186/s12957-017-1295-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Zheng Zhou
- Department of Hepatobiliary Surgery, Third Affiliated Hospital of Sun Yat-sen University, No. 600 Tianhe Road, Guangzhou, Guangdong, China
| | - Mingxing Xu
- Department of Hepatobiliary Surgery, Third Affiliated Hospital of Sun Yat-sen University, No. 600 Tianhe Road, Guangzhou, Guangdong, China
| | - Nan Lin
- Department of Hepatobiliary Surgery, Third Affiliated Hospital of Sun Yat-sen University, No. 600 Tianhe Road, Guangzhou, Guangdong, China
| | - Chuzhi Pan
- Department of Hepatobiliary Surgery, Third Affiliated Hospital of Sun Yat-sen University, No. 600 Tianhe Road, Guangzhou, Guangdong, China
| | - Boxuan Zhou
- Department of Hepatobiliary Surgery, Third Affiliated Hospital of Sun Yat-sen University, No. 600 Tianhe Road, Guangzhou, Guangdong, China
| | - Yuesi Zhong
- Department of Hepatobiliary Surgery, Third Affiliated Hospital of Sun Yat-sen University, No. 600 Tianhe Road, Guangzhou, Guangdong, China
| | - Ruiyun Xu
- Department of Hepatobiliary Surgery, Third Affiliated Hospital of Sun Yat-sen University, No. 600 Tianhe Road, Guangzhou, Guangdong, China.
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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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Al Hasan I, Tun-Abraham ME, Wanis KN, Garcia-Ochoa C, Levstik MA, Al-Judaibi B, Hernandez-Alejandro R. Optimizing associated liver partition and portal vein ligation for staged hepatectomy outcomes: Surgical experience or appropriate patient selection? Can J Surg 2017; 60:408-415. [PMID: 29173259 PMCID: PMC5726970 DOI: 10.1503/cjs.005817] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/05/2017] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Early reports of associated liver partition and portal vein ligation for staged hepatectomy (ALPPS) outcomes have been suboptimal. The literature has confirmed that learning curves influence surgical outcomes. We have 54 months of continuous experience performing ALPPS with strict selection criteria. This study aimed to evaluate the impact of the learning curve on ALPPS outcomes. METHODS We retrospectively compared patients who underwent ALPPS between April 2012 and March 2016. Patients were grouped into 2 24-month (early and late) periods. All candidates had a high tumour load requiring staged hepatectomy after chemotherapy response, a predicted future liver remnant (FLR) less than 30% and good performance status. RESULTS Thirty-three patients underwent ALPPS during the study period: 16 in the early group (median age 65 yr, mean body mass index [BMI] 27) and 17 in the late group (median age 60 yr, mean BMI 25). Bilobar disease was comparable in both groups (94% v. 88%, p > 0.99). Duration of surgery was not statistically different. Intraoperative blood loss and need for transfusion were significantly lower in the late group (200 ± 109 mL v. 100 ± 43 mL, p < 0.05). The late group had a higher proportion of monosegment ALPPS (4:1). There were no deaths within 90 days in either cohort. Rates of postoperative complications were not statistically significant between groups. The R0 resection rate was similar. The entire 1-year disease-free and overall survival were 52% and 84%, respectively. CONCLUSION Excellent results can be obtained in innovative complex surgery with careful patient selection and good technical skills. Additionally, the learning curve brought confidence to perform more complex procedures while maintaining good outcomes.
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Affiliation(s)
- Ibrahim Al Hasan
- From the Department of Surgery, Schulich School of Medicine & Dentistry, University of Western Ontario, London, Ont. (Al Hasan, Tun-Abraham, Garcia-Ochoa, Hernandez-Alejandro); the Department of Surgery, Prince Sultan Military Medical City, Riyadh, Saudi Arabia (Al Hasan); the Multi-Organ Transplant Program, London Health Sciences Centre, London, Ont. (Al-Judaibi); the Division of Transplantation, University of Rochester Medical Center, Rochester, Minn. (Levstik); and the Department of Medicine, King Saud University, King Khalid University Hospital, Riyadh, Saudi Arabia (Al-Judaibi)
| | - Mauro Enrique Tun-Abraham
- From the Department of Surgery, Schulich School of Medicine & Dentistry, University of Western Ontario, London, Ont. (Al Hasan, Tun-Abraham, Garcia-Ochoa, Hernandez-Alejandro); the Department of Surgery, Prince Sultan Military Medical City, Riyadh, Saudi Arabia (Al Hasan); the Multi-Organ Transplant Program, London Health Sciences Centre, London, Ont. (Al-Judaibi); the Division of Transplantation, University of Rochester Medical Center, Rochester, Minn. (Levstik); and the Department of Medicine, King Saud University, King Khalid University Hospital, Riyadh, Saudi Arabia (Al-Judaibi)
| | - Kerollos N. Wanis
- From the Department of Surgery, Schulich School of Medicine & Dentistry, University of Western Ontario, London, Ont. (Al Hasan, Tun-Abraham, Garcia-Ochoa, Hernandez-Alejandro); the Department of Surgery, Prince Sultan Military Medical City, Riyadh, Saudi Arabia (Al Hasan); the Multi-Organ Transplant Program, London Health Sciences Centre, London, Ont. (Al-Judaibi); the Division of Transplantation, University of Rochester Medical Center, Rochester, Minn. (Levstik); and the Department of Medicine, King Saud University, King Khalid University Hospital, Riyadh, Saudi Arabia (Al-Judaibi)
| | - Carlos Garcia-Ochoa
- From the Department of Surgery, Schulich School of Medicine & Dentistry, University of Western Ontario, London, Ont. (Al Hasan, Tun-Abraham, Garcia-Ochoa, Hernandez-Alejandro); the Department of Surgery, Prince Sultan Military Medical City, Riyadh, Saudi Arabia (Al Hasan); the Multi-Organ Transplant Program, London Health Sciences Centre, London, Ont. (Al-Judaibi); the Division of Transplantation, University of Rochester Medical Center, Rochester, Minn. (Levstik); and the Department of Medicine, King Saud University, King Khalid University Hospital, Riyadh, Saudi Arabia (Al-Judaibi)
| | - Mark A. Levstik
- From the Department of Surgery, Schulich School of Medicine & Dentistry, University of Western Ontario, London, Ont. (Al Hasan, Tun-Abraham, Garcia-Ochoa, Hernandez-Alejandro); the Department of Surgery, Prince Sultan Military Medical City, Riyadh, Saudi Arabia (Al Hasan); the Multi-Organ Transplant Program, London Health Sciences Centre, London, Ont. (Al-Judaibi); the Division of Transplantation, University of Rochester Medical Center, Rochester, Minn. (Levstik); and the Department of Medicine, King Saud University, King Khalid University Hospital, Riyadh, Saudi Arabia (Al-Judaibi)
| | - Bandar Al-Judaibi
- From the Department of Surgery, Schulich School of Medicine & Dentistry, University of Western Ontario, London, Ont. (Al Hasan, Tun-Abraham, Garcia-Ochoa, Hernandez-Alejandro); the Department of Surgery, Prince Sultan Military Medical City, Riyadh, Saudi Arabia (Al Hasan); the Multi-Organ Transplant Program, London Health Sciences Centre, London, Ont. (Al-Judaibi); the Division of Transplantation, University of Rochester Medical Center, Rochester, Minn. (Levstik); and the Department of Medicine, King Saud University, King Khalid University Hospital, Riyadh, Saudi Arabia (Al-Judaibi)
| | - Roberto Hernandez-Alejandro
- From the Department of Surgery, Schulich School of Medicine & Dentistry, University of Western Ontario, London, Ont. (Al Hasan, Tun-Abraham, Garcia-Ochoa, Hernandez-Alejandro); the Department of Surgery, Prince Sultan Military Medical City, Riyadh, Saudi Arabia (Al Hasan); the Multi-Organ Transplant Program, London Health Sciences Centre, London, Ont. (Al-Judaibi); the Division of Transplantation, University of Rochester Medical Center, Rochester, Minn. (Levstik); and the Department of Medicine, King Saud University, King Khalid University Hospital, Riyadh, Saudi Arabia (Al-Judaibi)
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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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Maulat C, Philis A, Charriere B, Mokrane FZ, Guimbaud R, Otal P, Suc B, Muscari F. Rescue associating liver partition and portal vein ligation for staged hepatectomy after portal embolization: Our experience and literature review. World J Clin Oncol 2017; 8:351-359. [PMID: 28848702 PMCID: PMC5554879 DOI: 10.5306/wjco.v8.i4.351] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Revised: 06/05/2017] [Accepted: 07/10/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To report a single-center experience in rescue associating liver partition and portal vein ligation for staged hepatectomy (ALPPS), after failure of previous portal embolization. We also performed a literature review.
METHODS Between January 2014 and December 2015, every patient who underwent a rescue ALPPS procedure in Toulouse Rangueil University Hospital, France, was included. Every patient included had a project of major hepatectomy and a previous portal vein embolization (PVE) with insufficient future liver remnant to body weight ratio after the procedure. The ALPPS procedure was performed in two steps (ALPPS-1 and ALPPS-2), separated by an interval phase. ALPPS-2 was done within 7 to 9 d after ALPPS-1. To estimate the FLR, a computed tomography scan examination was performed 3 to 6 wk after the PVE procedure and 6 to 8 d after ALPPS-1. A transcystic stent was placed during ALPPS-1 and remained opened during the interval phase, in order to avoid biliary complications. Postoperative liver failure was defined using the 50-50 criteria. Postoperative complications were assessed according to the Dindo-Clavien Classification.
RESULTS From January 2014 to December 2015, 7 patients underwent a rescue ALPPS procedure. Median FLR before PVE, ALPPS-1 and ALPPS-2 were respectively 263 cc (221-380), 450 cc (372-506), and 660 cc (575-776). Median FLR/BWR before PVE, ALPPS-1 and ALPPS-2 were respectively 0.4% (0.3-0.5), 0.6% (0.5-0.8), and 1% (0.8-1.2). Median volume growth of FLR was 69% (18-92) after PVE, and 45% (36-82) after ALPPS-1. The combination of PVE and ALPPS induced a growth of median initial FLR of +408 cc (254-513), leading to an increase of +149% (68-199). After ALPPS-2, 4 patients had stage I-II complications. Three patients had more severe complications (one stage III, one stage IV and one death due to bowel perforation). Two patients suffered from postoperative liver failure according to the 50/50 criteria. None of our patients developed any biliary complication during the ALPPS procedure.
CONCLUSION Rescue ALPPS may be an alternative after unsuccessful PVE and could allow previously unresectable patients to reach surgery. Biliary drainage seems to reduce biliary complications.
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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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Alghamdi T, Viebahn C, Justinger C, Lorf T. Arterial Blood Supply of Liver Segment IV and Its Possible Surgical Consequences. Am J Transplant 2017; 17:1064-1070. [PMID: 27775870 PMCID: PMC5396263 DOI: 10.1111/ajt.14089] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2016] [Revised: 09/21/2016] [Accepted: 10/09/2016] [Indexed: 01/25/2023]
Abstract
The risk of ischemia of segment IV after split liver resection is high. This anatomical study was done to identify the arterial blood supply and the intrahepatic distribution of liver segment IV. The anatomy of segment IV was studied in 29 livers from adult cadavers. To identify the arterial blood supply of segment IV, water and ink were injected into the various branches of the hepatic artery and the outflow through segment IV and discoloration of the liver parenchyma were observed. In 23 of the 29 livers (79.3%), the arterial perfusion of segment IV was separated by a line drawn from the left side of the inferior vena cava at the top of and lateral to the falciform ligament to the medial point of the gallbladder bed. The area lateral to this line was supplied mainly by the right hepatic artery, and the area medial to it was supplied mainly by the left hepatic artery. In addition to the classification system of Couinaud, we describe here a new division of liver segment IV based on arterial blood supply. These anatomical findings may be useful in defining the resection line for split liver to prevent necrosis of segment IV.
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Affiliation(s)
- T. Alghamdi
- Department of General and Visceral SurgeryStädtisches Klinikum KarlsruheKarlsruheGermany
| | - C. Viebahn
- Anatomy CenterGeorg August UniversityGöttingenGermany
| | - C. Justinger
- Department of General and Visceral SurgeryStädtisches Klinikum KarlsruheKarlsruheGermany
| | - T. Lorf
- Department of General, Visceral and Pediatric SurgeryUniversitätsmedizin GöttingenGöttingenGermany
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Iqbal S, Iqbal R, Iqbal F. Surgical Implications of Portal Vein Variations and Liver Segmentations: A Recent Update. J Clin Diagn Res 2017; 11:AE01-AE05. [PMID: 28384848 DOI: 10.7860/jcdr/2017/25028.9453] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Accepted: 12/28/2016] [Indexed: 12/30/2022]
Abstract
The Couinaud's liver segmentation is based on the identification of portal vein bifurcation and origin of hepatic veins. It is widely used clinically, because it is better suited for surgery and is more accurate in localizing and monitoring various intra parenchymal lesions. According to standard anatomy, the portal vein bifurcates into right and left branches; the left vein drains segment II, III and IV and the right vein divides into two secondary branches - the anterior portal vein drains segments V and VIII, and the posterior drains segments VI and VII. The portal vein variants such as portal trifurcation, with division of the main portal vein into the left, right anterior, and posterior branches, and the early origin of the right posterior branch directly from the main portal vein were found to be more frequent and was seen in about 20 - 35% of the population. Accurate knowledge of the portal variants and consequent variations in vascular segments are essential for intervention radiologists and transplant surgeons in the proper diagnosis during radiological investigations and in therapeutic applications such as preparation for biopsy, Portal Vein Embolization (PVE), Transjugular Intrahepatic Porto-Systemic Shunt (TIPS), tumour resection and partial hepatectomy for split or living donor transplantations. The advances in the knowledge will reduce intra and postoperative complications and avoid major catastrophic events. The purpose of the present review is to update the normal and variant portal venous anatomy and their implications in the liver segmentations, complex liver surgeries and various radiological intervention procedures.
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Affiliation(s)
- Showkathali Iqbal
- Professor, Department of Anatomy, Amala Institute of Medical Sciences , Amala Nagar, Thrissur, Kerala, India
| | - Raiz Iqbal
- Resident/House Surgeon/CRRI, Government Medical College , Kozhikode, Kerala, India
| | - Faiz Iqbal
- Student, Madras Medical College , Chennai, Tamil Nadu, India
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35
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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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A literature review of associating liver partition and portal vein ligation for staged hepatectomy (ALPPS): so far, so good. Updates Surg 2016; 69:9-19. [DOI: 10.1007/s13304-016-0401-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2016] [Accepted: 09/29/2016] [Indexed: 12/24/2022]
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Donati M, Stavrou GA, Stang A, Basile F, Oldhafer KJ. "Liver-first" approach with ALPPS: The natural combination of two new concepts in liver surgery. Surg Oncol 2016; 25:278-280. [PMID: 27566034 DOI: 10.1016/j.suronc.2016.05.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2016] [Accepted: 05/19/2016] [Indexed: 11/25/2022]
Affiliation(s)
- Marcello Donati
- Department of Surgery and Medical-Surgical Specialties, General and Oncologic Surgery Unit, Vittorio-Emanuele University Hospital of Catania, Italy; Semmelweiss University of Budapest, Asklepios Campus Hamburg, Germany.
| | - Gregor A Stavrou
- Department of General and Abdominal Surgery, Asklepios Barmbek Hospital, Germany.
| | - Axel Stang
- Department of Oncology, Asklepios Barmbek Hospital, Hamburg, Germany.
| | - Francesco Basile
- Department of Surgery and Medical-Surgical Specialties, General and Oncologic Surgery Unit, Vittorio-Emanuele University Hospital of Catania, Italy.
| | - Karl J Oldhafer
- Department of General and Abdominal Surgery, Asklepios Barmbek Hospital, Germany; Semmelweiss University of Budapest, Asklepios Campus Hamburg, Germany.
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Kimura K, Yoshizumi T, Itoh S, Harimoto N, Motomura T, Harada N, Nagatsu A, Ikegami T, Ninomiya M, Soejima Y, Maehara Y. Efficacy of recombinant thrombomodulin for DIC after deceased donor liver transplantation: a case report. Surg Case Rep 2016; 2:81. [PMID: 27495993 PMCID: PMC4975734 DOI: 10.1186/s40792-016-0208-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Accepted: 07/28/2016] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND Disseminated intravascular coagulation (DIC) after liver transplantation (LT) is a difficult complication. We report a case of disseminated intravascular coagulation after deceased donor liver transplantation (DDLT) treated with recombinant thrombomodulin (rTM). CASE PRESENTATION A 30-year-old woman underwent right tri-segment split graft DDLT for acute liver failure. She developed disseminated intravascular coagulation on post-operative day 5 with fever. Computed tomography revealed necrosis of hepatic segment IV, and her acute-phase disseminated intravascular coagulation score was seven points. She was given rTM, and the inflammation, liver function, and coagulation disorders immediately improved. However, pleural effusion drainage from the chest tube became bloody on post-operative day 11, and rTM was discontinued. She progressed well and was discharged from the hospital on post-operative day 28. rTM is an effective treatment for disseminated intravascular coagulation; however, rTM for cases with coagulation disorders, which can occur after liver transplantation, has both risks and benefits. CONCLUSIONS We report a case of DIC after LT, in which rTM was potentially effective. Further studies are needed to determine the appropriate dosages, duration, and additional considerations for rTM therapy in liver transplantation patients.
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Affiliation(s)
- Koichi Kimura
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, 812-8582, Japan.
| | - Tomoharu Yoshizumi
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, 812-8582, Japan
| | - Shinji Itoh
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, 812-8582, Japan
| | - Norifumi Harimoto
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, 812-8582, Japan
| | - Takashi Motomura
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, 812-8582, Japan
| | - Noboru Harada
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, 812-8582, Japan
| | - Akihisa Nagatsu
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, 812-8582, Japan
| | - Toru Ikegami
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, 812-8582, Japan
| | - Mizuki Ninomiya
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, 812-8582, Japan
| | - Yuji Soejima
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, 812-8582, Japan
| | - Yoshihiko Maehara
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, 812-8582, Japan
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Lund T. Treatment Opportunities for Colorectal Liver Metastases. EUROPEAN MEDICAL JOURNAL 2016. [DOI: 10.33590/emj/10311794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2023] Open
Abstract
Colorectal liver metastases (CLM) are the most common hepatic malignancy and are caused by disseminated tumour cells (DTCs) seeded early in the tumourigenesis of colorectal cancer. Despite optimal treatment, CLM are associated with high mortality rates. This review provides an overview of three promising strategies to extend survival in CLM: treatment of DTCs, immunotherapy, and new surgical resection techniques.
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Affiliation(s)
- Tormod Lund
- Surgical Department, Vestre Viken Hospital Trust, Drammen, Norway
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