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Guidetti C, Müller PC, Magistri P, Jonas JP, Odorizzi R, Kron P, Guerrini G, Oberkofler CE, Di Sandro S, Clavien PA, Petrowsky H, Di Benedetto F. Full robotic versus open ALPPS: a bi-institutional comparison of perioperative outcomes. Surg Endosc 2024; 38:3448-3454. [PMID: 38698258 PMCID: PMC11133099 DOI: 10.1007/s00464-024-10804-z] [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: 01/16/2024] [Accepted: 03/17/2024] [Indexed: 05/05/2024]
Abstract
BACKGROUND In primarily unresectable liver tumors, ALPPS (Associating Liver Partition and Portal Vein Ligation for Staged hepatectomy) may offer curative two-stage hepatectomy trough a fast and extensive hypertrophy. However, concerns have been raised about the invasiveness of the procedure. Full robotic ALPPS has the potential to reduce the postoperative morbidity trough a less invasive access. The aim of this study was to compare the perioperative outcomes of open and full robotic ALPPS. METHODS The bicentric study included open ALPPS cases from the University Hospital Zurich, Switzerland and robotic ALPPS cases from the University of Modena and Reggio Emilia, Italy from 01/2015 to 07/2022. Main outcomes were intraoperative parameters and overall complications. RESULTS Open and full robotic ALPPS were performed in 36 and 7 cases. Robotic ALPPS was associated with less blood loss after both stages (418 ± 237 ml vs. 319 ± 197 ml; P = 0.04 and 631 ± 354 ml vs. 258 ± 53 ml; P = 0.01) as well as a higher rate of interstage discharge (86% vs. 37%; P = 0.02). OT was longer with robotic ALPPS after both stages (371 ± 70 min vs. 449 ± 81 min; P = 0.01 and 282 ± 87 min vs. 373 ± 90 min; P = 0.02). After ALPPS stage 2, there was no difference for overall complications (86% vs. 86%; P = 1.00) and major complications (43% vs. 39%; P = 0.86). The total length of hospital stay was similar (23 ± 17 days vs. 26 ± 13; P = 0.56). CONCLUSION Robotic ALPPS was safely implemented and showed potential for improved perioperative outcomes compared to open ALPPS in an experienced robotic center. The robotic approach might bring the perioperative risk profile of ALPPS closer to interventional techniques of portal vein embolization/liver venous deprivation.
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Affiliation(s)
- Cristiano Guidetti
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University Hospital of Modena "Policlinico", University of Modena and Reggio Emilia, 41124, Modena, Italy
| | - Philip C Müller
- Swiss HPB and Transplantation Center, Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
- Department of Surgery, Clarunis - University Centre for Gastrointestinal and Hepatopancreatobiliary Diseases, Basel, Switzerland
| | - Paolo Magistri
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University Hospital of Modena "Policlinico", University of Modena and Reggio Emilia, 41124, Modena, Italy
| | - Jan Philipp Jonas
- Swiss HPB and Transplantation Center, Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - Roberta Odorizzi
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University Hospital of Modena "Policlinico", University of Modena and Reggio Emilia, 41124, Modena, Italy
| | - Philipp Kron
- Swiss HPB and Transplantation Center, Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - Gianpiero Guerrini
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University Hospital of Modena "Policlinico", University of Modena and Reggio Emilia, 41124, Modena, Italy
| | - Christian E Oberkofler
- Swiss HPB and Transplantation Center, Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
- Vivévis - Clinic Hirslanden Zurich, Zurich, Switzerland
| | - 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
| | - Pierre-Alain Clavien
- Swiss HPB and Transplantation Center, Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - Henrik Petrowsky
- Swiss HPB and Transplantation Center, Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - 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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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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Hung KC, Wang HP, Li WF, Lin YC, Wang CC. Single center experience with ALPPS and timing with stage 2 in patients with fibrotic/cirrhotic liver. Updates Surg 2024:10.1007/s13304-024-01782-x. [PMID: 38494567 DOI: 10.1007/s13304-024-01782-x] [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: 06/02/2023] [Accepted: 02/03/2024] [Indexed: 03/19/2024]
Abstract
Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) is a novel procedure for major resection in patients with insufficient future liver remnant (FLR). Effective FLR augmentation is pivotal in the completion of ALPPS. Liver fibrosis/cirrhosis associated with chronic viral hepatitis impairs liver regeneration. To investigate the augmentation of FLR in associating ALPPS between patients with fibrotic/cirrhotic livers (FL) and non-fibrotic livers (NFL) and compare their short-term clinical outcomes and long-term survival. Patients were divided into two groups based on the Ishak modified staging: non-fibrotic liver group (NFL, stage 0) and fibrotic/cirrhotic liver group (FL, stage 1-5/6). Weekly liver regeneration in FLR, perioperative data, and survival outcomes were investigated. Twenty-seven patients with liver tumors underwent ALPPS (NFL, n = 7; FL, n = 20). NFL and FL patients had viral hepatitis (28.6% [n = 2] and 95% [n = 19]), absolute FLR volume increments of 134.90 ml and 161.85 ml (p = 0.825), and rates of hypertrophy were 16.46 ml/day and 13.66 ml/day (p = 0.507), respectively. In the FL group, baseline FLR volume was 360.13 ml, postoperatively it increased to a plateau (542.30 ml) in week 2 and declined (378.45 ml) in week 3. One patient (3.7%) with cirrhotic liver (stage 6) failed to proceed to ALPPS-II. The overall ALPPS-related major complication rate was 7.4%. ALPPS is feasible for fibrotic liver patients classified by Ishak modified stages ≤ 5. After ALPPS-I, 14 days for FLR augmentation seems an appropriate waiting time to reach a maximum FLR volume in these patients.
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Affiliation(s)
- Kuo-Chen Hung
- Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, 123 Ta-Pei Road, Niao-Song, Kaohsiung, 833, Taiwan
- Chang Gung University College of Medicine, Taoyüan, Taiwan
| | - Hao-Ping Wang
- Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, 123 Ta-Pei Road, Niao-Song, Kaohsiung, 833, Taiwan
- Chang Gung University College of Medicine, Taoyüan, Taiwan
| | - Wei-Feng Li
- Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, 123 Ta-Pei Road, Niao-Song, Kaohsiung, 833, Taiwan
- Chang Gung University College of Medicine, Taoyüan, Taiwan
| | - Yu-Cheng Lin
- Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, 123 Ta-Pei Road, Niao-Song, Kaohsiung, 833, Taiwan
- Chang Gung University College of Medicine, Taoyüan, Taiwan
| | - Chih-Chi Wang
- Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, 123 Ta-Pei Road, Niao-Song, Kaohsiung, 833, Taiwan.
- Chang Gung University College of Medicine, Taoyüan, Taiwan.
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Arend J, Franz M, Rose A, March C, Rahimli M, Perrakis A, Lorenz E, Croner R. Robotic Complete ALPPS (rALPPS)-First German Experiences. Cancers (Basel) 2024; 16:1070. [PMID: 38473426 DOI: 10.3390/cancers16051070] [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: 01/25/2024] [Revised: 03/02/2024] [Accepted: 03/04/2024] [Indexed: 03/14/2024] Open
Abstract
BACKGROUND ALPPS leads to fast and effective liver hypertrophy. This enables the resection of extended tumors. Conventional ALPPS is associated with high morbidity and mortality. MILS reduces morbidity and the robot adds technical features that make complex procedures safe. MATERIAL AND METHODS The MD-MILS was screened for patients who underwent rALPPS. Demographic and perioperative data were evaluated retrospectively. Ninety days postoperative morbidity was scored according to the CD classification. The findings were compared with the literature. RESULTS Since November 2021, five patients have been identified. The mean age and BMI of the patients were 50.0 years and 22.7 kg/m2. In four cases, patients suffered from colorectal liver metastases and, in one case, intrahepatic cholangiocarcinoma. Prior to the first operation, the mean liver volume of the residual left liver was 380.9 mL with a FLR-BWR of 0.677%. Prior to the second operation, the mean volume of the residual liver was 529.8 mL with a FLR-BWR of 0.947%. This was an increase of 41.9% of the residual liver volume. The first and second operations were carried out within 17.8 days. The mean time of the first and second operations was 341.2 min and 440.6 min. The mean hospital stay was 27.2 days. Histopathology showed the largest tumor size of 39 mm in diameter with a mean amount of 4.7 tumors. The mean tumor-free margin was 12.3 mm. One complication CD > 3a occurred. No patient died during the 90-day follow up. CONCLUSION In the first German series, we demonstrated that rALPPS can be carried out safely with reduced morbidity and mortality in selected patients.
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Affiliation(s)
- Jörg Arend
- Department of General-, Visceral-, Vascular- and Transplant Surgery, University Hospital Magdeburg, 39120 Magdeburg, Germany
| | - Mareike Franz
- Department of General-, Visceral-, Vascular- and Transplant Surgery, University Hospital Magdeburg, 39120 Magdeburg, Germany
| | - Alexander Rose
- Department of General-, Visceral-, Vascular- and Transplant Surgery, University Hospital Magdeburg, 39120 Magdeburg, Germany
| | - Christine March
- Department of Radiology and Nuclear Medicine, University Hospital Magdeburg, 39120 Magdeburg, Germany
| | - Mirhasan Rahimli
- Department of General-, Visceral-, Vascular- and Transplant Surgery, University Hospital Magdeburg, 39120 Magdeburg, Germany
| | - Aristotelis Perrakis
- Department of General-, Visceral-, Vascular- and Transplant Surgery, University Hospital Magdeburg, 39120 Magdeburg, Germany
| | - Eric Lorenz
- Department of General-, Visceral-, Vascular- and Transplant Surgery, University Hospital Magdeburg, 39120 Magdeburg, Germany
| | - Roland Croner
- Department of General-, Visceral-, Vascular- and Transplant Surgery, University Hospital Magdeburg, 39120 Magdeburg, Germany
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Maspero M, Yilmaz S, Cazzaniga B, Raj R, Ali K, Mazzaferro V, Schlegel A. The role of ischaemia-reperfusion injury and liver regeneration in hepatic tumour recurrence. JHEP Rep 2023; 5:100846. [PMID: 37771368 PMCID: PMC10523008 DOI: 10.1016/j.jhepr.2023.100846] [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: 02/17/2023] [Revised: 06/20/2023] [Accepted: 07/01/2023] [Indexed: 09/30/2023] Open
Abstract
The risk of cancer recurrence after liver surgery mainly depends on tumour biology, but preclinical and clinical evidence suggests that the degree of perioperative liver injury plays a role in creating a favourable microenvironment for tumour cell engraftment or proliferation of dormant micro-metastases. Understanding the contribution of perioperative liver injury to tumour recurrence is imperative, as these pathways are potentially actionable. In this review, we examine the key mechanisms of perioperative liver injury, which comprise mechanical handling and surgical stress, ischaemia-reperfusion injury, and parenchymal loss leading to liver regeneration. We explore how these processes can trigger downstream cascades leading to the activation of the immune system and the pro-inflammatory response, cellular proliferation, angiogenesis, anti-apoptotic signals, and release of circulating tumour cells. Finally, we discuss the novel therapies under investigation to decrease ischaemia-reperfusion injury and increase regeneration after liver surgery, including pharmaceutical agents, inflow modulation, and machine perfusion.
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Affiliation(s)
- Marianna Maspero
- Transplantation Center, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
- General Surgery and Liver Transplantation Unit, IRCCS Istituto Tumori, Milan, Italy
| | - Sumeyye Yilmaz
- Transplantation Center, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Beatrice Cazzaniga
- Transplantation Center, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Roma Raj
- Transplantation Center, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Khaled Ali
- Transplantation Center, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Vincenzo Mazzaferro
- General Surgery and Liver Transplantation Unit, IRCCS Istituto Tumori, Milan, Italy
- Department of Oncology and Hemato-Oncology, University of Milan, Italy
| | - Andrea Schlegel
- Transplantation Center, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
- Department of Immunology, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
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Horisberger K, Rössler F, Oberkofler CE, Raptis D, Petrowsky H, Clavien PA. The value of intraoperative dynamic liver function test ICG in predicting postoperative complications in patients undergoing staged hepatectomy: a pilot study. Langenbecks Arch Surg 2023; 408:264. [PMID: 37403000 PMCID: PMC10319685 DOI: 10.1007/s00423-023-02983-5] [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: 04/10/2023] [Accepted: 06/13/2023] [Indexed: 07/06/2023]
Abstract
PURPOSE To assess the predictive value of intraoperative indocyanine green (ICG) test in patients undergoing staged hepatectomy. METHODS We analyzed intraoperative ICG measurements of future liver remnant (FLR), preoperative ICG, volumetry, and hepatobiliary scintigraphy in 15 patients undergoing associated liver partition and portal vein ligation for staged hepatectomy (ALPPS). Main endpoints were the correlation of intraoperative ICG values to postoperative complications (Comprehensive Complication Index (CCI®)) at discharge and 90 days after surgery, and to postoperative liver function. RESULTS Median intraoperative R15 (ICG retention rate at 15 min) correlated significantly with CCI® at discharge (p = 0.05) and with CCI® at 90 days (p = 0.0036). Preoperative ICG, volumetry, and scintigraphy did not correlate to postoperative outcome. ROC curve analysis revealed a cutoff value of 11.4 for the intraoperative R15 to predict major complications (Clavien-Dindo ≥ III) with 100% sensitivity and 63% specificity. No patient with R15 ≤ 11 developed major complications. CONCLUSION This pilot study suggests that intraoperative ICG clearance determines the functional capacity of the future liver remnant more accurately than preoperative tests. This may further reduce the number of postoperative liver failures, even if it means intraoperative abortion of hepatectomy in individual cases.
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Affiliation(s)
- Karoline Horisberger
- Swiss HPB Center Zurich, Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland.
- Department of General, Visceral and Transplant Surgery, University Medical Center Mainz, Langenbeckstrasse 1, 55131, Mainz, Germany.
| | - Fabian Rössler
- Swiss HPB Center Zurich, Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - Christian E Oberkofler
- Swiss HPB Center Zurich, Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
- vivèvis AG - Visceral, Tumor and Robotic Surgery Clinic Hirslanden Zürich, Zurich, Switzerland
| | - Dimitri Raptis
- Organ Transplant Center of Excellence, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia
| | - Henrik Petrowsky
- Swiss HPB Center Zurich, Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - Pierre-Alain Clavien
- Swiss HPB Center Zurich, Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
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Xu LL, Zhou L, Liang X, Zheng LL, Xu HS, Chen C, Hu P, Li SY. Preoperative Value of Contrast-Enhanced Ultrasound in Totally Laparoscopic Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy for Liver Tumors: A Preliminary Study. Ultrasound Q 2023; 39:95-99. [PMID: 36580400 DOI: 10.1097/ruq.0000000000000631] [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: 12/30/2022]
Abstract
ABSTRACT The clinical data of 15 cases that planned to receive totally laparoscopic associating liver partition and portal vein ligation for staged hepatectomy were retrospectively collected. Before the stage 1 operation, the size and number of the tumors in future liver remnant (FLR) and the presence of cancer embolus in the portal vein were assessed using contrast-enhanced ultrasound (CEUS) and contrast-enhanced computed tomography (CECT). Before the stage 2 operation, CEUS was performed to assess the presence of traffic blood flow between the diseased liver and FLR after round-the-liver ligation. Before the stage 1 operation, 5 cases with tumors in FLR were found by CEUS and 6 cases were found by CECT ( P > 0.05). Similarly, CEUS found 5 cases with cancer thrombus in portal vein, and CECT found 7 cases ( P = 0.500). The consistency between the 2 modalities was good (κ = 0.857, P < 0.05, κ = 0.727, P < 0.05, respectively). Before the stage 2 operation, CEUS confirmed that there were 7 cases without traffic blood flow between the diseased liver and FLR, and 3 cases with residual traffic blood flow. The daily growth rate of FLR in the group without traffic blood flow (mean rank = 7.00) was higher than that in the group with traffic blood flow (2.00) significantly ( P < 0.05). Contrast-enhanced ultrasound is a promising application in the preoperative evaluation of totally laparoscopic associating liver partition and portal vein ligation for staged hepatectomy.
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Affiliation(s)
| | | | | | | | | | - Chao Chen
- Radiology, Sir Run Run Shaw Hospital, Zhejiang University, School of Medicine, Hangzhou, China
| | - Peng Hu
- Radiology, Sir Run Run Shaw Hospital, Zhejiang University, School of Medicine, Hangzhou, China
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Rodimova S, Mozherov A, Elagin V, Karabut M, Shchechkin I, Kozlov D, Krylov D, Gavrina A, Bobrov N, Zagainov V, Zagaynova E, Kuznetsova D. Effect of Hepatic Pathology on Liver Regeneration: The Main Metabolic Mechanisms Causing Impaired Hepatic Regeneration. Int J Mol Sci 2023; 24:ijms24119112. [PMID: 37298064 DOI: 10.3390/ijms24119112] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 05/15/2023] [Accepted: 05/17/2023] [Indexed: 06/12/2023] Open
Abstract
Liver regeneration has been studied for many decades, and the mechanisms underlying regeneration of normal liver following resection are well described. However, no less relevant is the study of mechanisms that disrupt the process of liver regeneration. First of all, a violation of liver regeneration can occur in the presence of concomitant hepatic pathology, which is a key factor reducing the liver's regenerative potential. Understanding these mechanisms could enable the rational targeting of specific therapies to either reduce the factors inhibiting regeneration or to directly stimulate liver regeneration. This review describes the known mechanisms of normal liver regeneration and factors that reduce its regenerative potential, primarily at the level of hepatocyte metabolism, in the presence of concomitant hepatic pathology. We also briefly discuss promising strategies for stimulating liver regeneration and those concerning methods for assessing the regenerative potential of the liver, especially intraoperatively.
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Affiliation(s)
- Svetlana Rodimova
- Institute of Experimental Oncology and Biomedical Technologies, Privolzhsky Research Medical University, 10/1 Minin and Pozharsky Sq., 603000 Nizhny Novgorod, Russia
| | - Artem Mozherov
- Institute of Experimental Oncology and Biomedical Technologies, Privolzhsky Research Medical University, 10/1 Minin and Pozharsky Sq., 603000 Nizhny Novgorod, Russia
- Laboratory of Molecular Genetic Research, Institute of Clinical Medicine, N.I. Lobachevsky Nizhny Novgorod National Research State University, 23 Gagarina Ave., 603022 Nizhny Novgorod, Russia
| | - Vadim Elagin
- Institute of Experimental Oncology and Biomedical Technologies, Privolzhsky Research Medical University, 10/1 Minin and Pozharsky Sq., 603000 Nizhny Novgorod, Russia
| | - Maria Karabut
- Institute of Experimental Oncology and Biomedical Technologies, Privolzhsky Research Medical University, 10/1 Minin and Pozharsky Sq., 603000 Nizhny Novgorod, Russia
| | - Ilya Shchechkin
- Institute of Experimental Oncology and Biomedical Technologies, Privolzhsky Research Medical University, 10/1 Minin and Pozharsky Sq., 603000 Nizhny Novgorod, Russia
- Laboratory of Molecular Genetic Research, Institute of Clinical Medicine, N.I. Lobachevsky Nizhny Novgorod National Research State University, 23 Gagarina Ave., 603022 Nizhny Novgorod, Russia
| | - Dmitry Kozlov
- Institute of Experimental Oncology and Biomedical Technologies, Privolzhsky Research Medical University, 10/1 Minin and Pozharsky Sq., 603000 Nizhny Novgorod, Russia
- Laboratory of Molecular Genetic Research, Institute of Clinical Medicine, N.I. Lobachevsky Nizhny Novgorod National Research State University, 23 Gagarina Ave., 603022 Nizhny Novgorod, Russia
| | - Dmitry Krylov
- Institute of Experimental Oncology and Biomedical Technologies, Privolzhsky Research Medical University, 10/1 Minin and Pozharsky Sq., 603000 Nizhny Novgorod, Russia
- Laboratory of Molecular Genetic Research, Institute of Clinical Medicine, N.I. Lobachevsky Nizhny Novgorod National Research State University, 23 Gagarina Ave., 603022 Nizhny Novgorod, Russia
| | - Alena Gavrina
- Institute of Experimental Oncology and Biomedical Technologies, Privolzhsky Research Medical University, 10/1 Minin and Pozharsky Sq., 603000 Nizhny Novgorod, Russia
- Laboratory of Molecular Genetic Research, Institute of Clinical Medicine, N.I. Lobachevsky Nizhny Novgorod National Research State University, 23 Gagarina Ave., 603022 Nizhny Novgorod, Russia
| | - Nikolai Bobrov
- Institute of Experimental Oncology and Biomedical Technologies, Privolzhsky Research Medical University, 10/1 Minin and Pozharsky Sq., 603000 Nizhny Novgorod, Russia
- The Volga District Medical Centre of Federal Medical and Biological Agency, 14 Ilinskaya St., 603000 Nizhny Novgorod, Russia
| | - Vladimir Zagainov
- Institute of Experimental Oncology and Biomedical Technologies, Privolzhsky Research Medical University, 10/1 Minin and Pozharsky Sq., 603000 Nizhny Novgorod, Russia
- Nizhny Novgorod Regional Clinical Oncologic Dispensary, Delovaya St., 11/1, 603126 Nizhny Novgorod, Russia
| | - Elena Zagaynova
- Institute of Experimental Oncology and Biomedical Technologies, Privolzhsky Research Medical University, 10/1 Minin and Pozharsky Sq., 603000 Nizhny Novgorod, Russia
| | - Daria Kuznetsova
- Institute of Experimental Oncology and Biomedical Technologies, Privolzhsky Research Medical University, 10/1 Minin and Pozharsky Sq., 603000 Nizhny Novgorod, Russia
- Laboratory of Molecular Genetic Research, Institute of Clinical Medicine, N.I. Lobachevsky Nizhny Novgorod National Research State University, 23 Gagarina Ave., 603022 Nizhny Novgorod, Russia
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Calderon Novoa F, Ardiles V, de Santibañes E, Pekolj J, Goransky J, Mazza O, Sánchez Claria R, de Santibañes M. Pushing the Limits of Surgical Resection in Colorectal Liver Metastasis: How Far Can We Go? Cancers (Basel) 2023; 15:cancers15072113. [PMID: 37046774 PMCID: PMC10093442 DOI: 10.3390/cancers15072113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 03/24/2023] [Accepted: 03/30/2023] [Indexed: 04/05/2023] Open
Abstract
Colorectal cancer is the third most common cancer worldwide, and up to 50% of all patients diagnosed will develop metastatic disease. Management of colorectal liver metastases (CRLM) has been constantly improving, aided by newer and more effective chemotherapy agents and the use of multidisciplinary teams. However, the only curative treatment remains surgical resection of the CRLM. Although survival for surgically resected patients has shown modest improvement, this is mostly because of the fact that what is constantly evolving is the indication for resection. Surgeons are constantly pushing the limits of what is considered resectable or not, thus enhancing and enlarging the pool of patients who can be potentially benefited and even cured with aggressive surgical procedures. There are a variety of procedures that have been developed, which range from procedures to stimulate hepatic growth, such as portal vein embolization, two-staged hepatectomy, or the association of both, to technically challenging procedures such as simultaneous approaches for synchronous metastasis, ex-vivo or in-situ perfusion with total vascular exclusion, or even liver transplant. This article reviewed the major breakthroughs in liver surgery for CRLM, showing how much has changed and what has been achieved in the field of CRLM.
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Affiliation(s)
- Francisco Calderon Novoa
- Department of Surgery, Division of HPB Surgery, Hospital Italiano de Buenos Aires, Buenos Aires C1199, Argentina
| | - Victoria Ardiles
- Department of Surgery, Division of HPB Surgery, Hospital Italiano de Buenos Aires, Buenos Aires C1199, Argentina
| | - Eduardo de Santibañes
- Department of Surgery, Division of HPB Surgery, Hospital Italiano de Buenos Aires, Buenos Aires C1199, Argentina
| | - Juan Pekolj
- Department of Surgery, Division of HPB Surgery, Hospital Italiano de Buenos Aires, Buenos Aires C1199, Argentina
| | - Jeremias Goransky
- Department of Surgery, Division of HPB Surgery, Hospital Italiano de Buenos Aires, Buenos Aires C1199, Argentina
| | - Oscar Mazza
- Department of Surgery, Division of HPB Surgery, Hospital Italiano de Buenos Aires, Buenos Aires C1199, Argentina
| | - Rodrigo Sánchez Claria
- Department of Surgery, Division of HPB Surgery, Hospital Italiano de Buenos Aires, Buenos Aires C1199, Argentina
| | - Martín de Santibañes
- Department of Surgery, Division of HPB Surgery, Hospital Italiano de Buenos Aires, Buenos Aires C1199, Argentina
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Khajeh E, Ramouz A, Dooghaie Moghadam A, Aminizadeh E, Ghamarnejad O, Ali-Hassan-Al-Saegh S, Hammad A, Shafiei S, Abbasi Dezfouli S, Nickkholgh A, Golriz M, Goncalves G, Rio-Tinto R, Carvalho C, Hoffmann K, Probst P, Mehrabi A. Efficacy of Technical Modifications to the Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy (ALPPS) Procedure: A Systematic Review and Meta-Analysis. ANNALS OF SURGERY OPEN 2022; 3:e221. [PMID: 37600287 PMCID: PMC10406102 DOI: 10.1097/as9.0000000000000221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Accepted: 09/30/2022] [Indexed: 11/11/2022] Open
Abstract
To compare the outcomes of modified-Associating Liver Partition and Portal vein Ligation for Staged hepatectomy (ALPPS) techniques with those of conventional-ALPPS. Background ALPPS is an established technique for treating advanced liver tumors. Methods PubMed, Web of Science, and Cochrane databases were searched. The outcomes were assessed by single-arm and 2-arm analyses. Results Seventeen studies containing 335 modified-ALPPS patients were included in single-arm meta-analysis. The estimated blood loss was 267 ± 29 mL (95% confidence interval [CI], 210-324 mL) during the first and 662 ± 51 mL (95% CI, 562-762 mL) during the second stage. The operation time was 166 ± 18 minutes (95% CI, 131-202 minutes) during the first and 225 ± 19 minutes (95% CI, 188-263 minutes) during the second stage. The major morbidity rate was 14% (95% CI, 9%-22%) after the first stage. The future liver remnant hypertrophy rate was 65.2% ± 5% (95% CI, 55%-75%) and the interstage interval was 16 ± 1 days (95% CI, 14-17 days). The dropout rate was 9% (95% CI, 5%-15%). The overall complication rate was 46% (95% CI, 37%-56%) and the major complication rate was 20% (95% CI, 14%-26%). The postoperative mortality rate was 7% (95% CI, 4%-11%). Seven studies containing 215 patients were included in comparative analysis. The hypertrophy rate was not different between 2 methods (mean difference [MD], -5.01; 95% CI, -19.16 to 9.14; P = 0.49). The interstage interval was shorter for partial-ALPPS (MD, 9.43; 95% CI, 3.29-15.58; P = 0.003). The overall complication rate (odds ratio [OR], 10.10; 95% CI, 2.11-48.35; P = 0.004) and mortality rate (OR, 3.74; 95% CI, 1.36-10.26; P = 0.01) were higher in the conventional-ALPPS. Conclusions The hypertrophy rate in partial-ALPPS was similar to conventional-ALPPS. This shows that minimizing the first stage of the operation does not affect hypertrophy. Moreover, the postoperative overall morbidity and mortality rates were lower following partial-ALPPS.
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Affiliation(s)
- Elias Khajeh
- From the Department of General, Visceral, and Transplantation Surgery, Ruprecht-Karls University, Heidelberg, Germany
- Department of Digestive Surgery, Hepato-Pancreato-Biliary Surgery Unit, Champalimaud Foundation, Lisbon, Portugal
| | - Ali Ramouz
- From the Department of General, Visceral, and Transplantation Surgery, Ruprecht-Karls University, Heidelberg, Germany
| | - Arash Dooghaie Moghadam
- From the Department of General, Visceral, and Transplantation Surgery, Ruprecht-Karls University, Heidelberg, Germany
| | - Ehsan Aminizadeh
- From the Department of General, Visceral, and Transplantation Surgery, Ruprecht-Karls University, Heidelberg, Germany
| | - Omid Ghamarnejad
- From the Department of General, Visceral, and Transplantation Surgery, Ruprecht-Karls University, Heidelberg, Germany
| | - Sadeq Ali-Hassan-Al-Saegh
- From the Department of General, Visceral, and Transplantation Surgery, Ruprecht-Karls University, Heidelberg, Germany
| | - Ahmed Hammad
- From the Department of General, Visceral, and Transplantation Surgery, Ruprecht-Karls University, Heidelberg, Germany
| | - Saeed Shafiei
- From the Department of General, Visceral, and Transplantation Surgery, Ruprecht-Karls University, Heidelberg, Germany
| | - Sepehr Abbasi Dezfouli
- From the Department of General, Visceral, and Transplantation Surgery, Ruprecht-Karls University, Heidelberg, Germany
| | - Arash Nickkholgh
- From the Department of General, Visceral, and Transplantation Surgery, Ruprecht-Karls University, Heidelberg, Germany
| | - Mohammad Golriz
- From the Department of General, Visceral, and Transplantation Surgery, Ruprecht-Karls University, Heidelberg, Germany
| | - Gil Goncalves
- Department of Digestive Surgery, Hepato-Pancreato-Biliary Surgery Unit, Champalimaud Foundation, Lisbon, Portugal
| | - Ricardo Rio-Tinto
- Department of Gastroenterology, Digestive Oncology Unit, Champalimaud Foundation, Lisbon, Portugal
| | - Carlos Carvalho
- Department of Clinical Oncology, Digestive Unit, Champalimaud Clinical Centre, Lisbon, Portugal
| | - Katrin Hoffmann
- From the Department of General, Visceral, and Transplantation Surgery, Ruprecht-Karls University, Heidelberg, Germany
| | - Pascal Probst
- From the Department of General, Visceral, and Transplantation Surgery, Ruprecht-Karls University, Heidelberg, Germany
| | - Arianeb Mehrabi
- From the Department of General, Visceral, and Transplantation Surgery, Ruprecht-Karls University, Heidelberg, Germany
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Tomida H, Notake T, Shimizu A, Kubota K, Umemura K, Kamachi A, Goto T, Yamazaki S, Soejima Y. Rescue percutaneous transhepatic portal vein embolization after failed associated liver partition and portal vein ligation for staged hepatectomy in a patient with multiple liver metastases of rectal cancer: a case report. Surg Case Rep 2022; 8:132. [PMID: 35831765 PMCID: PMC9279524 DOI: 10.1186/s40792-022-01491-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 07/09/2022] [Indexed: 11/13/2022] Open
Abstract
Background Liver metastasis is the most common form of distant spread of colorectal cancer. Despite oncological and surgical advances, only about 25% of patients are eligible to undergo resection. As the liver has a limited resectable volume, tumor reduction and remnant liver hypertrophy are of critical importance in treating initially unresectable colorectal cancer liver metastasis. Associated liver partition and portal vein ligation for staged hepatectomy (ALPPS) allows rapid liver hypertrophy within a short period and has been reported to be useful in recent years. Case presentation A 29-year-old woman complaining of bloody stool was referred to our hospital. She was diagnosed with rectal cancer (Rb) with simultaneous multiple liver and lung metastases. The patient was then initially commenced on chemotherapy and completed it with a satisfactory response. Right trisectionectomy was necessary to achieve hepatic clearance; however, the future liver remnant (FLR) volume was insufficient. Therefore, we decided to perform totally laparoscopic ALPPS to obtain enough FLR volume. However, the FLR increase was slow, and FLR did not attain the required volume for right trisectionectomy. Computed tomography showed that right portal venous blood flow was increased via developed collateral vessels around the portal vein. We attempted to induce further liver growth by blocking portal blood flow using additional percutaneous transhepatic portal vein embolization (PTPE), and a rapid increase in FLR was obtained. The patient underwent right trisectionectomy and partial resection of S2 with negative margins, and the patient was discharged without postoperative liver failure. Conclusions Resumption of the portal venous blood flow through collateral vessels after ALPPS may have interfered with the planned residual liver hypertrophy. Performing PTPE in addition to ALPPS increased the FLR volume, and radical hepatectomy was completed safely. Remnant portal venous blood flow following ALPPS is an important issue to be considered in surgical planning, and early additional portal vein embolization could be effective.
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Lv JH, Chen WZ, Li YN, Wang JX, Fu YK, Zeng ZX, Wu JY, Wang SJ, Huang XX, Huang LM, Huang RF, Wei YG, Yan ML. Should associating liver partition and portal vein ligation for staged hepatectomy be applied to hepatitis B virus-related hepatocellular carcinoma patients with cirrhosis? A multi-center study. HPB (Oxford) 2022; 24:2175-2184. [PMID: 36280426 DOI: 10.1016/j.hpb.2022.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2022] [Revised: 06/30/2022] [Accepted: 10/03/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND It is unclear whether associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) can be performed in hepatitis B virus-related hepatocellular carcinoma (HCC) patients with cirrhosis. We explored the efficacy of ALPPS in HCC patients. METHODS Data of 54 patients who underwent ALPPS between August 2014 and July 2020 at three centers were collected. Adverse factors affecting their prognosis were analyzed and subsequently compared with 184 patients who underwent transcatheter arterial chemoembolization (TACE). RESULTS Overall survival rates of the ALPPS group at 1, 3, and 5 years were 70.6%, 38.4%, and 31.7%, respectively; corresponding disease-free survival rates were 50.5%, 22.4%, and 19.2%, respectively. The ALPPS group had a significantly greater long-term survival rate than the TACE group (before propensity score matching, P < 0.001; after propensity score matching, P = 0.002). Multivariate analysis demonstrated that multifocal lesions (P = 0.018) and macroscopic vascular invasion (P = 0.001) were prognostic factors for HCC patients who underwent ALPPS. After the propensity score matching, the multifocal lesions (P = 0.031), macroscopic vascular invasion (P = 0.003), and treatment type (ALPPS/TACE) (P = 0.026) were the factors adversely affecting the prognosis of HCC patients. CONCLUSION ALPPS was feasible in hepatitis B virus-related HCC patients with cirrhosis and resulted in better survival than TACE.
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Affiliation(s)
- Jia-Hui Lv
- Shengli Clinical Medical College of Fujian Medical University, Department of Hepatobiliary Pancreatic Surgery, Fujian Provincial Hospital, Fuzhou, China
| | - Wei-Zhao Chen
- Shengli Clinical Medical College of Fujian Medical University, Department of Hepatobiliary Pancreatic Surgery, Fujian Provincial Hospital, Fuzhou, China
| | - Yi-Nan Li
- Shengli Clinical Medical College of Fujian Medical University, Department of Hepatobiliary Pancreatic Surgery, Fujian Provincial Hospital, Fuzhou, China
| | - Jin-Xiu Wang
- Shengli Clinical Medical College of Fujian Medical University, Department of Hepatobiliary Pancreatic Surgery, Fujian Provincial Hospital, Fuzhou, China
| | - Yang-Kai Fu
- Shengli Clinical Medical College of Fujian Medical University, Department of Hepatobiliary Pancreatic Surgery, Fujian Provincial Hospital, Fuzhou, China
| | - Zhen-Xin Zeng
- Shengli Clinical Medical College of Fujian Medical University, Department of Hepatobiliary Pancreatic Surgery, Fujian Provincial Hospital, Fuzhou, China
| | - Jia-Yi Wu
- Shengli Clinical Medical College of Fujian Medical University, Department of Hepatobiliary Pancreatic Surgery, Fujian Provincial Hospital, Fuzhou, China
| | - Shuang-Jia Wang
- Department of Hepatobiliary Pancreatic Vascular Surgery, The First Affiliated Hospital of Xiamen University, Xiamen, China
| | - Xiao-Xiao Huang
- Shengli Clinical Medical College of Fujian Medical University, Department of Hepatobiliary Pancreatic Surgery, Fujian Provincial Hospital, Fuzhou, China
| | - Li-Ming Huang
- Shengli Clinical Medical College of Fujian Medical University, Department of Hepatobiliary Pancreatic Surgery, Fujian Provincial Hospital, Fuzhou, China
| | - Rong-Fa Huang
- Shengli Clinical Medical College of Fujian Medical University, Department of Hepatobiliary Pancreatic Surgery, Fujian Provincial Hospital, Fuzhou, China
| | - Yong-Gang Wei
- Department of Liver Surgery, Liver Transplantation Center, West China Hospital of Sichuan University, Chengdu, China.
| | - Mao-Lin Yan
- Shengli Clinical Medical College of Fujian Medical University, Department of Hepatobiliary Pancreatic Surgery, Fujian Provincial Hospital, Fuzhou, China.
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Entezari P, Toskich BB, Kim E, Padia S, Christopher D, Sher A, Thornburg B, Hohlastos ES, Salem R, Collins JD, Lewandowski RJ. Promoting Surgical Resection through Future Liver Remnant Hypertrophy. Radiographics 2022; 42:2166-2183. [PMID: 36206182 DOI: 10.1148/rg.220050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
An inadequate future liver remnant (FLR) can preclude curative-intent surgical resection for patients with primary or secondary hepatic malignancies. For patients with normal baseline liver function and without risk factors, an FLR of 20% is needed to maintain postsurgical hepatic function. However, the FLR requirement is higher for patients who are exposed to systemic chemotherapy (FLR, >30%) or have cirrhosis (FLR, >40%). Interventional radiologic and surgical methods to achieve FLR hypertrophy are evolving, including portal vein ligation, portal vein embolization, radiation lobectomy, hepatic venous deprivation, and associating liver partition and portal vein ligation for staged hepatectomy. Each technique offers particular advantages and disadvantages. Knowledge of these procedures can help clinicians to choose the suitable technique for each patient. The authors review the techniques used to develop FLR hypertrophy, focusing on technical considerations, outcomes, and the advantages and disadvantages of each approach. Online supplemental material is available for this article. ©RSNA, 2022.
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Affiliation(s)
- Pouya Entezari
- From the Department of Radiology, Section of Interventional Radiology (P.E., B.T., E.S.H., R.S., R.J.L.), and Department of Surgery, Division of Transplant Surgery (D.C.), Northwestern University, 676 N Saint Clair St, Chicago, IL 60611-2927; Department of Radiology, Section of Interventional Radiology, Mayo Clinic Florida, Jacksonville, Fla (B.B.T.); Department of Radiology, Section of Interventional Radiology, Mount Sinai University Hospitals, New York, NY (E.K., A.S.); Department of Radiology, Section of Interventional Radiology, University of California-Los Angeles, Los Angeles, Calif (S.P.); and Department of Radiology, Mayo Clinic Rochester, Rochester, Minn (J.D.C.)
| | - Beau B Toskich
- From the Department of Radiology, Section of Interventional Radiology (P.E., B.T., E.S.H., R.S., R.J.L.), and Department of Surgery, Division of Transplant Surgery (D.C.), Northwestern University, 676 N Saint Clair St, Chicago, IL 60611-2927; Department of Radiology, Section of Interventional Radiology, Mayo Clinic Florida, Jacksonville, Fla (B.B.T.); Department of Radiology, Section of Interventional Radiology, Mount Sinai University Hospitals, New York, NY (E.K., A.S.); Department of Radiology, Section of Interventional Radiology, University of California-Los Angeles, Los Angeles, Calif (S.P.); and Department of Radiology, Mayo Clinic Rochester, Rochester, Minn (J.D.C.)
| | - Edward Kim
- From the Department of Radiology, Section of Interventional Radiology (P.E., B.T., E.S.H., R.S., R.J.L.), and Department of Surgery, Division of Transplant Surgery (D.C.), Northwestern University, 676 N Saint Clair St, Chicago, IL 60611-2927; Department of Radiology, Section of Interventional Radiology, Mayo Clinic Florida, Jacksonville, Fla (B.B.T.); Department of Radiology, Section of Interventional Radiology, Mount Sinai University Hospitals, New York, NY (E.K., A.S.); Department of Radiology, Section of Interventional Radiology, University of California-Los Angeles, Los Angeles, Calif (S.P.); and Department of Radiology, Mayo Clinic Rochester, Rochester, Minn (J.D.C.)
| | - Siddharth Padia
- From the Department of Radiology, Section of Interventional Radiology (P.E., B.T., E.S.H., R.S., R.J.L.), and Department of Surgery, Division of Transplant Surgery (D.C.), Northwestern University, 676 N Saint Clair St, Chicago, IL 60611-2927; Department of Radiology, Section of Interventional Radiology, Mayo Clinic Florida, Jacksonville, Fla (B.B.T.); Department of Radiology, Section of Interventional Radiology, Mount Sinai University Hospitals, New York, NY (E.K., A.S.); Department of Radiology, Section of Interventional Radiology, University of California-Los Angeles, Los Angeles, Calif (S.P.); and Department of Radiology, Mayo Clinic Rochester, Rochester, Minn (J.D.C.)
| | - Derrick Christopher
- From the Department of Radiology, Section of Interventional Radiology (P.E., B.T., E.S.H., R.S., R.J.L.), and Department of Surgery, Division of Transplant Surgery (D.C.), Northwestern University, 676 N Saint Clair St, Chicago, IL 60611-2927; Department of Radiology, Section of Interventional Radiology, Mayo Clinic Florida, Jacksonville, Fla (B.B.T.); Department of Radiology, Section of Interventional Radiology, Mount Sinai University Hospitals, New York, NY (E.K., A.S.); Department of Radiology, Section of Interventional Radiology, University of California-Los Angeles, Los Angeles, Calif (S.P.); and Department of Radiology, Mayo Clinic Rochester, Rochester, Minn (J.D.C.)
| | - Alex Sher
- From the Department of Radiology, Section of Interventional Radiology (P.E., B.T., E.S.H., R.S., R.J.L.), and Department of Surgery, Division of Transplant Surgery (D.C.), Northwestern University, 676 N Saint Clair St, Chicago, IL 60611-2927; Department of Radiology, Section of Interventional Radiology, Mayo Clinic Florida, Jacksonville, Fla (B.B.T.); Department of Radiology, Section of Interventional Radiology, Mount Sinai University Hospitals, New York, NY (E.K., A.S.); Department of Radiology, Section of Interventional Radiology, University of California-Los Angeles, Los Angeles, Calif (S.P.); and Department of Radiology, Mayo Clinic Rochester, Rochester, Minn (J.D.C.)
| | - Bartley Thornburg
- From the Department of Radiology, Section of Interventional Radiology (P.E., B.T., E.S.H., R.S., R.J.L.), and Department of Surgery, Division of Transplant Surgery (D.C.), Northwestern University, 676 N Saint Clair St, Chicago, IL 60611-2927; Department of Radiology, Section of Interventional Radiology, Mayo Clinic Florida, Jacksonville, Fla (B.B.T.); Department of Radiology, Section of Interventional Radiology, Mount Sinai University Hospitals, New York, NY (E.K., A.S.); Department of Radiology, Section of Interventional Radiology, University of California-Los Angeles, Los Angeles, Calif (S.P.); and Department of Radiology, Mayo Clinic Rochester, Rochester, Minn (J.D.C.)
| | - Elias S Hohlastos
- From the Department of Radiology, Section of Interventional Radiology (P.E., B.T., E.S.H., R.S., R.J.L.), and Department of Surgery, Division of Transplant Surgery (D.C.), Northwestern University, 676 N Saint Clair St, Chicago, IL 60611-2927; Department of Radiology, Section of Interventional Radiology, Mayo Clinic Florida, Jacksonville, Fla (B.B.T.); Department of Radiology, Section of Interventional Radiology, Mount Sinai University Hospitals, New York, NY (E.K., A.S.); Department of Radiology, Section of Interventional Radiology, University of California-Los Angeles, Los Angeles, Calif (S.P.); and Department of Radiology, Mayo Clinic Rochester, Rochester, Minn (J.D.C.)
| | - Riad Salem
- From the Department of Radiology, Section of Interventional Radiology (P.E., B.T., E.S.H., R.S., R.J.L.), and Department of Surgery, Division of Transplant Surgery (D.C.), Northwestern University, 676 N Saint Clair St, Chicago, IL 60611-2927; Department of Radiology, Section of Interventional Radiology, Mayo Clinic Florida, Jacksonville, Fla (B.B.T.); Department of Radiology, Section of Interventional Radiology, Mount Sinai University Hospitals, New York, NY (E.K., A.S.); Department of Radiology, Section of Interventional Radiology, University of California-Los Angeles, Los Angeles, Calif (S.P.); and Department of Radiology, Mayo Clinic Rochester, Rochester, Minn (J.D.C.)
| | - Jeremy D Collins
- From the Department of Radiology, Section of Interventional Radiology (P.E., B.T., E.S.H., R.S., R.J.L.), and Department of Surgery, Division of Transplant Surgery (D.C.), Northwestern University, 676 N Saint Clair St, Chicago, IL 60611-2927; Department of Radiology, Section of Interventional Radiology, Mayo Clinic Florida, Jacksonville, Fla (B.B.T.); Department of Radiology, Section of Interventional Radiology, Mount Sinai University Hospitals, New York, NY (E.K., A.S.); Department of Radiology, Section of Interventional Radiology, University of California-Los Angeles, Los Angeles, Calif (S.P.); and Department of Radiology, Mayo Clinic Rochester, Rochester, Minn (J.D.C.)
| | - Robert J Lewandowski
- From the Department of Radiology, Section of Interventional Radiology (P.E., B.T., E.S.H., R.S., R.J.L.), and Department of Surgery, Division of Transplant Surgery (D.C.), Northwestern University, 676 N Saint Clair St, Chicago, IL 60611-2927; Department of Radiology, Section of Interventional Radiology, Mayo Clinic Florida, Jacksonville, Fla (B.B.T.); Department of Radiology, Section of Interventional Radiology, Mount Sinai University Hospitals, New York, NY (E.K., A.S.); Department of Radiology, Section of Interventional Radiology, University of California-Los Angeles, Los Angeles, Calif (S.P.); and Department of Radiology, Mayo Clinic Rochester, Rochester, Minn (J.D.C.)
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Evolution of associating liver partition and portal vein ligation for staged hepatectomy from 2012 to 2021: A bibliometric analysis. Review. Int J Surg 2022; 103:106648. [PMID: 35513249 DOI: 10.1016/j.ijsu.2022.106648] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 04/15/2022] [Accepted: 04/19/2022] [Indexed: 02/08/2023]
Abstract
BACKGROUND Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) has become increasingly popular during the past few decades, and its indications have extended from patients with normal liver to post-chemotherapy patients and even patients with cirrhosis. However, few studies have assessed the publications in relation to ALPPS. METHODS Web of Science was searched to identify studies related to ALPPS published from 2012 to 2021. The analysis was performed using the bibliometric package (Version 3.1.0) in R software. RESULTS In total, 486 publications were found. These articles were published in 159 journals and authored by 2157 researchers from 694 organizations. The most prolific journal was Annals of Surgery (24 articles and 1170 citations). The most frequently cited article was published in Annals of Surgery (average citations, 72.7; total citations, 727). China was the most productive country for ALPPS publications but had comparatively less interaction with other countries. Both thematic evolution and co-occurrence network analysis showed low numbers of topics such as failure, resection, and safety among the publications but large numbers of highly cited papers on outcomes, prediction, mechanisms, multicenter analysis, and novel procedures such as liver venous deprivation. A total of 196 studies focused the clinical application of ALPPS, and most studies were IDEAL Stages I and II. The specific mechanism of ALPPS liver regeneration remains unclear. CONCLUSIONS This is the first bibliometric analysis offering an overview of the development of ALPPS research publications. Our findings identified prominent studies, countries, institutions, journals, and authors to indicate the future direction of ALPPS research. The role of ALPPS in liver regeneration and the long-term results of ALPPS need further study. Future research directions include comparison of ALPPS with portal vein embolization, liver venous deprivation, and other two-stage hepatectomies as well as patients' quality of life after ALPPS.
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Richter B, Sänger C, Mussbach F, Scheuerlein H, Settmacher U, Dahmen U. The Interplay Between Biliary Occlusion and Liver Regeneration: Repeated Regeneration Stimuli Restore Biliary Drainage by Promoting Hepatobiliary Remodeling in a Rat Model. Front Surg 2022; 9:799669. [PMID: 35548189 PMCID: PMC9081651 DOI: 10.3389/fsurg.2022.799669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Accepted: 03/21/2022] [Indexed: 12/04/2022] Open
Abstract
Background and Aims Patients with malignant biliary obstruction do not seem to benefit from “two-stage hepatectomy” due to an impairment of liver regeneration. We designed a novel model of “repeated regeneration stimuli” in rats mimicking a “two-stage hepatectomy” with selective or complete biliary occlusion mimicking Klatskin tumors III° or IV°. Using this new model, we wanted to investigate (1) the impact of preexistent cholestasis of different extent on the time course of liver regeneration and (2) the dynamics of hepatobiliary remodeling under regeneration conditions. Materials and Methods Rats were subjected to a sequence of three operations: surgical induction of biliary occlusion, followed by “repeated regeneration stimuli” consisting of ligation of the left branch of the portal vein (supplying 70% of the liver volume, sPVL) as first stage and a 70%-hepatectomy (70%PHx) as second stage. Biliary occlusion (1st procedure) was induced by ligating and transection of either the common (100%, tBDT) or the left bile duct (70%, sBDT). A sham operation without ligating the bile duct was performed as control (0%, Sham). Two weeks later, on day 14 (POD14), the sPVL (2nd procedure) was performed. Another week later (POD 21), the 70%PHx (3rd procedure) took place and animals were observed for 1 week (POD 28). The first experiment (n = 45 rats) was dedicated to investigating liver regeneration (hypertrophy/atrophy), proliferative activity and hepatobiliary histomorphology (2D-histology: HE, BrdU) in the future liver remnant (FLR). The second experiment (n = 25 rats) was performed to study the dynamics of hepatobiliary remodeling in livers with different regenerative pressure (tBDT only POD21 vs. tBDT only POD 28 vs. tBDT + sPVL vs. tBDT + 70%PHx vs. tBDT + sPVL + 70%PHx) using μCT scans of explanted livers. Results Effect of biliary occlusion Total biliary occlusion (tBDT) led to a 2.4-fold increase in whole liver volume due to severe biliary proliferation within 14 days. In contrast, partial biliary occlusion (sBDT) caused only a volume gain of the obstructed liver lobes due to biliary proliferates, resulting in a minor increase of total liver volume (1.7-fold) without an increase in bilirubin levels. Liver regeneration and atrophy As expected, sPVL caused substantial volume gain (tBDT: 3-fold; sBDT: 2.8-fold; Sham 2.8-fold) of FLR and a substantial volume loss (tBDT: 0.9-fold; sBDT: 0.6-fold; Sham: 0.4-fold) of the portally deprived “future resected lobes” compared to the preoperative liver volume. The subsequent 70%PHx promoted a further volume gain of the FLR in all groups (tBDT: 4-fold; sBDT: 3-fold; Sham 3-fold compared to original volume) until POD 28. Hepatobiliary remodeling: After tBDT, we identified histologically three phases of hepatobiliary remodeling in the FLR. Following tBDT, biliary proliferates developed, replacing about 15% of the hepatocellular tissue. After sPVL we found incomplete restoration of the hepatocellular tissue with a visible reduction of the biliary proliferates. The 70%PHx led to an almost complete recovery of the hepatocellular tissue in the FLR with a nearly normal liver architecture. In contrast, after sBDT and Sham we observed a near normal liver morphology in the FLR at all time points. CT-scanning of the explanted livers and subsequent 3D reconstruction visualized the development of extrahepatic biliary collaterals. Collaterals were detected in 0/5 cases 1 week after sPVL (first regeneration stimulus), and in even more cases (3/5) 1 week after the 70%PHx (second regeneration stimulus). Histological workup identified the typical biliary cuboid epithelium as inner lining of the collaterals and peribiliary glands. Conclusion Liver volume of the FLR increased in cholestatic rats mainly due to biliary proliferates. Application of repeated regeneration stimuli in the style of a “two-stage hepatectomy” promoted almost full restoration of hepatocellular tissue and architecture in the FLR by reestablishing biliary drainage via formation of biliary collaterals. Further exploration of the dynamics in hepatobiliary modeling using this model might help to better understand the underlying mechanism.
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Affiliation(s)
- Beate Richter
- Department of General, Visceral and Vascular Surgery, University Hospital Jena, Jena, Germany
- *Correspondence: Beate Richter
| | - Constanze Sänger
- Department of General, Visceral and Vascular Surgery, University Hospital Jena, Jena, Germany
| | - Franziska Mussbach
- Department of General, Visceral and Vascular Surgery, University Hospital Jena, Jena, Germany
| | - Hubert Scheuerlein
- Clinic for General, Visceral and Paediatric Surgery, St. Vincenz Hospital Paderborn, University of Göttingen, Paderborn, Germany
| | - Utz Settmacher
- Department of General, Visceral and Vascular Surgery, University Hospital Jena, Jena, Germany
| | - Uta Dahmen
- Department of General, Visceral and Vascular Surgery, University Hospital Jena, Jena, Germany
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Vaghiri S, Alaghmand Nejad S, Kasprowski L, Prassas D, Safi SA, Schimmöller L, Krieg A, Rehders A, Lehwald-Tywuschik N, Knoefel WT. A single center comparative retrospective study of in situ split plus portal vein ligation versus conventional two-stage hepatectomy for cholangiocellular carcinoma. Acta Chir Belg 2022:1-12. [PMID: 35317718 DOI: 10.1080/00015458.2022.2056680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
INTRODUCTION Cholangiocellular carcinoma (CCA) has a poor prognosis and the goldstandard even in locally advanced cases remains radical surgical resection. This approach however is limited by the future liver remnant volume (FLRV) after extensive parenchymal dissection leading to post-operative liver failure and high mortality rates. The aim of this study was to compare the outcome of in situ liver transection with portal vein ligation (ISLT) procedure and conventional two-stage hepatectomy with portal vein embolization (PVE/TSH) in patients with CCA. METHODS All patients with CCA and insufficient FLR considered for either ISLT or PVE/TSH were analyzed for outcomes including post-operative morbidity, mortality, and overall survival rates (OS). RESULTS Sixteen patients received ISLT and eight patients underwent PVE/TSH. The completion rate of the second stage in the PVE/TSH group was 62% and 100% in the ISLT group (p = 0.027). The overall 90-day morbidity rates including severe complications (Clavien-Dindo ≥3b) were comparable (PVE/TSH 40% vs. ISLT 69%, p = 0.262). The median OS (PVE/TSH 7 months vs. ISLT 3 months) and the 90-day mortality rates (PVE/TSH 0% vs. ISLT 50%) did not significantly differ between the two groups (p > 0.05). In multivariate analysis, biliary resection and reconstruction was the only risk factor independently associated with 90-day post-operative morbidity [HR = 20.0; 95%CI (1.68-238.63); p = 0.018]. CONCLUSION Our results demonstrate comparable outcomes in both groups in a rather prognostically unfavorable disease. The completion rate in the ISLT group was significantly higher than in the PVE/TSH cohort. This work encourages specialized hepato-biliary-pancreatic centers in applying the ISLT procedure in selected cases with CCA.
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Affiliation(s)
- Sascha Vaghiri
- Department of Surgery A, University Hospital Duesseldorf, Duesseldorf, Germany
| | | | - Laszlo Kasprowski
- Department of Diagnostic and Interventional Radiology, University Hospital Duesseldorf, Duesseldorf, Germany
| | - Dimitrios Prassas
- Department of Surgery A, University Hospital Duesseldorf, Duesseldorf, Germany
| | - Sami-Alexander Safi
- Department of Surgery A, University Hospital Duesseldorf, Duesseldorf, Germany
| | - Lars Schimmöller
- Department of Diagnostic and Interventional Radiology, University Hospital Duesseldorf, Duesseldorf, Germany
| | - Andreas Krieg
- Department of Surgery A, University Hospital Duesseldorf, Duesseldorf, Germany
| | - Alexander Rehders
- Department of Surgery A, University Hospital Duesseldorf, Duesseldorf, Germany
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Cannella R, Tselikas L, Douane F, Cauchy F, Rautou PE, Duran R, Ronot M. Imaging-guided interventions modulating portal venous flow: evidence and controversies. JHEP REPORTS : INNOVATION IN HEPATOLOGY 2022; 4:100484. [PMID: 35677591 PMCID: PMC9168703 DOI: 10.1016/j.jhepr.2022.100484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 03/23/2022] [Accepted: 03/25/2022] [Indexed: 12/07/2022]
Abstract
Portal hypertension is defined by an increase in the portosystemic venous gradient. In most cases, increased resistance to portal blood flow is the initial cause of elevated portal pressure. More than 90% of cases of portal hypertension are estimated to be due to advanced chronic liver disease or cirrhosis. Transjugular intrahepatic portosystemic shunts, a non-pharmacological treatment for portal hypertension, involve the placement of a stent between the portal vein and the hepatic vein or inferior vena cava which helps bypass hepatic resistance. Portal hypertension may also be a result of extrahepatic portal vein thrombosis or compression. In these cases, percutaneous portal vein recanalisation restores portal trunk patency, thus preventing portal hypertension-related complications. Any portal blood flow impairment leads to progressive parenchymal atrophy and triggers hepatic regeneration in preserved areas. This provides the rationale for using portal vein embolisation to modulate hepatic volume in preparation for extended hepatic resection. The aim of this paper is to provide a comprehensive evidence-based review of the rationale for, and outcomes associated with, the main imaging-guided interventions targeting the portal vein, as well as to discuss the main controversies around such approaches.
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Kupffer cells depletion alters cytokine expression and delays liver regeneration after Radio-frequency-assisted Liver Partition with Portal Vein Ligation. Mol Immunol 2022; 144:71-77. [PMID: 35203023 DOI: 10.1016/j.molimm.2022.02.016] [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: 11/25/2021] [Accepted: 02/15/2022] [Indexed: 11/22/2022]
Abstract
Radio-frequency-assisted Liver Partition with Portal Vein Ligation (RALPP) induces comparable hypertrophy of the liver remnant compared to Associating Liver Partition and Portal vein ligation for Staged hepatectomy (ALPPS) in humans. However, whether it is significantly improved compared to ALPPS is unclear, and the underlying mechanisms of liver regeneration after RALPP need to further investigate. The present study was to develop an animal model mimicking RALPP and explore mechanisms of liver regeneration. The mice in RALPP group received liver radiofrequency ablation and 90% portal vein ligation (PVL), followed by resection of the targeted liver within two days after the first surgery. The mice in ALPPS group underwent 90% PVL combined with parenchyma transection. Controls received liver radiofrequency ablation (RAF group) or PVL (PVL group) or small left lateral lobe (LLL group) resection alone. Liver regeneration was assessed by liver weight and proliferation-associated molecules. The role of Kupffer cells (KCs) in liver regeneration was investigated after RALPP. The results showed that RALPP induced comparable liver regeneration compared to ALPPS, but with less liver injury and mortality in mice. RALPP led to over-expression of TNF-α and IL-6 in the circulating plasma compared with PVL. KCs infiltrating in liver tissues was a characteristic of mice in the RALPP group. KCs depletion markedly depressed cytokine expression and delayed liver regeneration after RALPP. These results suggested that RALPP in mice induced accelerated liver regeneration similar to ALPPS, but safer than ALPPS. KCs depletion altered cytokine expression and delayed liver regeneration after RALPP.
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Gutiérrez Sáenz de Santa María J, Herrero de la Parte B, Gutiérrez-Sánchez G, Ruiz Montesinos I, Iturrizaga Correcher S, Mar Medina C, García-Alonso I. Folinic Acid Potentiates the Liver Regeneration Process after Selective Portal Vein Ligation in Rats. Cancers (Basel) 2022; 14:cancers14020371. [PMID: 35053534 PMCID: PMC8773925 DOI: 10.3390/cancers14020371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 12/30/2021] [Accepted: 01/07/2022] [Indexed: 11/25/2022] Open
Abstract
Simple Summary Fewer than 30% of patients with liver metastases are eligible for major liver resection, because liver remaining after such a surgery would be insufficient to cover the patient’s needs; this is called a low percentage of future liver remnant (FLR). Folinic acid (FA) has been shown to play a crucial role in cellular synthesis, regeneration, and nucleotide and amino acid biosynthesis. The aim of this piece of research was to evaluate the effect of FA as a potential hypertrophic hepatic enhancer agent after selective portal vein ligation (PVL) to ensure adequate FLR. We have confirmed in our rodent model that FA accelerates liver regeneration after PVL and enhances recovery of liver function. These findings may allow more patients to be eligible for liver resection without jeopardizing postoperative liver function. Abstract Liver resection remains the gold standard for hepatic metastases. The future liver remnant (FLR) and its functional status are two key points to consider before performing major liver resections, since patients with less than 25% FLR or a Child–Pugh B or C grade are not eligible for this procedure. Folinic acid (FA) is an essential agent in cell replication processes. Herein, we analyze the effect of FA as an enhancer of liver regeneration after selective portal vein ligation (PVL). Sixty-four male WAG/RijHsd rats were randomly distributed into eight groups: a control group and seven subjected to 50% PVL, by ligation of left portal branch. The treated animals received FA (2.5 m/kg), while the rest were given saline. After 36 h, 3 days or 7 days, liver tissue and blood samples were obtained. FA slightly but significantly increased FLR percentage (FLR%) on the 7th day (91.88 ± 0.61%) compared to control or saline-treated groups (86.72 ± 2.5 vs. 87 ± 3.33%; p < 0.01). The hepatocyte nuclear area was also increased both at 36 h and 7days with FA (61.55 ± 16.09 µm2, and 49.91 ± 15.38 µm2; p < 0.001). Finally, FA also improved liver function. In conclusion, FA has boosted liver regeneration assessed by FLR%, nuclear area size and restoration of liver function after PVL.
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Affiliation(s)
| | - Borja Herrero de la Parte
- Department of Surgery and Radiology and Physical Medicine, Faculty of Medicine and Nursing, University of the Basque Country UPV/EHU, ES48940 Leioa, Spain;
- Interventional Radiology Research Group, Biocruces Bizkaia Health Research Institute, ES48903 Barakaldo, Spain
- Correspondence: (B.H.d.l.P.); (I.R.M.)
| | - Gaizka Gutiérrez-Sánchez
- Department of Anesthesiology, Santa Creu i Sant Pau University Hospital, ES08025 Barcelona, Spain;
| | - Inmaculada Ruiz Montesinos
- Department of Surgery and Radiology and Physical Medicine, Faculty of Medicine and Nursing, University of the Basque Country UPV/EHU, ES48940 Leioa, Spain;
- Department of Gastrointestinal Surgery, Donostia University Hospital, ES20014 Donostia, Spain
- Correspondence: (B.H.d.l.P.); (I.R.M.)
| | - Sira Iturrizaga Correcher
- Department of Clinical Analyses, Galdakao-Usansolo Hospital, ES48960 Galdakao, Spain; (S.I.C.); (C.M.M.)
| | - Carmen Mar Medina
- Department of Clinical Analyses, Galdakao-Usansolo Hospital, ES48960 Galdakao, Spain; (S.I.C.); (C.M.M.)
| | - Ignacio García-Alonso
- Department of Surgery and Radiology and Physical Medicine, Faculty of Medicine and Nursing, University of the Basque Country UPV/EHU, ES48940 Leioa, Spain;
- Interventional Radiology Research Group, Biocruces Bizkaia Health Research Institute, ES48903 Barakaldo, Spain
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Lang H, Baumgart J, Mittler J. Associated Liver Partition and Portal Vein Ligation for Staged Hepatectomy (ALPPS) Registry: What Have We Learned? Gut Liver 2021; 14:699-706. [PMID: 32036644 PMCID: PMC7667932 DOI: 10.5009/gnl19233] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Revised: 10/01/2019] [Accepted: 10/24/2019] [Indexed: 12/15/2022] Open
Abstract
In 2007, the first associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) procedure was performed in Regensburg, Germany. ALPPS is a variation of two-stage hepatectomy to induce rapid liver hypertrophy allowing the removal of large tumors otherwise considered irresectable due to a too small future liver remnant. In 2012, the international ALPPS registry was created, and it now contains more than 1,000 cases. During the past years, improved patient selection and refinements in operative techniques, in particular, less invasive approaches such as Partial ALPPS, Tourniquet ALPPS, Ablation-assisted ALPPS, Hybrid ALPPS or Laparoscopic or Robotic approaches, have resulted in significant improvements in safety. The most frequent indication for ALPPS is colorectal liver metastases. In the first randomized controlled study, ALPPS provided a higher resectability rate than conventional two-stage hepatectomy, with similar complication rates. Long-term outcome data are still missing. The initial results of ALPPS for hepatocellular carcinoma and for perihilar cholangiocarcinoma were devastating, but with progress in surgical technic and better patient selection, ALPPS could serve as a treatment alternative in carefully selected cases, even for these tumors. ALPPS has enlarged the armamentarium of hepato-pancreato-biliary surgeons, but there is still discussion regarding how to use this novel technique, which may allow resection of tumors that are otherwise deemed irresectable.
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Affiliation(s)
- Hauke Lang
- Department of General, Visceral, and Transplant Surgery, University Medical Center, Mainz, Germany
| | - Janine Baumgart
- Department of General, Visceral, and Transplant Surgery, University Medical Center, Mainz, Germany
| | - Jens Mittler
- Department of General, Visceral, and Transplant Surgery, University Medical Center, Mainz, Germany
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Liver Venous Deprivation (LVD) or Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy (ALPPS)?: A Retrospective Multicentric Study. Ann Surg 2021; 274:874-880. [PMID: 34334642 DOI: 10.1097/sla.0000000000005121] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To compare two techniques of remnant liver hypertrophy in candidates for extended hepatectomy: radiological simultaneous portal vein (PVE) and hepatic vein embolization (HVE); namely liver venous deprivation (LVD), and ALPPS. SUMMARY BACKGROUND DATA Recent advances in chemotherapy and surgical techniques have widened indications for extended hepatectomy, before which remnant liver augmentation is mandatory. ALPPS and LVD typically show higher hypertrophy rates than PVE, but their respective places in patient management remain unclear. METHODS All consecutive ALPPS and LVD procedures performed in eight French centers between 2011 and 2020 were included. The main endpoint was the successful resection rate (resection rate without 90-day mortality) analyzed according to an intention-to-treat principle. Secondary endpoints were hypertrophy rates, intra- and post-operative outcomes. RESULTS Among 209 patients, 124 had LVD 37 [13,1015] days before surgery, while 85 underwent ALPPS with an inter-stages period of 10 [6, 69] days. ALPPS was mostly-performed for colorectal liver metastases (CRLM), LVD for CRLM and perihilar cholangiocarcinoma. Hypertrophy was faster for ALPPS. Successful resection rates were 72.6% for LVD ± rescue ALPPS (n=6) versus 90.6% for ALPPS (p<0.001). Operative duration, blood losses and length-of-stay were lower for LVD, while 90-day major complications and mortality were comparable. Results were globally unchanged for CRLM patients, or after excluding the early 2 years of experience (learning-curve effect). CONCLUSIONS This study is the first one comparing LVD versus ALPPS in the largest cohort so far. Despite its retrospective design, it yields original results that may serve as the basis for a prospective study.
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Lai Q, Mennini G, Larghi Laureiro Z, Rossi M. Uncommon indications for associating liver partition and portal vein ligation for staged hepatectomy: a systematic review. Hepatobiliary Surg Nutr 2021; 10:210-225. [PMID: 33898561 DOI: 10.21037/hbsn-20-355] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) represents an innovative surgical technique used for the treatment of large hepatic lesions at high risk for post-resection liver failure due to a small future liver remnant. The most significant amount of literature concerns the use of ALPPS for the treatment of hepatocellular carcinoma (HCC), cholangiocarcinoma (CCC), and colorectal liver metastases (CRLM). On the opposite, few is known about the role of ALPPS for the treatment of uncommon liver pathologies. The objective of the present study was to evaluate the current literature on this topic. A systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Eligible articles published up to February 2020 were included using the MEDLINE, Scopus, and Cochrane databases. Among the 486 articles screened, 45 papers met the inclusion criteria, with 136 described cases of ALPPS for rare indications. These 136 cases were reported in 18 different countries. Only in two countries, namely Germany and Brazil, more than ten cases were observed. As for the ALPPS indications, we reported 41 (30.1%) cases of neuroendocrine tumor (NET) metastases, followed by 27 (19.9%) cases of gallbladder cancer (GBC), nine (6.6%) pediatric cases, six (4.4%) gastrointestinal stromal tumors, six (4.4%) adult cases of benign primary liver disease, four (2.9%) adult cases of malignant primary liver disease, and 43 (31.6%) adult cases of malignant secondary liver disease. According to the International ALPPS Registry data, less than 10% of the ALPPS procedures have been performed for the treatment of uncommon liver pathologies. NET and GBC are the unique pathologies with acceptable numerosity. ALPPS for NET appears to be a safe procedure, with satisfactory long-term results. On the opposite, the results observed for the treatment of GBC are poor. However, these data should be considered with caution. The rationale for treating benign pathologies with ALPPS appears to be weak. No definitive response should be given for all the other pathologies. Multicenter studies are needed with the intent to clarify the potentially beneficial effect of ALPPS for their treatment.
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Affiliation(s)
- Quirino Lai
- Hepatobiliary Surgery and Organ Transplantation Unit, Department of General Surgery and Organ Transplantation, Sapienza University of Rome, Rome, Italy
| | - Gianluca Mennini
- Hepatobiliary Surgery and Organ Transplantation Unit, Department of General Surgery and Organ Transplantation, Sapienza University of Rome, Rome, Italy
| | - Zoe Larghi Laureiro
- Hepatobiliary Surgery and Organ Transplantation Unit, Department of General Surgery and Organ Transplantation, Sapienza University of Rome, Rome, Italy
| | - Massimo Rossi
- Hepatobiliary Surgery and Organ Transplantation Unit, Department of General Surgery and Organ Transplantation, Sapienza University of Rome, Rome, Italy
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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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ALPPS Improves Survival Compared With TSH in Patients Affected of CRLM: Survival Analysis From the Randomized Controlled Trial LIGRO. Ann Surg 2021; 273:442-448. [PMID: 32049675 DOI: 10.1097/sla.0000000000003701] [Citation(s) in RCA: 58] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To evaluate the oncological outcome for patients with colorectal liver metastases (CRLM) randomized to associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) or 2-stage hepatectomy (TSH). BACKGROUND TSH with portal vein occlusion is an established method for patients with CRLM and a low volume of the future liver remnant (FLR). ALPPS is a less established method. The oncological outcome of these methods has not been previously compared in a randomized controlled trial. METHODS One hundred patients with CRLM and standardized FLR (sFLR) <30% were included and randomized to resection by ALPPS or TSH, with the option of rescue ALPPS in the TSH group, if the criteria for volume increase was not met. The first radiological follow-up was performed approximately 4 weeks postoperatively and then after 4, 8, 12, 18, and 24 months. At all the follow-ups, the remaining/recurrent tumor was noted. After the first follow-up, chemotherapy was administered, if indicated. RESULTS The resection rate, according to the intention-to-treat principle, was 92% (44 patients) for patients randomized to ALPPS compared with 80% (39 patients) for patients randomized to TSH (P = 0.091), including rescue ALPPS. At the first postoperative follow-up, 37 patients randomized to ALPPS were assessed as tumor free in the liver, and also 28 patients randomized to TSH (P = 0.028). The estimated median survival for patients randomized to ALPPS was 46 months compared with 26 months for patients randomized to TSH (P = 0.028). CONCLUSIONS ALPPS seems to improve survival in patients with CRLM and sFLR <30% compared with TSH.
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Modern therapeutic approaches for the treatment of malignant liver tumours. Nat Rev Gastroenterol Hepatol 2020; 17:755-772. [PMID: 32681074 DOI: 10.1038/s41575-020-0314-8] [Citation(s) in RCA: 102] [Impact Index Per Article: 25.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/05/2020] [Indexed: 02/06/2023]
Abstract
Malignant liver tumours include a wide range of primary and secondary tumours. Although surgery remains the mainstay of curative treatment, modern therapies integrate a variety of neoadjuvant and adjuvant strategies and have achieved dramatic improvements in survival. Extensive tumour loads, which have traditionally been considered unresectable, are now amenable to curative treatment through systemic conversion chemotherapies followed by a variety of interventions such as augmentation of the healthy liver through portal vein occlusion, staged surgeries or ablation modalities. Liver transplantation is established in selected patients with hepatocellular carcinoma but is now emerging as a promising option in many other types of tumour such as perihilar cholangiocarcinomas, neuroendocrine or colorectal liver metastases. In this Review, we summarize the available therapies for the treatment of malignant liver tumours, with an emphasis on surgical and ablative approaches and how they align with other therapies such as modern anticancer drugs or radiotherapy. In addition, we describe three complex case studies of patients with malignant liver tumours. Finally, we discuss the outlook for future treatment, including personalized approaches based on molecular tumour subtyping, response to targeted drugs, novel biomarkers and precision surgery adapted to the specific tumour.
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Guiu B, Quenet F, Panaro F, Piron L, Cassinotto C, Herrerro A, Souche FR, Hermida M, Pierredon-Foulongne MA, Belgour A, Aho-Glele S, Deshayes E. Liver venous deprivation versus portal vein embolization before major hepatectomy: future liver remnant volumetric and functional changes. Hepatobiliary Surg Nutr 2020; 9:564-576. [PMID: 33163507 DOI: 10.21037/hbsn.2020.02.06] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Background We previously showed that embolization of portal inflow and hepatic vein (HV) outflow (liver venous deprivation, LVD) promotes future liver remnant (FLR) volume (FLR-V) and function (FLR-F) gain. Here, we compared FLR-V and FLR-F changes after portal vein embolization (PVE) and LVD. Methods This study included all patients referred for liver preparation before major hepatectomy over 26 months. Exclusion criteria were: unavailable baseline/follow-up imaging, cirrhosis, Klatskin tumor, two-stage hepatectomy. 99mTc-mebrofenin SPECT-CT was performed at baseline and at day 7, 14 and 21 after PVE or LVD. FLR-V and FLR-F variations were compared using multivariate generalized linear mixed models (joint modelling) with/without missing data imputation. Results Baseline FLR-F was lower in the LVD (n=29) than PVE group (n=22) (P<0.001). Technical success was 100% in both groups without any major complication. Changes in FLR-V at day 14 and 21 (+14.2% vs. +50%, P=0.002; and +18.6% vs. +52.6%, P=0.001), and in FLR-F at day 7, 14 and 21 (+23.1% vs. +54.3%, P=0.02; +17.6% vs. +56.1%, P=0.006; and +29.8% vs. +63.9%, P<0.001) differed between PVE and LVD group. LVD (P=0.009), age (P=0.027) and baseline FLR-V (P=0.001) independently predicted FLR-V variations, whereas only LVD (P=0.01) predicted FLR-F changes. After missing data handling, LVD remained an independent predictor of FLR-V and FLR-F variations. Conclusions LVD is safe and provides greater FLR-V and FLR-F increase than PVE. These results are now evaluated in the HYPERLIV-01 multicenter randomized trial.
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Affiliation(s)
- Boris Guiu
- Department of Radiology, St-Eloi University Hospital, Montpellier, France
| | - François Quenet
- Department of Surgery, Institut du Cancer de Montpellier (ICM), Montpellier, France
| | - Fabrizio Panaro
- Department of Surgery, St-Eloi University Hospital, Montpellier, France
| | - Lauranne Piron
- Department of Radiology, St-Eloi University Hospital, Montpellier, France
| | | | - Astrid Herrerro
- Department of Surgery, St-Eloi University Hospital, Montpellier, France
| | | | - Margaux Hermida
- Department of Radiology, St-Eloi University Hospital, Montpellier, France
| | | | - Ali Belgour
- Department of Radiology, St-Eloi University Hospital, Montpellier, France
| | - Serge Aho-Glele
- Department of Epidemiology, Dijon University Hospital, Dijon, France
| | - Emmanuel Deshayes
- Department of Nuclear Medicine, Institut de Recherche en Cancérologie de Montpellier (IRCM), INSERM U1194, Montpellier, France
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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: 23] [Impact Index Per Article: 5.8] [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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Starlinger P, Luyendyk JP, Groeneveld DJ. Hemostasis and Liver Regeneration. Semin Thromb Hemost 2020; 46:735-742. [PMID: 32906177 DOI: 10.1055/s-0040-1715450] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The liver is unique in its remarkable regenerative capacity, which enables the use of liver resection as a treatment for specific liver diseases, including removal of neoplastic liver disease. After resection, the remaining liver tissue (i.e, liver remnant) regenerates to maintain normal hepatic function. In experimental settings as well as patients, removal of up to two-thirds of the liver mass stimulates a rapid and highly coordinated process resulting in the regeneration of the remaining liver. Mechanisms controlling the initiation and termination of regeneration continue to be discovered, and many of the fundamental signaling pathways controlling the proliferation of liver parenchymal cells (i.e., hepatocytes) have been uncovered. Interestingly, while hemostatic complications (i.e., bleeding and thrombosis) are primarily thought of as a complication of surgery itself, strong evidence suggests that components of the hemostatic system are, in fact, powerful drivers of liver regeneration. This review focuses on the clinical and translational evidence supporting a link between the hemostatic system and liver regeneration, and the mechanisms whereby the hemostatic system directs liver regeneration discovered using experimental settings.
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Affiliation(s)
- Patrick Starlinger
- Department of Surgery, Vienna General Hospital, Medical University of Vienna, Vienna, Austria.,Department of Surgery, Mayo Clinic, Rochester, Minnesota
| | - James P Luyendyk
- Department of Pathobiology and Diagnostic Investigation, Michigan State University, East Lansing, Michigan
| | - Dafna J Groeneveld
- Department of Pathobiology and Diagnostic Investigation, Michigan State University, East Lansing, Michigan
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Zhang L, Yang Z, Zhang S, Wang W, Zheng S. Conventional Two-Stage Hepatectomy or Associating Liver Partitioning and Portal Vein Ligation for Staged Hepatectomy for Colorectal Liver Metastases? A Systematic Review and Meta-Analysis. Front Oncol 2020; 10:1391. [PMID: 32974141 PMCID: PMC7471772 DOI: 10.3389/fonc.2020.01391] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Accepted: 07/01/2020] [Indexed: 12/14/2022] Open
Abstract
Background: Pushing the surgical limits for initially unresectable colorectal liver metastases (CRLM) are two approaches for sequential liver resection: two-stage hepatectomy (TSH) and associating liver partitioning and portal vein ligation for staged hepatectomy (ALPPS). However, the role of each treatment modality remains ill-defined. The present meta-analysis was designed to compare the safety, efficacy, and oncological benefits between ALPPS and TSH in the management of advanced CRLM. Methods: A systematic literature search was conducted from online databases through to February 2020. Single-arm synthesis and cumulative meta-analysis were performed. Results: Eight studies were included, providing a total of 409 subjects for analysis (ALPPS: N = 161; TSH: N = 248). The completions of the second stage of the hepatectomy [98 vs. 78%, odds ratio (OR) 5.75, p < 0.001] and R0 resection (66 vs. 37%; OR 4.68; p < 0.001) were more frequent in patients receiving ALPPS than in those receiving TSH, and the waiting interval was dramatically shortened in ALPPS (11.6 vs. 45.7 days, weighted mean difference = −35.3 days, p < 0.001). Nevertheless, the rate of minor complications was significantly higher in ALPPS (59 vs. 18%, OR 6.5, p < 0.001) than in TSH. The two treatments were similar in 90-day mortality (7 vs. 5%, p = 0.43), major complications (29 vs. 22%, p = 0.08), posthepatectomy liver failure (PHLF; 9 vs. 9%, p = 0.3), biliary leakage (11 vs. 14%, p = 0.86), length of hospital stay (27.95 vs. 26.88 days, p = 0.8), 1-year overall survival (79 vs. 84%, p = 0.61), 1-year recurrence (49 vs. 39%, p = 0.32), and 1-year disease-free survival (34 vs. 39%, p = 0.66). Cumulative meta-analyses indicated chronological stability for the pooled effect sizes of resection rate, 90-day mortality, major complications, and PHLF. Conclusions: Compared with TSH, ALPPS for advanced CRLM resulted in superior surgical efficacy with comparable perioperative mortality rate and short-term oncological outcomes, while this was at the cost of increased perioperative minor complications.
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Affiliation(s)
- Liang Zhang
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, School of Medicine, The First Affiliated Hospital, Zhejiang University, Hangzhou, China
- NHC Key Laboratory of Combined Multi-Organ Transplantation, Key Laboratory of the Diagnosis and Treatment of Organ Transplantation, CAMS, Hangzhou, China
| | - Zhentao Yang
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, School of Medicine, The First Affiliated Hospital, Zhejiang University, Hangzhou, China
- NHC Key Laboratory of Combined Multi-Organ Transplantation, Key Laboratory of the Diagnosis and Treatment of Organ Transplantation, CAMS, Hangzhou, China
| | - Shiyu Zhang
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, School of Medicine, The First Affiliated Hospital, Zhejiang University, Hangzhou, China
- NHC Key Laboratory of Combined Multi-Organ Transplantation, Key Laboratory of the Diagnosis and Treatment of Organ Transplantation, CAMS, Hangzhou, China
| | - Wenchao Wang
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, School of Medicine, The First Affiliated Hospital, Zhejiang University, Hangzhou, China
- NHC Key Laboratory of Combined Multi-Organ Transplantation, Key Laboratory of the Diagnosis and Treatment of Organ Transplantation, CAMS, Hangzhou, China
| | - Shusen Zheng
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, School of Medicine, The First Affiliated Hospital, Zhejiang University, Hangzhou, China
- NHC Key Laboratory of Combined Multi-Organ Transplantation, Key Laboratory of the Diagnosis and Treatment of Organ Transplantation, CAMS, Hangzhou, China
- *Correspondence: Shusen Zheng
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First Long-term Oncologic Results of the ALPPS Procedure in a Large Cohort of Patients With Colorectal Liver Metastases. Ann Surg 2020; 272:793-800. [DOI: 10.1097/sla.0000000000004330] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Hernandez-Alejandro R, Ruffolo LI, Alikhanov R, Björnsson B, Torres OJM, Serrablo A. Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy (ALPPS) procedure for colorectal liver metastasis. Int J Surg 2020; 82S:103-108. [PMID: 32305531 DOI: 10.1016/j.ijsu.2020.04.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 03/24/2020] [Accepted: 04/01/2020] [Indexed: 12/24/2022]
Abstract
Since first described, Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy (ALPPS) has garnered boisterous praise and fervent criticism. Its rapid adoption and employment for a variety of indications resulted in high perioperative morbidity and mortality. However recent risk stratification, refinement of technique to reduce the impact of stage I and progression along the learning curve have resulted in improved outcomes. The first randomized trial comparing ALPPS to two stage hepatectomy (TSH) for colorectal liver metastases (CRLM) was recently published demonstrating comparable perioperative morbidity and mortality with improved resectability and survival following ALPPS. In this review, as ALPPS enters the thirteenth year since conception, the current status of this contentious two stage technique is presented and best practices for deployment in the treatment of CRLM is codified.
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Affiliation(s)
- Roberto Hernandez-Alejandro
- Department of Surgery and Division of Abdominal Transplantation and Hepatobiliary Surgery, University of Rochester Medical Center, Rochester, USA.
| | - Luis I Ruffolo
- Department of Surgery and Division of Abdominal Transplantation and Hepatobiliary Surgery, University of Rochester Medical Center, Rochester, USA
| | - Ruslan Alikhanov
- Department of Liver and Pancreatic Surgery, Clinical Research Center of Moscow, Moscow, Russia
| | - Bergthor Björnsson
- Department of Surgery in Linköping, And Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Orlando Jorge M Torres
- Department of Gastrointestinal Surgery, Hepatopancreatobiliary Unit, University Hospital and School of Medicine, Federal University of Maranhão, São Luís, Brazil
| | - Alejandro Serrablo
- Division of Surgery, Miguel Servet University Hospital and University of Zaragoza School of Medicine, Zaragoza, Spain
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Abstract
BACKGROUND Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) has gained both interest and controversy, as an alternative to portal vein embolisation (PVE) by inducing future liver remnant hypertrophy in patients at risk of liver failure following major hepatectomy. Open ALPPS induces more extensive hypertrophy in a shorter timespan than PVE; however, it is also associated with higher complication rates and mortality. Minimally invasive surgery (MIS), with its known benefits, has been applied to ALPPS in the hope of reducing the surgical insult and improving functional recovery time while preserving the extensive FLR hypertrophy. METHODS A search of the PubMed, Medline, EMBASE and Cochrane Library databases was conducted on 10 July 2019. 1231 studies were identified and screened. 19 open ALPPS studies, 3 MIS ALPPS and 1 study reporting on both were included in the analysis. RESULTS 1088 open and 46 MIS-ALPPS cases were included in the analysis. There were significant differences in the baseline characteristic: open ALPPS patients had a more diverse profile of underlying pathologies (p = 0.028) and comparatively more right extended hepatectomies (p = 0.006) as compared to right hepatectomy and left extended hepatectomy performed. Operative parameters (time and blood loss) did not differ between the two groups. MIS ALPPS had a lower rate of severe Clavien-Dindo complications (≥ IIIa) following stage 1 (p = 0.063) and significantly lower median mortality (0.00% vs 8.45%) (p = 0.007) compared to open ALPPS. CONCLUSION Although MIS ALPPS would seem to be better than open ALPPS with reduced morbidity and mortality rates, there is still limited evidence on MIS ALPPS. There is a need for a higher quality of evidence on MIS ALPPS vs. open ALPPS to answer whether MIS ALPPS can replace open ALPPS.
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Lehwald-Tywuschik N, Vaghiri S, Schulte Am Esch J, Alaghmand S, Klosterkemper Y, Schimmöller L, Lachenmayer A, Ashmawy H, Krieg A, Topp SA, Rehders A, Knoefel WT. In situ split plus portal vein ligation (ISLT) - a salvage procedure following inefficient portal vein embolization to gain adequate future liver remnant volume prior to extended liver resection. BMC Surg 2020; 20:63. [PMID: 32252737 PMCID: PMC7333278 DOI: 10.1186/s12893-020-00721-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Accepted: 03/23/2020] [Indexed: 02/07/2023] Open
Abstract
Background Right extended liver resection is frequently required to achieve tumor-free margins. Portal venous embolization (PVE) of the prospective resected hepatic segments for conditioning segments II/III does not always induce adequate hypertrophy in segments II and III (future liver remnant volume (FLRV)) for extended right-resection. Here, we present the technique of in situ split dissection along segments II/III plus portal disruption to segments IV-VIII (ISLT) as a salvage procedure to overcome inadequate gain of FLRV after PVE. Methods In eight patients, FLRV was further pre-conditioned following failed PVE prior to hepatectomy (ISLT-group). We compared FLRV changes in the ISLT group with patients receiving extended right hepatectomy following sufficient PVE (PVEres-group). Survival of the ISLT-group was compared to PVEres patients and PVE patients with insufficient FLRV gain or tumor progress who did not receive further surgery (PVEnores-group). Results Patient characteristics and surgical outcome were comparable in both groups. The mean FLRV-to-body-weight ratio in the ISLT group was smaller than in the PVEres-group pre- and post-PVE. One intraoperative mortality due to a coronary infarction was observed for an ISLT patient. ISLT was successfully completed in the remaining seven ISLT patients. Liver function and 2-year survival of ~ 50% was comparable to patients with extended right hepatectomy after efficient PVE. Patients who received a PVE but who were not subsequently resected (PVEnores) demonstrated no survival beyond 4 months. Conclusion Despite extended embolization of segments I and IV-VIII, ISLT should be considered if hypertrophy was not adequate. Liver function and overall survival after ISLT was comparable to patients with trisectionectomy after efficient PVE.
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Affiliation(s)
- Nadja Lehwald-Tywuschik
- Department of Surgery A, University Hospital Duesseldorf, Duesseldorf, Germany.,Department of General, Visceral, Thorax and Pediatric Surgery,Heinrich-Heine-University Hospital, Moorenstr. 5, 40225, Duesseldorf, Germany
| | - Sascha Vaghiri
- Department of Surgery A, University Hospital Duesseldorf, Duesseldorf, Germany.,Department of General, Visceral, Thorax and Pediatric Surgery,Heinrich-Heine-University Hospital, Moorenstr. 5, 40225, Duesseldorf, Germany
| | - Jan Schulte Am Esch
- Present address: Center of Visceral Medicine, Department of Visceral Surgery, Protestant Hospital of Bethel Foundation, Bielefeld, Germany
| | - Salman Alaghmand
- Department of Surgery A, University Hospital Duesseldorf, Duesseldorf, Germany
| | - Yan Klosterkemper
- Department of Diagnostic and Interventional Radiology, University Hospital Duesseldorf, Duesseldorf, Germany
| | - Lars Schimmöller
- Department of Diagnostic and Interventional Radiology, University Hospital Duesseldorf, Duesseldorf, Germany
| | - Anja Lachenmayer
- Present ccaddress: Department of Visceral Surgery and Medicine, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Hany Ashmawy
- Department of Surgery A, University Hospital Duesseldorf, Duesseldorf, Germany.,Department of General, Visceral, Thorax and Pediatric Surgery,Heinrich-Heine-University Hospital, Moorenstr. 5, 40225, Duesseldorf, Germany
| | - Andreas Krieg
- Department of Surgery A, University Hospital Duesseldorf, Duesseldorf, Germany.,Department of General, Visceral, Thorax and Pediatric Surgery,Heinrich-Heine-University Hospital, Moorenstr. 5, 40225, Duesseldorf, Germany
| | - Stefan A Topp
- Present address: Department of Surgery, Ameos Hospital, Bremerhaven, Germany
| | - Alexander Rehders
- Department of Surgery A, University Hospital Duesseldorf, Duesseldorf, Germany.,Department of General, Visceral, Thorax and Pediatric Surgery,Heinrich-Heine-University Hospital, Moorenstr. 5, 40225, Duesseldorf, Germany
| | - Wolfram Trudo Knoefel
- Department of Surgery A, University Hospital Duesseldorf, Duesseldorf, Germany. .,Department of General, Visceral, Thorax and Pediatric Surgery,Heinrich-Heine-University Hospital, Moorenstr. 5, 40225, Duesseldorf, Germany.
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Rassam F, Olthof PB, van Lienden KP, Bennink RJ, Erdmann JI, Swijnenburg RJ, Busch OR, Besselink MG, van Gulik TM. Comparison of functional and volumetric increase of the future remnant liver and postoperative outcomes after portal vein embolization and complete or partial associating liver partition and portal vein ligation for staged hepatectomy (ALPPS). ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:436. [PMID: 32395480 PMCID: PMC7210209 DOI: 10.21037/atm.2020.03.191] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Background Portal vein embolization (PVE) is performed to induce hypertrophy of an insufficient future remnant liver (FRL) before major liver resection. Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) aims to offer a more rapid and increased hypertrophy response. The first stage can be performed with complete or partial (laparoscopic) transection of the liver parenchyma. This study aimed to investigate the increase in FRL volume and function, as well as postoperative outcomes after PVE or complete- or partial-ALPPS1. Methods Patients with insufficient FRL undergoing either PVE or ALPPS underwent CT-volumetry and functional assessment using 99mTc-mebrofenin hepatobiliary scintigraphy (HBS). Severe complications and 90-day mortality were evaluated after liver resection. Results Seventy-two patients were included; 51 underwent PVE, 12 complete-ALPPS1 and 9 partial-ALPPS1 of which 7 laparoscopic. The median increase in FRL function was 1.5-, 1.7- and 1.3-fold higher, respectively, than the increase in volume; (P<0.01, P<0.01 and P=0.44). The target hypertrophy response did not differ between the groups, but was reached earlier in both ALPPS1 groups (8 and 10 days) compared to the PVE group (23 days). Of the resected patients, 18%, 30% and 17% had severe postoperative complications and the 90-day mortality was 2%, 25% and 0%, respectively. Conclusions Increase of FRL function exceeded increase of volume after both PVE and ALPPS1. The target hypertrophy response was reached earlier in ALPPS. Complete and partial-ALPPS1 showed comparable functional and volumetric hypertrophy responses. A (laparoscopic) partial-ALPPS1 is preferred considering lower morbidity and mortality rates after resection.
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Affiliation(s)
- Fadi Rassam
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, The Netherlands
| | - Pim B Olthof
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, The Netherlands
| | - Krijn P van Lienden
- Departments of Radiology and Nuclear Medicine, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, The Netherlands
| | - Roel J Bennink
- Departments of Radiology and Nuclear Medicine, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, The Netherlands
| | - Joris I Erdmann
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, The Netherlands
| | - Rutger-Jan Swijnenburg
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, The Netherlands
| | - Olivier R Busch
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, The Netherlands
| | - Marc G Besselink
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, The Netherlands
| | - Thomas M van Gulik
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, The Netherlands
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Linecker M, Kambakamba P, Raptis DA, Malagó M, Ratti F, Aldrighetti L, Robles-Campos R, Lehwald-Tywuschik N, Knoefel WT, Balci D, Ardiles V, De Santibañes E, Truant S, Pruvot FR, Stavrou GA, Oldhafer KJ, Voskanyan S, Mahadevappa B, Kozyrin I, Low JK, Ferrri V, Vicente E, Prachalias A, Pizanias M, Clift AK, Petrowsky H, Clavien PA, Frilling A. ALPPS in neuroendocrine liver metastases not amenable for conventional resection - lessons learned from an interim analysis of the International ALPPS Registry. HPB (Oxford) 2020; 22:537-544. [PMID: 31540885 DOI: 10.1016/j.hpb.2019.08.011] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Revised: 07/10/2019] [Accepted: 08/15/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Surgery is the most effective treatment option for neuroendocrine liver metastases (NELM). This study investigated the role of associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) as a novel strategy in treatment of NELM. METHODS The International ALPPS Registry was reviewed to study patients who underwent ALPPS for NELM. RESULTS From 2010 to 2017, 954 ALPPS procedures from 135 international centers were recorded in the International ALPPS Registry. Of them, 24 (2.5%) were performed for NELM. Twenty-one patients entered the final analysis. Overall grade ≥3b morbidity was 9% after stage 1 and 27% after stage 2. Ninety-day mortality was 5%. R0 resection was achieved in 19 cases (90%) at stage 2. Median follow-up was 28 (19-48) months. Median disease free survival (DFS) was 17.3 (95% CI: 7.1-27.4) months, 1-year and 2-year DFS was 73.2% and 41.8%, respectively. Median overall survival (OS) was not reached. One-year and 2-year OS was 95.2% and 95.2%, respectively. CONCLUSIONS ALPPS appears to be a suitable strategy for inclusion in the multimodal armamentarium of well-selected patients with neuroendocrine liver metastases. In light of the morbidity in this initial series and a high rate of disease-recurrence, the procedure should be taken with caution.
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Affiliation(s)
- Michael Linecker
- Swiss HPB and Transplantation Center, Department of Surgery, University Hospital Zurich, Switzerland
| | - Patryk Kambakamba
- Swiss HPB and Transplantation Center, Department of Surgery, University Hospital Zurich, Switzerland
| | - Dimitri A Raptis
- Department of HPB- and Liver Transplantation Surgery, University College London, Royal Free Hospitals, London, UK
| | - Massimo Malagó
- Department of HPB- and Liver Transplantation Surgery, University College London, Royal Free Hospitals, London, UK
| | - Francesca Ratti
- Hepatobiliary Surgery Division, Department of Surgery, IRCCS San Raffaele Hospital, School of Medicine, Milan, Italy
| | - Luca Aldrighetti
- Hepatobiliary Surgery Division, Department of Surgery, IRCCS San Raffaele Hospital, School of Medicine, Milan, Italy
| | - Ricardo Robles-Campos
- Department of Surgery and Liver and Pancreas Transplantation, Virgen de la Arrixaca Clinic and University Hospital, IMIB-Arrixaca, Murcia, Spain
| | | | - Wolfram T Knoefel
- Department of Surgery, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Deniz Balci
- Department of Surgery, Ankara University, Ankara, Turkey
| | - 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
| | - 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
| | - Gregor A Stavrou
- Department of General and Abdominal Surgery, Asklepios Hospital Barmbek, Hamburg, Germany; Semmelweis University Budapest, Campus Hamburg, Germany
| | - Karl J Oldhafer
- Department of General and Abdominal Surgery, Asklepios Hospital Barmbek, Hamburg, Germany; Semmelweis University Budapest, Campus Hamburg, Germany
| | - Sergey Voskanyan
- Department of Surgery, A.I. Burnazyan FMBC Russian State Scientific Center of FMBA, Moscow, Russia
| | - Basant Mahadevappa
- Department of HPB and Liver Transplantation, HCG Hospitals, Bangalore, India
| | - Ivan Kozyrin
- Department of Thoracic and Abdominal Surgery and Oncology, Clinical Hospital #1 MEDSI, Moscow, Russia
| | - Jee K Low
- Department of Surgery, Tan Tock Seng Hospital, Singapore, Singapore
| | - Valentina Ferrri
- General Surgery Department, Madrid Norte Sanchinarro San Pablo University Hospital, Madrid, Spain
| | - Emilio Vicente
- General Surgery Department, Madrid Norte Sanchinarro San Pablo University Hospital, Madrid, Spain
| | | | | | - Ashley K Clift
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Henrik Petrowsky
- Swiss HPB and Transplantation Center, Department of Surgery, University Hospital Zurich, Switzerland
| | - Pierre-Alain Clavien
- Swiss HPB and Transplantation Center, Department of Surgery, University Hospital Zurich, Switzerland
| | - Andrea Frilling
- Department of Surgery and Cancer, Imperial College London, London, UK.
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Balci D, Kirimker EO, Üstüner E, Yilmaz AA, Azap A. Stage I-laparoscopy partial ALPPS procedure for perihilar cholangiocarcinoma. J Surg Oncol 2020; 121:1022-1026. [PMID: 32068265 DOI: 10.1002/jso.25868] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Accepted: 02/07/2020] [Indexed: 12/12/2022]
Abstract
The treatment for perihilar cholangiocarcinoma (PHC) is a challenge for the surgeon requiring complex resections with a reported perioperative mortality rate between 15% and 48%. In PHC patients with future liver remnant (FLR) less than 30%, it is advised that hepatectomy can be safely performed after the FLR is modified. Associating Liver Partition and Portal vein ligation for Staged Hepatectomy (ALPPS) procedure is criticized heavily due to its high morbidity and mortality rate in this setting. Hereby, we are reporting a modification of ALPPS procedure for PHC. Clinical presentation, preoperative work-up as well as operation and postoperative course of two cases were described in detail. Both patients were jaundiced preoperatively, stage 1 partial-ALPPS procedures were performed laparoscopically, there was sufficient remnant hypertrophy during the interval stage and there was no posthepatectomy liver failure after the second stage (Supporting Information Video). We have followed patients with a mean follow up of 35 months without any recurrence. Here we describe the key technical aspects of this approach that are discussed in three parts: minimally invasive first stage, biliary drainage of both FLR, and deportalized liver at first stage and biliary reconstruction at the second stage. This technique, in selected patients, can extend the indication of ALPPS procedure for PHC with preoperative jaundice.
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Affiliation(s)
- Deniz Balci
- Department of Surgery, Ankara University School of Medicine, Ankara, Turkey
| | | | - Evren Üstüner
- Department of Radiology, Ankara University School of Medicine, Ankara, Turkey
| | - Ali Abbas Yilmaz
- Department of Anesthesiology, Ankara University School of Medicine, Ankara, Turkey
| | - Alpay Azap
- Department of Infectious Disease, Ankara University School of Medicine, Ankara, Turkey
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Björnsson B, Hasselgren K, Røsok B, Larsen PN, Urdzik J, Schultz NA, Carling U, Fallentin E, Gilg S, Sandström P, Lindell G, Sparrelid E. Segment 4 occlusion in portal vein embolization increase future liver remnant hypertrophy - A Scandinavian cohort study. Int J Surg 2020; 75:60-65. [PMID: 32001330 DOI: 10.1016/j.ijsu.2020.01.129] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Accepted: 01/20/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND The additional value of including segment 4 (S4) portal branches in right portal vein embolization (rPVE) is debated. The aim of the study was to explore this in a large multicenter cohort. MATERIAL AND METHODS A retrospective cohort study consisting of all patients subjected to rPVE from August 2012 to May 2017 at six Scandinavian university hospitals. PVE technique was essentially the same in all centers, except for the selection of main embolizing agent (particles or glue). All centers used coils or particles to embolize S4 branches. A subgroup analysis was performed after excluding patients with parts of or whole S4 included in the future liver remnant (FLR). RESULTS 232 patients were included in the study, of which 36 received embolization of the portal branches to S4 in addition to rPVE. The two groups (rPVE vs rPVE + S4) were similar (gender, age, co-morbidity, diagnosis, neoadjuvant chemotherapy, bilirubin levels prior to PVE and embolizing material), except for diabetes mellitus which was more frequent in the rPVE + S4 group (p = 0.02). Pre-PVE FLR was smaller in the S4 group (333 vs 380 ml, p = 0.01). rPVE + S4 resulted in a greater percentage increase of the FLR size compared to rPVE alone (47 vs 38%, p = 0.02). A subgroup analysis, excluding all patients with S4 included in the FLR, was done. There was no longer a difference in pre-PVE FLR between groups (333 vs 325 ml, p = 0.9), but still a greater percentage increase and also absolute increase of the FLR in the rPVE + S4 group (48 vs 38% and 155 vs 112 ml, p = 0.01 and 0.02). CONCLUSION In this large multicenter cohort study, additional embolization of S4 did demonstrate superior growth of the FLR compared to standard right PVE.
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Affiliation(s)
- Bergthor Björnsson
- Department of Surgery and Clinical and Experimental Medicine, Linköping University, Sweden
| | - Kristina Hasselgren
- Department of Surgery and Clinical and Experimental Medicine, Linköping University, Sweden
| | - Bård Røsok
- Department of Hepato-Pancreato-Biliary Surgery, Oslo University Hospital, Norway
| | - Peter Noergaard Larsen
- Department of Surgical Gastroenterology and Transplantation, Rigshospitalet, University of Copenhagen, Denmark
| | - Jozef Urdzik
- Department of Surgery, Uppsala University Hospital, University of Uppsala, Sweden
| | - Nicolai A Schultz
- Department of Surgical Gastroenterology and Transplantation, Rigshospitalet, University of Copenhagen, Denmark
| | - Ulrik Carling
- Department of Radiology, Oslo University Hospital, Norway
| | - Eva Fallentin
- Department of Radiology and Nuclear Medicine, Rigshospitalet, University of Copenhagen, Denmark
| | - Stefan Gilg
- Department of Clinical Science, Intervention and Technology, Division of Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Per Sandström
- Department of Surgery and Clinical and Experimental Medicine, Linköping University, Sweden
| | - Gert Lindell
- Department of Surgery, Skåne University Hospital, Lund University, Sweden
| | - Ernesto Sparrelid
- Department of Clinical Science, Intervention and Technology, Division of Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden.
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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: 0.8] [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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Jouffret L, Ewald J, Marchese U, Garnier J, Gilabert M, Mokart D, Piana G, Delpero JR, Turrini O. Is progression in the future liver remnant a contraindication for second-stage hepatectomy? HPB (Oxford) 2019; 21:1478-1484. [PMID: 30962135 DOI: 10.1016/j.hpb.2019.03.357] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Revised: 02/25/2019] [Accepted: 03/10/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Two-stage hepatectomy (TSH) strategy is used to treat patients with bilobar colorectal liver metastasis (CLM). However, many patients do not undergo the second hepatectomy owing to disease progression in the future liver remnant (FLR) after portal vein embolization (PVE). This study aimed to assess the impact of disease progression in the FLRs of patients who completed the first hepatectomy. METHODS 68 consecutive patients underwent the first hepatectomy followed by PVE. Six patients (9%) dropped out after the PVE (two-stage failed [TSF] group) because of unresectable hepatic or general disease progression. Seventeen patients (25%) completed their second hepatectomy despite disease progression in the FLR (new CLM [nCLM] group) as it was considered resectable, while 45 patients (66%) underwent the second hepatectomy (control group). RESULTS The 5-year overall survival rates in the TSF, nCLM, and control groups were 0%, 7%, and 60%, respectively (P < 0.001). The median overall survival times between the TSF and nCLM groups were 26 months and 42 months (P = 0.005). Patients in the nCLM group whose hepatic disease progression was detected preoperatively versus intraoperatively had comparable survival rates. CONCLUSION Resectable hepatic disease progression in the FLR after PVE should not be considered a contraindication for the second hepatectomy.
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Affiliation(s)
- Lionel Jouffret
- Department of Surgery, Institut Paoli-Calmettes, Marseille, France.
| | - Jacques Ewald
- Department of Surgery, Institut Paoli-Calmettes, Marseille, France
| | - Ugo Marchese
- Department of Surgery, Institut Paoli-Calmettes, Marseille, France
| | - Jonathan Garnier
- Department of Surgery, Institut Paoli-Calmettes, Marseille, France
| | - Marine Gilabert
- Aix-Marseille University, Institut Paoli-Calmettes, Department of Oncology, CNRS, Inserm, CRCM, Marseille, France
| | - Djamel Mokart
- Department of Reanimation, Institut Paoli-Calmettes, Marseille, France
| | - Gilles Piana
- Department of Radiology, Institut Paoli-Calmettes, Marseille, France
| | | | - Olivier Turrini
- Aix-Marseille University, Institut Paoli-Calmettes, Department of Surgery, CNRS, Inserm, CRCM, Marseille, France
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40
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Affiliation(s)
- Hauke Lang
- Department of General, Visceral, and Transplant Surgery, University Medical Center, Mainz, Germany.
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41
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Abstract
OBJECTIVE Associating Liver Partition and Portal vein ligation for Staged hepatectomy (ALPPS) has been tested in various indications and clinical scenarios, leading to steady improvements in safety. This report presents the current status of ALPPS. SUMMARY BACKGROUND DATA ALPPS offers improved resectability, but drawbacks are regularly pointed out regarding safety and oncologic benefits. METHODS During the 12th biennial congress of the European African-Hepato-Pancreato-Biliary Association (Mainz, Germany, May 23-26, 2017) an expert meeting "10th anniversary of ALPP" was held to discuss indications, management, mechanisms of regeneration, as well as pitfalls of this novel technique. The aim of the meeting was to make an inventory of what has been achieved and what remains unclear in ALPPS. RESULTS Precise knowledge of liver anatomy and its variations is paramount for success in ALPPS. Technical modifications, mainly less invasive approaches like partial, mini- or laparoscopic ALPPS, mostly aiming at minimizing the extensiveness of the first-stage procedure, are associated with improved safety. In fibrotic/cirrhotic livers the degree of future liver remnant hypertrophy after ALPPS appears some less than that in noncirrhotic. Recent data from the only prospective randomized controlled trial confirmed significant higher resection rates in ALPPS with similar peri-operative morbidity and mortality rates compared with conventional 2-stage hepatectomy including portal vein embolization. ALPPS is effective reliably even after failure of portal vein embolization. CONCLUSIONS Although ALPPS is now an established 2-stage hepatectomy additional data are warranted to further refine indication and technical aspects. Long-term oncological outcome results are needed to establish the place of ALPPS in patients with initially nonresectable liver tumors.
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42
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Esposito F, Lim C, Lahat E, Shwaartz C, Eshkenazy R, Salloum C, Azoulay D. Combined hepatic and portal vein embolization as preparation for major hepatectomy: a systematic review. HPB (Oxford) 2019; 21:1099-1106. [PMID: 30926329 DOI: 10.1016/j.hpb.2019.02.023] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Revised: 02/12/2019] [Accepted: 02/18/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Some patients remain deemed unsuitable for resection after portal vein embolization (PVE) because of insufficient hypertrophy of the future remnant liver (FRL). Hepatic and portal vein embolization (HPVE) has been shown to induce hypertrophy of the FRL. The aim of this study was to provide a systematic review of the available literature on HPVE as preparation for major hepatectomy. METHODS The literature search was performed on online databases. Studies including patients who underwent preoperative HPVE were retrieved for evaluation. RESULTS Six articles including 68 patients were published between 2003 and 2017. HPVE was performed successfully in all patients with no mortality and morbidity-related procedures. The degree of hypertrophy of the FRL after HPVE ranged from 33% to 63.3%. Surgical resection after preoperative HPVE could be performed in 85.3% of patients, but 14.7% remained unsuitable for resection because of insufficient hypertrophy of the FRL or tumor progression. Posthepatectomy morbidity and mortality rates were 10.3% and 5.1%, respectively. The postoperative liver failure rate was nil. CONCLUSION HPVE as a preparation for major hepatectomy appears to be feasible and safe and could increase the resectability of patients initially deemed unsuitable for resection because of absent or insufficient hypertrophy of the FRL after PVE alone.
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Affiliation(s)
- Francesco Esposito
- Department of Hepatobiliary and Pancreatic Surgery and Liver Transplantation, Henri Mondor Hospital, Créteil, France
| | - Chetana Lim
- Department of Hepatobiliary and Pancreatic Surgery and Liver Transplantation, Henri Mondor Hospital, Créteil, France
| | - Eylon Lahat
- Department of Hepatobiliary and Pancreatic Surgery and Liver Transplantation, Henri Mondor Hospital, Créteil, France; Department of General Surgery and Transplantation, Sheba Medical Center, Faculty of Medicine, Tel Aviv University, Israel
| | - Chaya Shwaartz
- Department of General Surgery and Transplantation, Sheba Medical Center, Faculty of Medicine, Tel Aviv University, Israel
| | - Rony Eshkenazy
- Department of General Surgery and Transplantation, Sheba Medical Center, Faculty of Medicine, Tel Aviv University, Israel
| | - Chady Salloum
- Department of Hepatobiliary and Pancreatic Surgery and Liver Transplantation, Henri Mondor Hospital, Créteil, France; Department of Hepatobiliary and Pancreatic Surgery and Liver Transplantation, Paul Brousse Hospital, Villejuif, France
| | - Daniel Azoulay
- Department of Hepatobiliary and Pancreatic Surgery and Liver Transplantation, Henri Mondor Hospital, Créteil, France; Department of General Surgery and Transplantation, Sheba Medical Center, Faculty of Medicine, Tel Aviv University, Israel; Department of Hepatobiliary and Pancreatic Surgery and Liver Transplantation, Paul Brousse Hospital, Villejuif, France.
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43
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Schlegel A, Sakuraoka Y, Kalisvaart M, Coldham C, Isaac J, Muiesan P. Future liver remnant portal or hepatic vein reconstruction at stage I of ALPPS-How far can we push the boundaries? J Surg Oncol 2019; 120:654-660. [PMID: 31309549 DOI: 10.1002/jso.25618] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Accepted: 06/21/2019] [Indexed: 12/12/2022]
Abstract
Preservation of the future liver remnant (FLR) vascular integrity has always been considered crucial to achieving successful liver growths after major hepatectomies. Most surgeons appeared therefore reluctant to combine stage I of associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) with vascular reconstructions. Here we describe a case series, where we combine parenchymal transection and venous in- or outflow reconstruction of the FLR at stage I of ALPPS. In addition, the cold flush of the FLR or delayed portal vein embolization is applied in selected cases.
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Affiliation(s)
- Andrea Schlegel
- The Liver Unit, Queen Elizabeth Hospital Birmingham, University of Birmingham, Birmingham, United Kingdom.,NIHR Liver Biomedical Research Unit, University Hospitals Birmingham, Birmingham, United Kingdom
| | - Yuhki Sakuraoka
- The Liver Unit, Queen Elizabeth Hospital Birmingham, University of Birmingham, Birmingham, United Kingdom.,Second Department of Surgery, Dokkyo Medical University, Tokyo, Japan
| | - Marit Kalisvaart
- The Liver Unit, Queen Elizabeth Hospital Birmingham, University of Birmingham, Birmingham, United Kingdom
| | - Chris Coldham
- The Liver Unit, Queen Elizabeth Hospital Birmingham, University of Birmingham, Birmingham, United Kingdom
| | - John Isaac
- The Liver Unit, Queen Elizabeth Hospital Birmingham, University of Birmingham, Birmingham, United Kingdom
| | - Paolo Muiesan
- The Liver Unit, Queen Elizabeth Hospital Birmingham, University of Birmingham, Birmingham, United Kingdom.,Department of Liver Surgery, Birmingham Children's Hospital NHS Foundation Trust, Birmingham, United Kingdom
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44
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Huiskens J, Schadde E, Lang H, Malago M, Petrowsky H, de Santibañes E, Oldhafer K, van Gulik TM, Olthof PB. Avoiding postoperative mortality after ALPPS-development of a tumor-specific risk score for colorectal liver metastases. HPB (Oxford) 2019; 21:898-905. [PMID: 30611560 DOI: 10.1016/j.hpb.2018.11.010] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Revised: 11/07/2018] [Accepted: 11/18/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND ALPPS is a two-stage hepatectomy that induces more rapid liver growth compared to conventional strategies. This report aims to establish a risk-score to avoid adverse outcomes of ALPPS only for patients with colorectal liver metastases (CRLM) as primary indication for ALPPS. METHODS All patients with CRLM included in the ALPPS registry were included. Risk score analysis was performed for 90-day mortality after ALPPS, defined as death within 90 days after either stage. Two risk scores were generated i.e. one for application before stage-1, and one for application before stage-2. Logistic regression analysis was performed to establish the risk-score. RESULTS In total, 486 patients were included, of which 35 (7%) died 90 days after stage-1 or 2. In the stage-1 risk score, age ≥67 years (OR 3.7), FLR/BW ratio <0.40 (OR 2.9) and total center-volume (OR 2.4) were included. For the stage-2 score age ≥67 years (OR 3.7), FLR/BW ratio <0.40 (OR 2.8), bilirubin 5 days after stage-1 >50 μmol/L (OR 2.4), and stage-1 morbidity grade IIIA or higher (OR 6.3) were included. CONCLUSIONS The CRLM risk-score to predict mortality after ALPPS demonstrates that older patients with small remnant livers in inexperienced centers, especially after experiencing morbidity after stage-1 have adverse outcomes. The risk score may be used to restrict ALPPS to low-risk patient populations.
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Affiliation(s)
- Joost Huiskens
- Department of Experimental Surgery, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands; Department of Surgery, Erasmus Medical Center, Erasmus University, Rotterdam, the Netherlands
| | - Erik Schadde
- Department of Surgery, Division of Transplantation, Rush University Medical Center, Chicago, IL, United States; Cantonal Hospital Winterthur, Kanton, Zurich, Switzerland; Institute of Physiology, Center for Integrative Human Physiology, University of Zurich, Zurich, Switzerland
| | - Hauke Lang
- Department of General, Visceral and Transplant Surgery, Universitaetsmedizin Mainz, Mainz, Germany
| | - Massimo Malago
- Department of HPB and Liver Transplantation Surgery, University College London, Royal Free Hospitals, London, UK
| | - Henrik Petrowsky
- Swiss HPB and Transplantation Center, Department of Surgery, University Hospital Zurich, Zurich, Switzerland
| | | | - Karl Oldhafer
- Department of General & Abdominal Surgery, Asklepios Hospital Barmbek, Semmelweis University of Medicine, Germany
| | - Thomas M van Gulik
- Department of Experimental Surgery, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Pim B Olthof
- Department of Experimental Surgery, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands; Department of Surgery, Reinier de Graaf Gasthuis, Delft, the Netherlands.
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45
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Albati NA, Korairi AA, Al Hasan I, Almodhaiberi HK, Algarni AA. Outcomes of staged hepatectomies for liver malignancy. World J Hepatol 2019; 11:513-521. [PMID: 31293719 PMCID: PMC6603508 DOI: 10.4254/wjh.v11.i6.513] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2019] [Revised: 05/27/2019] [Accepted: 06/18/2019] [Indexed: 02/06/2023] Open
Abstract
Liver malignancies are the fifth most common cause of death worldwide. Surgical intervention with curative intent is the treatment of choice for liver tumors as it provides long-term survival. However, only 20% of patients with metastatic liver lesions can be managed by curative liver resection. In most of the cases, hepatectomy is not feasible because of insufficient future liver remnant (FLR). Two-stage hepatectomy is advocated to achieve liver resection in a patient who is considered to not be a candidate for resection. Procedures of staged hepatectomy include conventional two-stage hepatectomy, portal vein embolization, and associating liver partition and portal vein ligation for a staged hepatectomy. Technical success is high for each of these procedures but variable between them. All the procedures have been reported as being effective in achieving a satisfactory FLR and completing the second-stage resection. Moreover, the overall survival and disease-free survival rates have improved significantly for patients who were otherwise considered nonresectable; yet, an increase in the morbidity and mortality rates has been observed. We suggest that this type of procedure should be carried out in high-flow centers and through a multidisciplinary approach. An experienced surgeon is key to the success of those interventions.
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Affiliation(s)
- Naif A Albati
- Hepatobiliary and Liver Transplant Unit, Department of General Surgery, Prince Sultan Military Medical City, Riyadh 11159, Saudi Arabia
| | - Ali A Korairi
- Hepatobiliary and Liver Transplant Unit, Department of General Surgery, Prince Sultan Military Medical City, Riyadh 11159, Saudi Arabia
| | - Ibrahim Al Hasan
- Hepatobiliary and Liver Transplant Unit, Department of General Surgery, Prince Sultan Military Medical City, Riyadh 11159, Saudi Arabia
| | - Helayel K Almodhaiberi
- Hepatobiliary and Liver Transplant Unit, Department of General Surgery, Prince Sultan Military Medical City, Riyadh 11159, Saudi Arabia
| | - Abdullah A Algarni
- Hepatobiliary and Liver Transplant Unit, Department of General Surgery, Prince Sultan Military Medical City, Riyadh 11159, Saudi Arabia
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Linecker M, Kuemmerli C, Kambakamba P, Schlegel A, Muiesan P, Capobianco I, Nadalin S, Torres OJ, Mehrabi A, Stavrou GA, Oldhafer KJ, Lurje G, Balci D, Lang H, Robles-Campos R, Hernandez-Alejandro R, Malago M, De Santibanes E, Clavien PA, Petrowsky H. Performance validation of the ALPPS risk model. HPB (Oxford) 2019; 21:711-721. [PMID: 30477898 DOI: 10.1016/j.hpb.2018.10.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Revised: 09/27/2018] [Accepted: 10/03/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Based on the International ALPPS registry, we have recently proposed two easily applicable risk models (pre-stage1 and 2) for predicting 90-day mortality in ALPPS but a validation of both models has not been performed yet. METHODS The validation cohort (VC) was composed of subsequent cases of the ALPPS registry and cases of centers outside the ALPPS registry. RESULTS The VC was composed of a total of 258 patients including 70 patients outside the ALPPS registry with 32 cases of early mortalities (12%). Development cohort (DC) and VC were comparable in terms of patient and surgery characteristics. The VC validated both models with an acceptable prediction for the pre-stage 1 (c-statistic 0.64, P = 0.009 vs. 0.77, P < 0.001) and a good prediction for the pre-stage 2 model (c-statistic 0.77, P < 0.001 vs. 0.85, P < 0.001) as compared to the DC. Overall model performance measured by Brier score was comparable between VC and DC for the pre-stage 1 (0.089 vs. 0.081) and pre-stage 2 model (0.079 vs. 0087). CONCLUSION The ALPPS risk score is a fully validated model to estimate the individual risk of patients undergoing ALPPS and to assist clinical decision making to avoid procedure-related early mortality after ALPPS.
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Affiliation(s)
- Michael Linecker
- Swiss HPB and Transplantation Center, Department of Surgery, University Hospital Zurich, Switzerland
| | - Christoph Kuemmerli
- Swiss HPB and Transplantation Center, Department of Surgery, University Hospital Zurich, Switzerland
| | - Patryk Kambakamba
- Swiss HPB and Transplantation Center, Department of Surgery, University Hospital Zurich, Switzerland
| | - Andrea Schlegel
- Liver Unit, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Paolo Muiesan
- Liver Unit, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Ivan Capobianco
- Department of General, Visceral and Transplant Surgery, University Hospital Tübingen, Tübingen, Germany
| | - Silvio Nadalin
- Department of General, Visceral and Transplant Surgery, University Hospital Tübingen, Tübingen, Germany
| | - Orlando J Torres
- Department of Surgery, Universidade Federal do Maranhão, Sao Luis, MA, Brazil
| | - Arianeb Mehrabi
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Gregor A Stavrou
- Department of Abdominal, Thoracic and Pediatric Surgery, Saarbruecken General Hospital, Saarbruecken; Semmelweis University, Budapest, Campus Hamburg, Germany
| | - Karl J Oldhafer
- Semmelweis University, Budapest, Campus Hamburg, Germany; Department of General and Abdominal Surgery, Asklepios Hospital Barmbek, Hamburg, Germany
| | - Georg Lurje
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen, Germany
| | - Deniz Balci
- Department of Surgery, Ankara University, Ankara, Turkey
| | - Hauke Lang
- Department of General, Visceral, and Transplant Surgery, Universitatsmedizin Mainz, Mainz, Germany
| | - Ricardo Robles-Campos
- Department of Surgery and Liver and Pancreas Transplantation, Virgen de la Arrixaca Clinic and University Hospital, Murcia, Spain
| | - Roberto Hernandez-Alejandro
- Department of Surgery, Division of HPB Surgery and Liver Transplantation, London Health Sciences Centre, London, Ontario, Canada; Division of Transplantation, Hepatobiliary Surgery, University of Rochester, Rochester, USA
| | - Massimo Malago
- Department of HPB- and Liver Transplantation Surgery, University College London, Royal Free Hospitals, London, UK
| | - Eduardo De Santibanes
- Department of Surgery, Division of HPB Surgery, Liver Transplant Unit, Italian Hospital Buenos Aires, Argentina
| | - Pierre-Alain Clavien
- Swiss HPB and Transplantation Center, Department of Surgery, University Hospital Zurich, Switzerland
| | - Henrik Petrowsky
- Swiss HPB and Transplantation Center, Department of Surgery, University Hospital Zurich, Switzerland.
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47
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Linecker M, Kuemmerli C, Clavien PA, Petrowsky H. Dealing with insufficient liver remnant: Associating liver partition and portal vein ligation for staged hepatectomy. J Surg Oncol 2019; 119:604-612. [PMID: 30847941 DOI: 10.1002/jso.25435] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2019] [Revised: 02/16/2019] [Accepted: 02/18/2019] [Indexed: 12/12/2022]
Abstract
Liver resection for colorectal liver metastases has emerged to highly successful treatment in the last decades. Key to this success is complete hepatic tumor removal and systemic disease control by chemotherapy. Associating liver partition and portal vein ligation for staged hepatectomy is the most recent two-stage resection strategy for patients with very small future liver remnant making complete tumor removal possible within 1 to 2 weeks. Oncological outcome data are being collected at the moment and first results from small series reveal promising results.
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Affiliation(s)
- Michael Linecker
- Department of Surgery and Transplantation, Swiss HPB and Transplantation Center, University Hospital Zürich, Zürich, Switzerland
| | - Christoph Kuemmerli
- Department of Surgery and Transplantation, Swiss HPB and Transplantation Center, University Hospital Zürich, Zürich, Switzerland
| | - Pierre-Alain Clavien
- Department of Surgery and Transplantation, Swiss HPB and Transplantation Center, University Hospital Zürich, Zürich, Switzerland
| | - Henrik Petrowsky
- Department of Surgery and Transplantation, Swiss HPB and Transplantation Center, University Hospital Zürich, Zürich, Switzerland
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48
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Yamazaki S, Takayama T. Current topics in liver surgery. Ann Gastroenterol Surg 2019; 3:146-159. [PMID: 30923784 PMCID: PMC6422805 DOI: 10.1002/ags3.12233] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Revised: 11/02/2018] [Accepted: 12/04/2018] [Indexed: 01/01/2023] Open
Abstract
Liver resection is one of the main treatment strategies for liver malignancies. Mortality and morbidity of liver surgery has improved significantly with progress in selection criteria, development of operative procedures and improvements in perioperative management. Safe liver resection has thus become more available worldwide. We have identified four current topics related to liver resection (anatomical liver resection, laparoscopic liver resection, staged liver resection and chemotherapy-induced liver injury). The balance between treatment effect and patient safety needs to be considered when planning liver resection. Progress in this area has been rapid thanks to the efforts of many surgeons, and outcomes have improved significantly as a result. These topics remain to be solved and more robust evidence is needed. Precise selection of the optimal procedure and risk evaluation should be standardized with further development of each topic. The present article reviews these four current topics with a focus on safety and efficacy in recent series.
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Affiliation(s)
- Shintaro Yamazaki
- Department of Digestive SurgeryNihon University School of MedicineTokyoJapan
| | - Tadatoshi Takayama
- Department of Digestive SurgeryNihon University School of MedicineTokyoJapan
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49
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Brustia R, Monsel A, Conti F, Savier E, Rousseau G, Perdigao F, Bernard D, Eyraud D, Loncar Y, Langeron O, Scatton O. Enhanced Recovery in Liver Transplantation: A Feasibility Study. World J Surg 2019; 43:230-241. [PMID: 30094639 DOI: 10.1007/s00268-018-4747-y] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Enhanced Recovery After Surgery (ERAS) programmes after surgery are effective in reducing length of stay, functional recovery and complication rates in liver surgery (LS) with the indirect advantage of reducing hospitalisation costs. Preoperative comorbidities, challenging surgical procedures and complex post-operative management are the points that liver transplantation (LT) shares with LS. Nevertheless, there is little evidence regarding the feasibility and safety of ERAS programmes in LT. METHODS We designed a pilot, small-scale, feasibility study to assess the impact on hospital stay, protocol compliance and safety of an ERAS programme tailored for LT. The ERAS arm was compared with a 1:2 match paired control arm with similar characteristics. All patients with MELD <25 were included. A dedicated LT-tailored protocol was derived from publications on ERAS liver surgery. RESULTS Ten patients were included in the Fast-Trans arm. It was observed a 47% reduction of the total LOS, as compared to the control arm: 9.5 (9.0-10.5) days versus 18.0 (14.3-24.3) days, respectively, p <0.001. The protocol achieved 72.9% compliance. No differences were observed in terms of post-operative complications or readmission rates after discharge between the two arms. Overall, it was observed a reduction of length of stay in ICU and surgical ward in the Fast-Trans arm compared with the control arm. CONCLUSION Considered the main points in common between LS and LT, this small-scale study suggests that the application of an ERAS programme tailored to the LT setting is feasible. Further testing will be appropriate to generalise these findings.
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Affiliation(s)
- Raffaele Brustia
- Liver Transplantation Surgical Programme and Hepatobiliary Surgical Department, Hôpital de la Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, 47-83 Boulevard de l'Hôpital, Paris, France.,Sorbonne Universités, Paris, France
| | - Antoine Monsel
- Multidisciplinary Intensive Care Unit, Department of Anaesthesiology and Critical Care, Hôpital de la Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France.,Sorbonne Universités, Paris, France
| | - Filomena Conti
- Liver Transplantation and Hepatology Department, Hôpital de la Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, 47-83 Boulevard de l'Hôpital, Paris, 75013, France.,Sorbonne Universités, Paris, France
| | - Eric Savier
- Liver Transplantation Surgical Programme and Hepatobiliary Surgical Department, Hôpital de la Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, 47-83 Boulevard de l'Hôpital, Paris, France
| | - Geraldine Rousseau
- Liver Transplantation Surgical Programme and Hepatobiliary Surgical Department, Hôpital de la Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, 47-83 Boulevard de l'Hôpital, Paris, France.,Sorbonne Universités, Paris, France
| | - Fabiano Perdigao
- Liver Transplantation Surgical Programme and Hepatobiliary Surgical Department, Hôpital de la Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, 47-83 Boulevard de l'Hôpital, Paris, France
| | - Denis Bernard
- Multidisciplinary Intensive Care Unit, Department of Anaesthesiology and Critical Care, Hôpital de la Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Daniel Eyraud
- Multidisciplinary Intensive Care Unit, Department of Anaesthesiology and Critical Care, Hôpital de la Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Yann Loncar
- Multidisciplinary Intensive Care Unit, Department of Anaesthesiology and Critical Care, Hôpital de la Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Olivier Langeron
- Multidisciplinary Intensive Care Unit, Department of Anaesthesiology and Critical Care, Hôpital de la Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France.,Sorbonne Universités, Paris, France
| | - Olivier Scatton
- Liver Transplantation Surgical Programme and Hepatobiliary Surgical Department, Hôpital de la Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, 47-83 Boulevard de l'Hôpital, Paris, France. .,Sorbonne Universités, Paris, France.
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50
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Truant S, El Amrani M, Baillet C, Ploquin A, Lecolle K, Ernst O, Hebbar M, Huglo D, Pruvot FR. Laparoscopic Partial ALPPS: Much Better Than ALPPS! Ann Hepatol 2019; 18:269-273. [PMID: 31113604 DOI: 10.5604/01.3001.0012.7937] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Accepted: 04/20/2018] [Indexed: 02/04/2023]
Abstract
Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy (ALPPS) has emerged as an alternative for patients with bilobar colorectal liver metastasis deemed unresectable due to inadequate future remnant liver (FRL). Nevertheless, high morbidity and mortality rates have been reported. In this setting, including hepatobiliary scintigraphy in the clinical and surgical management of patients offered ALPPS has been advocated to both assess eligibility for ALPPS stagel and suitable time for ALPPS stage2. Recently, it was stated that partial ALPPS with a liver split restricted to 50% of the transection line (or up to the middle hepatic vein in case of right extended hepatectomy) and a shortened stagel allows improving the postoperative course without precluding the inter-stages FRL hypertrophy. We describe a case series of p-ALPPS with stagel performed laparoscopically, including sequential assessments of the FRL volumes and functions via pre-stagel and pre-stage2 computed tomography volumetry and HIDA SPECT-scintigraphy. In five patients, laparoscopic p-ALPPS was associated with rapid and significant gain of remnant functional volume - much better than previously observed for ALPPS - facilitating early stage2 without inflammatory adherences. In conclusion, laparoscopic p-ALPPS is feasible and seems less aggressive than the original ALPPS technique with total transection. It may be an interesting alternative to the classical portal vein embolization (PVE) and two-stage hepatectomy strategy.
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Affiliation(s)
- Stéphanie Truant
- Department of Digestive Surgery and Transplantation, Huriez Hospital, University of Lille, France.
| | - Mehdi El Amrani
- Department of Digestive Surgery and Transplantation, Huriez Hospital, University of Lille, France
| | - Clio Baillet
- Department of Nuclear Medicine, Huriez Hospital, University of Lille, France
| | - Anne Ploquin
- Department of Medical Oncology, Huriez Hospital, University of Lille, France
| | - Katia Lecolle
- Department of Digestive Surgery and Transplantation, Huriez Hospital, University of Lille, France
| | - Olivier Ernst
- Department of Radiology, Huriez Hospital, University of Lille, France
| | - Mohamed Hebbar
- Department of Medical Oncology, Huriez Hospital, University of Lille, France
| | - Damien Huglo
- Department of Nuclear Medicine, Huriez Hospital, University of Lille, France
| | - François-René Pruvot
- Department of Digestive Surgery and Transplantation, Huriez Hospital, University of Lille, France
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