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Magistri P, Guidetti C, Catellani B, Caracciolo D, Odorizzi R, Frassoni S, Bagnardi V, Guerrini GP, Di Sandro S, Di Benedetto F. Robotic ALPPS for primary and metastatic liver tumours: short-term outcomes versus open approach. Updates Surg 2024; 76:435-445. [PMID: 38326663 DOI: 10.1007/s13304-023-01680-8] [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: 06/08/2023] [Accepted: 10/25/2023] [Indexed: 02/09/2024]
Abstract
Associating Liver Partition and Portal vein ligation for Staged hepatectomy (ALPPS) is one of the strategies available for patients initially unresectable. High risk of peri-operative morbidity and mortality limited its application and diffusion. We aimed to analyse short-term outcomes of robotic ALPPS versus open approach, to assess safety and reproducibility of this technique. A retrospective analysis of prospectively maintained databases at University of Modena and Reggio Emilia on patients that underwent ALPPS between January 2015 and September 2022 was conducted. The main aim of the study was to evaluate safety and feasibility of robotic approach, either full robotic or only first-stage robotic, compared to a control group of patients who underwent open ALPPS in the same Institution. 23 patients were included. Nine patients received a full open ALPPS (O-ALPPS), 7 received a full robotic ALPPS (R-ALPPS), and 7 underwent a robotic approach for stage 1, followed by an open approach for stage 2 (R + O-ALPPS). PHLF grade B-C after stage 1 was 0% in all groups, rising to 58% in the R + O-ALPPS group after stage 2 and remaining 0% in the R-ALPPS group. 86% of R-ALPPS cases were discharged from the hospital between stages 1 and 2, and median total in-hospital stay and ICU stay favoured full robotic approach as well. This contemporary study represents the largest series of robotic ALPPS, showing potential advantages from full robotic ALPPS over open approach, resulting in reduced hospital stay and complications and lower incidence of 90-day mortality.
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Affiliation(s)
- Paolo Magistri
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University Hospital of Modena "Policlinico", University of Modena and Reggio Emilia, 41124, Modena, Italy
| | - Cristiano Guidetti
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University Hospital of Modena "Policlinico", University of Modena and Reggio Emilia, 41124, Modena, Italy
| | - Barbara Catellani
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University Hospital of Modena "Policlinico", University of Modena and Reggio Emilia, 41124, Modena, Italy
| | - Daniela Caracciolo
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University Hospital of Modena "Policlinico", University of Modena and Reggio Emilia, 41124, Modena, Italy
| | - Roberta Odorizzi
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University Hospital of Modena "Policlinico", University of Modena and Reggio Emilia, 41124, Modena, Italy
| | - Samuele Frassoni
- Department of Statistics and Quantitative Methods, University of Milan-Bicocca, Milan, Italy
| | - Vincenzo Bagnardi
- Department of Statistics and Quantitative Methods, University of Milan-Bicocca, Milan, Italy
| | - Gian Piero Guerrini
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University Hospital of Modena "Policlinico", University of Modena and Reggio Emilia, 41124, Modena, Italy
| | - Stefano Di Sandro
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University Hospital of Modena "Policlinico", University of Modena and Reggio Emilia, 41124, Modena, Italy
| | - Fabrizio Di Benedetto
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University Hospital of Modena "Policlinico", University of Modena and Reggio Emilia, 41124, Modena, Italy.
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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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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: 1.0] [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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Balci D, Nadalin S, Mehrabi A, Alikhanov R, Fernandes ESM, Di Benedetto F, Hernandez-Alejandro R, Björnsson B, Efanov M, Capobianco I, Clavien PA, Kirimker EO, Petrowsky H. Revival of associating liver partition and portal vein ligation for staged hepatectomy for perihilar cholangiocarcinoma: An international multicenter study with promising outcomes. Surgery 2023; 173:1398-1404. [PMID: 36959071 DOI: 10.1016/j.surg.2023.02.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 01/25/2023] [Accepted: 02/09/2023] [Indexed: 03/25/2023]
Abstract
BACKGROUND Associating liver partition and portal vein ligation for staged hepatectomy for perihilar cholangiocarcinoma has been considered to be contraindicated due to the initial poor results. Given the recent reports of improved outcomes, we aimed to collect the recent experiences of different centers performing associating liver partition and portal vein ligation for staged hepatectomy for perihilar cholangiocarcinoma to analyze factors related to improved outcomes. METHODS This proof-of-concept study collected contemporary cases of associating liver partition and portal vein ligation for staged hepatectomy for perihilar cholangiocarcinoma and analyzed for morbidity, short and long-term survival, and factors associated with outcomes. RESULTS In total, 39 patients from 8 centers underwent associating liver partition and portal vein ligation for staged hepatectomy for perihilar cholangiocarcinoma from 2010 to 2020. The median preoperative future liver remnant volume was 323 mL (155-460 mL). The median future liver remnant increase was 58.7% (8.9% -264.5%) with a median interstage interval of 13 days (6-60 days). Post-stage 1 and post-stage 2 biliary leaks occurred in 2 (7.7%) and 4 (15%) patients. Six patients (23%) after stage 1 and 6 (23%) after stage 2 experienced grade 3 or higher complications. Two patients (7.7%) died within 90 days after stage 2. The 1-, 3-, and 5-year survival was 92%, 69%, and 55%, respectively. A subgroup analysis revealed poor survival for patients undergoing additional vascular resection and lymph node positivity. Lymph node-negative patients showed excellent survival demonstrated by 1-, 3-, and 5-year survival of 86%, 86%, and 86%. CONCLUSION This study highlights that the critical attitude toward associating liver partition and portal vein ligation for staged hepatectomy for perihilar cholangiocarcinoma needs to be revised. In selected patients with perihilar cholangiocarcinoma, associating liver partition and portal vein ligation for staged hepatectomy can achieve favorable survival that compares to the outcome of established surgical treatment strategies reported in benchmark studies for perihilar cholangiocarcinoma including 1-stage hepatectomy and liver transplantation.
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Affiliation(s)
- Deniz Balci
- Department of Surgery, Bahcesehir University School of Medicine, Istanbul, Turkey.
| | - Silvio Nadalin
- Department of General, Visceral, and Transplant Surgery, University Hospital Tübingen, Germany
| | - Arianeb Mehrabi
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Germany
| | - Ruslan Alikhanov
- Department of Hepato-Pancreato-Biliary Surgery, Moscow Clinical Research Center Named After Loginov A.S., Russia
| | - Eduardo S M Fernandes
- Department of General Surgery and Transplantation, Hospital Adventista Silvestre, and Department of Surgery, Faculty of Medicine, Universidade Federal do Rio de Janeiro, Brazil
| | - Fabrizio Di Benedetto
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University of Modena and Reggio Emilia, Italy
| | | | - Bergthor Björnsson
- Department of Surgery in Linköping and Department of Biomedical and Clinical Sciences, Linköping University, Sweden
| | - Mikhail Efanov
- Department of Hepato-Pancreato-Biliary Surgery, Moscow Clinical Research Center Named After Loginov A.S., Russia
| | - Ivan Capobianco
- Department of General, Visceral, and Transplant Surgery, University Hospital Tübingen, Germany
| | - Pierre-Alain Clavien
- Department of Surgery and Transplantation, Swiss Hepatopancreaticobiliary and Transplant Center Zürich, University Hospital Zürich, Switzerland
| | | | - Henrik Petrowsky
- Department of Surgery and Transplantation, Swiss Hepatopancreaticobiliary and Transplant Center Zürich, University Hospital Zürich, Switzerland
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Cioffi L, Belli G, Izzo F, Fantini C, D’Agostino A, Russo G, Patrone R, Granata V, Belli A. Minimally Invasive ALPPS Procedure: A Review of Feasibility and Short-Term Outcomes. Cancers (Basel) 2023; 15:cancers15061700. [PMID: 36980586 PMCID: PMC10046857 DOI: 10.3390/cancers15061700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 02/27/2023] [Accepted: 03/05/2023] [Indexed: 03/12/2023] Open
Abstract
Background: Associated liver partition with portal vein ligation for staged hepatectomy (ALPPS) represents a recent strategy to improve resectability of extensive hepatic malignancies. Recent surgical advances, such as the application of technical variants and use of a mini-invasive approach (MI-ALPPS), have been proposed to improve clinical outcomes in terms of morbidity and mortality. Methods: A total of 119 MI-ALPPS cases from 6 series were identified and discussed to evaluate the feasibility of the procedure and short-term clinical outcomes. Results: Hepatocellular carcinoma were widely the most common indication for MI-ALPPS. The median estimated blood loss was 260 mL during Stage 1 and 1625 mL in Stage 2. The median length of the procedures was 230 min in Stage 1 and 184 in Stage 2. The median increase ratio of future liver remnant volume was 87.8%. The median major morbidity was 8.14% in Stage 1 and 23.39 in Stage 2. The mortality rate was 0.6%. Conclusions: MI-ALPPS appears to be a feasible and safe procedure, with potentially better short-term outcomes in terms of blood loss, morbidity, and mortality rate if compared with those of open series.
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Affiliation(s)
- Luigi Cioffi
- Department of General Surgery, Ospedale del Mare, 80147 Naples, Italy
- Correspondence: ; Tel.: +39-81-18775110
| | - Giulio Belli
- Department of General and HPB Surgery, Loreto Nuovo Hospital, 80127 Naples, Italy
| | - Francesco Izzo
- Division of Epatobiliary Surgical Oncology, Istituto Nazionale Tumori IRCCS Fondazione Pascale-IRCCS di Napoli, 80131 Naples, Italy
| | - Corrado Fantini
- Department of General Surgery, Pellegrini Hospital, 80134 Naples, Italy
| | | | - Gianluca Russo
- Department of General Surgery, Pellegrini Hospital, 80134 Naples, Italy
- Department of General Surgery, University of Campania Luigi Vanvitelli, 80131 Naples, Italy
| | - Renato Patrone
- Division of Epatobiliary Surgical Oncology, Istituto Nazionale Tumori IRCCS Fondazione Pascale-IRCCS di Napoli, 80131 Naples, Italy
| | - Vincenza Granata
- Division of Radiology, Istituto Nazionale Tumori IRCCS Fondazione Pascale-IRCCS di Napoli, 80131 Naples, Italy
| | - Andrea Belli
- Division of Epatobiliary Surgical Oncology, Istituto Nazionale Tumori IRCCS Fondazione Pascale-IRCCS di Napoli, 80131 Naples, Italy
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Balci D, Kirimker EO, Raptis DA, Gao Y, Kow AWC. Uses of a dedicated 3D reconstruction software with augmented and mixed reality in planning and performing advanced liver surgery and living donor liver transplantation (with videos). Hepatobiliary Pancreat Dis Int 2022; 21:455-461. [PMID: 36123242 DOI: 10.1016/j.hbpd.2022.09.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 09/02/2022] [Indexed: 02/05/2023]
Abstract
The development of digital intelligent diagnostic and treatment technology has opened countless new opportunities for liver surgery from the era of digital anatomy to a new era of digital diagnostics, virtual surgery simulation and using the created scenarios in real-time surgery using mixed reality. In this article, we described our experience on developing a dedicated 3 dimensional visualization and reconstruction software for surgeons to be used in advanced liver surgery and living donor liver transplantation. Furthermore, we shared the recent developments in the field by explaining the outreach of the software from virtual reality to augmented reality and mixed reality.
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Affiliation(s)
- Deniz Balci
- Department of Surgery, Medical Park Göztepe Hastanesi Organ Nakli Merkezi Nisan Sok, Bahçeşehir University, No. 23 Merdivenköy Kadıköy, İstanbul, Türkiye.
| | | | - Dimitri Aristotle Raptis
- Clinical Service of HPB Surgery and Liver Transplantation, NHS Foundation Trust, Royal Free London Hospital, London, UK; Division of Surgery & Interventional Science, University College London, London, UK
| | - Yujia Gao
- Division of Hepatobiliary & Pancreatic Surgery, Department of Surgery, National University of Singapore, Singapore; Liver Transplant Program, National University Center for Organ Transplantation (NUCOT), National University Health System, Singapore
| | - Alfred Wei Chieh Kow
- Division of Hepatobiliary & Pancreatic Surgery, Department of Surgery, National University of Singapore, Singapore; Liver Transplant Program, National University Center for Organ Transplantation (NUCOT), National University Health System, Singapore
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Di Benedetto F, Magistri P, Guerrini GP, Di Sandro S. Robotic liver partition and portal vein embolization for staged hepatectomy for perihilar cholangiocarcinoma. Updates Surg 2021; 74:773-777. [PMID: 34846695 PMCID: PMC8630284 DOI: 10.1007/s13304-021-01209-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Accepted: 11/18/2021] [Indexed: 12/31/2022]
Abstract
Perihilar cholangiocarcinoma (pCCA) is one of the most complex challenges for hepatobiliary surgeons. Poor results and high incidence of morbidity after Associating Liver Partition and Portal vein ligation for Staged hepatectomy (ALPPS) for pCCA discouraged this indication. It has been proposed that minimally invasive approach for ALPPS first stage, as well as combination of surgical liver partition and radiologic portal vein embolization (PVE), may improve outcomes reducing interstage morbidity. We report a case of right trisectionectomy with enbloc caudatectomy ALPPS scheduled for pCCA with robotic approach at stage-1, the full video is provided as supplementary material. Due to intraoperative presence of portal vein tumor infiltration during hilar dissection (no evidence in the pre-operative work-up), a radiologic right PVE was performed after stage-1 instead of portal vein ligation, followed by portal vein resection and biductal hepatico-jejunostomy at stage-2 with open approach. The patient was a 74-year-old female diagnosed with 3-cm mass-forming pCCA. The total clean liver volume was 1231 cc, with future liver remnant (FLR) volume of 25.1% (segments II and III). She was discharged in the interstage interval on postoperative day (POD) 4; CT scan on POD 12 showed that FLR increased up to 33% (369 cc) (Fig. 1). ALPPS was completed on POD 17, the postoperative course was uneventful, and the patient was discharged in good general condition on POD 19 after stage-2. Besides the already demonstrated advantages in terms of reduced interstage morbidity, robotic ALPPS represents a promising strategy to expand surgical indication in patients with pCCA. The combination of liver partition and PVE may increase the opportunities to perform radical resections in selected patients with pCCA and portal vein infiltration.
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Affiliation(s)
- Fabrizio Di Benedetto
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University of Modena and Reggio Emilia, Largo del Pozzo 71, 41124, Modena, Italy.
| | - Paolo Magistri
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University of Modena and Reggio Emilia, Largo del Pozzo 71, 41124, Modena, Italy
| | - Gian Piero Guerrini
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University of Modena and Reggio Emilia, Largo del Pozzo 71, 41124, Modena, Italy
| | - Stefano Di Sandro
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University of Modena and Reggio Emilia, Largo del Pozzo 71, 41124, Modena, Italy
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Huang X, Chen Y, Shi X. Laparoscopic hepatectomy versus open hepatectomy for tumors located in right posterior segment: A single institution study. Asian J Surg 2021; 45:110-116. [PMID: 33863627 DOI: 10.1016/j.asjsur.2021.03.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 02/04/2021] [Accepted: 03/24/2021] [Indexed: 11/29/2022] Open
Abstract
OBJECT With the gradual advancement of laparoscopic technology, surgeries can be successfully performed with the help of laparoscopy increasingly. This study initially explored the difference between laparoscopic right posterior sectionectomy (LRPS) and open right posterior sectionectomy (ORPS)of liver in our center, discussed the effectiveness, benefits and safety of LRPS and introduce some surgical techniques in our center. MATERIALS AND METHODS We retrospectively analyze 96 cases of liver tumor located in the right posterior lobe of liver in our institution from January 2015 to January 2018. There were 46 cases performed the LRPS surgery and 50 cases performed the ORPS surgery. Through analysis of the perioperative outcomes of these two groups by a case control study, we compare the differences between these two groups. RESULTS There was no significant difference between the LRPS and ORPS group in demographic and baseline characteristics before surgery. Patients in the LRPS group were significantly superior to ORPS in terms of postoperative liver function recovery, postoperative inflammatory factor level, pain sensation (3.03 ± 0.79 vs 4.58 ± 1.25), abdominal incision length (6.25 ± 2.34 vs 32.15 ± 3.21), carrying abdominal drainage tube time (3.26 ± 0.77 vs 4.83 ± 0.76), recovery of bowel function time (1.6 ± 0.61 VS 3.05 ± 0.85)and postoperative hospital stay (5.73 ± 0.99 vs 7.16 ± 0.95) (P < 0.05). CONCLUSION Compared with the traditional ORPS, LRPS has the advantages of minor injury, faster recovery and mild inflammatory reaction. The LRPS is safe and feasible, and it should be gradually promoted in clinical practice.
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Affiliation(s)
- Xiaodong Huang
- Faculty of Hepato-Pancreato-Biliary Surgery, 1th Medical Center, Chinese PLA General Hospital, Beijing, 100853, PR China.
| | - Yongwei Chen
- Faculty of Hepato-Pancreato-Biliary Surgery, 1th Medical Center, Chinese PLA General Hospital, Beijing, 100853, PR China.
| | - Xianjie Shi
- Faculty of Hepato-Pancreato-Biliary Surgery, 1th Medical Center, Chinese PLA General Hospital, Beijing, 100853, PR China.
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Balci D, McCormack L. Perihilar cholangiocarcinoma: A difficult surgery in a difficult patient where experience matters most. Surgery 2021; 170:644-645. [PMID: 33810855 DOI: 10.1016/j.surg.2021.02.049] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Accepted: 02/17/2021] [Indexed: 10/21/2022]
Affiliation(s)
- Deniz Balci
- Department of Surgery, School of Medicine, Ankara University, Ankara, Turkey.
| | - Lucas McCormack
- Department of Surgery, School of Medicine, Ankara University, Ankara, Turkey
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Induction of liver hypertrophy for extended liver surgery and partial liver transplantation: State of the art of parenchyma augmentation-assisted liver surgery. Langenbecks Arch Surg 2021; 406:2201-2215. [PMID: 33740114 PMCID: PMC8578101 DOI: 10.1007/s00423-021-02148-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 03/03/2021] [Indexed: 12/17/2022]
Abstract
Background Liver surgery and transplantation currently represent the only curative treatment options for primary and secondary hepatic malignancies. Despite the ability of the liver to regenerate after tissue loss, 25–30% future liver remnant is considered the minimum requirement to prevent serious risk for post-hepatectomy liver failure. Purpose The aim of this review is to depict the various interventions for liver parenchyma augmentation–assisting surgery enabling extended liver resections. The article summarizes one- and two-stage procedures with a focus on hypertrophy- and corresponding resection rates. Conclusions To induce liver parenchymal augmentation prior to hepatectomy, most techniques rely on portal vein occlusion, but more recently inclusion of parenchymal splitting, hepatic vein occlusion, and partial liver transplantation has extended the technical armamentarium. Safely accomplishing major and ultimately total hepatectomy by these techniques requires integration into a meaningful oncological concept. The advent of highly effective chemotherapeutic regimen in the neo-adjuvant, interstage, and adjuvant setting has underlined an aggressive surgical approach in the given setting to convert formerly “palliative” disease into a curative and sometimes in a “chronic” disease.
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Italian Clinical Practice Guidelines on Cholangiocarcinoma - Part II: Treatment. Dig Liver Dis 2020; 52:1430-1442. [PMID: 32952071 DOI: 10.1016/j.dld.2020.08.030] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 08/17/2020] [Accepted: 08/17/2020] [Indexed: 01/27/2023]
Abstract
Currently, the only curative treatment for cholangiocarcinoma (CCA) is surgical resection, though this treatment is possible in less than 40% of patients. However, recent improvements in preoperative management have led to a higher number of patients who are candidates for this procedure. For unresectable patients, progress is ongoing in terms of locoregional and chemoradiation treatments and target therapies, especially in the definition of patient selection criteria. This is the second part of the Italian CCA guidelines, dealing with CCA treatment, that have been formulated in accordance with Italian National Institute of Health indications and developed according to the GRADE method and related advancements.
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Balci D, Sakamoto Y, Li J, Di Benedetto F, Kirimker EO, Petrowsky H. Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) procedure for cholangiocarcinoma. Int J Surg 2020; 82S:97-102. [PMID: 32645441 DOI: 10.1016/j.ijsu.2020.06.045] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Accepted: 06/26/2020] [Indexed: 12/15/2022]
Abstract
Perihilar cholangiocarcinoma (PHCC) has been a great challenge for surgeons, requiring advanced skills and expertise and was often associated with high morbidity and mortality. Resectability rates are up to 75% even in experienced centers. In patients with PHCC, radical liver and bile duct resection aiming R0 surgical margins offers the best long-term survival. Therefore, extensive resections with low FLR are commonly needed and PVE is offered to induce remnant liver hypertrophy for a long period. Associating liver partition with portal vein ligation for staged hepatectomy (ALPPS) is considered a promising approach inducing rapid remnant hypertrophy to prevent dropouts due to complications or tumor progression and increase resectability. Although poor results were reported initially, refinements in technique and risk adjustment of patient selection improved outcomes. The procedure is still under debate for the indication of PHCC. This article reviews the current literature on ALPPS in treatment of perihilar and intrahepatic cholangiocarcinoma.
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Affiliation(s)
- Deniz Balci
- Department of Surgery and Liver Transplantation Unit, Ankara University School of Medicine, Ankara, Turkey.
| | - Yoshihiro Sakamoto
- Department of Hepato-Biliary-Pancreatic Surgery, Kyorin University Hospital, Japan.
| | - Jun Li
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| | - Fabrizio Di Benedetto
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University of Modena and Reggio Emilia, Modena, Italy.
| | - Elvan Onur Kirimker
- Department of Surgery and Liver Transplantation Unit, Ankara University School of Medicine, Ankara, Turkey.
| | - Henrik Petrowsky
- Swiss HPB and Transplantation Center, Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland.
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Turkoglu MA. Stage I-laparoscopy partial ALPPS procedure for perihilar cholangiocarcinoma. J Surg Oncol 2020; 122:487-488. [PMID: 32424875 DOI: 10.1002/jso.25982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 04/22/2020] [Indexed: 11/07/2022]
Affiliation(s)
- Mehmet Akif Turkoglu
- Department of General Surgery, Gazi University Faculty of Medicine, Ankara, Turkey
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