Monosegment ALPPS hepatectomy: Extending resectability by rapid hypertrophy

Conversion treatment for advanced intrahepatic cholangiocarcinoma: Opportunities and challenges

The prevalence of intrahepatic cholangiocarcinoma (ICC) is increasing globally. Despite advancements in comprehending this intricate malignancy and formulating novel therapeutic approaches over the past few decades, the prognosis for ICC remains poor. Owing to the high degree of malignancy and insidious onset of ICC, numerous cases are detected at intermediate or advanced stages of the disease, hence eliminating the chance for surgical intervention. Moreover, because of the highly invasive characteristics of ICC, recurrence and metastasis postresection are prevalent, leading to a 5-year survival rate of only 20%-35% following surgery. In the past decade, different methods of treatment have been investigated, including transarterial chemoembolization, transarterial radioembolization, radiotherapy, systemic therapy, and combination therapies. For certain patients with advanced ICC, conversion treatment may be utilized to facilitate surgical resection and manage disease progression. This review summarizes the definition of downstaging conversion treatment and presents the clinical experience and evidence concerning conversion treatment for advanced ICC.

Extended Right Hepatectomy following Clearance of the Left Liver Lobe and Portal Vein Embolization for Curatively Intended Treatment of Extensive Bilobar Colorectal Liver Metastases: A Single-Center Case Series

BACKGROUND

Two-staged hepatectomy (TSH) including portal vein embolization (PVE) may offer surgical treatment for extensive bilobar colorectal liver metastases (CRLM). This study aimed to investigate the feasibility and outcomes of extended right hepatectomy (ERH) within TSH including PVE for patients with extended CRLM.

METHODS

We retrospectively collected data of patients who underwent TSH for extended CRLM between 2015 and 2021 at our institution. Clearance of the left liver lobe (clear-up, CU) associated with PVE was followed by ERH.

RESULTS

Minimally invasive (n = 12, 46%, MIH) or open hepatectomy (n = 14, 54%, OH) was performed. Postoperative major morbidity and 90-day mortality were 54% and 0%. Three-year overall survival was 95%. Baseline characteristics, postoperative and long-term outcomes were comparable between MIH and OH. However, hospital stay was significantly shorter after MIH (8 vs. 15 days, p = 0.008). Additionally, the need for intraoperative transfusions tended to be lower in the MIH group (17% vs. 50%, p = 0.110).

CONCLUSIONS

ERH following CU and PVE for extended CRLM is feasible and safe in laparoscopic and open approaches. MIH for ERH may result in shorter postoperative hospital stays. Further high-volume, multicenter studies are required to evaluate the potential superiority of MIH.

Extreme hepatectomy with modified ALPPS in a rat model: gradual portal vein restriction associated with hepatic artery restriction

BACKGROUND & AIM

Associating liver partition and portal vein ligation (PVL) for staged hepatectomy (ALPPS) is a creative strategy for enlarging the future liver remnant (FLR) and increasing the tumor resectability rate. However, the indications for ALPPS must have a certain limit when the FLR is too small. We aimed to establish a modified ALPPS model with more widen applicability in rats.

METHODS

An extreme ALPPS model was established in rodents with only a 6.5% FLR. The portal vein (PV) was subjected to restriction to different degrees, then the portal vein pressure (PVP) was measured. Then, different modifications of ALPPS, including hepatic artery restriction (HAR), gradual portal vein restriction (GPVR), and GPVR-associated HAR (HAR+GPVR), were applied in the extreme ALPPS models.

RESULTS

PVL or PVR provoked an immediate increase in the PVP. The PVP in the PVR -1.28 mm, PVR -0.81 mm, PVR -0.63 mm, and PVL groups was 11.05±1.57 cmH2O, 16.18±1.92 cmH2O, 20.66±1.99 cmH2O, and 24.10±3.33 cmH2O, respectively, and the corresponding 3-day survival rate was 100%, 90.09%, 36.33% and 0, respectively. Then, in the extreme ALPPS model, the growth ratio of the FLR in the control, HAR, GPVR, and HAR+GPVR groups was 0.43±0.21, 0.50±0.16, 4.80±0.86, and 7.40±2.56, and as a consequence, the corresponding 30-day survival rate was 9.09%, 15.38%, 84.61% and 92.90%, respectively.

CONCLUSION

ALPPS itself has a limit, and high PVP after PVL contributes to postoperative death in the extreme ALPPS model. Furthermore, a modified method for extreme ALPPS is proposed, i.e., GPVR+HAR in place of PVL, which significantly improves the survival rate of extreme hepatectomy in rat models.

Pushing the Limits of Surgical Resection in Colorectal Liver Metastasis: How Far Can We Go?

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.

Pushing the limit of liver regeneration - Safety and survival after monosegment-ALPPS: systematic review and individual patient data meta-analysis

BACKGROUND

Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) has expanded and spearheaded development in hepatobiliary surgery. Monosegment-ALPPS tests liver regeneration limits and may present as the last feasible curative treatment option.

METHODS

Electronic databases (MEDLINE, Web of Science, Google Scholar, Cochrane Library and WHO International Clinical Trials Registry Platform) were searched for publications on mono-ALPPS using a predefined strategy without date or language restrictions. Individual patient data was extracted and analyzed.

RESULTS

237 publications were identified. 19 patients were identified to have undergone mono-ALPPS. Primarily, mono-ALPPS has been utilized as curative treatment for CRLM (17 of 19 cases). Successful mono-ALPPS was possible in FLR above 8% SLV. All patients received either chemotherapy alone or in combination with radiotherapy prior to surgery. 8 of 19 patients experienced PHLF grade A or B. There was no in-hospital mortality described. Recurrent disease has occurred in 7 of 19 patients and 3 have died during follow-up.

CONCLUSION

Mono-ALPPS is an experimental procedure that provides a reasonably safe opportunity to curatively treat extensive liver malignancies in patients with FLR as low as 8% SLV. PHLF is the most prevalent complication in mono-ALPPS. Mono-ALPPS should be evaluated in a multicentral study setting.

Monosegment associating liver partition and portal vein ligation for staged hepatectomy: Preserving segment 1 as the only liver remnant after hepatocellular carcinoma recurrence

Since the inception of the associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) procedure, many centres have used this technique for patients who would otherwise be considered unresectable due to insufficient future liver remnant. In this report, we presented the case of a paediatric patient with recurrent hepatocellular carcinoma who underwent monosegment ALPPS (M-ALPPS) hepatectomy preserving segment 1 as the sole liver remnant using indocyanine green (ICG) as a fluorescence guide.

Repeated hepatectomy after ALPPS for recurrence of colorectal liver metastasis: the edge of limits?

BACKGROUND

Repeated liver resections for the recurrence of colorectal liver metastasis (CRLM) are described as safe and have similar oncological outcomes compared to first hepatectomy. Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) is performed in patients with conventionally non-resectable CRLM. Repeated resections after ALPPS has not yet been described.

METHODS

Patients that underwent repeated liver resection in recurrence of CRLM after ALPPS were included in this study. The primary endpoint was morbidity and secondary endpoints were mortality, resection margin and survival.

RESULTS

Thirty patients were included in this study. During ALPPS, most of the patients had classical split (60%, n = 18) and clearance of the FLR (77%, n = 23). Hepatic recurrence was treated with non-anatomical resection (57%, n = 17), resection combined with local ablation (13%, n = 4), open ablation (13%, n = 4), segmentectomy (10%, n = 3) or subtotal segmentectomy (7%, n = 2). Six patients (20%) developed complications (10% minor complications). No post-hepatectomy liver failure or perioperative mortality was observed. One-year patient survival was 87%. Five patients received a third hepatectomy.

CONCLUSION

Repeated resections after ALPPS for CRLM in selected patients are safe and feasible with low morbidity and no mortality. Survival seems to be comparable with repeated resections after conventional hepatectomy.

Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) in colorectal liver metastases: review of the literature

The liver is considered as one of the most common sites of metastasis and a key determining factor of survival in patients with isolated colorectal liver metastasis (CRLM). For longer survival of patients, surgical resection is the only available option. Especially in CRLM bilobar patients, to achieve R0 resection, maintaining an adequate volume of the future liver remnant (FLR) is the main technical challenge to avoid post-hepatectomy liver failure (PHLF). As standard procedures in the treatment of patients with severe metastatic liver disease, techniques such as portal vein embolization/portal vein ligation (PVE/PVL) accompanied by two-stage hepatectomy (TSH) have been introduced. These methods, however, have drawbacks depending on the severity of the disease and the capacity of the patient to expand the liver remnant. Eventually, implementation of the novel ALPPS technique ignited excitement among the community of hepatobiliary surgeons because ALPPS challenged the idea of unrespectability and extended the limit of liver surgery and it was reported that FLR hypertrophy of up to 80% was induced in a shorter time than PVL or PVE. Nonetheless, ALPPS techniques caused serious concerns due to the associated high morbidity and mortality levels of up to 40% and 15% respectively, and PHLF and bile leak are critical morbidity- and mortality-related factors. Carefully establishing the associated risk factors of ALPPS has opened up a new dimension in the field of ALPPS technique for improved surgical outcome by carefully choosing patients. The benefit of ALPPS technique is enhanced when performed for young patients with very borderline remnant volume. Adopting ALPPS technical modifications such as middle hepatic vein preservation, surgical management of the hepatoduodenal ligament, the anterior approach and partial ALPPS may lead to the improvement of ALPPS surgical performance. Research findings to validate the translatability of ALPPS’ theoretical advantages into real survival benefits are scarce.

The role of associating liver partition and portal vein ligation for staged hepatectomy in the management of patients with colorectal liver metastasis

Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) approach emerged as a promising surgical strategy for rapid and large hypertrophy of the future liver remnant (FLR) when a major liver resection is necessary. Colorectal liver metastasis (CRLM) is their main indication. However, the promising results published so far, are very difficult to interpret since they usually focus on the technique and not on the underlying disease. Moreover, they are usually made up of complex populations, which received different chemotherapy schemes, with the ALPPS technical variations implemented over time and without consistent long-term follow-up results as well. Whereby, its role in CRLM should be analyzed as carefully as possible to indicate and select the best candidates who will benefit the most from this approach. We conducted a computerized search using PubMed and Google Scholar for reports published so far, using mesh headings and keywords related to the ALPPS and CRLM.

Monosegment ALPPS for bilateral colorectal liver metastasis - One is enough

Associated liver partition and portal vein ligation for staged hepatectomy – ALPPS – procedure emerged as an alternative to treat patients needing extensive hepatic resections, but with a small future liver remnant. Initially described using the left lateral segments as liver remnant, ALPPS has been adapted to leave as remainder only one segment. Describe a case of a patiente with bilobar colorectal liver metastasis submitted to segment 4-1 ALPPS. A 63-year-old man, previously submitted to transversostomy, due to a left colon stenosing adenocarcinoma, associated to bilobar liver metastasis, was referred for our evaluation, after receiving a FOLFOX based chemotherapy. Due to the large load of tumor within the liver, we opted to perform a segment 4-1 ALPPS, which was carried out with an interval of 21 days between first and second stages. The liver remnant increased from 250 cc to 694 cc (18% to 48% of standard liver volume). The patient was discharged 15 days after second stage surgery and was subjected to left colectomy after five months. He is disease-free ten months after liver surgery. Monosegment ALPPS is a challenging, but feasible procedure, that should be criteriously indicated in selected patients and performed by a hepatobiliary surgery team with experience in complex major hepatectomies.

Associated liver partition and portal vein ligation for staged hepatectomy: a review

Outcomes of liver resection have improved with advances in surgical techniques, improvements in critical care and expansion of resectability criteria. However, morbidity and mortality following liver resection continue to plague surgeons. Post-hepatectomy liver failure (PHLF) due to inadequate future liver remnant (FLR) is an important cause of morbidity and mortality following liver resection. Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) is a novel two-staged procedure described in 2012, which aims to induce rapid hypertrophy of the FLR unlike conventional two-stage hepatectomy, which require a longer time for FLR hypertrophy. Careful patient selection and modifications in surgical technique has improved morbidity and mortality rates in ALPPS. Colorectal liver metastases (CRLM) confers the best outcomes post-ALPPS. Patients <60 years old and low-grade fibrosis with underlying hepatocellular carcinoma (HCC) are also eligible for ALPPS. Evidence for other types of cancers is less promising. Current studies, though limited, demonstrate that ALPPS has comparable oncological outcomes with conventional two-stage hepatectomy. Modifications such as partial-ALPPS and mini-ALPPS have shown improved morbidity and mortality compared to classic ALPPS. ALPPS may be superior to conventional two-stage hepatectomy in carefully selected groups of patients and has a promising outlook in liver surgery.

ALPPS for Locally Advanced Intrahepatic Cholangiocarcinoma: Did Aggressive Surgery Lead to the Oncological Benefit? An International Multi-center Study

BACKGROUND

ALPPS is found to increase the resectability of primary and secondary liver malignancy at the advanced stage. The aim of the study was to verify the surgical and oncological outcome of ALPPS for intrahepatic cholangiocarcinoma (ICC).

METHODS

The study cohort was based on the ALPPS registry with patients from 31 international centers between August 2009 and January 2018. Propensity score matched patients receiving chemotherapy only were selected from the SEER database as controls for the survival analysis.

RESULTS

One hundred and two patients undergoing ALPPS were recruited, 99 completed the second stage with median inter-stage duration of 11 days. The median kinetic growth rate was 23 ml/day. R0 resection was achieved in 87 (85%). Initially high rates of morbidity and mortality decreased steadily to a 29% severe complication rate and 7% 90-day morbidity in the last 2 years. Post-hepatectomy liver failure remained the main cause of 90-day mortality. Multivariate analysis revealed insufficient future liver remnant at the stage-2 operation (FLR2) to be the only risk factor for severe complications (OR 2.91, p = 0.02). The propensity score matching analysis showed a superior overall survival in the ALPPS group compared to palliative chemotherapy (median overall survival: 26.4 months vs 14 months; 1-, 2-, and 3-year survival rates: 82.4%, 70.5% and 39.6% vs 51.2%, 21.4% and 11.3%, respectively, p < 0.01). The survival benefit, however, was not confirmed in the subgroup analysis for patients with insufficient FLR2 or multifocal ICC.

CONCLUSION

ALPPS showed high efficacy in achieving R0 resections in locally advanced ICC. To get the most oncological benefit from this aggressive surgery, ALPPS would be restricted to patients with single lesions and sufficient FLR2.

Future liver remnant portal or hepatic vein reconstruction at stage I of ALPPS-How far can we push the boundaries?

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.

Avoiding postoperative mortality after ALPPS-development of a tumor-specific risk score for colorectal liver metastases

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.

Outcomes of staged hepatectomies for liver malignancy

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.

Associating liver partition and portal vein ligation for staged hepatectomy: establishment of an animal model with insufficient liver remnant

Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) allows extended hepatectomy in patients with an extremely small future liver remnant (FLR). Current rodent models of ALPPS do not include resection resulting in insufficient-for-survival FLR, or they do incorporate liver mass reduction prior to ALPPS. Differences in FLR volume and surgical procedures could bias our understanding of physiological and hemodynamic mechanisms. We aimed to establish a rat ALPPS model with minimal FLR without prior parenchymal resection. In rodents, the left median lobe (LML) represents 10% of total liver. Partial hepatectomy (PHx) sparing LML and pericaval parenchyma represents our reference 87% resection. The first step in the procedure is either portal vein ligation (PVL) corresponding to ligation of all but the LML portal branches, or PVL with transection between the left and right median lobe segments (PVLT), and is defined as ALPPS stage-1. Second, ligated lobes were removed: PVL-PHx represents a conventional 2-stage hepatectomy, while PVLT followed by PHx is a strict reproduction of human ALPPS. In Group A, liver hypertrophy was analyzed after PVL (n = 38), PVLT (n = 47), T (n = 10), and sham (n = 10); In group B, mortality and FLR hypertrophy was assessed after PHx (n = 42), Sham-PHx (n = 6), PVL-PHx (n = 37), and PVLT-PHx (n = 45). In group A, PVLT induced rapid FLR hypertrophy compared to PVL (p < 0,05). Hepatocyte proliferation was higher in PVLT remnants (p < 0,05). In group B, PHx had a 5-day mortality rate of 84%. Sham operation prior to PHx did not improve survival (p = 0.23). In both groups, major fatalities occurred within 48 h after resection. PVL or PVLT prior to PHx reduced mortality to 33.3% (p = 0,007) or 25% (p = 0.0002) respectively, with no difference between the 2 two-stage procedures (p = 0.6). 7-day FLR hypertrophy was higher after the PVLT-PHx compared to PVL-PHx and PHx (p = 0.024). Our model reproduces human ALPPS with FLR that is insufficient for survival without liver resection prior to the stage-1 procedure. It offers an appropriate model for analyzing the mechanisms driving survival rescue and increased hypertrophy.

Monosegmental ALPPS: a long-term survival alternative to liver transplant in PRETEXT IV hepatoblastoma

A 3-year-old female was treated with neoadjuvant chemotherapy (NACT) for a PRETEXT IV hepatoblastoma. POST-TEXT IV findings merited a liver transplant (LT), but multiple limitations precluded it. The initial future liver remnant (FLR) was small (21.3%). Monosegment 6 ALPPS was a rational approach given that the inferior right hepatic vein (IRHV) provided adequate outflow. Therefore, the procedure was performed after parental informed consent. On PO15 of the first stage, FLR had reached 32.6% and then the second-stage was carried out. The patient was discharged on POD 31, and she is about to reach the 5-year disease-free survival milestone.

A systematic review and meta-analysis of associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) versus traditional staged hepatectomy

It is still controversial whether associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) or traditional staged hepatectomy such as portal vein embolization (PVE) and 2-staged hepatectomy (TSH) is better. The aim of this study was to compare these 3 available strategies in extended hepatectomy.Trials were identified by searching MEDLINE, PubMed, the Cochrane Library, and Embase and additional articles were identified by hand searching. Comparative clinical studies reporting volumetric changes, mortality, morbidity, and feasibility of the second stage about ALPPS versus PVE or ALPPS versus TSH were included.Nine studies involving 557 patients met the inclusion criteria. Five studies reported on comparison of ALPPS and PVE, and the other 4 reported about ALPPS and TSH. In the comparison of ALPPS versus traditional staged hepatectomy (PVE and TSH), ALPPS was associated with a greater increase in the future liver remnant (FLR) (RR: 4.87; 95%CI, 3.41-6.33) and more frequent completion of stage 2 resection (RR: 1.32; 95%CI, 1.21-1.44). Compared with the traditional staged hepatectomy, ALPPS had a trend toward higher morbidity (RR: 1.19, 95%CI, 0.96-1.47) and mortality (RR: 2.11, 95%CI, 1.02-4.33) after stage 2 resection.ALPPS is associated with greater future liver remnant hypertrophy and a higher rate of completion of stage 2, but this may be at the price of greater morbidity and mortality.

Simultaneous hepatic and portal vein ligation induces rapid liver hypertrophy: A study in pigs

BACKGROUND

Liver hypertrophy induced by partial portal vein occlusion (PVL) is accelerated by adding simultaneous parenchymal transection ("ALPPS procedure"). This preclinical experimental study in pigs tests the hypothesis that simultaneous ligation of portal and hepatic veins of the liver also accelerates regeneration by abrogation of porto-portal collaterals without need for operative transection.

METHODS

A pig model of portal vein occlusion was compared with the novel model of simultaneous portal and hepatic vein occlusion, where major hepatic veins draining the portal vein-deprived lobe were identified with intraoperative ultrasonography and ligated using pledgeted transparenchymal sutures. Kinetic growth was compared, and the portal vein system was then studied after 7 days using epoxy casts of the portal circulation. Portal vein flow and portal pressure were measured, and Ki-67 staining was used to evaluate the proliferative response.

RESULTS

Pigs were randomly assigned to portal vein occlusion (n = 8) or simultaneous portal and hepatic vein occlusion (n = 6). Simultaneous portal and hepatic vein occlusion was well tolerated and led to mild cytolysis, with no necrosis in the outflow vein-deprived liver sectors. The portal vein-supplied sector increased by 90 ± 22% (mean ± standard deviation) after simultaneous portal and hepatic vein occlusion compared with 29 ± 18% after PVL (P < .001). Collaterals to the deportalized liver developed after 7 days in both procedures but were markedly reduced in simultaneous portal and hepatic vein occlusion. Ki-67 staining at 7 days was comparable.

CONCLUSION

This study in pigs found that simultaneous portal and hepatic vein occlusion led to rapid hypertrophy without necrosis of the deportalized liver. The findings suggest that the use of simultaneous portal and hepatic vein occlusion accelerates liver hypertrophy for extended liver resections and should be evaluated further.

Functional and volumetric assessment of liver segments after portal vein embolization: Differences in hypertrophy response

BACKGROUND

Patients considered for liver resection with insufficient volume or function of the future remnant liver are candidates for portal vein embolization to allow safe resection. The aim of this study is to analyze the volumetric and functional responses after portal vein embolization and to evaluate predictors of the hypertrophy response.

METHODS

All patients who underwent portal vein embolization before liver resection 2006-2017 were included. Patients who did not undergo computed tomography-volumetry and functional assessment with technetium-99m mebrofenin hepatobiliary scintigraphy before and after portal vein embolization were excluded. The functional and volumetric response rates were calculated. Multiple regression analysis was conducted to examine the relationship between the hypertrophy response and potential predictors.

RESULTS

A total of 90 patients underwent portal vein embolization of the right liver. After 3 weeks, there was a significant increase in both volumetric and functional share of the future remnant liver (both P < .01). The increase in functional share exceeded the increase in volumetric share (P < .01). The median functional contribution of segment 4 after portal vein embolization was 41.5% (31.7%-48.7%) of the nonembolized lobe. Preoperative chemotherapy was not a significant predictor of the increase in function or volume. Compared with benign lesions, malignant diseases were significant negative predictors of the functional response.

CONCLUSION

A total of 3 weeks after portal vein embolization, the functional response exceeded that of the volumetric response, meaning that the waiting time to resection potentially can be decreased. Segment 4 had a significant share of both volume and function, enabling surgical strategies only leaving segment 4 as a monosegment. Neoadjuvant chemotherapy had no negative influence on the hypertrophy response.

Role of associating liver partition and portal vein ligation in staged hepatectomy (ALPPS)-strategy for colorectal liver metastases

Colorectal carcinoma (CRC) is the third leading cause of cancer-related death in the United States. The liver is the most frequent site of metastasis and a key determinant of survival in patients with isolated colorectal liver metastasis (CRLM). Surgical resection remains the only hope for prolonged survival in patients with CRLM. However, most patients are deemed to be unresectable at presentation due to a small future liver remnant (FLR) and fear of post-hepatectomy liver failure. Procedures such as portal vein ligation or embolization (PVL/PVE) followed by hepatectomy have been established as standard methods to increase FLR volume, but have limitations dependent upon extent of disease and patient's ability to grow the liver remnant. Recently, associating liver partition and portal vein ligation in staged hepatectomy (ALPPS) has been introduced as a technique to induce liver hypertrophy over a shorter time period. Being a complex two-stage surgical procedure, initial reports of higher ALPPS-associated complications and mortality limited its worldwide adoption by hepatobiliary surgeons. However, recent studies have showed ALPPS superiority over conventional procedures in terms of feasibility and inducing liver hypertrophy, with comparable morbidity and mortality. We herein review the role of ALPPS in management of patients with CRLM.

Conversion therapy and suitable timing for subsequent salvage surgery for initially unresectable hepatocellular carcinoma: What is new?

AIM

To review the conversion therapy for initially unresectable hepatocellular carcinoma (HCC) patients and the suitable timing for subsequent salvage surgery.

METHODS

A PubMed search was undertaken from 1987 to 2017 to identify articles using the keywords including “unresectable” “hepatocellular carcinoma”, ”hepatectomy”, ”conversion therapy”, “resection”, “salvage surgery” and “downstaging”. Additional studies were investigated through a manual search of the references from the articles. The exclusion criteria were duplicates, case reports, case series, videos, contents unrelated to the topic, comments, and editorial essays. The main and widely used conversion therapies and the suitable timing for subsequent salvage surgery were discussed in detail. Two members of our group independently performed the literature search and data extraction.

RESULTS

Liver volume measurements [future liver remnant (FLR)/total liver volume or residual liver volume/bodyweight ratio] and function tests (scoring systems and liver stiffness) were often performed in order to justify whether patients were suitable candidates for surgery. Successful conversion therapy was usually defined as downstaging the tumor, increasing FLR and providing subsequent salvage surgery, without increasing complications, morbidity or mortality. The requirements for performing salvage surgery after transcatheter arterial chemoembolization were the achievement of a partial remission in radiology, the disappearance of the portal vein thrombosis, and the lack of extrahepatic metastasis. Patients with a standardized FLR (sFLR) > 20% were good candidates for surgery after portal vein embolization, while other predictive parameters like growth rate, kinetic growth rate were treated as an effective supplementary. There was probably not enough evidence to provide a standard operation time after associating liver partition and portal vein ligation for staged hepatectomy or yttrium-90 microsphere radioembolization. The indications of any combinations of conversion therapies and the subsequent salvage surgery time still need to be carefully and comprehensively evaluated.

CONCLUSION

Conversion therapy is recommended for the treatment of initially unresectable HCC, and the suitable subsequent salvage surgery time should be reappraised and is closely related to its previous therapeutic effect.

Monosegmental ALPPS after Bilateral Hepatectomy

Associated liver partition and portal vein ligation for staged hepatectomy (ALPPS) has emerged as an alternative for patients with bilobar colorectal liver metastasis and a small future liver remnant (FLR). In cases of extensive disease, ALPPS can be performed, leaving only one segment of the liver as FLR. We describe a case of monosegmental ALPPS using segment 4 as FLR. In conclusion, ALPPS should be reserved for a selected group of patients. Monosegmental ALPPS is feasible, but should be performed by hepatobiliary surgeons in specialized centers.

Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy in the Treatment of Colorectal Liver Metastases: Current Scenario

Associating Liver Partition and Portal vein ligation for Staged hepatectomy (ALPPS) has expanded the surgical armamentarium for patients with advanced and bilateral colorectal liver metastases. However, the enthusiasm that the medical fraternity had about ALPPS was hampered by a high mortality rate and early and frequent tumor recurrence. While surgical safety has improved, mainly due to technical refinements and a better patient selection, the oncological value in the face of early tumor recurrence remains unclear. The only randomized controlled trial on ALPPS versus two-stage hepatectomy (TSH) so far confirmed that ALPPS led to higher resectability with comparable perioperative complication rate, but oncological outcome was not measured. Robust data regarding long-term outcome are still missing. TSH and ALPPS might be complementary strategies for the resection of colorectal liver metatsases (CRLM) with ALPPS being reserved for patients with no other surgical option, that is, after failed portal vein embolization or those with an extremely small future liver remnant. In other words, ALPPS can be considered a supplementary tool and a last resort in the liver surgeon's hand to offer resectability in otherwise nonresectable CRLM. In these individual cases, and always embedded into a multimodal treatment setting, ALPPS may offer a chance of complete tumor removal and prolonged survival and even a chance for cure.

Monosegment ALPPS hepatectomy preserving segment 4 for colorectal liver metastases: literature review and our experience

Monosegment 4±1 Associating Liver Partition and Portal Vein ligation for Staged hepatectomy (ALPPS) for bilateral colorectal liver metastases decreases the risk of drop-out of two stage hepatectomy, triggering a rapid and significant increase in future liver remnant (FLR) with promising oncological outcomes. We report two cases of segment 4+1 monosegment ALPPS for multiple colorectal liver metastases performed at our institution. In the literature, seven similar cases have been reported. Short and long term outcomes of our two patients were reported along with a review of data from the literature. Our patients showed a FLR increase from 13% to 37% and from 14% to 41% of total liver volume, respectively. This was compared to a median growth from 19% at baseline to 34% before stage 2, in the literature. After 20 and 27 months since resection both patients are alive and disease-free. In the literature, median overall survival and disease free survival were 13 months (range, 5-24 months) and 5 months (range, 3-23 months), respectively. Segment 4±1 ALPPS is associated with promising oncological outcomes and a significant FLR growth. It may be safely performed in selected patients as a salvage procedure, reducing the risk of the dropout of two-stage hepatectomy.

Totally laparoscopic associating liver partition and portal vein ligation for staged hepatectomy using anterior approach in HCC patient with Type II portal vein anomaly: a case report

Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) has gradually developed because of rapid hypertrophy of the future liver remnant volume (FLR) in spite of high morbidity. To minimize the patient's postoperative pain and morbidity including wound complication caused by two consecutive major abdominal operations, we adopted a totally laparoscopic approach and used a composite mesh graft. Also, to maximize the oncologic efficacy, we adopted the “anterior approach” technique. A 44-year-old woman with large hepatitis B-related hepatocellular carcinoma (HCC) in her right lobe was transferred to our hospital for surgical treatment. Preoperatively predicted FLR by a CT scan was 21% and type II portal vein anomaly was detected. A totally laparoscopic approach was planned. During the first stage operation, right anterior and posterior portal veins were meticulously dissected and tied. After parenchymal transection by the “anterior approach” technique, two glissonian pedicles of the right liver were individually isolated. A composite mesh graft was used to prevent severe adhesion on both liver partition surfaces. During the second-stage operation, 9 days after the first stage operation, the two isolated glissonian pedicles were initially transected. After full mobilization of the right lobe, the right hepatic vein was also transected. The right lobe was removed through the Pfannenstiel incision. She was discharged 7 days after the second stage operation. Her postoperative course was uneventful and there was no HCC recurrence for 15 months after hepatectomy. A totally laparoscopic ALPPS procedure can be a feasible technique that ensures patient safety and oncologic superiority, even in patients with complicated anatomical variation.

Functional considerations in ALPPS - consequences for clinical management

BACKGROUND

Since perioperative morbidity and mortality in ALPPS are extraordinarily high, a deeper understanding of actual liver function during the procedure is essential to make the approach safer.

METHODS

Data from 17 patients who underwent ALLPS were analyzed regarding their course of liver function capacity assessed with the LiMAx test and compared to an equal-sized matched cohort of patients that underwent PVE.

RESULTS

A comparison of LiMAx prior to and following ALPPS Step I (330 [258-385] vs. 197 [144-224] μg/kg/h, p = 0.003) and prior to and following PVE (386 [330-519] vs. 378 [336-455] μg/kg/h, p = 0.534) demonstrated a significant drop in function after ALLPS. A volume/function analysis predicting FLR function regarding step II revealed an excellent correlation of predicted versus assessed postoperative liver function with a mean relative difference of 9 (-6 to 18)% and an ICC of 0.905 (123 [74-138] vs. 107 [77-175] μg/kg/h, p = 0.310).

CONCLUSIONS

We provide evidence that liver function capacity is significantly impaired due to ALPPS step I. This is particularly notable when compared to PVE. Our data also shows that the portal ligated liver lobe still continues to contribute significantly to overall liver function. Therefore, FLR function after step II is still predictable by volume/function analysis.

Modifications of ALPPS - from complex to more complex or from complex to less complex operations

BACKGROUND

Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) has recently been developed to induce rapid liver hypertrophy to reduce the chance of post-hepatectomy liver failure in patients with borderline or insufficient future liver remnant. ALPPS is still in an early developmental stage and its techniques have not been standardized. This study aimed to review the technical modifications of the conventional ALPPS procedure.

DATA SOURCES

Studies were identified by searching MEDLINE and PubMed for articles published from January 2007 to December 2016 using the keywords "associating liver partition and portal vein ligation for staged hepatectomy" and "ALPPS". Additional articles were identified by a manual search of references from key articles.

RESULTS

There have been a lot of modifications of the conventional ALPPS. These are classified as: (1) modifications aiming to improve surgical results; (2) modifications aiming to expand surgical indications; (3) salvage ALPPS; (4) ALPPS using the minimally invasive approach. Some of these modifications have made the conventional ALPPS procedure to become even more complex, although there have also been other attempts to make the procedure less complex. The results of most of these modifications have been reported in small case series or case reports. We need better well-designed studies to establish the true roles of these modifications. However, it is interesting to see how this conventional ALPPS procedure has evolved since its introduction.

CONCLUSIONS

There is a trend for the use of minimally invasive procedure in the phase 1 or 2 of the conventional ALPPS procedure. Some of these modifications have expanded the use of ALPPS in patients who have been considered to have unresectable liver tumors. The long-term oncological outcomes of these modifications are still unknown.

Rat Model of the Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy (ALPPS) Procedure

Recent clinical data support an aggressive surgical approach to both primary and metastatic liver tumors. For some indications, like colorectal liver metastases, the amount of liver tissue left behind after liver resection has become the main limiting factor of resectability of large or multiple liver tumors. A minimal amount of functional tissue is required to avoid the severe complication of post-hepatectomy liver failure, which has high morbidity and mortality. Inducing liver growth of the prospective remnant prior to resection has become more established in liver surgery, either in the form of portal vein embolization by interventional radiologists or in the form of portal vein ligation several weeks prior to resection. Recently, it was shown that liver regeneration is more extensive and rapid, when the parenchymal transection is added to portal vein ligation in a first stage and then, after only one week of waiting, resection performed in a second stage (Associating Liver Partition and Portal vein ligation for Staged hepatectomy = ALPPS). ALPPS has rapidly become popular across the world, but has been criticized for its high perioperative mortality. The mechanism of accelerated and extensive growth induced by this procedure has not been well understood. Animal models have been developed to explore both the physiological and molecular mechanisms of accelerated liver regeneration in ALPPS. This protocol presents a rat model that allows mechanistic exploration of accelerated regeneration.

Does mesenchymal stem cell improve the liver regeneration after the 70% hepatectomy?

Purpose:

To evaluate the effects of mesenchymal stem cells on liver regeneration in rats following a 70% hepatectomy.

Methods:

Forty rats were subjected to 70% hepatectomy and then ~106 mesenchymal stem cells (test group), or saline solution (control group), were infused into their livers via the portal vein. Each treatment group was divided into early and late subgroups (euthanized 3 d and 5 d following the operation, respectively). Group comparisons of Albumin, aminotransaminases (AST, ALT), and Alcaline Phosphatase (AP) levels, proliferative index (ki-67+ straining), and mitotic cell counts were conducted.

Results:

No significant differences in liver regeneration rate, number of mitoses, proliferative index, or serum levels of albumin, AST, or AP were observed. ALT levels were higher in the test group than in the control group (p<.05).

Conclusions:

Mesenchymal stem-cell therapy did not improve liver regeneration rate 3 d or 5 d after 70% hepatectomy in rats. Likewise, the therapy appeared not to affect liver function, proliferative index, or number of mitoses significantly.

Extreme liver resections with preservation of segment 4 only

AIM

To evaluate safety and outcomes of a new technique for extreme hepatic resections with preservation of segment 4 only.

METHODS

The new method of extreme liver resection consists of a two-stage hepatectomy. The first stage involves a right hepatectomy with middle hepatic vein preservation and induction of left lobe congestion; the second stage involves a left lobectomy. Thus, the remnant liver is represented by the segment 4 only (with or without segment 1, ± S1). Five patients underwent the new two-stage hepatectomy (congestion group). Data from volumetric assessment made before the second stage was compared with that of 10 matched patients (comparison group) that underwent a single-stage right hepatectomy with middle hepatic vein preservation.

RESULTS

The two stages of the procedure were successfully carried out on all 5 patients. For the congestion group, the overall volume of the left hemiliver had increased 103% (mean increase from 438 mL to 890 mL) at 4 wk after the first stage of the procedure. Hypertrophy of the future liver remnant (i.e., segment 4 ± S1) was higher than that of segments 2 and 3 (144% vs 54%, respectively, P < 0.05). The median remnant liver volume-to-body weight ratio was 0.3 (range, 0.28-0.40) before the first stage and 0.8 (range, 0.45-0.97) before the second stage. For the comparison group, the rate of hypertrophy of the left liver after right hepatectomy with middle hepatic vein preservation was 116% ± 34%. Hypertrophy rates of segments 2 and 3 (123% ± 47%) and of segment 4 (108% ± 60%, P > 0.05) were proportional. The mean preoperative volume of segments 2 and 3 was 256 ± 64 cc and increased to 572 ± 257 cc after right hepatectomy. Mean preoperative volume of segment 4 increased from 211 ± 75 cc to 439 ± 180 cc after surgery.

CONCLUSION

The proposed method for extreme hepatectomy with preservation of segment 4 only represents a technique that could allow complete resection of multiple bilateral liver metastases.

Abdominal cross-sectional imaging of the associating liver partition and portal vein ligation for staged hepatectomy procedure

Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) is a recently introduced technique aimed to perform two-stage hepatectomy in patients with a variety of primary or secondary neoplastic lesions. ALPSS is based on a preliminary liver resection associated with ligation of the portal branch directed to the diseased hemiliver (DH), followed by hepatectomy after an interval of time in which the future liver remnant (FLR) hypertrophied adequately (partly because of preserved arterialization of the DH). Multidetector computed tomography (MDCT) and magnetic resonance imaging (MRI) play a pivotal role in patients’ selection and FLR assessment before and after the procedure, as well as in monitoring early and late complications, as we aim to review in this paper. Moreover, we illustrate main abdominal MDCT and MRI findings related to ALPPS.

Modified ALPPS procedures: more safety through less invasive surgery

PURPOSE

Although associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) has been advocated for treating advanced liver tumors, increased morbidity and mortality remain serious problems. Many modified procedures have been devised to improve patient safety, but some confusion persists as to benefits and risks.

METHODS

Modifications to ALPPS as originally reported were reviewed to clarify their contributions to safety and their clinical relevance.

RESULTS

A variety of modifications are explained and considered. Modifications mainly aim to reduce adhesions, prevent tumor spread, avoid devascularization during liver splitting, and reduce surgical severity. Such changes aiming to increase safety and reduce invasiveness are needed to avoid high morbidity and mortality rates with this innovative procedure. However, these modified procedures still require more meaningful statistical comparisons of outcome.

CONCLUSIONS

Prospective controlled studies are needed to confirm which modified procedures should be adopted in a standardized manner as an alternative to the original ALPPS. Further, we need to further explore mechanisms of liver regeneration, functional recovery, histopathologic changes of hepatocytes, and blood distribution during ALPPS simultaneously to developing and evaluating modifications of the procedure.

Survival after associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) for advanced colorectal liver metastases: A case-matched comparison with palliative systemic therapy

BACKGROUND

Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) allows the resection of colorectal liver metastases with curative intent which would otherwise be unresectable and only eligible for palliative systemic therapy. This study aimed to compare outcomes of ALPPS in patients with otherwise unresectable colorectal liver metastases with matched historic controls treated with palliative systemic treatment.

METHODS

All patients with colorectal liver metastases from the international ALPPS registry were identified and analyzed. Survival data were compared according to the extent of disease. Otherwise unresectable ALPPS patients were defined by at least 2 of the following criteria: ≥6 metastasis, ≥2 future remnant liver metastasis, ≥6 involved segments excluding segment 1. These patients were matched with patients included in 2, phase 3, metastatic, colorectal cancer trials (CAIRO and CAIRO2) using propensity scoring in order to compare survival.

RESULTS

Of 295 patients with colorectal liver metastases in the ALPPS registry, 70 patients had otherwise unresectable disease defined by the proposed criteria. Two-year overall survival was 49% and 72% for patients with ≥2 and <2 criteria, respectively (P = .002). Median disease-free survival was 6 months compared to 12 months (P < .001) in the ≥2 and <2 criteria groups, respectively. Median overall survival was comparable between ALPPS patients with ≥2 criteria and case-matched patients who received palliative treatment (24.0 vs 17.6 months, P = .088).

CONCLUSION

Early oncologic outcomes of patients with advanced liver metastases undergoing ALPPS were not superior to results of matched patients receiving systemic treatment with palliative intent. Careful patient selection is essential in order to improve outcomes.

Safety and efficacy of radiofrequency-assisted ALPPS (RALPPS) in patients with cirrhosis-related hepatocellular carcinoma

BACKGROUND AND AIMS

Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) has high morbidity and mortality. In this study, the safety and efficacy of a modification of ALPPS (radiofrequency-assisted ALPPS, RALPPS) were assessed in patients with hepatocellular carcinoma (HCC).

MATERIALS AND METHODS

Patients who were diagnosed with HCC and were considered to have an insufficient future liver remnant (FLR) were enrolled. In stage I, a radiofrequency ablation (RFA) device was used to cauterise along the planned transection plane to form a coagulum avascular area. When the FLR reached above 40%, hepatectomy was performed in stage II along the coagulum area established previously. After two stages, operative morbidity, mortality, per cent increase in FLR, operative time and blood loss were evaluated.

RESULTS

Between July 2014 and September 2015, 10 patients with HCC (9 with hepatitis-related cirrhosis) were treated with the RALPPS procedure. The incidence of severe complications (Clavien-Dindo ≥ IIIb) was 20% (2/10). One patient died. No biliary leakage, intraperitoneal infection or post-hepatectomy liver failure (PHLF) occurred after both stages. The median FLR before stage I was 31% (364 ml). This increased to 47% (632 ml) before stage II after a median interval of 28 days. The median percentage increase in FLR was 53% (210 ml). Additionally, the median operative time during the first and second stages was 214 and 281 min, respectively. The corresponding median blood loss was 200 and 550 ml, respectively.

CONCLUSIONS

RALPPS has a potential advantage in eliminating serious complications of biliary leakage and PHLF associated with classic ALPPS. On the basis of rigorous patient selection criteria, RALPPS may achieve the same effect of promoting significant growth of the FLR in patients with cirrhosis-related HCC and insufficient FLR volume, albeit at the cost of a longer interval time.

Hypoxia of the growing liver accelerates regeneration

BACKGROUND

After portal vein ligation of 1 side of the liver, the other side regenerates at a slow rate. This slow growth may be accelerated to rapid growth by adding a transection between the 2 sides, i.e., performing portal vein ligation and parenchymal transection. We found that in patients undergoing portal vein ligation and parenchymal transection, portal vein hyperflow in the regenerating liver causes a significant reduction of arterial flow due to the hepatic arterial buffer response. We postulated that the reduction of arterial flow induces hypoxia in the regenerating liver and used a rat model to assess hypoxia and its impact on kinetic growth.

METHODS

A rat model of rapid (portal vein ligation and parenchymal transection) and slow regeneration (portal vein ligation) was established. Portal vein flow and pressure data were collected. Liver regeneration was assessed in rats using computed tomography, proliferation with Ki-67, and hypoxia with pimonidazole and HIF-1α staining.

RESULTS

The rat model confirmed acceleration of regeneration in portal vein ligation and parenchymal transection as well as the portal vein hyperflow seen in patients. Additionally, tissue hypoxia was observed after portal vein ligation and parenchymal transection, while little hypoxia staining was detected after portal vein ligation. To determine if hypoxia is a consequence or an inciting stimulus of rapid liver regeneration, we used a prolyl-hydroxylase blocker to activate hypoxia signaling pathways in the slow model. This clearly accelerated slow to rapid liver regeneration. Inversely, abrogation of hypoxia led to a blunting of rapid growth to slow growth. The topical application of prolyl-hydroxylase inhibitors on livers in rats induced spontaneous areas of regeneration.

CONCLUSION

This study shows that pharmacologically induced hypoxic signaling accelerates liver regeneration similar to portal vein ligation and parenchymal transection. Hypoxia is likely an accelerator of liver regeneration. Also, prolyl-hydroxylase inhibitors may be used to enhance liver regeneration pharmaceutically.

Associating liver partition and portal vein ligation for staged hepatectomy: the current role and development

BACKGROUND

Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) has recently been developed to induce rapid liver hypertrophy and reduce post-hepatectomy liver failure in patients with insufficient future liver remnant (FLR). ALPPS is still considered to be in an early developmental phase because surgical indications and techniques have not been standardized. This article aimed to review the current role and future developments of ALPPS.

DATA SOURCES

Studies were identified by searching MEDLINE and PubMed for articles from January 2007 to October 2016 using the keywords "associating liver partition and portal vein ligation for staged hepatectomy" and "ALPPS". Additional papers were identified by a manual search of references from key articles.

RESULTS

ALPPS induces more hypertrophy of the FLR in less time than portal vein embolization or portal vein ligation. The benefits of ALPPS include rapid hypertrophy 47%-110% of the liver over a median of 6-16.4 days, and 95%-100% completion rate of the second stage of ALPPS. The main criticisms of ALPPS are centered on its high morbidity and mortality rates. Morbidity rates after ALPPS have been reported to be 15.3%-100%, with ≥ the Clavien-Dindo grade III morbidity of 13.6%-44%. Mortality rates have been reported to be 0%-29%. The important questions to ask even if oncologic long-term results are acceptable are: whether the gain in quality and quantity of life can be off balance by the substantial risks of morbidity and mortality, and whether stimulation of rapid liver hypertrophy also accelerates rapid tumor progression and spread. Up till now, the documentations of the ALPPS procedure come mainly from case series, and most of these series include heterogeneous groups of malignancies. The numbers are also too small to separately evaluate survival for different tumor etiologies.

CONCLUSIONS

Currently, knowledge on ALPPS is limited, and prospective randomized studies are lacking. From the reported preliminary results, safety of the ALPPS procedure remains questionable. ALPPS should only be used in experienced, high-volume hepatobiliary centers.

Rescue ALPPS is efficient and safe after failed portal vein occlusion in patients with colorectal liver metastases

PURPOSE

The aim of this study was to investigate whether associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) can be used as an effective and safe rescue procedure in patients with colorectal liver metastases (CRLM) and insufficient effect on the future liver remnant (FLR) after previous portal vein occlusion (PVO).

METHODS

Eleven patients with bilobar CRLM treated with neoadjuvant chemotherapy and previous PVO with insufficient effect on the FLR were analyzed retrospectively from a prospective database. FLR was evaluated with computed tomography volumetry 6 days after stage 1, and stage 2 was performed on day seven.

RESULTS

Six days after stage 1, the median increase of the FLR was 209 ml (range 87-314, P < 0.001). This corresponded to a median FLR growth of 61.8 % (range 19.3-120) resulting in an FLR/BW ratio >0.5 % in all patients and successful subsequent removal of the tumor bearing liver (segments IV-VIII) in all patients with no 90-day mortality. No patient had a 3b-complication or more according to Clavien-Dindo. No patient developed severe posthepatectomy liver failure.

CONCLUSIONS

The powerful hypertrophy of the FLR associated with ALPPS seems to be maintained in patients with CRLM and previous failed PVO.

Transition from open to laparoscopic ALPPS for patients with very small FLR: the initial experience

BACKGROUND

Laparoscopic ALPPS (Associating Liver Partition and Portal vein ligation for Staged hepatectomy) has previously been reported but has been the authors' default option since 2015 in patients with small future liver remnant.

METHODS

A retrospective analysis of all consecutive patients undergoing ALPPS at a single referral center was performed using a prospective database from July 2011 to June 2016. Feasibility was studied by assessing conversions. The 90-day mortality and complications were analyzed using a Dindo-Clavien score and the comprehensive complication index. Operative time, blood loss, volumetric growth, and hospital stay were examined. The CUSUM analysis was performed.

RESULTS

ALPPS was performed in 30 patients, 10 of whom underwent a laparoscopic approach. There was no mortality and no complication grade ≥3A observed in laparoscopic ALPPS. In open ALPPS, 10 of 20 patients experienced complications grade ≥3A (p = 0.006) and one patient died. Liver failure was not observed after laparoscopic ALPPS, but two patients in the open ALPPS group developed complications that precluded the second stage. The total hospital stay was shorter in the laparoscopic ALPPS group.

CONCLUSION

Laparoscopic ALPPS is feasible as the default procedure for patients with very small FLR, and it is not inferior to the open approach. Surgeons experienced with complex laparoscopy should be encouraged to use a laparoscopic approach to ALPPS.

Dynamic Evaluation of Liver Volume and Function in Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy

BACKGROUND

Despite a fast and potent growth of the future liver remnant (FLR), patients operated with associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) are at risk of developing posthepatectomy liver failure. In this study, the relation between liver volume and function in ALPPS was studied using a multimodal assessment.

METHODS

Nine patients with colorectal liver metastases treated with neoadjuvant chemotherapy and operated with ALPPS were studied with hepatobiliary scintigraphy, computed tomography, indocyanine green clearance test, and serum liver function tests. A comparison between liver volume and function was conducted.

RESULTS

The preoperative FLR volume of 19.5% underestimated the preoperative FLR function of 25.3% (p = 0.011). The increase in FLR volume exceeded the increase in function at day 6 after stage 1 (FLR volume increase 56.7% versus FLR function increase 28.2%, p = 0.021), meaning that the increase in function was 50% of the increase in volume. After stage 2, functional increase exceeded the volume increase, resulting in similar values 28 days after stage 2.

CONCLUSIONS

In the inter-stage period of ALPPS, the high volume increase is not paralleled by a corresponding functional increase. This may in part explain the high morbidity and mortality rates associated with ALPPS. Functional assessment of the FLR is advised.

Liver resection for cancer: New developments in prediction, prevention and management of postresectional liver failure

Hepatic failure is a feared complication that accounts for up to 75% of mortality after extensive liver resection. Despite improved perioperative care, the increasing complexity and extensiveness of surgical interventions, in combination with an expanding number of resections in patients with compromised liver function, still results in an incidence of postresectional liver failure (PLF) of 1-9%. Preventive measures aim to enhance future remnant liver size and function. Numerous non-invasive techniques to assess liver function and predict remnant liver volume are being developed, along with introduction of novel surgical strategies that augment growth of the future remnant liver. Detection of PLF is often too late and treatment is primarily symptomatic. Current therapeutic research focuses on ([bio]artificial) liver function support and regenerative medicine. In this review we discuss the current state and new developments in prediction, prevention and management of PLF, in light of novel insights into the aetiology of this complex syndrome.

LAY SUMMARY

Liver failure is the main cause of death after partial liver resection for cancer, and is presumably caused by an insufficient quantity and function of the liver remnant. Detection of liver failure is often too late, and current treatment focuses on relieve of symptoms. New research initiatives explore artificial support of liver function and stimulation of regrowth of the remnant liver.