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Alvarez FA, Ardiles V, Chara C, de Santibañes M, Sánchez Clariá R, Pekolj J, de Santibañes E. Adjuvant chemotherapy is associated with better oncological outcomes after ALPPS for colorectal liver metastases. Updates Surg 2024:10.1007/s13304-024-01835-1. [PMID: 38647857 DOI: 10.1007/s13304-024-01835-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Accepted: 03/15/2024] [Indexed: 04/25/2024]
Abstract
ALPPS enables complete tumor resection in a shorter interval and a larger number of patients than classic two-stage hepatectomies. However, there is little evidence regarding long-term outcomes in patients with colorectal liver metastases (CLM). This study aims to evaluate the short and long-term outcomes of ALPPS in patients with CRM. Single-cohort, prospective, observational study. Patients with unresectable CLM due to insufficient liver remnant who underwent ALPPS between June 2011 and June 2021 were included. Of 32 patients treated, 21 were male (66%) and the median age was 56 years (range = 29-81). Both stages were completed in 30 patients (93.7%), with an R0 rate of 75% (24/32). Major morbidity was 37.5% and the mortality nil. Median overall survival (OS) and recurrence-free survival (RFS) were 28.1 and 8.8 months, respectively. The 1-3, and 5-year OS was 86%, 45%, and 21%, and RFS was 42%, 14%, and 14%, respectively. The only independent risk factor associated with poor RFS (5.7 vs 11.6 months; p = 0.038) and OS (15 vs 37 months; p = 0.009) was not receiving adjuvant chemotherapy. KRAS mutation was associated with worse OS from disease diagnosis (24.3 vs. 38.9 months; p = 0.025). ALPPS is associated with favorable oncological outcomes, comparable to traditional strategies to increase resectability in patients with CLM and high tumor burden. Our results suggest for the first time that adjuvant chemotherapy is independently associated with better short- and long-term outcomes after ALPPS. Selection of patients with KRAS mutations should be performed with caution, as this could affect oncological outcomes.
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Affiliation(s)
- Fernando A Alvarez
- General Surgery Service, Hepato-Pancreato-Biliary Surgery Section and Liver Transplant Unit, Hospital Italiano de Buenos Aires, Juan D. Perón 4190, C1181AC, Buenos Aires, Argentina
| | - Victoria Ardiles
- General Surgery Service, Hepato-Pancreato-Biliary Surgery Section and Liver Transplant Unit, Hospital Italiano de Buenos Aires, Juan D. Perón 4190, C1181AC, Buenos Aires, Argentina
| | - Camila Chara
- General Surgery Service, Hepato-Pancreato-Biliary Surgery Section and Liver Transplant Unit, Hospital Italiano de Buenos Aires, Juan D. Perón 4190, C1181AC, Buenos Aires, Argentina
| | - Martin de Santibañes
- General Surgery Service, Hepato-Pancreato-Biliary Surgery Section and Liver Transplant Unit, Hospital Italiano de Buenos Aires, Juan D. Perón 4190, C1181AC, Buenos Aires, Argentina
| | - Rodrigo Sánchez Clariá
- General Surgery Service, Hepato-Pancreato-Biliary Surgery Section and Liver Transplant Unit, Hospital Italiano de Buenos Aires, Juan D. Perón 4190, C1181AC, Buenos Aires, Argentina
| | - Juan Pekolj
- General Surgery Service, Hepato-Pancreato-Biliary Surgery Section and Liver Transplant Unit, Hospital Italiano de Buenos Aires, Juan D. Perón 4190, C1181AC, Buenos Aires, Argentina
| | - Eduardo de Santibañes
- General Surgery Service, Hepato-Pancreato-Biliary Surgery Section and Liver Transplant Unit, Hospital Italiano de Buenos Aires, Juan D. Perón 4190, C1181AC, Buenos Aires, Argentina.
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Barcena AJR, Owens TC, Melancon S, Workeneh I, Tran Cao HS, Vauthey JN, Huang SY. Current Perspectives and Progress in Preoperative Portal Vein Embolization with Stem Cell Augmentation (PVESA). Stem Cell Rev Rep 2024:10.1007/s12015-024-10719-1. [PMID: 38613627 DOI: 10.1007/s12015-024-10719-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/03/2024] [Indexed: 04/15/2024]
Abstract
Portal vein embolization with stem cell augmentation (PVESA) is an emerging approach for enhancing the growth of the liver segment that will remain after surgery (i.e., future liver remnant, FLR) in patients with liver cancer. Conventional portal vein embolization (PVE) aims to induce preoperative FLR growth, but it has a risk of failure in patients with underlying liver dysfunction and comorbid illnesses. PVESA combines PVE with stem cell therapy to potentially improve FLR size and function more effectively and efficiently. Various types of stem cells can help improve liver growth by secreting paracrine signals for hepatocyte growth or by transforming into hepatocytes. Mesenchymal stem cells (MSCs), unrestricted somatic stem cells, and small hepatocyte-like progenitor cells have been used to augment liver growth in preclinical animal models, while clinical studies have demonstrated the benefit of CD133 + bone marrow-derived MSCs and hematopoietic stem cells. These investigations have shown that PVESA is generally safe and enhances liver growth after PVE. However, optimizing the selection, collection, and application of stem cells remains crucial to maximize benefits and minimize risks. Additionally, advanced stem cell technologies, such as priming, genetic modification, and extracellular vesicle-based therapy, that could further enhance efficacy outcomes should be evaluated. Despite its potential, PVESA requires more investigations, particularly mechanistic studies that involve orthotopic animal models of liver cancer with concomitant liver injury as well as larger human trials.
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Affiliation(s)
- Allan John R Barcena
- Department of Interventional Radiology, Division of Diagnostic Imaging, The University of Texas MD Anderson Cancer Center, 1400 Pressler St, Unit, Houston, TX, 1471, 77030, United States
- College of Medicine, University of the Philippines Manila, Manila, NCR, 1000, Philippines
| | - Tyler C Owens
- Department of Interventional Radiology, Division of Diagnostic Imaging, The University of Texas MD Anderson Cancer Center, 1400 Pressler St, Unit, Houston, TX, 1471, 77030, United States
| | - Sophie Melancon
- Department of Interventional Radiology, Division of Diagnostic Imaging, The University of Texas MD Anderson Cancer Center, 1400 Pressler St, Unit, Houston, TX, 1471, 77030, United States
| | - Isias Workeneh
- Department of Interventional Radiology, Division of Diagnostic Imaging, The University of Texas MD Anderson Cancer Center, 1400 Pressler St, Unit, Houston, TX, 1471, 77030, United States
| | - Hop S Tran Cao
- Department of Surgical Oncology, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, 77030, United States
| | - Jean-Nicolas Vauthey
- Department of Surgical Oncology, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, 77030, United States
| | - Steven Y Huang
- Department of Interventional Radiology, Division of Diagnostic Imaging, The University of Texas MD Anderson Cancer Center, 1400 Pressler St, Unit, Houston, TX, 1471, 77030, United States.
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Moga DFC, Gavrilă GA, Dan AA, Smarandache CG. Complete regression of intrahepatic cholangiocarcinoma after right portal vein ligation. Case report. Int J Surg Case Rep 2024; 117:109580. [PMID: 38547696 PMCID: PMC11010678 DOI: 10.1016/j.ijscr.2024.109580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Revised: 03/18/2024] [Accepted: 03/20/2024] [Indexed: 04/07/2024] Open
Abstract
INTRODUCTION Spontaneous tumor regression is an extremely rare phenomenon in the oncology field. PRESENTATION OF CASE We present the case of a 72-years-old male patient presenting with a bulky hepatic tumor mass located in segment V and extending into segments IVb and VI with MRI features of atypical cholangiocarcinoma with a liver metastasis in segment III. In first surgical step, excision of the metastasis, and ligation of the right portal vein was done. A new MRI examination performed 5 weeks later shows significant tumor regression, and 2 weeks later, during the second surgery, the tumor was not found. Under these conditions we performed a limited segment V liver resection, in the area indicated by the radiologist as the site of the tumor. No viable malignant cells existed in the tumor specimen, and a third MRI examination didn't identify any residual tumor. DISCUSSION From our literature study this is the only case of complete tumor regression of an intrahepatic cholangiocarcinoma following portal vein ligation. We believe the portal vein ligation resulted in a marked regression/deficiency in the tumor blood supply. CONCLUSION Serial MRI examinations demonstrated the regression of intrahepatic cholangiocarcinoma after portal vein ligation. Intrahepatic cholangiocarcinoma should be included in the tumors that could extremely rarely spontaneously regress.
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Affiliation(s)
- Doru-Florian-Cornel Moga
- Clinical Department of Surgery, Military Clinical Emergency Hospital Sibiu and Lucian Blaga University Sibiu, Romania.
| | - Gabriela-Ariadna Gavrilă
- Medical Analysis Laboratory, Military Clinical Emergency Hospital Sibiu and Lucian Blaga University Sibiu, Romania
| | - Andreea-Alina Dan
- Department of Radiology, Military Clinical Emergency Hospital Sibiu, Romania
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Díaz Vico T, Granero Castro P, Alcover Navarro L, Suárez Sánchez A, Mihic Góngora L, Montalvá Orón EM, Maupoey Ibáñez J, Truán Alonso N, González-Pinto Arrillaga I, Granero Trancón JE. Two stage hepatectomy (TSH) versus ALPPS for initially unresectable colorectal liver metastases: A systematic review and meta-analysis. Eur J Surg Oncol 2023; 49:550-559. [PMID: 36424260 DOI: 10.1016/j.ejso.2022.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 10/03/2022] [Accepted: 11/03/2022] [Indexed: 11/10/2022]
Abstract
BACKGROUND Although numerous comparisons between conventional Two Stage Hepatectomy (TSH) and Associating Liver Partition and Portal Vein Ligation for staged hepatectomy (ALPPS) have been reported, the heterogeneity of malignancies previously compared represents an important source of selection bias. This systematic review and meta-analysis aimed to compare perioperative and oncological outcomes between TSH and ALPPS to treat patients with initially unresectable colorectal liver metastases (CRLM). METHODS Main electronic databases were searched using medical subject headings for CRLM surgically treated with TSH or ALPPS. Patients treated for primary or secondary liver malignancies other than CRLM were excluded. RESULTS A total of 335 patients from 5 studies were included. Postoperative major complications were higher in the ALPPS group (relative risk [RR] 1.46, 95% confidence interval [CI] 1.04-2.06, I2 = 0%), while no differences were observed in terms of perioperative mortality (RR 1.53, 95% CI 0.64-3.62, I2 = 0%). ALPPS was associated with higher completion of hepatectomy rates (RR 1.32, 95% CI 1.09-1.61, I2 = 85%), as well as R0 resection rates (RR 1.61, 95% CI 1.13-2.30, I2 = 40%). Nevertheless, no significant differences were achieved between groups in terms of overall survival (OS) (RR 0.93, 95% CI 0.68-1.27, I2 = 52%) and disease-free survival (DFS) (RR 1.08, 95% CI 0.47-2.49, I2 = 54%), respectively. CONCLUSION ALPPS and TSH to treat CRLM seem to have comparable operative risks in terms of mortality rates. No definitive conclusions regarding OS and DFS can be drawn from the results.
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Affiliation(s)
- Tamara Díaz Vico
- Department of HPB Surgery and Transplantation Unit, Division of General Surgery, Hospital Universitario Central de Asturias (HUCA), Oviedo, Spain; Health Research Institute of the Principality of Asturias (ISPA), Spain.
| | - Pablo Granero Castro
- Department of HPB Surgery and Transplantation Unit, Division of General Surgery, Hospital Universitario Central de Asturias (HUCA), Oviedo, Spain; Department of Surgery, University of Oviedo, Spain
| | - Laura Alcover Navarro
- Department of Anaesthesiology, Hospital Universitario Central de Asturias (HUCA), Oviedo, Spain
| | - Aida Suárez Sánchez
- Department of General Surgery, Hospital Universitario San Agustín (HUSA), Avilés, Spain
| | - Luka Mihic Góngora
- Department of Medical Oncology, Hospital Universitario Central de Asturias (HUCA), Oviedo, Spain
| | - Eva María Montalvá Orón
- Department of HPB Surgery and Transplantation Unit, Division of General Surgery, Hospital La Fe, Valencia, Spain
| | - Javier Maupoey Ibáñez
- Department of HPB Surgery and Transplantation Unit, Division of General Surgery, Hospital La Fe, Valencia, Spain
| | - Nuria Truán Alonso
- Department of Colorectal Surgery, Division of General Surgery, Hospital Universitario Central de Asturias (HUCA), Oviedo, Spain
| | - Ignacio González-Pinto Arrillaga
- Department of HPB Surgery and Transplantation Unit, Division of General Surgery, Hospital Universitario Central de Asturias (HUCA), Oviedo, Spain; Department of Surgery, University of Oviedo, Spain
| | - José Electo Granero Trancón
- Department of Surgery, University of Oviedo, Spain; Department of Colorectal Surgery, Division of General Surgery, Hospital Universitario Central de Asturias (HUCA), Oviedo, Spain
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Yi F, Zhang W, Feng L. Efficacy and safety of different options for liver regeneration of future liver remnant in patients with liver malignancies: a systematic review and network meta-analysis. World J Surg Oncol 2022; 20:399. [PMID: 36527081 PMCID: PMC9756618 DOI: 10.1186/s12957-022-02867-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 12/04/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Several treatments induce liver hypertrophy for patients with liver malignancies but insufficient future liver remnant (FLR). Herein, the aim of this study is to compare the efficacy and safety of existing surgical techniques using network meta-analysis (NMA). METHODS We searched PubMed, Web of Science, and Cochrane Library from databases for abstracts and full-text articles published from database inception through Feb 2022. The primary outcome was the efficacy of different procedures, including standardized FLR (sFLR) increase, time to hepatectomy, resection rate, and R0 resection margin. The secondary outcome was the safety of different treatments, including the rate of Clavien-Dindo≥3a and 90-day mortality. RESULTS Twenty-seven studies, including three randomized controlled trials (RCTs), three prospective trials (PTs), and twenty-one retrospective trials (RTs), and a total number of 2075 patients were recruited in this study. NMA demonstrated that the Associating Liver Partition and Portal vein ligation for Staged hepatectomy (ALPPS) had much higher sFLR increase when compared to portal vein embolization (PVE) (55.25%, 95% CI 45.27-65.24%), or liver venous deprivation(LVD) (43.26%, 95% CI 22.05-64.47%), or two-stage hepatectomy (TSH) (30.53%, 95% CI 16.84-44.21%), or portal vein ligation (PVL) (58.42%, 95% CI 37.62-79.23%). ALPPS showed significantly shorter time to hepatectomy when compared to PVE (-32.79d, 95% CI -42.92-22.66), or LVD (-34.02d, 95% CI -47.85-20.20), or TSH (-22.85d, 95% CI -30.97-14.72), or PVL (-43.37d, 95% CI -64.11-22.62); ALPPS was considered as the highest resection rate when compared to TSH (OR=6.09; 95% CI 2.76-13.41), or PVL (OR =3.52; 95% CI 1.16-10.72), or PVE (OR =4.12; 95% CI 2.19-7.77). ALPPS had comparable resection rate with LVD (OR =2.20; 95% CI 0.83-5.86). There was no significant difference between them when considering the R0 marge rate. ALPPS had a higher Clavien-Dindo≥3a complication rate and 90-day mortality compared to other treatments, although there were no significant differences between different procedures. CONCLUSIONS ALPPS demonstrated a higher regeneration rate, shorter time to hepatectomy, and higher resection rate than PVL, PVE, or TSH. There was no significant difference between them when considering the R0 marge rate. However, ALPPS developed the trend of higher Clavien-Dindo≥3a complication rate and 90-day mortality compared to other treatments.
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Affiliation(s)
- Fengming Yi
- grid.412455.30000 0004 1756 5980Department of Oncology, Second Affiliated Hospital of Nanchang University, Nanchang, 330006 People’s Republic of China ,JiangXi Key Laboratory of Clinical and Translational Cancer Research, Nanchang, 330006 People’s Republic of China
| | - Wei Zhang
- grid.412455.30000 0004 1756 5980Department of Obstetrics and Gynecology, Second Affiliated Hospital of Nanchang University, Nanchang, 330006 People’s Republic of China
| | - Long Feng
- grid.412455.30000 0004 1756 5980Department of Oncology, Second Affiliated Hospital of Nanchang University, Nanchang, 330006 People’s Republic of China ,JiangXi Key Laboratory of Clinical and Translational Cancer Research, Nanchang, 330006 People’s Republic of China
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Gavriilidis P, Sutcliffe RP, Roberts KJ, Pai M, Spalding D, Habib N, Jiao LR, Sodergren MH. No difference in mortality among ALPPS, two-staged hepatectomy, and portal vein embolization/ligation: A systematic review by updated traditional and network meta-analyses. Hepatobiliary Pancreat Dis Int 2020; 19:411-419. [PMID: 32753333 DOI: 10.1016/j.hbpd.2020.07.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Accepted: 07/17/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND There is an ongoing debate on the feasibility, safety, and oncological efficacy of the associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) technique. The aim of this study was to compare ALPPS, two-staged hepatectomy (TSH), and portal vein embolization (PVE)/ligation (PVL) using updated traditional meta-analysis and network meta-analysis (NMA). DATA SOURCES Electronic databases were used in a systematic literature search. Updated traditional meta-analysis and NMA were performed and compared. Mortality and major morbidity were selected as primary outcomes. RESULTS Nineteen studies including 1200 patients were selected from the pool of 436 studies. Of these patients, 315 (31%) and 702 (69%) underwent ALPPS and portal vein occlusion (PVO), respectively. Ninety-day mortality based on updated traditional meta-analysis, subgroup analysis of the randomized controlled trials (RCTs), and both Bayesian and frequentist NMA did not demonstrate significant differences between the ALPPS cohort and the PVE, PVL, and TSH cohorts. Moreover, analysis of RCTs did not demonstrate significant differences of major morbidity between the ALPPS and PVO cohorts. The ALPPS cohort demonstrated significantly more favorable outcomes in hypertrophy parameters, time to operation, definitive hepatectomy, and R0 margins rates compared with the PVO cohort. In contrast, 1-year disease-free survival was significantly higher in the PVO cohort compared to the ALPPS cohort. CONCLUSIONS This study is the first to use updated traditional meta-analysis and both Bayesian and frequentist NMA and demonstrated no significant differences in 90-day mortality between the ALPPS and other hepatic hypertrophy approaches. Furthermore, two high quality RCTs including 147 patients demonstrated no significant differences in major morbidity between the ALPPS and PVO cohorts.
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Affiliation(s)
- Paschalis Gavriilidis
- Department of Hepatopanceaticobiliary Surgery, Imperial College Healthcare NHS Trust, Hammersmith Hospital, London W12 0HS, UK.
| | - Robert P Sutcliffe
- Department of Hepato-Pancreato-Biliary and Liver Transplant Surgery, Queen Elizabeth University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TH, UK
| | - Keith J Roberts
- Department of Hepato-Pancreato-Biliary and Liver Transplant Surgery, Queen Elizabeth University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TH, UK
| | - Madhava Pai
- Department of Hepatopanceaticobiliary Surgery, Imperial College Healthcare NHS Trust, Hammersmith Hospital, London W12 0HS, UK
| | - Duncan Spalding
- Department of Hepatopanceaticobiliary Surgery, Imperial College Healthcare NHS Trust, Hammersmith Hospital, London W12 0HS, UK
| | - Nagy Habib
- Department of Hepatopanceaticobiliary Surgery, Imperial College Healthcare NHS Trust, Hammersmith Hospital, London W12 0HS, UK
| | - Long R Jiao
- Department of Hepatopanceaticobiliary Surgery, Imperial College Healthcare NHS Trust, Hammersmith Hospital, London W12 0HS, UK
| | - Mikael H Sodergren
- Department of Hepatopanceaticobiliary Surgery, Imperial College Healthcare NHS Trust, Hammersmith Hospital, London W12 0HS, UK
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Jia C, Ge K, Xu S, Liu L, Weng J, Chen Y. Selective occlusion of the hepatic artery and portal vein improves liver hypertrophy for staged hepatectomy. World J Surg Oncol 2019; 17:167. [PMID: 31590665 PMCID: PMC6781355 DOI: 10.1186/s12957-019-1710-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Accepted: 09/10/2019] [Indexed: 12/23/2022] Open
Abstract
Background To evaluate the safety and feasibility of selective occlusion of the hepatic artery and portal vein (SOAP) for staged hepatectomy (SOAPS) in patients with hepatocellular carcinoma (HCC) Methods From December 2014 to August 2018, 9 patients with unresectable HCC were chosen to undergo SOAPS. SOAP without liver partition was performed in the first stage. The second stage was performed when future liver remnant (FLR) was equal to or bigger than 40% of the standard liver volume (SLV). The growth rate of FLR, perioperative outcomes, and survival data was recorded. Results In the first stage, all the 9 patients completed SOAP. Two cases received radiological interventional method and 7 cases received open operation. None of them developed liver failure and died following SOAP. After SOAP, FLR increased 145.0 ml (115.0 to 210 ml) and 37.1% (25.6 to 51.7%) on average. The average time interval between the two stages was 14.1 days (8 to 18 days). In the second stage, no in-hospital deaths occurred after SOAPS. One patient suffered from liver failure after SOAPS, and artificial liver support was adopted and his total bilirubin level returned to normal after postoperative day 35. The alpha-fetoprotein level of 8 patients reduced to normal within 2 months after SOAPS. Among 9 patients, 5 patients survived, 4 patients died of intrahepatic recurrence, lung metastasis, or bone metastasis. In the 5 survived cases, bone metastasis and intrahepatic recurrence were found in 1 patient, intrahepatic recurrence was found in another patient, and the remaining 3 patients were free of recurrence. The median disease-free survival time and overall survival time were 10.4 and 13.9 months, respectively. Conclusion SOAP can facilitate rapid and sustained FLR hypertrophy, and SOAPS is safe and effective in patients with unresectable HCC.
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Affiliation(s)
- Changku Jia
- Department of Hepatobiliary Pancreatic Surgery, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Zhejiang Clinical Research Center of Hepatobiliary and Pancreatic Diseases, No. 261, Huansha Road, Hangzhou, 310006, China.
| | - Ke Ge
- Department of Hepatobiliary Pancreatic Surgery, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Zhejiang Clinical Research Center of Hepatobiliary and Pancreatic Diseases, No. 261, Huansha Road, Hangzhou, 310006, China
| | - Sunbing Xu
- Department of Hepatobiliary Pancreatic Surgery, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Zhejiang Clinical Research Center of Hepatobiliary and Pancreatic Diseases, No. 261, Huansha Road, Hangzhou, 310006, China.
| | - Ling Liu
- Department of Hepatobiliary Pancreatic Surgery, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Zhejiang Clinical Research Center of Hepatobiliary and Pancreatic Diseases, No. 261, Huansha Road, Hangzhou, 310006, China
| | - Jie Weng
- Department of Hepatobiliary Pancreatic Surgery, The First Affiliated Hospital of Hainan Medical College, Haikou, 570102, China
| | - Youke Chen
- Department of Hepatobiliary Pancreatic Surgery, The First Affiliated Hospital of Hainan Medical College, Haikou, 570102, China
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Rocca A, Andolfi E, Zamboli AGI, Surfaro G, Tafuri D, Costa G, Frezza B, Scricciolo M, Amato M, Bianco P, Brongo S, Ceccarelli G, Giuliani A, Amato B. Management of Complications of First Instance of Hepatic Trauma in a Liver Surgery Unit: Portal Vein Ligation as a Conservative Therapeutic Strategy. Open Med (Wars) 2019; 14:376-383. [PMID: 31157303 PMCID: PMC6534101 DOI: 10.1515/med-2019-0038] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Accepted: 03/15/2019] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND According to the National Trauma Data Bank, the liver, after the spleen, is the first most injured organ in closed abdominal trauma. METHODS From June 2010 to December 2015 we observed in our department of Hepato-biliary Surgery and Liver Transplant Unit of the A.O.R.N. A. Cardarelli of Naples 40 patients affected by hepatic trauma. In our retrospective study, we review our experience and propose portal vein ligation (PVL) as a first - line strategy for damage control surgery (DCS) in liver trauma. RESULTS 26/40 patients (65%) which received gauze-packing represented our study group. In 10 cases out of 26 patients (38,4%) the abdominal packing was enough to control the damage. In 7 cases (18,4%) we performed a liver resection. In 7 cases, after de-packing, we adopted PVL to achieve DCS. Trans Arterial Embolization was chosen in 6 patients. 2 of them were discharged 14 days later without performing any other procedure.In 3 cases we had to perform a right epatectomy in second instance. Two hepatectomies were due to hemoperitoneum, and the other for coleperitoneum. Two patients were treated in first instance by only doing hemostasis on the bleeding site. We observed 6 patients in first instance. Five of them underwent surgery with hepatic resection and surgical hemostasis of the bleeding site. The other one underwent to conservative management. In summary we performed 15 hepatic resections, 8 of them were right hepatectomies, 1 left hepatectomy, 2 trisegmentectomies V-VI-VII. So in second instance we operated on 10 patients out of 34 (30%). CONCLUSIONS The improved knowledge of clinical physio-pathology and the improvement of diagnostic and instrumental techniques had a great impact on the prognosis of liver trauma. We think that a rigid diagnostic protocol should be applied as this allows timely pathological finding, and consists of three successive but perfectly integrated steps: 1) patient reception, in close collaboration with the resuscitator; 2) accurate but quick diagnostic framing 3) therapeutic decisional making. Selective portal vein ligation is a well-tolerated and safe manoeuvre, which could be effective, even if not definitive, in treating these subjects. That is why we believe that it can be a choice to keep in mind especially in post-depacking bleeding.
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Affiliation(s)
- Aldo Rocca
- Department of Translational Medical Sciences, University of Naples “Federico II”, Naples, Italy
- Via Sergio Pansini, 80131 Naples, Italy General Surgery Unit, Clinica Padre Pio, Mondragone (CE), Italy Department of Abdominal Oncology, Fondazione Giovanni Pascale, IRCCS, Naples, Italy
- Centre of Hepatobiliarypancreatic surgery, Pineta Grande Hospital, Castelvolturno (CE), Italy
| | - Enrico Andolfi
- Department of Surgery, Division of general Surgery, San Donato Hospital, via Pietro Nenni 20-22, 52100Arezzo, Italy
| | | | | | - Domenico Tafuri
- Department of Sport Sciences and Wellness, University of Naples “Parthenope”, Naples, Italy
| | - Gianluca Costa
- Surgical and Medical Department of Traslational Medicine, Sapienza University of Rome, Sant’Andrea Hospital, Via di Grottarossa 1035-39, 00189Rome, Italy
| | - Barbara Frezza
- Department of Surgery, Division of general Surgery, San Donato Hospital, via Pietro Nenni 20-22, 52100Arezzo, Italy
| | - Marta Scricciolo
- Department of Surgery, Division of general Surgery, San Donato Hospital, via Pietro Nenni 20-22, 52100Arezzo, Italy
| | - Maurizio Amato
- Department of Clinical Medicine and Surgery, University Federico II of Naples. Naples, Italy
| | - Paolo Bianco
- Centre of Hepatobiliarypancreatic surgery, Pineta Grande Hospital, Castelvolturno (CE), Italy
| | - Sergio Brongo
- Plastic Surgery Unit, Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", San Giovanni di Dio e Ruggi D'Aragona University Hospital, University of Salerno, Salerno, Italy
| | - Graziano Ceccarelli
- Department of Surgery, Division of general Surgery, San Donato Hospital, via Pietro Nenni 20-22, 52100Arezzo, Italy
| | - Antonio Giuliani
- Department of Transplantation, Unit of Hepatobiliary Surgery and Liver Transplant Center, ‘A. Cardarelli’ Hospital, Naples, Italy
| | - Bruno Amato
- Department of Clinical Medicine and Surgery, University Federico II of Naples. Naples, Italy
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10
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Rauchfuß F, Nadalin S, Königsrainer A, Settmacher U. Living donor liver transplantation with two-stage hepatectomy for patients with isolated, irresectable colorectal liver-the LIVER-T(W)O-HEAL study. World J Surg Oncol 2019; 17:11. [PMID: 30621712 PMCID: PMC6325801 DOI: 10.1186/s12957-018-1549-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Accepted: 12/23/2018] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Colorectal cancer is the third most common malignancy worldwide. The occurrence of liver metastases worsens the prognosis of the patient significantly if the tumor burden is not resectable. Liver transplantation might be an option for otherwise irresectable colorectal liver metastases. In this study, we evaluate the role of two-stage hepatectomy in combination with a left-lateral living donor liver transplantation. METHODS Patients with irresectable liver metastases having a stable disease or tumor regression after at least 8 weeks of systemic chemotherapy without an extrahepatic tumor burden (except resectable lung metastases) are suitable for study inclusion. A randomization is not planned since the control arm (systemic chemotherapy) is well established and the superiority of the transplantation procedure has to be expected. The surgical treatment consists of two steps: in a first operation, a left hemihepatectomy in the recipient will be performed. At this place, the left lateral liver lobe (segments II and III) of a living donor will be transplanted. To induce a growth of the graft, a portal vein ligation will be performed. Approximately after 2 weeks, the removal of the right hemiliver will be conducted if the control imaging shows a sufficient growth of the graft. RESULTS The patient recruitment is ongoing. In total, three patients have been already transplanted with this protocol. Up to now, they are tumor-free and in good clinical health. DISCUSSION With the design of the LIVER-T(W)O-HEAL study, it might be possible to offer patients with otherwise irresectable colorectal liver metastases a curative treatment option. The key point of this study will be, most probably, the patient's selection. TRIAL REGISTRATION Registered at Clinical Trials; NCT03488953 ; registered on April 5, 2018.
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Affiliation(s)
- Falk Rauchfuß
- Department of General, Visceral and Vascular Surgery, Jena University Hospital, 07747, Jena, Germany.
| | - Silvio Nadalin
- Department of General, Visceral and Transplant Surgery, University Hospital Tübingen, Tübingen, Germany
| | - Alfred Königsrainer
- Department of General, Visceral and Transplant Surgery, University Hospital Tübingen, Tübingen, Germany
| | - Utz Settmacher
- Department of General, Visceral and Vascular Surgery, Jena University Hospital, 07747, Jena, Germany
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11
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Hasselgren K, Sandström P, Røsok BI, Sparrelid E, Lindell G, Larsen PN, Larsson AL, Schultz NA, Björnbeth BA, Isaksson B, Rizell M, Björnsson B. Future Liver Remnant (FLR) Increase in Patients with Colorectal Liver Metastases Is Highest the First Week After Portal Vein Occlusion : FLR Increase in Patients with CRLM Is Highest the First Week After PVO. J Gastrointest Surg 2019; 23:556-62. [PMID: 30465187 DOI: 10.1007/s11605-018-4031-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Accepted: 05/21/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND Portal vein occlusion (PVO) is an established method to increase the volume of the future liver remnant (FLR). The main reasons for not proceeding to radical hepatectomy are lack of volume increase and tumor progression due to a wait-time interval of up to 8 weeks. The hypothesis was that the increase in FLR volume is not linear and is largest during the first weeks. METHODS Patients with colorectal liver metastases (CRLM) and standardized future liver remnant (sFLR) < 30% treated with PVO were prospectively included. All patients had at least one CT evaluation before radical hepatectomy. RESULTS Forty-eight patients were included. During the first week after PVO, the kinetic growth rate (KGR) was 5.4 (± 4), compared to 1.5 (± 2) between the first and second CT (p < 0.05). For patients reaching adequate FLR and therefore treated with radical hepatectomy, the KGR was 7 (± 4) the first week, compared to 4.3 (± 2) for patients who failed to reach a sufficient volume (p = 0.4). During the interval between the first and second CT, the KGR was 2.2 (± 2), respectively (± 0.1) (p = 0.017). DISCUSSION The increase in liver volume after PVO is largest during the first week. As KGR decreases over time, it is important to shorten the interval between PVO and the first volume evaluation; this may aid in decision-making and reduce unnecessary waiting time.
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12
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Kovács T, Déri M, Fülöp A, Pálházy T, Háfra E, Sirok D, Kiss ÁF, Lotz G, Szijártó A, Monostory K. Isoform-Dependent Changes in Cytochrome P450-Mediated Drug Metabolism after Portal Vein Ligation in the Rat. Eur Surg Res 2018; 59:301-319. [PMID: 30419560 DOI: 10.1159/000493923] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Accepted: 09/19/2018] [Indexed: 11/19/2022]
Abstract
BACKGROUND Surgical removal of complicated liver tumors may be realized in two stages via selective portal vein ligation, inducing the atrophy of portally ligated lobes and the compensatory hypertrophy of nonligated liver lobes. Unlike morphological changes, functional aspects such as hepatic cytochrome P450 (CYP)-mediated drug metabolism remain vaguely understood, despite its critical role in both drug biotransformation and hepatic functional analysis. Our goal was the multilevel characterization of hepatic CYP-mediated drug metabolism after portal vein ligation in the rat. METHODS Male Wistar rats (n = 24, 210-230 g) were analyzed either untreated (controls; n = 4) or 24/48/72/168/336 h (n = 4 each) following portal vein ligation affecting approximately 80% of the liver parenchyma. Besides the weights of ligated and nonligated lobes, pentobarbital (30 mg/kg)-induced sleeping time, CYP1A(2), CYP 2B(1/2), CYP2C(6/11/13), CYP3A(1) enzyme activities, and corresponding isoform mRNA expressions, as well as CYP3A1 protein expression were determined by in vivo sleeping test, CYP isoform-selective assays, polymerase chain reaction, and immunohistochemistry, respectively. RESULTS Portal vein ligation triggered atrophy in ligated lobes and hypertrophy nonligated lobes. Sleeping time was transiently elevated (p = 0.0451). After an initial rise, CYP1A, CYP2B, and CYP3A enzyme activities dropped until 72 h, followed by a potent increase only in the nonligated lobes, paralleled by an early (24-48 h) transcriptional activation only in nonligated lobes. CYP2C enzyme activities and mRNA levels were bilaterally rapidly decreased, showing a late reconvergence only in nonligated lobes. CYP3A1 immunohistochemistry indicated substantial differences in positivity in the early period. CONCLUSIONS Beyond the atrophy-hypertrophy complex, portal vein ligation generated a transient suppression of global and regional drug metabolism, re-established by an adaptive, CYP isoform-dependent transcriptional response of the nonligated lobes.
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Affiliation(s)
- Tibor Kovács
- Hepato-Pancreatico-Biliary Surgery Research Center Hungary, 1st Department of Surgery, Semmelweis University, Budapest, Hungary
| | - Máté Déri
- Institute of Enzymology, Research Centre for Natural Sciences, Hungarian Academy of Sciences, Budapest, Hungary
| | - András Fülöp
- Hepato-Pancreatico-Biliary Surgery Research Center Hungary, 1st Department of Surgery, Semmelweis University, Budapest, Hungary
| | - Tímea Pálházy
- Hepato-Pancreatico-Biliary Surgery Research Center Hungary, 1st Department of Surgery, Semmelweis University, Budapest, Hungary
| | - Edit Háfra
- Institute of Enzymology, Research Centre for Natural Sciences, Hungarian Academy of Sciences, Budapest, Hungary
| | - Dávid Sirok
- Institute of Enzymology, Research Centre for Natural Sciences, Hungarian Academy of Sciences, Budapest, Hungary
| | - Ádám Ferenc Kiss
- Institute of Enzymology, Research Centre for Natural Sciences, Hungarian Academy of Sciences, Budapest, Hungary
| | - Gábor Lotz
- 2nd Department of Pathology, Semmelweis University, Budapest, Hungary
| | - Attila Szijártó
- Hepato-Pancreatico-Biliary Surgery Research Center Hungary, 1st Department of Surgery, Semmelweis University, Budapest, Hungary
| | - Katalin Monostory
- Institute of Enzymology, Research Centre for Natural Sciences, Hungarian Academy of Sciences, Budapest, Hungary,
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13
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Koga Y, Beppu T, Imai K, Kuramoto K, Miyata T, Kitano Y, Nakagawa S, Okabe H, Okabe K, Yamashita YI, Chikamoto A, Baba H. Complete remission of advanced hepatocellular carcinoma following transient chemoembolization and portal vein ligation. Surg Case Rep 2018; 4:102. [PMID: 30159613 PMCID: PMC6115322 DOI: 10.1186/s40792-018-0510-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2017] [Accepted: 08/16/2018] [Indexed: 12/15/2022] Open
Abstract
Background Macroscopic diffuse-type hepatocellular carcinoma with concomitant major portal vein tumor thrombus (PVTT) and peritoneal dissemination indicates poor prognosis. Additionally, triple-positive tumor marker status is a predictor of poor outcome even after hepatectomy. Sorafenib is recommended in such patients, but it has limited therapeutic effectiveness. Case presentation A 54-year-old man was diagnosed with a liver abscess that was treated by puncture and drainage at a regional hospital. However, the diagnosis was subsequently changed to hepatocellular carcinoma with macroscopic portal vein tumor thrombus, based on the results obtained for the triple-positive tumor markers (alpha-fetoprotein, 45,928 ng/ml; protein induced by vitamin K absence or antagonist-II, 125,350 mAU/ml; and alpha-fetoprotein-L3, 38.3%). As the patient’s liver functional reserve was not adequate for curative resection, chemoembolization was performed with a hepatic arterial infusion of cisplatin (50 mg) and 5-FU (1000 mg), followed by mild embolization with cisplatin (50 mg) suspended in lipiodol (5 ml) and starch microspheres (300 mg) containing mitomycin C (4 mg). As the thrombus had progressed to the bifurcation of the right and left portal veins, the right vein was surgically ligated. Three peritoneal nodules could be identified and were removed. Three additional rounds of hepatic arterial chemotherapy/chemoembolization were performed after the initial surgery. At the 2-year evaluation, all tumor markers were observed to have normalized and diagnostic imaging showed complete remission. Conclusions Complete remission of hepatocellular carcinoma with macroscopic portal vein tumor thrombus and peritoneal dissemination was obtained with a treatment regimen that involved four rounds of hepatic arterial infusion chemotherapy and transient chemoembolization, portal vein ligation, and the removal of peritoneal dissemination. This regimen can be recommended for patients with advanced hemiliver lesions who cannot undergo curative resection.
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Affiliation(s)
- Yuki Koga
- Department of Surgery, Yamaga City Medical Center, Kumamoto, Japan.,Department of Gastroenterological Surgery, Graduate School of Life Sciences Kumamoto University, 1-1-1 Honjo, Chuo-ku, Kumamoto, 860-8556, Japan
| | - Toru Beppu
- Department of Surgery, Yamaga City Medical Center, Kumamoto, Japan.,Department of Gastroenterological Surgery, Graduate School of Life Sciences Kumamoto University, 1-1-1 Honjo, Chuo-ku, Kumamoto, 860-8556, Japan
| | - Katsunori Imai
- Department of Gastroenterological Surgery, Graduate School of Life Sciences Kumamoto University, 1-1-1 Honjo, Chuo-ku, Kumamoto, 860-8556, Japan
| | - Kunitaka Kuramoto
- Department of Surgery, Yamaga City Medical Center, Kumamoto, Japan.,Department of Gastroenterological Surgery, Graduate School of Life Sciences Kumamoto University, 1-1-1 Honjo, Chuo-ku, Kumamoto, 860-8556, Japan
| | - Tatsunori Miyata
- Department of Gastroenterological Surgery, Graduate School of Life Sciences Kumamoto University, 1-1-1 Honjo, Chuo-ku, Kumamoto, 860-8556, Japan
| | - Yuki Kitano
- Department of Gastroenterological Surgery, Graduate School of Life Sciences Kumamoto University, 1-1-1 Honjo, Chuo-ku, Kumamoto, 860-8556, Japan
| | - Shigeki Nakagawa
- Department of Gastroenterological Surgery, Graduate School of Life Sciences Kumamoto University, 1-1-1 Honjo, Chuo-ku, Kumamoto, 860-8556, Japan
| | - Hirohisa Okabe
- Department of Gastroenterological Surgery, Graduate School of Life Sciences Kumamoto University, 1-1-1 Honjo, Chuo-ku, Kumamoto, 860-8556, Japan
| | - Kazutoshi Okabe
- Department of Gastroenterological Surgery, Graduate School of Life Sciences Kumamoto University, 1-1-1 Honjo, Chuo-ku, Kumamoto, 860-8556, Japan
| | - Yo-Ichi Yamashita
- Department of Gastroenterological Surgery, Graduate School of Life Sciences Kumamoto University, 1-1-1 Honjo, Chuo-ku, Kumamoto, 860-8556, Japan
| | - Akira Chikamoto
- Department of Gastroenterological Surgery, Graduate School of Life Sciences Kumamoto University, 1-1-1 Honjo, Chuo-ku, Kumamoto, 860-8556, Japan
| | - Hideo Baba
- Department of Gastroenterological Surgery, Graduate School of Life Sciences Kumamoto University, 1-1-1 Honjo, Chuo-ku, Kumamoto, 860-8556, Japan.
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14
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Goto Y, Uchino Y, Sasaki S, Shirahama N, Nomura Y, Akiba J, Ishikawa H, Akagi Y, Tanaka H, Okuda K. Complete spontaneous necrosis of hepatocellular carcinoma accompanied by portal vein tumor thrombosis: A case report. Int J Surg Case Rep 2018; 44:220-225. [PMID: 29544184 PMCID: PMC5854926 DOI: 10.1016/j.ijscr.2018.02.045] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Revised: 02/21/2018] [Accepted: 02/28/2018] [Indexed: 01/27/2023] Open
Abstract
INTRODUCTION We report a rare case of complete spontaneous necrosis of a hepatocellular carcinoma (HCC) accompanied by portal vein tumor thrombosis (PVTT), as confirmed by resection. CASE PRESENTATION A 64-year-old man was referred to our hospital for suspected HCC. Contrast-enhanced computed tomography (CECT) findings before admission revealed a 53-mm tumor in the posterior segment of the liver and were suspicious for PVTT in the right posterior PV. Both alpha-fetoprotein (AFP) and proteins induced by vitamin K absence or antagonist-II (PIVKA-II) were elevated at 17,562 ng/mL and 153 mAU/mL, respectively. We diagnosed the findings as HCC with PVTT. Seven days after the first CECT scan, we performed CECT volumetry, which revealed that the tumor had regressed to 30 mm, along with regression of the PVTT. We performed portal vein ligation (PVL), and 10 days later, CECT revealed that the tumor had shrunk to 20 mm. AFP and PIVKA-II levels were 643 ng/mL and 14 mAU/mL, respectively. We suspected spontaneous regression of the patient's HCC, but performed a hepatectomy. Histopathology revealed a 22-mm tumor with a thin fibrous capsule and a tumor thrombus in the PV. Trabecular and pseudoglandular structures consisting of denucleated HCC epithelial cells made up both the tumor and thrombus, and the finding confirmed the spontaneous necrosis of HCC. CONCLUSIONS We present an extremely rare case of complete spontaneous necrosis of HCC with PVTT. When spontaneous necrosis is suspected, surgery should be considered because of the potential risk of residual viable cancer cells.
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Affiliation(s)
- Yuichi Goto
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Kurume University School of Medicine, 67 Asahi-machi, Kurume, 8300011, Japan.
| | - Yoshihiro Uchino
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Kurume University School of Medicine, 67 Asahi-machi, Kurume, 8300011, Japan.
| | - Shin Sasaki
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Kurume University School of Medicine, 67 Asahi-machi, Kurume, 8300011, Japan.
| | - Nobuhisa Shirahama
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Kurume University School of Medicine, 67 Asahi-machi, Kurume, 8300011, Japan.
| | - Yoriko Nomura
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Kurume University School of Medicine, 67 Asahi-machi, Kurume, 8300011, Japan.
| | - Jun Akiba
- Department of Pathology, Kurume University School of Medicine, 67 Asahi-machi, Kurume, 8300011, Japan.
| | - Hiroto Ishikawa
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Kurume University School of Medicine, 67 Asahi-machi, Kurume, 8300011, Japan.
| | - Yoshito Akagi
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Kurume University School of Medicine, 67 Asahi-machi, Kurume, 8300011, Japan.
| | - Hiroyuki Tanaka
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Kurume University School of Medicine, 67 Asahi-machi, Kurume, 8300011, Japan.
| | - Koji Okuda
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Kurume University School of Medicine, 67 Asahi-machi, Kurume, 8300011, Japan.
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15
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Khan AS, Garcia-Aroz S, Ansari MA, Atiq SM, Senter-Zapata M, Fowler K, Doyle MB, Chapman WC. Assessment and optimization of liver volume before major hepatic resection: Current guidelines and a narrative review. Int J Surg 2018; 52:74-81. [PMID: 29425829 DOI: 10.1016/j.ijsu.2018.01.042] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2017] [Revised: 01/20/2018] [Accepted: 01/29/2018] [Indexed: 02/06/2023]
Abstract
Post hepatectomy liver failure (PHLF) remains a significant cause of morbidity and mortality after major liver resection. Although the etiology of PHLF is multifactorial, an inadequate functional liver remnant (FLR) is felt to be the most important modifiable predictor of PHLF. Pre-operative evaluation of FLR function and volume is of paramount importance before proceeding with any major liver resection. Patients with inadequate or borderline FLR volume must be considered for volume optimization strategies such as portal vein embolization (PVE), two stage hepatectomy with portal vein ligation (PVL), Yttrium-90 radioembolization, and associating liver partition and portal vein ligation for staged hepatectomy (ALPPS). This paper provides an overview of assessing FLR volume and function, and discusses indications and outcomes of commonly used volume optimization strategies.
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Affiliation(s)
- Adeel S Khan
- Section of Transplant Surgery, Department of Surgery, Washington University in St. Louis, MO, USA.
| | - Sandra Garcia-Aroz
- Section of Transplant Surgery, Department of Surgery, Washington University in St. Louis, MO, USA
| | | | - Syed M Atiq
- Sanford University of South Dakota Medical Center, Sioux Falls, SD, USA
| | - Michael Senter-Zapata
- Section of Transplant Surgery, Department of Surgery, Washington University in St. Louis, MO, USA
| | - Kathryn Fowler
- Section of Transplant Surgery, Department of Surgery, Washington University in St. Louis, MO, USA
| | - M B Doyle
- Section of Transplant Surgery, Department of Surgery, Washington University in St. Louis, MO, USA
| | - W C Chapman
- Section of Transplant Surgery, Department of Surgery, Washington University in St. Louis, MO, USA
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16
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Deal R, Frederiks C, Williams L, Olthof PB, Dirscherl K, Keutgen X, Chan E, Deziel D, Hertl M, Schadde E. Rapid Liver Hypertrophy After Portal Vein Occlusion Correlates with the Degree of Collateralization Between Lobes-a Study in Pigs. J Gastrointest Surg 2018; 22:203-213. [PMID: 28766271 DOI: 10.1007/s11605-017-3512-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Accepted: 07/12/2017] [Indexed: 01/31/2023]
Abstract
BACKGROUND Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) induces more rapid liver growth than portal vein ligation (PVL). Transection of parenchyma in ALPPS may prevent the formation of collaterals between lobes. The aim of this study was to determine if abrogating the formation of collaterals through parenchymal transection impacted growth rate. METHODS Twelve Yorkshire Landrace pigs were randomized to undergo ALPPS, PVL, or "partial ALPPS" by varying degrees of parenchymal transection. Hepatic volume was measured after 7 days. Portal blood flow and pressure were measured. Portal vein collaterals were examined from epoxy casts. RESULTS PVL, ALPPS, and partial ALPPS led to volume increases of the RLL by 15.5% (range 3-22), 64% (range 45-76), and 32% (range 18-77), respectively, with significant differences between PVL and ALPPS/partial ALPPS (p < 0.05). In PVL and partial ALPPS, substantial new portal vein collaterals were found. The number of collaterals correlated inversely with the growth rate (p = 0.039). Portal vein pressure was elevated in all models after ligation suggesting hyperflow to the portal vein-supplied lobe (p < 0.05). CONCLUSIONS These data suggest that liver hypertrophy following PVL is inversely proportional to the development of collaterals. Hypertrophy after ALPPS is likely more rapid due to reduction of collaterals through transection.
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Affiliation(s)
- Rebecca Deal
- Department of Surgery - Transplant Surgery, Rush University Medical Center, 1653, W. Congress Pkwy Jelke Building 7th Floor, Chicago, IL, 60612, USA
| | - Charles Frederiks
- Department of Surgery - Transplant Surgery, Rush University Medical Center, 1653, W. Congress Pkwy Jelke Building 7th Floor, Chicago, IL, 60612, USA
| | - Lauren Williams
- Department of Surgery - Transplant Surgery, Rush University Medical Center, 1653, W. Congress Pkwy Jelke Building 7th Floor, Chicago, IL, 60612, USA
| | - Pim B Olthof
- Department of Experimental Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - Konstantin Dirscherl
- Institute of Physiology, Center for Integrative Human Physiology, University of Zurich, Winterthurerstr. 190, 8057, Zurich, Switzerland
| | - Xavier Keutgen
- Department of Surgery - Transplant Surgery, Rush University Medical Center, 1653, W. Congress Pkwy Jelke Building 7th Floor, Chicago, IL, 60612, USA
| | - Edie Chan
- Department of Surgery - Transplant Surgery, Rush University Medical Center, 1653, W. Congress Pkwy Jelke Building 7th Floor, Chicago, IL, 60612, USA
| | - Daniel Deziel
- Department of Surgery - Transplant Surgery, Rush University Medical Center, 1653, W. Congress Pkwy Jelke Building 7th Floor, Chicago, IL, 60612, USA
| | - Martin Hertl
- Department of Surgery - Transplant Surgery, Rush University Medical Center, 1653, W. Congress Pkwy Jelke Building 7th Floor, Chicago, IL, 60612, USA
| | - Erik Schadde
- Department of Surgery - Transplant Surgery, Rush University Medical Center, 1653, W. Congress Pkwy Jelke Building 7th Floor, Chicago, IL, 60612, USA. .,Institute of Physiology, Center for Integrative Human Physiology, University of Zurich, Winterthurerstr. 190, 8057, Zurich, Switzerland. .,Cantonal Hospital Winterthur, Brauerstr. 15, 8401, Winterthur, Kanton Zurich, Switzerland.
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17
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Hackl C, Brunner SM, Schmidt KM, Schlitt HJ. [Surgical innovations in treatment of metastatic colorectal cancer : Complexity of metastatic surgery as example for personalized medicine]. Chirurg 2018; 89:191-6. [PMID: 29318366 DOI: 10.1007/s00104-017-0583-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND Extensive, bilobular and multifocal colorectal liver metastases (CLM) or metastases that are critically situated require an experienced surgeon and advanced surgical techniques to enable curative resection. OBJECTIVE This article describes the toolbox of hepato-oncologic surgery including functional augmentation of liver segments by portal vein embolization/ligation, combinations of ablation and resection, two-stage resections and in situ split liver resection, also known as associating liver partition and portal vein ligation for staged hepatectomy (ALPPS). Furthermore, the curative resection of extrahepatic, oligometastatic disease are briefly discussed. MATERIAL AND METHODS Review of current literature as well as discussion of the ALPPS procedure, which was developed at our institute. RESULTS In recent years, oncologic resections for CLM have been significantly refined, leading to a constant increase of curative resection rates. CONCLUSION In a multimodality treatment setting, surgical resection of CLM remains the gold standard curative approach and even in the event of presumed hopeless cases with extensive metastasis, experienced hepatobiliary surgeons must evaluate the resectability of colorectal metastases.
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Moris D, Vernadakis S, Papalampros A, Vailas M, Dimitrokallis N, Petrou A, Dimitroulis D. Mechanistic insights of rapid liver regeneration after associating liver partition and portal vein ligation for stage hepatectomy. World J Gastroenterol 2016; 22:7613-7624. [PMID: 27672282 PMCID: PMC5011675 DOI: 10.3748/wjg.v22.i33.7613] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2016] [Revised: 06/09/2016] [Accepted: 07/06/2016] [Indexed: 02/06/2023] Open
Abstract
AIM To highlight the potential mechanisms of regeneration in the Associating Liver Partition and Portal vein ligation for Stage hepatectomy models (clinical and experimental) that could unlock the myth behind the extraordinary capability of the liver for regeneration, which would help in designing new therapeutic options for the regenerative drive in difficult setup, such as chronic liver diseases. Associating Liver Partition and Portal vein ligation for Stage hepatectomy has been recently advocated to induce rapid future liver remnant hypertrophy that significantly shortens the time for the second stage hepatectomy. The introduction of Associating Liver Partition and Portal vein ligation for Stage hepatectomy in the surgical armamentarium of therapeutic tools for liver surgeons represented a real breakthrough in the history of liver surgery.
METHODS A comprehensive literature review of Associating Liver Partition and Portal vein ligation for Stage hepatectomy and its utility in liver regeneration is performed.
RESULTS Liver regeneration after Associating Liver Partition and Portal vein ligation for Stage hepatectomy is a combination of portal flow changes and parenchymal transection that generate a systematic response inducing hepatocyte proliferation and remodeling.
CONCLUSION Associating Liver Partition and Portal vein ligation for Stage hepatectomy represents a real breakthrough in the history of liver surgery because it offers rapid liver regeneration potential that facilitate resection of liver tumors that were previously though unresectable. The jury is still out though in terms of safety, efficacy and oncological outcomes. As far as Associating Liver Partition and Portal vein ligation for Stage hepatectomy -induced liver regeneration is concerned, further research on the field should focus on the role of non-parenchymal cells in liver regeneration as well as on the effect of Associating Liver Partition and Portal vein ligation for Stage hepatectomy in liver regeneration in the setup of parenchymal liver disease.
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Lauber DT, Tihanyi DK, Czigány Z, Kovács T, Budai A, Drozgyik D, Fülöp A, Szijártó A. Liver regeneration after different degrees of portal vein ligation. J Surg Res 2016; 203:451-8. [PMID: 27363655 DOI: 10.1016/j.jss.2016.03.032] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2015] [Revised: 02/23/2016] [Accepted: 03/14/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND Selective portal vein ligation (PVL) is followed by ipsilateral atrophy and contralateral hypertrophy of the liver lobes. Although the atrophy-hypertrophy complex induced by PVL is a well-documented phenomenon, the effect of different degrees of extended portal vein occlusion on liver regeneration is not known. The aim of this study was to assess the effects of different degrees of portal occlusion on portal pressure and liver regeneration. MATERIALS AND METHODS Male Wistar rats (n = 96; 220-250 g) were randomized into three groups and underwent 70%, 80%, or 90% portal vein ligation, respectively. The portal pressure was measured immediately and 24, 48, 72, 120, and 168 h after PVL (n = 6/group/time point). The hepatic lobes and the spleen were weighed, and liver regeneration ratio was calculated. Changes in liver histology and the mitotic activity were assessed on hematoxylin-eosin stained slides. RESULTS Higher degree of portal occlusion triggered a stronger regenerative response (regeneration ratio of PVL 70%168h = 2.23 ± 0.13, PVL 80%168h = 3.11 ± 0.37, PVL 90%168h = 4.68 ± 0.48) PVL led to an immediate increase in portal pressure, the value of which changed proportionally to the mass of liver tissue deprived of portal perfusion (PVL 70%acute = 17 ± 2 mm Hg, PVL 80%acute = 19 ± 1 mm Hg, PVL 90%acute = 26 ± 4 mm Hg). Findings in histology showed necro-apoptotic lesions in the atrophic liver lobes and increased mitotic cell count in the hypertrophic lobes. The mitotic cell count of PVL 90% peaked earlier and at a significantly higher value than of PVL 70% and PVL 80% (PVL 9024h%: 96.0 ± 3.5 PVL 70%48h: 64.0 ± 2.1, PVL 80%48h: 56.3 ± 4.0). The mitotic index after 24 h showed a strong correlation with the acute portal hypertension. CONCLUSIONS A higher degree of portal vein occlusion leads to a greater regenerative response, presumably triggered by the proportional increase in portal pressure, which supports the role of the so-called "blood-flow" theory of PVL-triggered liver regeneration.
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Affiliation(s)
- David Tibor Lauber
- Hepato-Pancreatico-Biliary (HPB) Surgical Research Center, 1st Department of Surgery, Semmelweis University, Budapest, Hungary
| | - Dóra Krisztina Tihanyi
- Hepato-Pancreatico-Biliary (HPB) Surgical Research Center, 1st Department of Surgery, Semmelweis University, Budapest, Hungary
| | - Zoltán Czigány
- Hepato-Pancreatico-Biliary (HPB) Surgical Research Center, 1st Department of Surgery, Semmelweis University, Budapest, Hungary
| | - Tibor Kovács
- Hepato-Pancreatico-Biliary (HPB) Surgical Research Center, 1st Department of Surgery, Semmelweis University, Budapest, Hungary
| | - András Budai
- Hepato-Pancreatico-Biliary (HPB) Surgical Research Center, 1st Department of Surgery, Semmelweis University, Budapest, Hungary
| | - Dóra Drozgyik
- Hepato-Pancreatico-Biliary (HPB) Surgical Research Center, 1st Department of Surgery, Semmelweis University, Budapest, Hungary
| | - András Fülöp
- Hepato-Pancreatico-Biliary (HPB) Surgical Research Center, 1st Department of Surgery, Semmelweis University, Budapest, Hungary
| | - Attila Szijártó
- Hepato-Pancreatico-Biliary (HPB) Surgical Research Center, 1st Department of Surgery, Semmelweis University, Budapest, Hungary.
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Levi Sandri GB, Santoro R, Vennarecci G, Lepiane P, Colasanti M, Ettorre GM. Two-stage hepatectomy, a 10 years experience. Updates Surg 2015; 67:401-5. [PMID: 26534726 DOI: 10.1007/s13304-015-0332-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2015] [Accepted: 09/24/2015] [Indexed: 12/14/2022]
Abstract
Colorectal tumor represents in Europe the second most common cause of cancer death. Surgical resection in case of colorectal liver metastasis remain for patients the only cure. In 2003, Jaeck et al. described a one or two-stage hepatectomy combined with PVE for initially non-resectable colorectal liver metastases. The aim of our study was to retrospectively review all patients who underwent to a two-stage hepatectomy for CLM and evaluate the safety and feasibility of the procedure. We review all patient who underwent two-stage hepatectomy for CLM in our center. From 2004 to March 2014, 57 patients were candidate for a two-stage hepatectomy for CLM. Thirty-two patients (55.9 %) were men and twenty-five women (44.1 %). Median age was 60.9 years old. In forty-six cases, the two-stage hepatectomy was completed. Of these 46 patients, 38 patients completed the procedure with a PVL and 8 underwent a secondary PVE. Seven patients were planned but did not performed PVL after intraoperative evaluation and neither PVE after secondary evaluation due to disease progression. Five cases were treated with a laparoscopic approach for the first step procedure. We had no death in this series. Ten patients developed complications after the first-stage operation and 18 patients had complications after the second stage. The median interval between the two stages was 66 days. Long-term overall survival was 52 months from the first liver surgery. This study demonstrated the feasibility of two-stage hepatectomy without postoperative mortality. In our last experience in selected patient, a laparoscopic first step should be performed. Patients selection is extremely important to propose the best therapeutic option for each one.
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Affiliation(s)
- Giovanni Battista Levi Sandri
- Division of General Surgery and Liver Transplantation, S. Camillo Hospital, Circonvallazione Gianicolense 87, 00151, Rome, Lazio, Italy.
| | - Roberto Santoro
- Division of General Surgery and Liver Transplantation, S. Camillo Hospital, Circonvallazione Gianicolense 87, 00151, Rome, Lazio, Italy
| | - Giovanni Vennarecci
- Division of General Surgery and Liver Transplantation, S. Camillo Hospital, Circonvallazione Gianicolense 87, 00151, Rome, Lazio, Italy
| | - Pasquale Lepiane
- Division of General Surgery and Liver Transplantation, S. Camillo Hospital, Circonvallazione Gianicolense 87, 00151, Rome, Lazio, Italy
| | - Marco Colasanti
- Division of General Surgery and Liver Transplantation, S. Camillo Hospital, Circonvallazione Gianicolense 87, 00151, Rome, Lazio, Italy
| | - Giuseppe Maria Ettorre
- Division of General Surgery and Liver Transplantation, S. Camillo Hospital, Circonvallazione Gianicolense 87, 00151, Rome, Lazio, Italy
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Dhar DK, Mohammad GH, Vyas S, Broering DC, Malago M. A novel rat model of liver regeneration: possible role of cytokine induced neutrophil chemoattractant-1 in augmented liver regeneration. Ann Surg Innov Res 2015; 9:11. [PMID: 26535054 PMCID: PMC4631081 DOI: 10.1186/s13022-015-0020-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/22/2015] [Accepted: 10/14/2015] [Indexed: 02/08/2023]
Abstract
Background Liver resection is the mainstay of treatment for most of the liver tumors. Liver has a unique capability to restore the lost volume following resection, however, most of the primary tumors grow in a liver with preexisting parenchymal diseases
and secondary tumors often present in multiple liver lobes precluding a safe curative resection. Two-stage hepatectomy and portal vein ligation (PVL) are used to achieve a safer future remnant liver volume (FRLV), however, these procedures take several weeks to achieve adequate FRLV. A recently introduced faster alternative two-stage hepatectomy, also know as associated liver partitioning and portal vein ligation for staged hepatectomy (ALPPS), produces a desirable FRLV in days. Methods To have an insight into the mechanism of ALPPS associated liver regeneration, we reproduced a rat model of ALPPS and compared the results with the PVL group. Results Our results convincingly showed an advantage of the ALPPS procedure over PVL group in terms of early regeneration, however, in 1-week time the amount of regeneration was comparable. An early regeneration in the ALPPS group coincided with an early entry of hepatocytes into the cell proliferation phase, a significant increase in portal pressure and increase in hepatic enzymes in the ALPPS group compared with the PVL group. According to the protein array evaluation of 29 cytokines/chemokines, cytokine induced neutrophil chemoattractant-1 had the highest expression whereas IL-6 had the highest fold (>6 vs PVL group) expression at the early phase of regeneration in the ALPPS group. Conclusions This unique rat model of ALPPS would help to improve our understanding about the liver generation process and also will help in further refinement of the ALPPS procedure for the clinical benefit. Electronic supplementary material The online version of this article (doi:10.1186/s13022-015-0020-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Dipok Kumar Dhar
- Institute for Liver and Digestive Health, Royal Free Hospital, University College London, Pond Street, London, NW3 2PF UK ; Department of Organ Transplantation Centre and Comparative Medicine Department, King Faisal Specialist Hospital and Research Centre, MBC 03 P.O. Box 3354, Riyadh, 11211 Saudi Arabia
| | - Goran Hamid Mohammad
- Institute for Liver and Digestive Health, Royal Free Hospital, University College London, Pond Street, London, NW3 2PF UK ; Chemistry Department, School of Science, University of Sulaimani, Sulaimanyah, Kurdistan Region, Iraq
| | - Soumil Vyas
- Department of Surgery and Interventional Sciences, Royal Free Hospital, University College London, Pond Street, London, NW3 2PF UK
| | - Dieter Clemens Broering
- Department of Organ Transplantation Centre and Comparative Medicine Department, King Faisal Specialist Hospital and Research Centre, MBC 03 P.O. Box 3354, Riyadh, 11211 Saudi Arabia
| | - Massimo Malago
- Institute for Liver and Digestive Health, Royal Free Hospital, University College London, Pond Street, London, NW3 2PF UK ; Department of Surgery and Interventional Sciences, Royal Free Hospital, University College London, Pond Street, London, NW3 2PF UK
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22
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She WH, Chok KSH. Strategies to increase the resectability of hepatocellular carcinoma. World J Hepatol 2015; 7:2147-2154. [PMID: 26328026 PMCID: PMC4550869 DOI: 10.4254/wjh.v7.i18.2147] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2015] [Revised: 08/10/2015] [Accepted: 08/21/2015] [Indexed: 02/06/2023] Open
Abstract
Hepatocellular carcinoma (HCC) is best treated by liver transplantation, but the applicability of transplantation is greatly limited. Tumor resection in partial hepatectomy is hence resorted to. However, in most parts of the world, only 20%-30% of HCCs are resectable. The main reason for such a low resectability is a future liver remnant too small to be sufficient for the patient. To allow more HCC patients to undergo curative hepatectomy, a variety of ways have been developed to increase the resectability of HCC, mainly ways to increase the future liver remnants in patients through hypertrophy. They include portal vein embolization, sequential transarterial chemoembolization and portal vein embolization, staged hepatectomy, two-staged hepatectomy with portal vein ligation, and Associating Liver Partition and Portal Vein Ligation in Staged Hepatectomy. Herein we review, describe and evaluate these different ways, ways that can be life-saving.
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Fülöp A, Budai A, Czigány Z, Lotz G, Dezső K, Paku S, Harsányi L, Szijártó A. Alterations in hepatic lobar function in regenerating rat liver. J Surg Res 2015; 197:307-17. [PMID: 25963167 DOI: 10.1016/j.jss.2015.04.033] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2015] [Revised: 03/16/2015] [Accepted: 04/09/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND Ligation of a branch of the portal vein redirects portal blood to nonligated lobes resulting in lobar hypertrophy. Although the effect of portal vein ligation on liver volume is well documented, the parallel alterations in liver function are still the subject of controversy. Our aim was to assess the time-dependent reactions of regional hepatic function to portal vein ligation by selective biliary drainage. METHODS Male Wistar rats (n = 44) underwent 80% portal vein ligation. Before the operation as well as 1, 2, 3, 5, and 7 d after circulation, morphology and function (laboratory blood test; hepatic bile flow; plasma disappearance rate of indocyanine green; and biliary indocyanine green excretion) of the liver were examined. RESULTS Although portal vein ligation affected liver circulation and morphology to a great extent, serum albumin levels, bilirubin levels, and total hepatic bile flow did not change significantly after the operation. Nevertheless, plasma disappearance rate and biliary indocyanine green excretion indicated a temporary impairment of total liver function with the lowest value on the second day and normalization by the fifth day. Bile production and biliary indocyanine green excretion of ligated lobes decreased rapidly after the operation and remained persistently suppressed, whereas the secretory function of nonligated lobes--after a temporary decline--showed a greater increase than the weight of the lobes. CONCLUSIONS Portal vein ligation induced temporary impairment of total liver function, followed by rapid recovery mainly by reason of increase in the function of nonligated lobes. Functional increase in nonligated lobes was more pronounced than suggested by the degree of volume gain.
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Affiliation(s)
- András Fülöp
- 1st Department of Surgery, Semmelweis University, Budapest, Hungary
| | - András Budai
- 1st Department of Surgery, Semmelweis University, Budapest, Hungary
| | - Zoltán Czigány
- 1st Department of Surgery, Semmelweis University, Budapest, Hungary
| | - Gábor Lotz
- 2nd Department of Pathology, Semmelweis University, Budapest, Hungary
| | - Katalin Dezső
- 1st Department of Pathology and Experimental Cancer Research, Semmelweis University, Budapest, Hungary
| | - Sándor Paku
- 1st Department of Pathology and Experimental Cancer Research, Semmelweis University, Budapest, Hungary; Tumor Progression Research Group, Joint Research Organization of the Hungarian Academy of Sciences and Semmelweis University, Budapest, Hungary
| | - László Harsányi
- 1st Department of Surgery, Semmelweis University, Budapest, Hungary
| | - Attila Szijártó
- 1st Department of Surgery, Semmelweis University, Budapest, Hungary.
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Dimitroulis D, Tsaparas P, Valsami S, Mantas D, Spartalis E, Markakis C, Kouraklis G. Indications, limitations and maneuvers to enable extended hepatectomy: Current trends. World J Gastroenterol 2014; 20:7887-7893. [PMID: 24976725 PMCID: PMC4069316 DOI: 10.3748/wjg.v20.i24.7887] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2013] [Revised: 02/11/2014] [Accepted: 03/10/2014] [Indexed: 02/06/2023] Open
Abstract
The liver is a solid organ with a wide variety of primary benign or malignant tumors as well as metastatic lesions. Surgical resection of these tumors remains the only curative modality. Several limitations, however, do not allow the performance of these operations. This review evaluates the indications and limitations regarding these extended hepatic resections, as well as describing all the manipulations that increase the candidates for such operations. A thorough review of the literature was performed in order to define indications for extended hepatectomy, as well as to present all methods that contribute to increasing the volume of the future remnant liver. The role of portal vein ligation, portal vein embolization, two-stage hepatectomy, and in situ liver transection are evaluated in the setting of indications and results. Extended hepatectomies are a necessity due to oncological reasons. All methods developed in order to increase the volume of the remnant liver are safe and efficient. in situ liver transection is a novel and revolutionary two-step procedure for extended hepatic resections. Further clinical studies are required to estimate long-term results and the oncological basis of this technique.
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Dupré A, Gagnière J, Tixier L, Ines DD, Perbet S, Pezet D, Buc E. Massive hepatic necrosis with toxic liver syndrome following portal vein ligation. World J Gastroenterol 2013; 19:2826-2829. [PMID: 23687421 PMCID: PMC3653158 DOI: 10.3748/wjg.v19.i18.2826] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2012] [Revised: 01/08/2013] [Accepted: 02/06/2013] [Indexed: 02/06/2023] Open
Abstract
Right portal vein ligation (PVL) is a safe and widespread procedure to induce controlateral liver hypertrophy for the treatment of bilobar colorectal liver metastases. We report a case of a 60-year-old man treated by both right PVL and ligation of the glissonian branches of segment 4 for colorectal liver metastases surrounding the right and median hepatic veins. After surgery, the patient developed massive hepatic necrosis with secondary pulmonary and renal insufficiency requiring transfer to the intensive care unit. This so-called toxic liver syndrome finally regressed after hemofiltration and positive oxygen therapy. Diagnosis of acute congestion of the ligated lobe was suspected. The mechanism suspected was an increase in arterial inflow secondary to portal vein ligation concomitant with a decrease in venous outflow due to liver metastases encircling the right and median hepatic vein. This is the first documented case of toxic liver syndrome in a non-cirrhotic patient with favorable issue, and a rare complication of PVL.
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Iida H, Aihara T, Ikuta S, Yoshie H, Yamanaka N. Comparison of percutaneous transhepatic portal vein embolization and unilateral portal vein ligation. World J Gastroenterol 2012; 18:2371-6. [PMID: 22654428 PMCID: PMC3353371 DOI: 10.3748/wjg.v18.i19.2371] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2011] [Revised: 11/28/2011] [Accepted: 12/31/2011] [Indexed: 02/06/2023] Open
Abstract
AIM: To compare the effect of percutaneous transhepatic portal vein embolization (PTPE) and unilateral portal vein ligation (PVL) on hepatic hemodynamics and right hepatic lobe (RHL) atrophy.
METHODS: Between March 2005 and March 2009, 13 cases were selected for PTPE (n = 9) and PVL (n = 4) in the RHL. The PTPE group included hilar bile duct carcinoma (n = 2), intrahepatic cholangiocarcinoma (n = 2), hepatocellular carcinoma (n = 2) and liver metastasis (n = 3). The PVL group included hepatocellular carcinoma (n = 2) and liver metastasis (n = 2). In addition, observation of postoperative hepatic hemodynamics obtained from computed tomography and Doppler ultrasonography was compared between the two groups.
RESULTS: Mean ages in the two groups were 58.9 ± 2.9 years (PVL group) vs 69.7 ± 3.2 years (PTPE group), which was a significant difference (P = 0.0002). Among the indicators of liver function, including serum albumin, serum bilirubin, aspartate aminotransferase, alanine aminotransferase, platelets and indocyanine green retention rate at 15 min, no significant differences were observed between the two groups. Preoperative RHL volumes in the PTPE and PVL groups were estimated to be 804.9 ± 181.1 mL and 813.3 ± 129.7 mL, respectively, with volume rates of 68.9% ± 2.8% and 69.2% ± 4.2%, respectively. There were no significant differences in RHL volumes (P = 0.83) and RHL volume rates (P = 0.94), respectively. At 1 mo after PTPE or PVL, postoperative RHL volumes in the PTPE and PVL groups were estimated to be 638.4 ± 153.6 mL and 749.8 ± 121.9 mL, respectively, with no significant difference (P = 0.14). Postoperative RHL volume rates in the PTPE and PVL groups were estimated to be 54.6% ± 4.2% and 63.7% ± 3.9%, respectively, which was a significant difference (P = 0.0056). At 1 mo after the operation, the liver volume atrophy rate was 14.3% ± 2.3% in the PTPE group and 5.4% ± 1.6% in the PVL group, which was a significant difference (P = 0.0061).
CONCLUSION: PTPE is a more effective procedure than PVL because PTPE is able to occlude completely the portal branch throughout the right peripheral vein.
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Iida H, Yasui C, Aihara T, Ikuta S, Yoshie H, Yamanaka N. Simultaneous bile duct and portal venous branch ligation in two-stage hepatectomy. World J Gastroenterol 2011; 17:3554-9. [PMID: 21941424 PMCID: PMC3163255 DOI: 10.3748/wjg.v17.i30.3554] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2010] [Revised: 12/21/2010] [Accepted: 12/28/2010] [Indexed: 02/06/2023] Open
Abstract
Hepatectomy is an effective surgical treatment for multiple bilobar liver metastases from colon cancer; however, one of the primary obstacles to completing surgical resection for these cases is an insufficient volume of the future remnant liver, which may cause postoperative liver failure. To induce atrophy of the unilateral lobe and hypertrophy of the future remnant liver, procedures to occlude the portal vein have been conventionally used prior to major hepatectomy. We report a case of a 50-year-old woman in whom two-stage hepatectomy was performed in combination with intraoperative ligation of the portal vein and the bile duct of the right hepatic lobe. This procedure was designed to promote the atrophic effect on the right hepatic lobe more effectively than the conventional technique, and to the best of our knowledge, it was used for the first time in the present case. Despite successful induction of liver volume shift as well as the following procedure, the patient died of subsequent liver failure after developing recurrent tumors. We discuss the first case in which simultaneous ligation of the portal vein and the biliary system was successfully applied as part of the first step of two-stage hepatectomy.
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Sakai N, Clarke CN, Schuster R, Blanchard J, Tevar AD, Edwards MJ, Lentsch AB. Portal vein ligation accelerates tumor growth in ligated, but not contralateral lobes. World J Gastroenterol 2010; 16:3816-26. [PMID: 20698045 PMCID: PMC2921094 DOI: 10.3748/wjg.v16.i30.3816] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate the mechanisms of liver growth and atrophy after portal vein ligation (PVL) and its effects on tumor growth.
METHODS: Mice were subjected to PVL, partial hepatectomy, or sham surgery. The morphological alterations, activation of transcription factors, and expression of cytokines and growth factors involved in liver regeneration were evaluated. In a separate set of experiments, murine colorectal carcinoma cells were injected via the portal vein and the effect of each operation on liver tumor growth was studied.
RESULTS: Liver regeneration after PVL and partial hepatectomy were very similar. In ligated lobes, various cytokines, transcription factors and regulatory factors were significantly upregulated compared to non-ligated lobes after PVL. Atrophy in ligated lobes was a result of early necrosis followed by later apoptosis. Tumor growth was significantly accelerated in ligated compared to non-ligated lobes.
CONCLUSION: Tumor growth was accelerated in ligated liver lobes and appeared to be a result of increased growth factor expression.
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