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Bozkurt E, Sijberden JP, Kasai M, Abu Hilal M. Efficacy and perioperative safety of different future liver remnant modulation techniques: a systematic review and network meta-analysis. HPB (Oxford) 2024; 26:465-475. [PMID: 38245490 DOI: 10.1016/j.hpb.2024.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 11/20/2023] [Accepted: 01/03/2024] [Indexed: 01/22/2024]
Abstract
BACKGROUND In daily clinical practice, different future liver remnant (FLR) modulation techniques are increasingly used to allow a liver resection in patients with insufficient FLR volume. This systematic review and network meta-analysis aims to compare the efficacy and perioperative safety of portal vein ligation (PVL), portal vein embolization (PVE), liver venous deprivation (LVD) and associating liver partition and portal vein ligation for staged hepatectomy (ALPPS). METHODS A literature search for studies comparing liver resections following different FLR modulation techniques was performed in MEDLINE, Embase and Cochrane Central, and pairwise and network meta-analyses were conducted. RESULTS Overall, 23 studies comprising 1557 patients were included. LVD achieved the greatest increase in FLR (17.32 %, 95% CI 2.49-32.15), while ALPPS was most effective in preventing dropout before the completion hepatectomy (OR 0.29, 95% CI 0.15-0.55). PVL tended to be associated with a longer time to completion hepatectomy (MD 5.78 days, 95% CI -0.67-12.23). Liver failure occurred less frequently after LVD, compared to PVE (OR 0.35, 95% CI 0.14-0.87) and ALPPS (OR 0.28, 95% CI 0.09-0.85). DISCUSSION ALPPS and LVD seem superior to PVE and PVL in terms of achieved FLR increase and subsequent treatment completion. LVD was associated with lower rates of post hepatectomy liver failure, compared to both PVE and ALPPS. A summary of the protocol has been prospectively registered in the PROSPERO database (CRD42022321474).
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Affiliation(s)
- Emre Bozkurt
- Department of Surgery, Poliambulanza Foundation Hospital, Brescia, Italy; Department of Surgery, Hepatopancreatobiliary Surgery Division, Koç University Hospital, Istanbul, Turkey
| | - Jasper P Sijberden
- Department of Surgery, Poliambulanza Foundation Hospital, Brescia, Italy; Amsterdam UMC Location University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands; Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Meidai Kasai
- Department of Surgery, Meiwa Hospital, Hyogo, Japan
| | - Mohammad Abu Hilal
- Department of Surgery, Poliambulanza Foundation Hospital, Brescia, Italy; Department of Surgery, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom.
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Rushbrook SM, Kendall TJ, Zen Y, Albazaz R, Manoharan P, Pereira SP, Sturgess R, Davidson BR, Malik HZ, Manas D, Heaton N, Prasad KR, Bridgewater J, Valle JW, Goody R, Hawkins M, Prentice W, Morement H, Walmsley M, Khan SA. British Society of Gastroenterology guidelines for the diagnosis and management of cholangiocarcinoma. Gut 2023; 73:16-46. [PMID: 37770126 PMCID: PMC10715509 DOI: 10.1136/gutjnl-2023-330029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 09/05/2023] [Indexed: 10/03/2023]
Abstract
These guidelines for the diagnosis and management of cholangiocarcinoma (CCA) were commissioned by the British Society of Gastroenterology liver section. The guideline writing committee included a multidisciplinary team of experts from various specialties involved in the management of CCA, as well as patient/public representatives from AMMF (the Cholangiocarcinoma Charity) and PSC Support. Quality of evidence is presented using the Appraisal of Guidelines for Research and Evaluation (AGREE II) format. The recommendations arising are to be used as guidance rather than as a strict protocol-based reference, as the management of patients with CCA is often complex and always requires individual patient-centred considerations.
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Affiliation(s)
- Simon M Rushbrook
- Department of Hepatology, Norfolk and Norwich University Hospitals NHS Trust, Norwich, UK
| | - Timothy James Kendall
- Division of Pathology, University of Edinburgh, Edinburgh, UK
- University of Edinburgh MRC Centre for Inflammation Research, Edinburgh, UK
| | - Yoh Zen
- Department of Pathology, King's College London, London, UK
| | - Raneem Albazaz
- Department of Radiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | | | | | - Richard Sturgess
- Digestive Diseases Unit, Aintree University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Brian R Davidson
- Department of Surgery, Royal Free Campus, UCL Medical School, London, UK
| | - Hassan Z Malik
- Department of Surgery, University Hospital Aintree, Liverpool, UK
| | - Derek Manas
- Department of Surgery, Newcastle University, Newcastle upon Tyne, Tyne and Wear, UK
| | - Nigel Heaton
- Department of Hepatobiliary and Pancreatic Surgery, King's College London, London, UK
| | - K Raj Prasad
- John Goligher Colorectal Unit, St. James University Hospital, Leeds, UK
| | - John Bridgewater
- Department of Oncology, UCL Cancer Institute, University College London, London, UK
| | - Juan W Valle
- Department of Medical Oncology, The Christie NHS Foundation Trust/University of Manchester, Manchester, UK
| | - Rebecca Goody
- Department of Oncology, St James's University Hospital, Leeds, UK
| | - Maria Hawkins
- Department of Medical Physics and Biomedical Engineering, University College London, London, UK
| | - Wendy Prentice
- King's College Hospital NHS Foundation Trust, London, UK
| | | | | | - Shahid A Khan
- Hepatology and Gastroenterology Section, Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
- Imperial College Healthcare NHS Trust, London, UK
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3
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Shrikhande SV, Kunte AR, Chopde AN, Chaudhari VA, Bhandare MS. Big data and RCT's in surgical oncology: Impact on improving hepatopancreatobiliary cancer surgical care on the global stage. J Surg Oncol 2023; 128:1003-1010. [PMID: 37818909 DOI: 10.1002/jso.27467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Revised: 09/13/2023] [Accepted: 09/14/2023] [Indexed: 10/13/2023]
Abstract
Randomized controlled clinical trials (RCTs) are at the heart of "evidence-based" medicine. Conducting well-designed RCTs for surgical procedures is often challenged by inadequate recruitment accrual, blinding, or standardization of the surgical procedure, as well as lack of funding and evolution of the treatment strategy during the many years over which such trials are conducted. In addition, most clinical trials are performed in academic high-volume centers with highly selected patients, which may not necessarily reflect a "real-world" practice setting. Large databases provide easy and inexpensive access to data on a large and diverse patient population at a variety of treatment centers. Furthermore, large database studies provide the opportunity to answer questions that would be impossible or very arduous to answer using RCTs, including questions regarding health policy efficacy, trends in surgical practice, access to health care, the impact of hospital volume, and adherence to practice guidelines, as well as research questions regarding rare disease, infrequent surgical outcomes, and specific subpopulations. Prospective data registries may also allow for quality benchmarking and auditing. There are several high-quality RCTs providing evidence to support current practices in hepatopancreatobiliary (HPB) oncology. Evidence from big data bridges the gap in several instances where RCTs are lacking. In this article, we review the evidence from RCTs and big data in HPB oncology identify the existing lacunae, and discuss the future directions of research in HPB oncology.
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Affiliation(s)
- Shailesh V Shrikhande
- Gastrointestinal and Hepato-Pancreato-Biliary Service, Department of Surgical Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Aditya R Kunte
- Gastrointestinal and Hepato-Pancreato-Biliary Service, Department of Surgical Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Amit N Chopde
- Gastrointestinal and Hepato-Pancreato-Biliary Service, Department of Surgical Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Vikram A Chaudhari
- Gastrointestinal and Hepato-Pancreato-Biliary Service, Department of Surgical Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Manish S Bhandare
- Gastrointestinal and Hepato-Pancreato-Biliary Service, Department of Surgical Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
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Du S, Wang Z, Lin D. A bibliometric and visualized analysis of preoperative future liver remnant augmentation techniques from 1997 to 2022. Front Oncol 2023; 13:1185885. [PMID: 37333827 PMCID: PMC10272555 DOI: 10.3389/fonc.2023.1185885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 05/22/2023] [Indexed: 06/20/2023] Open
Abstract
Background The size and function of the future liver remnant (FLR) is an essential consideration for both eligibility for treatment and postoperative prognosis when planning surgical hepatectomy. Over time, a variety of preoperative FLR augmentation techniques have been investigated, from the earliest portal vein embolization (PVE) to the more recent Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) and liver venous deprivation (LVD) procedures. Despite numerous publications on this topic, no bibliometric analysis has yet been conducted. Methods Web of Science Core Collection (WoSCC) database was searched to identify studies related to preoperative FLR augmentation techniques published from 1997 to 2022. The analysis was performed using the CiteSpace [version 6.1.R6 (64-bit)] and VOSviewer [version 1.6.19]. Results A total of 973 academic studies were published by 4431 authors from 920 institutions in 51 countries/regions. The University of Zurich was the most published institution while Japan was the most productive country. Eduardo de Santibanes had the most published articles, and Masato Nagino was the most frequently co-cited author. The most frequently published journal was HPB, and the most cited journal was Ann Surg, with 8088 citations. The main aspects of preoperative FLR augmentation technique is to enhance surgical technology, expand clinical indications, prevent and treat postoperative complications, ensure long-term survival, and evaluate the growth rate of FLR. Recently, hot keywords in this field include ALPPS, LVD, and Hepatobiliary Scintigraphy. Conclusion This bibliometric analysis provides a comprehensive overview of preoperative FLR augmentation techniques, offering valuable insights and ideas for scholars in this field.
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Wang W, Ye CH, Deng ZF, Wang JL, Zhang L, Bao L, Xu BH, Zhu H, Guo Y, Wen Z. CD4 +CD25 + regulatory T cells decreased future liver remnant after associating liver partition and portal vein ligation for staged hepatectomy. World J Gastrointest Surg 2023; 15:917-930. [PMID: 37342857 PMCID: PMC10277939 DOI: 10.4240/wjgs.v15.i5.917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Revised: 12/22/2022] [Accepted: 04/04/2023] [Indexed: 05/26/2023] Open
Abstract
BACKGROUND Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) is an innovative surgical approach for the treatment of massive hepatocellular carcinoma (HCC), the key to successful planned stage 2 ALPPS is future liver remnant (FLR) volume growth, but the exact mechanism has not been elucidated. The correlation between regulatory T cells (Tregs) and postoperative FLR regeneration has not been reported.
AIM To investigate the effect of CD4+CD25+ Tregs on FLR regeneration after ALPPS.
METHODS Clinical data and specimens were collected from 37 patients who developed massive HCC treated with ALPPS. Flow cytometry was performed to detect changes in the proportion of CD4+CD25+ Tregs to CD4+ T cells in peripheral blood before and after ALPPS. To analyze the relationship between peripheral blood CD4+CD25+ Treg proportion and clinicopathological information and liver volume.
RESULTS The postoperative CD4+CD25+ Treg proportion in stage 1 ALPPS was negatively correlated with the amount of proliferation volume, proliferation rate, and kinetic growth rate (KGR) of the FLR after stage 1 ALPPS. Patients with low Treg proportion had significantly higher KGR than those with high Treg proportion (P = 0.006); patients with high Treg proportion had more severe postoperative pathological liver fibrosis than those with low Treg proportion (P = 0.043). The area under the receiver operating characteristic curve between the percentage of Tregs and proliferation volume, proliferation rate, and KGR were all greater than 0.70.
CONCLUSION CD4+CD25+ Tregs in the peripheral blood of patients with massive HCC at stage 1 ALPPS were negatively correlated with indicators of FLR regeneration after stage 1 ALPPS and may influence the degree of fibrosis in patients’ livers. Treg percentage was highly accurate in predicting the FLR regeneration after stage 1 ALPPS.
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Affiliation(s)
- Wei Wang
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning 530021, Guangxi Zhuang Autonomous Region, China
- Guangxi Key Laboratory of Enhanced Recovery after Surgery for Gastrointestinal Cancer, The First Affiliated Hospital of Guangxi Medical University, Nanning 530021, Guangxi Zhuang Autonomous Region, China
| | - Chun-Hui Ye
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning 530021, Guangxi Zhuang Autonomous Region, China
- Guangxi Key Laboratory of Enhanced Recovery after Surgery for Gastrointestinal Cancer, The First Affiliated Hospital of Guangxi Medical University, Nanning 530021, Guangxi Zhuang Autonomous Region, China
| | - Zhen-Feng Deng
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning 530021, Guangxi Zhuang Autonomous Region, China
- Guangxi Key Laboratory of Enhanced Recovery after Surgery for Gastrointestinal Cancer, The First Affiliated Hospital of Guangxi Medical University, Nanning 530021, Guangxi Zhuang Autonomous Region, China
| | - Ji-Long Wang
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning 530021, Guangxi Zhuang Autonomous Region, China
- Guangxi Key Laboratory of Enhanced Recovery after Surgery for Gastrointestinal Cancer, The First Affiliated Hospital of Guangxi Medical University, Nanning 530021, Guangxi Zhuang Autonomous Region, China
| | - Ling Zhang
- Department of Radiology, The First Affiliated Hospital of Guangxi Medical University, Nanning 530021, Guangxi Zhuang Autonomous Region, China
| | - Li Bao
- Key Laboratory of Cancer Prevention and Therapy, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Tianjin 300000, China
| | - Bang-Hao Xu
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning 530021, Guangxi Zhuang Autonomous Region, China
- Guangxi Key Laboratory of Enhanced Recovery after Surgery for Gastrointestinal Cancer, The First Affiliated Hospital of Guangxi Medical University, Nanning 530021, Guangxi Zhuang Autonomous Region, China
| | - Hai Zhu
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning 530021, Guangxi Zhuang Autonomous Region, China
- Guangxi Key Laboratory of Enhanced Recovery after Surgery for Gastrointestinal Cancer, The First Affiliated Hospital of Guangxi Medical University, Nanning 530021, Guangxi Zhuang Autonomous Region, China
| | - Ya Guo
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning 530021, Guangxi Zhuang Autonomous Region, China
- Guangxi Key Laboratory of Enhanced Recovery after Surgery for Gastrointestinal Cancer, The First Affiliated Hospital of Guangxi Medical University, Nanning 530021, Guangxi Zhuang Autonomous Region, China
| | - Zhang Wen
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning 530021, Guangxi Zhuang Autonomous Region, China
- Guangxi Key Laboratory of Enhanced Recovery after Surgery for Gastrointestinal Cancer, The First Affiliated Hospital of Guangxi Medical University, Nanning 530021, Guangxi Zhuang Autonomous Region, China
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Calderon Novoa F, Ardiles V, de Santibañes E, Pekolj J, Goransky J, Mazza O, Sánchez Claria R, de Santibañes M. Pushing the Limits of Surgical Resection in Colorectal Liver Metastasis: How Far Can We Go? Cancers (Basel) 2023; 15:cancers15072113. [PMID: 37046774 PMCID: PMC10093442 DOI: 10.3390/cancers15072113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 03/24/2023] [Accepted: 03/30/2023] [Indexed: 04/05/2023] Open
Abstract
Colorectal cancer is the third most common cancer worldwide, and up to 50% of all patients diagnosed will develop metastatic disease. Management of colorectal liver metastases (CRLM) has been constantly improving, aided by newer and more effective chemotherapy agents and the use of multidisciplinary teams. However, the only curative treatment remains surgical resection of the CRLM. Although survival for surgically resected patients has shown modest improvement, this is mostly because of the fact that what is constantly evolving is the indication for resection. Surgeons are constantly pushing the limits of what is considered resectable or not, thus enhancing and enlarging the pool of patients who can be potentially benefited and even cured with aggressive surgical procedures. There are a variety of procedures that have been developed, which range from procedures to stimulate hepatic growth, such as portal vein embolization, two-staged hepatectomy, or the association of both, to technically challenging procedures such as simultaneous approaches for synchronous metastasis, ex-vivo or in-situ perfusion with total vascular exclusion, or even liver transplant. This article reviewed the major breakthroughs in liver surgery for CRLM, showing how much has changed and what has been achieved in the field of CRLM.
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Affiliation(s)
- Francisco Calderon Novoa
- Department of Surgery, Division of HPB Surgery, Hospital Italiano de Buenos Aires, Buenos Aires C1199, Argentina
| | - Victoria Ardiles
- Department of Surgery, Division of HPB Surgery, Hospital Italiano de Buenos Aires, Buenos Aires C1199, Argentina
| | - Eduardo de Santibañes
- Department of Surgery, Division of HPB Surgery, Hospital Italiano de Buenos Aires, Buenos Aires C1199, Argentina
| | - Juan Pekolj
- Department of Surgery, Division of HPB Surgery, Hospital Italiano de Buenos Aires, Buenos Aires C1199, Argentina
| | - Jeremias Goransky
- Department of Surgery, Division of HPB Surgery, Hospital Italiano de Buenos Aires, Buenos Aires C1199, Argentina
| | - Oscar Mazza
- Department of Surgery, Division of HPB Surgery, Hospital Italiano de Buenos Aires, Buenos Aires C1199, Argentina
| | - Rodrigo Sánchez Claria
- Department of Surgery, Division of HPB Surgery, Hospital Italiano de Buenos Aires, Buenos Aires C1199, Argentina
| | - Martín de Santibañes
- Department of Surgery, Division of HPB Surgery, Hospital Italiano de Buenos Aires, Buenos Aires C1199, Argentina
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Stage IV Colorectal Cancer Management and Treatment. J Clin Med 2023; 12:jcm12052072. [PMID: 36902858 PMCID: PMC10004676 DOI: 10.3390/jcm12052072] [Citation(s) in RCA: 20] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Revised: 03/02/2023] [Accepted: 03/04/2023] [Indexed: 03/08/2023] Open
Abstract
(1) Background: Colorectal cancer (CRC) is the third most common cancer and the second leading cause of cancer-related mortality worldwide. Up to 50% of patients with CRC develop metastatic CRC (mCRC). Surgical and systemic therapy advances can now offer significant survival advantages. Understanding the evolving treatment options is essential for decreasing mCRC mortality. We aim to summarize current evidence and guidelines regarding the management of mCRC to provide utility when making a treatment plan for the heterogenous spectrum of mCRC. (2) Methods: A comprehensive literature search of PubMed and current guidelines written by major cancer and surgical societies were reviewed. The references of the included studies were screened to identify additional studies that were incorporated as appropriate. (3) Results: The standard of care for mCRC primarily consists of surgical resection and systemic therapy. Complete resection of liver, lung, and peritoneal metastases is associated with better disease control and survival. Systemic therapy now includes chemotherapy, targeted therapy, and immunotherapy options that can be tailored by molecular profiling. Differences between colon and rectal metastasis management exist between major guidelines. (4) Conclusions: With the advances in surgical and systemic therapy, as well as a better understanding of tumor biology and the importance of molecular profiling, more patients can anticipate prolonged survival. We provide a summary of available evidence for the management of mCRC, highlighting the similarities and presenting the difference in available literature. Ultimately, a multidisciplinary evaluation of patients with mCRC is crucial to selecting the appropriate pathway.
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Impact of neoadjuvant chemotherapy on post-hepatectomy regeneration for patients with colorectal cancer liver metastasis - Systematic review and meta-analysis. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2023; 49:533-541. [PMID: 36631347 DOI: 10.1016/j.ejso.2022.12.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 12/18/2022] [Accepted: 12/30/2022] [Indexed: 01/05/2023]
Abstract
BACKGROUND Today, there is still debate on the impact of neoadjuvant chemotherapy (NeoChem) on liver regeneration (LivReg). The objectives of this study were to assess the impact of NeoChem and its characteristics (addition of bevacizumab, number of cycles and time from end of NeoChem) on post-hepatectomy LivReg. MATERIAL & METHODS Studies reporting LivReg in patients submitted to liver resection were included. Pubmed, Scopus, Web of Science, Embase, and Cochrane databases were searched. Only studies comparing NeoChem vs no chemotherapy or comparing chemotherapy characteristics from 1990 to present were included. Two researchers individually screened the identified records registered in a predesigned database. Primary outcome was future liver remnant regeneration rate (FLR3). Bias of the studies was evaluated with the ROBINS-I tool, and quality of evidence with the GRADE system. Data was presented as mean difference or standard mean difference. RESULTS Eight studies with a total of 681 patients were selected. Seven were retrospective and one prospective comparative cohort studies. In patients submitted to major hepatectomy, NeoChem did not have an impact on LivReg (MD 3.12, 95% CI -2,12-8.36, p 0,24). Adding bevacizumab to standard NeoChem was associated with better FLR3 (SMD 0.45, 95% CI 0.19-0.71, p 0.0006). DISCUSSION The main drawback of this review is the retrospective nature of the available studies. NeoChem does not have a negative impact on postoperative LivReg in patients submitted to liver resection. Regimens with bevacizumab seem to be associated with better postoperative LivReg rates when compared to standard NeoChem.
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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. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 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] [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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Zhao J, Zhao W, Xu H, Luan W, Wang X, Fang Y, Yu L. Corosolic acid inhibits tumour growth without compromising associating liver partition and portal vein ligation-induced liver regeneration in rats. Ann Med 2022; 54:1188-1201. [PMID: 35481406 PMCID: PMC9067999 DOI: 10.1080/07853890.2022.2067893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Associating liver partition and portal vein ligation (ALPPS) technique is a promising strategy for unresectable primary liver tumours without sufficient future liver remnants (FLRs). OBJECTIVE Our study explored the effect of corosolic acid (CA) on inhibiting tumour growth without compromising ALPPS-induced liver regeneration. METHODS The ALPPS procedure was performed in Sprague-Dawley rats with orthotopic liver cancer. Blood, tumour, and FLR samples were collected, and the effect of CA on the inhibition of tumour progression and ALPPS-induced liver regeneration, and its possible mechanism, were investigated. RESULTS The tumour weight in the implantation/ALPPS group was higher than in the implantation without ALPPS group (p < .05), and the tumour weight in the implantation/ALPPS/CA group was lower than in the implantation/ALPPS group (p < .05). On postoperative day 15, the hepatic regeneration rate, and the expression of Ki67+ hepatocytes in the FLRs had increased significantly in the group that underwent ALPPS. The number of cluster of differentiation (CD) 86+ macrophages markedly increased in the FLRs and in the tumours of groups that underwent the ALPPS procedure. Additionally, the number of CD206+ macrophages was higher than the number of CD86+ macrophages in the tumours of the implantation and the implantation/ALPPS groups (p < .01, respectively); however, the opposite results were observed in the CA groups. The administration of CA downregulated the expression of transforming growth factor-beta (TGF-β), CD31, and programmed cell death protein 1 (PD-1) but increased the number of CD8+ lymphocytes in tumours. CONCLUSION Corosolic acid inhibits tumour growth without compromising ALPPS-induced liver regeneration. This result may be attributed to the CA-induced downregulation of PD-1 and TGF-β expression and the increased CD8+ lymphocyte infiltration in tumour tissue associated with the suppression of M2 macrophage polarisation. Key MessagesThis study aimed to investigate the effect of CA on ALPPS-induced liver regeneration and hepatic tumour progression after ALPPS-induced liver regeneration.Corosolic acid inhibits tumour growth without compromising ALPPS-induced liver regeneration. This result may be attributed to the CA-induced downregulation of PD-1 and TGF-β expression and the increased CD8+ lymphocyte infiltration in tumour tissue associated with the suppression of M2 macrophage polarisation.
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Affiliation(s)
- Jinwei Zhao
- Department of Hepatopancreatobiliary Surgery of Second Hospital of Jilin University, Key Laboratory for Zoonosis Research, Ministry of Education, Institute of Zoonosis, College of Veterinary Medicine Jilin University, Changchun, China
| | - Weiyi Zhao
- Medical College of YanBian University, YanBian, China
| | - Hongyue Xu
- Department of Hepatopancreatobiliary Surgery of Second Hospital of Jilin University, Key Laboratory for Zoonosis Research, Ministry of Education, Institute of Zoonosis, College of Veterinary Medicine Jilin University, Changchun, China
| | - Wenjing Luan
- Department of Hepatopancreatobiliary Surgery of Second Hospital of Jilin University, Key Laboratory for Zoonosis Research, Ministry of Education, Institute of Zoonosis, College of Veterinary Medicine Jilin University, Changchun, China
| | - Xuefei Wang
- Department of Hepatopancreatobiliary Surgery of Second Hospital of Jilin University, Key Laboratory for Zoonosis Research, Ministry of Education, Institute of Zoonosis, College of Veterinary Medicine Jilin University, Changchun, China
| | - Yimu Fang
- Department of Hepatopancreatobiliary Surgery of Second Hospital of Jilin University, Key Laboratory for Zoonosis Research, Ministry of Education, Institute of Zoonosis, College of Veterinary Medicine Jilin University, Changchun, China
| | - Lu Yu
- Department of Hepatopancreatobiliary Surgery of Second Hospital of Jilin University, Key Laboratory for Zoonosis Research, Ministry of Education, Institute of Zoonosis, College of Veterinary Medicine Jilin University, Changchun, China
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11
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Botea F, Bârcu A, Kraft A, Popescu I, Linecker M. Parenchyma-Sparing Liver Resection or Regenerative Liver Surgery: Which Way to Go? MEDICINA (KAUNAS, LITHUANIA) 2022; 58:1422. [PMID: 36295582 PMCID: PMC9609602 DOI: 10.3390/medicina58101422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Revised: 10/01/2022] [Accepted: 10/08/2022] [Indexed: 11/30/2022]
Abstract
Liver resection for malignant tumors should respect oncological margins while ensuring safety and improving the quality of life, therefore tumor staging, underlying liver disease and performance status should all be attentively assessed in the decision process. The concept of parenchyma-sparing liver surgery is nowadays used as an alternative to major hepatectomies to address deeply located lesions with intricate topography by means of complex multiplanar parenchyma-sparing liver resections, preferably under the guidance of intraoperative ultrasound. Regenerative liver surgery evolved as a liver growth induction method to increase resectability by stimulating the hypertrophy of the parenchyma intended to remain after resection (referred to as future liver remnant), achievable by portal vein embolization and liver venous deprivation as interventional approaches, and portal vein ligation and associating liver partition and portal vein ligation for staged hepatectomy as surgical techniques. Interestingly, although both strategies have the same conceptual origin, they eventually became caught in the never-ending parenchyma-sparing liver surgery vs. regenerative liver surgery debate. However, these strategies are both valid and must both be mastered and used to increase resectability. In our opinion, we consider parenchyma-sparing liver surgery along with techniques of complex liver resection and intraoperative ultrasound guidance the preferred strategy to treat liver tumors. In addition, liver volume-manipulating regenerative surgery should be employed when resectability needs to be extended beyond the possibilities of parenchyma-sparing liver surgery.
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Affiliation(s)
- Florin Botea
- Faculty of Medicine, “Titu Maiorescu” University, 031593 Bucharest, Romania
- “Dan Setlacec” Center of General Surgery and Liver Transplantation, Fundeni Clinical Institute, 022328 Bucharest, Romania
| | - Alexandru Bârcu
- Faculty of Medicine, “Titu Maiorescu” University, 031593 Bucharest, Romania
- “Dan Setlacec” Center of General Surgery and Liver Transplantation, Fundeni Clinical Institute, 022328 Bucharest, Romania
| | - Alin Kraft
- Faculty of Medicine, “Titu Maiorescu” University, 031593 Bucharest, Romania
| | - Irinel Popescu
- Faculty of Medicine, “Titu Maiorescu” University, 031593 Bucharest, Romania
- “Dan Setlacec” Center of General Surgery and Liver Transplantation, Fundeni Clinical Institute, 022328 Bucharest, Romania
| | - Michael Linecker
- Department of Surgery and Transplantation, UKSH Campus Kiel, 24105 Kiel, Germany
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Chrabaszcz S, Rajeev R, Witmer HDD, Dhiman A, Klooster B, Gamblin TC, Banerjee A, Johnston FM, Turaga KK. A Systematic Review of Conversion to Resectability in Unresectable Metastatic Colorectal Cancer Chemotherapy Trials. Am J Clin Oncol 2022; 45:366-372. [PMID: 35838247 DOI: 10.1097/coc.0000000000000921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Metastasectomy in patients with metastatic colorectal cancer (mCRC) confers a significant survival benefit. We hypothesized that conversion to resectability (C2R) correlates with superior overall survival (OS) in patients with unresectable mCRC. METHODS A prospectively registered systematic review (PROSPERO CRD42015024104) of randomized clinical trials published after 2003 was conducted. Exposure of interest was C2R with a primary outcome of OS. Clinical trials were classified based on difference in C2R between study arms (<2%, 2% to 2.9%, ≥3%). Generalized estimating equations were used to measure associations while adjusting for multiple observations from the same trial. RESULTS Of 2902 studies reviewed, 30 satisfied selection criteria (n=13,618 patients). Median C2R was 7.3% (interquartile range [IQR]: 5% to 12.9%), with maximum C2R in the FOLFOX/FOLFIRI+cetuximab arm (28.6%). The median difference in C2R between 2 arms of the same study was 2.3% (IQR: 1.3% to 3.4%) with a maximum difference of 15.4% seen in FOLFOX/FOLFIRI+cetuximab versus FOLFOX/FOLFIRI. Median OS for the entire patient cohort was 20.7 months (IQR: 18.9 to 22.7 mo), with a between group difference of 1.3 months (IQR: -1.2 to 3.6 mo). The median survival difference between the 2 study arms with <2% C2R difference was 0.8 months versus 1.6 months with ≥3% C2R rates . Increasing C2R had an incremental dose-effect response on OS ( P =0.021), and higher response rates correlated with C2R rates ( P =0.003). CONCLUSIONS C2R occurs infrequently and variably in clinical trials enrolling patients with unresectable mCRC. Prioritization of chemotherapeutic agents that enhance C2R might improve OS of patients.
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Affiliation(s)
| | - Rahul Rajeev
- Department of Surgery, Virginia Commonwealth University, Richmond, VA
| | | | - Ankit Dhiman
- Department of Surgery, University of Chicago, Chicago, IL
| | | | | | | | | | - Kiran K Turaga
- Department of Surgery, University of Chicago, Chicago, IL
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13
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Reese T, Galavics C, Schneider M, Brüning R, Oldhafer KJ. Sarcopenia influences the kinetic growth rate after ALPPS. Surgery 2022; 172:926-932. [DOI: 10.1016/j.surg.2022.04.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Revised: 04/08/2022] [Accepted: 04/12/2022] [Indexed: 10/18/2022]
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14
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Burlaka AA, Makhmudov DE, Lisnyi II, Paliichuk AV, Zvirych VV, Lukashenko AV. Parenchyma-sparing strategy and oncological prognosis in patients with colorectal cancer liver metastases. World J Surg Oncol 2022; 20:122. [PMID: 35430799 PMCID: PMC9013456 DOI: 10.1186/s12957-022-02579-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Accepted: 03/22/2022] [Indexed: 12/15/2022] Open
Abstract
Background Preliminary study results demonstrated parenchyma-sparing surgery (PSS) as an effective approach which allowed to remove colorectal cancer (CRC) metastatic lesions within the central liver cites and increased the probability of the liver re-resections. Methods The prospective analysis re-evaluation of the 185 CRC patients surgical treatment has been performed. Results An overall 5-year survival (OS) of the 185 enrolled patients was 43 ± 7%, and the mean and median value for OS was 48.7 ± 1.9% and 55.2 ± 5 (95% CI: 44.4–66.1) months. The 5-year OS for CRC patients whose metastatic lesions were predominantly located within peripheral and central liver segments was 56 ± 8% and 27 ± 9%, respectively (p = 0.08). A 5-year disease-free survival (DFS) rates of patients with peripheral and central liver cites metastatic lesions were 31 ± 7 % and 15 ± 7%, p = 0,12. And the DFS median was 34.2 and 46.5 months for R1v and R0 cohorts, respectively, p = 0.62. Conclusions Parenchyma-sparing surgery should be a priority pathway for complex treatment of patients with deeply located lesions of the right liver lobe. Trial registration The study is registered in https://www.researchregistry.com/browse-the-registry#home/registrationdetails/5ed9f60863e9bf0016624456/, no. 5679.
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15
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Omichi K, Inoue Y, Mise Y, Oba A, Ono Y, Sato T, Ito H, Takahashi Y, Saiura A. Hepatectomy with Perioperative Chemotherapy for Multiple Colorectal Liver Metastases is the Available Option for Prolonged Survival. Ann Surg Oncol 2022; 29:3567-3576. [PMID: 35118524 DOI: 10.1245/s10434-022-11345-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 01/05/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Hepatic resection combined with perioperative chemotherapy is the standard of care for patients with multiple colorectal liver metastases (CLMs). However, the optimal surgical strategy for treating advanced CLMs remains unclear. The role of the two-stage hepatectomy (TSH) strategy in the management of multiple CLMs remains challenging. This study aimed to compare the outcomes of one-step hepatectomy (OSH)-treated and TSH-treated patients with multiple CLMs. METHODS This single-institution study included 742 consecutive patients who underwent initial liver resection for histologically confirmed CLMs. The study enrolled patients with 10 or more tumors (n = 106). Clinicopathologic characteristics and long-term outcomes were compared between patients who underwent OSH and those who underwent TSH for 10 or more CLMs. RESULTS The study planned OSH for 67 patients (63%) and TSH for 39 patients (37%). One of the OSH-planned patients and two of the TSH-planned patients underwent a trial laparotomy because of non-curative factors. Five patients (13%) did not progress to the second stage of TSH. In the entire cohort, the cumulative 3-year overall survival rate was 58.4% for the patients who had 10 or more CLMs treated with OSH compared with 61.1% for the patients treated with TSH (P = 0.746). In the curative resection cohort, the cumulative 1-year recurrence-free survival rate was 18.2% for the patients treated with OSH and 17.9% for the patients treated with TSH (P = 0.640). CONCLUSIONS Hepatectomy with perioperative chemotherapy for advanced CLMs with 10 or more tumors is feasible and effective. To prolong survival, TSH is a promising option when curative resection with OSH is impossible.
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Affiliation(s)
- Kiyohiko Omichi
- Department of Hepato-Biliary-Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Yosuke Inoue
- Department of Hepato-Biliary-Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan.
| | - Yoshihiro Mise
- Department of Hepato-Biliary-Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan.,Department of Hepatobiliary-Pancreatic Surgery, Juntendo University School of Medicine, Hongo, Tokyo, Japan
| | - Atsushi Oba
- Department of Hepato-Biliary-Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Yoshihiro Ono
- Department of Hepato-Biliary-Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Takafumi Sato
- Department of Hepato-Biliary-Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Hiromichi Ito
- Department of Hepato-Biliary-Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Yu Takahashi
- Department of Hepato-Biliary-Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Akio Saiura
- Department of Hepato-Biliary-Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan.,Department of Hepatobiliary-Pancreatic Surgery, Juntendo University School of Medicine, Hongo, Tokyo, Japan
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16
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Montorfano L, Hutchins S, Bordes SJ, Simpfendorfer CH, Roy M. Synchronous Two-Stage Hepatectomy With Associated Liver Partition and Portal Vein Ligation in Addition to Low Anterior Resection for Metastatic Rectal Cancer. Cureus 2022; 14:e21381. [PMID: 35198293 PMCID: PMC8853701 DOI: 10.7759/cureus.21381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/18/2022] [Indexed: 11/07/2022] Open
Abstract
The associating liver partition and portal vein ligation for a staged hepatectomy (ALPPS) procedure is an excellent treatment strategy for patients with advanced primary or metastatic liver cancer and small liver remnants. This report discusses the surgical management of a 51-year-old male who was diagnosed with stage IV rectal cancer with multiple heterogeneous hypoenhancing solid masses seen in both lobes of the liver consistent with metastatic disease. He completed six cycles of preoperative FOLFOX chemotherapy with Avastin. Follow-up imaging demonstrated a good response. A combined low anterior resection and two-stage hepatectomy with ALPPS were discussed with the patient who agreed to proceed with the plan. He underwent a combined open low anterior resection with colorectal anastomosis in addition to the first stage of ALPPS. The patient tolerated the procedure well, and the immediate postoperative period was uncomplicated. Volumetric assessment of the left hepatic lobe on postoperative day seven demonstrated 26.7% of the original liver volume. The decision was made to take the patient back to the operating room on postoperative day nine for completion of the ALPPS, which entailed a total right hepatectomy. He tolerated the procedure well and was discharged home on postoperative day 16. No complications from the surgical procedure were reported on subsequent follow-up visits.
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Gutiérrez Sáenz de Santa María J, Herrero de la Parte B, Gutiérrez-Sánchez G, Ruiz Montesinos I, Iturrizaga Correcher S, Mar Medina C, García-Alonso I. Folinic Acid Potentiates the Liver Regeneration Process after Selective Portal Vein Ligation in Rats. Cancers (Basel) 2022; 14:cancers14020371. [PMID: 35053534 PMCID: PMC8773925 DOI: 10.3390/cancers14020371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 12/30/2021] [Accepted: 01/07/2022] [Indexed: 11/25/2022] Open
Abstract
Simple Summary Fewer than 30% of patients with liver metastases are eligible for major liver resection, because liver remaining after such a surgery would be insufficient to cover the patient’s needs; this is called a low percentage of future liver remnant (FLR). Folinic acid (FA) has been shown to play a crucial role in cellular synthesis, regeneration, and nucleotide and amino acid biosynthesis. The aim of this piece of research was to evaluate the effect of FA as a potential hypertrophic hepatic enhancer agent after selective portal vein ligation (PVL) to ensure adequate FLR. We have confirmed in our rodent model that FA accelerates liver regeneration after PVL and enhances recovery of liver function. These findings may allow more patients to be eligible for liver resection without jeopardizing postoperative liver function. Abstract Liver resection remains the gold standard for hepatic metastases. The future liver remnant (FLR) and its functional status are two key points to consider before performing major liver resections, since patients with less than 25% FLR or a Child–Pugh B or C grade are not eligible for this procedure. Folinic acid (FA) is an essential agent in cell replication processes. Herein, we analyze the effect of FA as an enhancer of liver regeneration after selective portal vein ligation (PVL). Sixty-four male WAG/RijHsd rats were randomly distributed into eight groups: a control group and seven subjected to 50% PVL, by ligation of left portal branch. The treated animals received FA (2.5 m/kg), while the rest were given saline. After 36 h, 3 days or 7 days, liver tissue and blood samples were obtained. FA slightly but significantly increased FLR percentage (FLR%) on the 7th day (91.88 ± 0.61%) compared to control or saline-treated groups (86.72 ± 2.5 vs. 87 ± 3.33%; p < 0.01). The hepatocyte nuclear area was also increased both at 36 h and 7days with FA (61.55 ± 16.09 µm2, and 49.91 ± 15.38 µm2; p < 0.001). Finally, FA also improved liver function. In conclusion, FA has boosted liver regeneration assessed by FLR%, nuclear area size and restoration of liver function after PVL.
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Affiliation(s)
| | - Borja Herrero de la Parte
- Department of Surgery and Radiology and Physical Medicine, Faculty of Medicine and Nursing, University of the Basque Country UPV/EHU, ES48940 Leioa, Spain;
- Interventional Radiology Research Group, Biocruces Bizkaia Health Research Institute, ES48903 Barakaldo, Spain
- Correspondence: (B.H.d.l.P.); (I.R.M.)
| | - Gaizka Gutiérrez-Sánchez
- Department of Anesthesiology, Santa Creu i Sant Pau University Hospital, ES08025 Barcelona, Spain;
| | - Inmaculada Ruiz Montesinos
- Department of Surgery and Radiology and Physical Medicine, Faculty of Medicine and Nursing, University of the Basque Country UPV/EHU, ES48940 Leioa, Spain;
- Department of Gastrointestinal Surgery, Donostia University Hospital, ES20014 Donostia, Spain
- Correspondence: (B.H.d.l.P.); (I.R.M.)
| | - Sira Iturrizaga Correcher
- Department of Clinical Analyses, Galdakao-Usansolo Hospital, ES48960 Galdakao, Spain; (S.I.C.); (C.M.M.)
| | - Carmen Mar Medina
- Department of Clinical Analyses, Galdakao-Usansolo Hospital, ES48960 Galdakao, Spain; (S.I.C.); (C.M.M.)
| | - Ignacio García-Alonso
- Department of Surgery and Radiology and Physical Medicine, Faculty of Medicine and Nursing, University of the Basque Country UPV/EHU, ES48940 Leioa, Spain;
- Interventional Radiology Research Group, Biocruces Bizkaia Health Research Institute, ES48903 Barakaldo, Spain
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18
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Di Martino M, Dorcaratto D, Primavesi F, Syn N, Blanco-Terés L, Dupré A, Piardi T, Rhaiem R, Fernández GB, De Armas Conde N, Rodríguez Sanjuán JC, Santiago RF, Fernández-Moreno MC, Ferret G, Ben SL, Suárez Muñoz MÁ, Perez-Alonso AJ, Koh YX, Jones R, Vennarecci G, Martín-Pérez E. Liver resection in elderly patients with extensive CRLM: Are we offering an adequate treatment? A propensity score matched analysis. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2021; 48:1331-1338. [PMID: 35000821 DOI: 10.1016/j.ejso.2021.12.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Revised: 11/24/2021] [Accepted: 12/21/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Data on the management of elderly patients with extensive colorectal liver metastases (CRLM) are scarce and conflicting. This study assesses differences in management and long-term oncological outcomes between older and younger patients with CRLM and a high Tumour Burden Score (TBS). METHODS International multicentre retrospective study on patients with CRLM and a category 3 TBS, submitted to liver resection. Patients were divided into two groups according to their age (younger and older than 75) and were compared using propensity score matching (PSM) analysis and multivariable regression models. Differences in management and oncological outcomes including recurrence-free survival (RFS) and overall survival (OS) were assessed. RESULTS The study included 386 patients, median follow-up was 48 months. The unmatched comparison revealed a higher ASA score (p = 0.035), less synchronous CRLM (47% vs 68%, p = 0.003), a lower median number of lesions (1 vs 3, p = 0.004) and less perioperative chemotherapy (CTx) (66% vs 88%, p < 0.001) in the elderly group. Despite the absence of CTx being an independent predictor of decreased RFS and OS (HR 0.760, p = 0.044 and HR 0.719, p = 0.049, respectively), the elderly group still received less CTx (OR 0.317, p = 0.001) than the younger group. After PSM (n = 100 patients), the two groups were comparable, however, CTx administration was still significantly lower in the elderly group. CONCLUSION Liver resection should be considered in patients aged 75 and older, even if they present with extensive liver disease. Despite CTx being associated with improved oncological outcomes, a large percentage of elderly patients with CRLM are undertreated.
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Affiliation(s)
- Marcello Di Martino
- HPB Unit, Department of General and Digestive Surgery, Hospital Universitario La Princesa, Instituto de Investigación Sanitaria Princesa (IIS-IP), Universidad Autónoma de Madrid (UAM), Madrid, Spain; Department Hepatobiliar Surgery and Liver Transplant. A.O.R.N. Cardarelli, Napoli, Italy
| | - Dimitri Dorcaratto
- Department of Surgery, Liver, Biliary, and Pancreatic Unit, Biomedical Research Institute INCLIVA, Hospital Clínico University of Valencia, Valencia, Spain.
| | - Florian Primavesi
- Aintree University Hospital, Liverpool University Hospitals NHS Foundation Trust, Liverpool, United Kingdom; Salzkammergutklinikum Vöcklabruck, Vöcklabruck, Austria.
| | - Nicholas Syn
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore.
| | - Lara Blanco-Terés
- HPB Unit, Department of General and Digestive Surgery, Hospital Universitario La Princesa, Instituto de Investigación Sanitaria Princesa (IIS-IP), Universidad Autónoma de Madrid (UAM), Madrid, Spain.
| | - Aurélien Dupré
- Aintree University Hospital, Liverpool University Hospitals NHS Foundation Trust, Liverpool, United Kingdom; Department of Surgical Oncology, Centre Léon Bérard, Lyon, France.
| | - Tullio Piardi
- Department of HBP and Digestive Oncological Surgery, Robert Debré University Hospital, Reims, France; Department of Surgery, HPB Unit, Simone Veil Hospital, Troyes, France.
| | - Rami Rhaiem
- Department of HBP and Digestive Oncological Surgery, Robert Debré University Hospital, Reims, France.
| | - Gerardo Blanco Fernández
- Department of HBP and Liver Transplantation Surgery. University Hospital of Badajoz. INUBE (Instituto Universitario de Investigación Biosanitaria de Extremadura). University of Extremadura, Badajoz, Spain.
| | - Noelia De Armas Conde
- Department of HBP and Liver Transplantation Surgery. University Hospital of Badajoz. INUBE (Instituto Universitario de Investigación Biosanitaria de Extremadura). University of Extremadura, Badajoz, Spain.
| | | | | | | | - Georgina Ferret
- Hospital Universitari de Girona Dr Josep Trueta, Girona, Spain.
| | | | | | - Alejandro J Perez-Alonso
- Unidad de Cirugia HBP y Trasplante Hepático, Hospital Universitario Virgen de las Nieves, Granada, Spain.
| | - Ye-Xin Koh
- Aintree University Hospital, Liverpool University Hospitals NHS Foundation Trust, Liverpool, United Kingdom.
| | - Robert Jones
- Department of Surgery, Liver, Biliary, and Pancreatic Unit, Biomedical Research Institute INCLIVA, Hospital Clínico University of Valencia, Valencia, Spain.
| | - Giovanni Vennarecci
- Department Hepatobiliar Surgery and Liver Transplant. A.O.R.N. Cardarelli, Napoli, Italy.
| | - Elena Martín-Pérez
- HPB Unit, Department of General and Digestive Surgery, Hospital Universitario La Princesa, Instituto de Investigación Sanitaria Princesa (IIS-IP), Universidad Autónoma de Madrid (UAM), Madrid, Spain.
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Tasoudis PT, Ziogas IA, Alexopoulos SP, Fung JJ, Tsoulfas G. Role of liver transplantation in the management of colorectal liver metastases: Challenges and opportunities. World J Clin Oncol 2021; 12:1193-1201. [PMID: 35070738 PMCID: PMC8716993 DOI: 10.5306/wjco.v12.i12.1193] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 07/29/2021] [Accepted: 11/28/2021] [Indexed: 02/06/2023] Open
Abstract
The liver is the most common site of colorectal cancer metastasis. Complete resection of the metastatic tumor is currently the only treatment modality available with a potential for cure. However, only 20% of colorectal liver metastases (CRLM) are considered resectable at the time of presentation. Liver transplantation (LT) has been proposed as an alternative oncologic treatment for patients with unresectable CRLM. This review summarizes the published experiences of LT in the setting of unresectable CRLM from the previous decades and discusses the challenges and future horizons in the field. Contemporary experiences that come mostly from countries with broader access to liver grafts are also explored and their promising findings in terms of overall survival (OS) and disease-free survival (DFS) are outlined along with their study design and methods. The rationale of establishing specific patient selection criteria and the dilemmas around immunosuppressive regimens in patients undergoing LT for CRLM are also highlighted. Additionally, this review describes the findings of studies comparing LT vs chemotherapy alone and LT vs portal vein embolization plus resection for CRLM in terms of OS and DFS. Last but not least, we present current perspectives and ongoing prospective trials that try to elucidate the role of LT for CRLM.
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Affiliation(s)
| | - Ioannis A Ziogas
- Department of Surgery, Division of Hepatobiliary Surgery and Liver Transplantation, Vanderbilt University Medical Center, Nashville, TN 37232, United States
| | - Sophoclis P Alexopoulos
- Department of Surgery, Division of Hepatobiliary Surgery and Liver Transplantation, Vanderbilt University Medical Center, Nashville, TN 37232, United States
| | - John J Fung
- Department of Surgery, University of Chicago Medicine Transplant Institute, Chicago, IL 60637, United States
| | - Georgios Tsoulfas
- Department of Transplant Surgery, Aristotle University School of Medicine, Thessaloniki 54622, Greece
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Maupoey Ibáñez J, Montalvá Orón EM, Boscà Robledo A, Camacho Ramírez A, Hernando Sanz A, Granero Castro P, Alegre Delgado A, López-Andújar R. From conventional two-stage hepatectomy to ALPPS: Fifteen years of experience in a hepatobiliary surgery unit. Hepatobiliary Pancreat Dis Int 2021; 20:542-550. [PMID: 34465545 DOI: 10.1016/j.hbpd.2021.08.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Accepted: 08/02/2021] [Indexed: 02/05/2023]
Abstract
BACKGROUND Hepatectomy in patients with large tumor load may result in postoperative liver failure and associated complications due to excessive liver parenchyma removal. Conventional two-stage hepatectomy (TSH) and associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) technique are possible solutions to this problem. Colorectal liver metastases (CRLM) is the most frequent indication, and there is a need to assess outcomes for both techniques to improve surgical and long-term oncological outcomes in these patients. METHODS A single-center retrospective study was designed to compare TSH with ALPPS in patients with initially unresectable bilateral liver tumors between January 2005 and January 2020. ALPPS was performed from January 2012 onwards as the technique of choice. Long-term overall survival (OS) and disease-free survival (DFS) were evaluated as primary outcome in CRLM patients. Postoperative morbidity, mortality and liver growth in all patients were also evaluated. RESULTS A total of 38 staged hepatectomies were performed: 17 TSH and 21 ALPPS. Complete resection rate was 76.5% (n = 13) in the TSH group and 85.7% (n = 18) in the ALPPS group (P = 0.426). Overall major morbidity (Clavien-Dindo ≥ 3a) (stage 1 + stage 2) was 41.2% (n = 7) in TSH and 33.3% (n = 7) in ALPPS patients (P = 0.389), and perioperative 90-day mortalities were 11.8% (n = 2) vs. 19.0% (n = 4) in each group, respectively (P = 0.654). Intention-to-treat OS rates at 1 and 5 years in CRLM patients for TSH (n = 15) were 80% and 33%, and for ALPPS (n = 17) 76% and 35%, respectively. DFS rates at 1 and 5 years were 36% and 27% in the TSH group vs. 33% and 27% in the ALPPS group, respectively. CONCLUSIONS ALPPS is an effective alternative to TSH in bilateral affecting liver tumors, allowing higher resection rate, but patients must be carefully selected. In CRLM patients similar long-term OS and DFS can be achieved with both techniques.
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Affiliation(s)
- Javier Maupoey Ibáñez
- Hepatobiliary Surgery and Transplant Unit, La Fe University and Polytechnic Hospital, Valencia, Spain.
| | - Eva María Montalvá Orón
- Hepatobiliary Surgery and Transplant Unit, La Fe University and Polytechnic Hospital, Valencia, Spain
| | - Andrea Boscà Robledo
- Hepatobiliary Surgery and Transplant Unit, La Fe University and Polytechnic Hospital, Valencia, Spain
| | - Alonso Camacho Ramírez
- Hepatobiliary Surgery and Transplant Unit, La Fe University and Polytechnic Hospital, Valencia, Spain
| | - Ana Hernando Sanz
- Hepatobiliary Surgery and Transplant Unit, La Fe University and Polytechnic Hospital, Valencia, Spain
| | - Pablo Granero Castro
- Hepatobiliary Surgery and Transplant Unit, La Fe University and Polytechnic Hospital, Valencia, Spain
| | | | - Rafael López-Andújar
- Hepatobiliary Surgery and Transplant Unit, La Fe University and Polytechnic Hospital, Valencia, Spain
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21
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Del Basso C, Gaillard M, Lainas P, Zervaki S, Perlemuter G, Chagué P, Rocher L, Voican CS, Dagher I, Tranchart H. Current strategies to induce liver remnant hypertrophy before major liver resection. World J Hepatol 2021; 13:1629-1641. [PMID: 34904033 PMCID: PMC8637666 DOI: 10.4254/wjh.v13.i11.1629] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 06/08/2021] [Accepted: 10/11/2021] [Indexed: 02/06/2023] Open
Abstract
Hepatic resection is the gold standard for patients affected by primary or metastatic liver tumors but is hampered by the risk of post-hepatectomy liver failure. Despite recent improvements, liver surgery still requires excellent clinical judgement in selecting patients for surgery and, above all, efficient pre-operative strategies to provide adequate future liver remnant. The aim of this article is to review the literature on the rational, the preliminary assessment, the advantages as well as the limits of each existing technique for preparing the liver for major hepatectomy.
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Affiliation(s)
- Celeste Del Basso
- Department of Minimally Invasive Digestive Surgery, Antoine Béclère Hospital, Clamart 92140, France
| | - Martin Gaillard
- Department of Minimally Invasive Digestive Surgery, Antoine Béclère Hospital, Clamart 92140, France
| | - Panagiotis Lainas
- Department of Minimally Invasive Digestive Surgery, Antoine Béclère Hospital, Clamart 92140, France
| | - Stella Zervaki
- Department of Minimally Invasive Digestive Surgery, Antoine Béclère Hospital, Clamart 92140, France
| | - Gabriel Perlemuter
- Department of Hepato-Gastroenterology and Nutrition, Antoine Béclère Hospital, Clamart 92140, France
| | - Pierre Chagué
- Department of Radiology, Antoine Béclère Hospital, Clamart 92140, France
| | - Laurence Rocher
- Department of Radiology, Antoine Béclère Hospital, Clamart 92140, France
| | - Cosmin Sebastian Voican
- Department of Hepato-Gastroenterology and Nutrition, Antoine Béclère Hospital, Clamart 92140, France
| | - Ibrahim Dagher
- Department of Minimally Invasive Digestive Surgery, Antoine Béclère Hospital, Clamart 92140, France
| | - Hadrien Tranchart
- Department of Minimally Invasive Digestive Surgery, Antoine Béclère Hospital, Clamart 92140, France
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22
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Burlaka AA, Gogo‐Abite A, Paliichuk AV, Makhmudov DE, Zvirych VV, Lukashenko AV. Systematic extended posterior right sectionectomy with simultaneous resection of the dorsal part of segment 1 and middle hepatic vein detachment. Clin Case Rep 2021; 9:e04803. [PMID: 34532049 PMCID: PMC8435224 DOI: 10.1002/ccr3.4803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 08/11/2021] [Accepted: 08/25/2021] [Indexed: 11/09/2022] Open
Abstract
Parenchymal sparing surgery should be the strategy of choice for patients with bilobar liver metastases and lesions within the central liver sites.
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Affiliation(s)
| | - Awofaa Gogo‐Abite
- Educational and Scientific Centre” Institute of Biology and Medicine”Department of Anatomy and Pathological PhysiologyTaras Shevchenko National University of KyivKyivUkraine
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23
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Lanari J, Hagness M, Sartori A, Rosso E, Gringeri E, Dueland S, Cillo U, Line PD. Liver transplantation versus liver resection for colorectal liver metastasis: a survival benefit analysis in patients stratified according to tumor burden score. Transpl Int 2021; 34:1722-1732. [PMID: 34448271 DOI: 10.1111/tri.13981] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Revised: 07/13/2021] [Accepted: 07/14/2021] [Indexed: 12/14/2022]
Abstract
Liver transplantation (LT) for colorectal liver metastasis (CRLM) may provide excellent survival rates in patients with unresectable disease. High tumor load is a risk factor for recurrence and low overall survival (OS) after liver resection (LR). We tested the hypothesis that LT could offer better survival than LR in patients with high tumor load. LR performed at Padua University Hospital for CRLM was compared with LT for unresectable CRLM performed both at Oslo and Padua. High tumor load was defined as tumor burden score (TBS) ≥ 9, and inclusion criteria were as in the SECA-I transplant study. 184 patients were eligible: 128 LRs and 56 LTs. 5-year OS after LR and LT was 40.5% and 54.7% (P = 0.102). In the high TBS cohort, 5-year OS after LR and LT was 22.7% and 52.2% (P = 0.055). In patients with Oslo score ≤ 2 and TBS ≥ 9 (13 LR; 24 LT) the 5-year OS after LR and LT was 14.6% and 69.1% (P = 0.002). The corresponding disease-free survival (DFS) was 0% and 22.9% (P = 0.005). Selected CRLM patients with low Oslo score and high TBS could benefit from LT with survival outcomes that are far better than what is achieved by LR.
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Affiliation(s)
- Jacopo Lanari
- Department of Surgery, Oncology and Gastroenterology (DiSCOG), Hepatobiliary Surgery and Liver Transplantation Unit, Padua University Hospital, Padua, Italy.,Department of Transplantation Medicine, Oslo universitetssykehus Rikshospitalet, Oslo, Norway
| | - Morten Hagness
- Department of Transplantation Medicine, Oslo universitetssykehus Rikshospitalet, Oslo, Norway.,Institute of Clinical Medicine, Oslo universitetssykehus Rikshospitalet, Oslo, Norway
| | - Alessandra Sartori
- Department of Surgery, Oncology and Gastroenterology (DiSCOG), Hepatobiliary Surgery and Liver Transplantation Unit, Padua University Hospital, Padua, Italy
| | - Eugenia Rosso
- Department of Surgery, Oncology and Gastroenterology (DiSCOG), Hepatobiliary Surgery and Liver Transplantation Unit, Padua University Hospital, Padua, Italy
| | - Enrico Gringeri
- Department of Surgery, Oncology and Gastroenterology (DiSCOG), Hepatobiliary Surgery and Liver Transplantation Unit, Padua University Hospital, Padua, Italy
| | - Svein Dueland
- Institute of Clinical Medicine, Oslo universitetssykehus Rikshospitalet, Oslo, Norway
| | - Umberto Cillo
- Department of Surgery, Oncology and Gastroenterology (DiSCOG), Hepatobiliary Surgery and Liver Transplantation Unit, Padua University Hospital, Padua, Italy
| | - Pål-Dag Line
- Department of Transplantation Medicine, Oslo universitetssykehus Rikshospitalet, Oslo, Norway.,Institute of Clinical Medicine, Oslo universitetssykehus Rikshospitalet, Oslo, Norway.,Experimental Transplantation and Malignancy Research Group, Division of Surgery, Inflammatory Diseases and Transplantation, Oslo universitetssykehus Rikshospitalet, Oslo, Norway
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24
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Lang H, Baumgart J, Mittler J. Associated Liver Partition and Portal Vein Ligation for Staged Hepatectomy (ALPPS) Registry: What Have We Learned? Gut Liver 2021; 14:699-706. [PMID: 32036644 PMCID: PMC7667932 DOI: 10.5009/gnl19233] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Revised: 10/01/2019] [Accepted: 10/24/2019] [Indexed: 12/15/2022] Open
Abstract
In 2007, the first associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) procedure was performed in Regensburg, Germany. ALPPS is a variation of two-stage hepatectomy to induce rapid liver hypertrophy allowing the removal of large tumors otherwise considered irresectable due to a too small future liver remnant. In 2012, the international ALPPS registry was created, and it now contains more than 1,000 cases. During the past years, improved patient selection and refinements in operative techniques, in particular, less invasive approaches such as Partial ALPPS, Tourniquet ALPPS, Ablation-assisted ALPPS, Hybrid ALPPS or Laparoscopic or Robotic approaches, have resulted in significant improvements in safety. The most frequent indication for ALPPS is colorectal liver metastases. In the first randomized controlled study, ALPPS provided a higher resectability rate than conventional two-stage hepatectomy, with similar complication rates. Long-term outcome data are still missing. The initial results of ALPPS for hepatocellular carcinoma and for perihilar cholangiocarcinoma were devastating, but with progress in surgical technic and better patient selection, ALPPS could serve as a treatment alternative in carefully selected cases, even for these tumors. ALPPS has enlarged the armamentarium of hepato-pancreato-biliary surgeons, but there is still discussion regarding how to use this novel technique, which may allow resection of tumors that are otherwise deemed irresectable.
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Affiliation(s)
- Hauke Lang
- Department of General, Visceral, and Transplant Surgery, University Medical Center, Mainz, Germany
| | - Janine Baumgart
- Department of General, Visceral, and Transplant Surgery, University Medical Center, Mainz, Germany
| | - Jens Mittler
- Department of General, Visceral, and Transplant Surgery, University Medical Center, Mainz, Germany
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25
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Fast-track two-stage hepatectomy by concurrent portal vein embolization at first-stage hepatectomy in hybrid interventional radiology / operating suite. Surg Oncol 2021; 39:101648. [PMID: 34438236 DOI: 10.1016/j.suronc.2021.101648] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 08/09/2021] [Accepted: 08/14/2021] [Indexed: 02/08/2023]
Abstract
OBJECTIVES In two-stage hepatectomy for bilateral liver metastases, patient dropout between stages is a major issue. We recently proposed a novel approach of fast-track two-staged hepatectomy (FT-TSH), in which patients undergo concurrent first-stage hepatectomy (FSH) with portal vein embolization (PVE) in a hybrid interventional radiology surgical suite. However, its efficacy remains unclear. METHODS Patients with bilateral liver metastases scheduled for FT-TSH at MD Anderson Cancer Center between October 2017 and December 2020 were included on a prospective registry. The effectiveness and feasibility were evaluated. RESULTS Nineteen patients were scheduled for FT-TSH. Primary site of tumor was colon/rectum in 18 patients and ovary in one patient. Median number of tumors was 10 and median size of largest tumor before surgery was 2.4 cm. Two (11%) patients did not undergo PVE and seventeen patients (89%) completed FSH + PVE. None of the patients had a major complication (Clavien-Dindo grade ≥ III) after FSH + PVE. Median kinetic growth rate after FSH + PVE was 2.9%/week (range 0.8-5.6). Twelve patients (71%) among the seventeen who underwent FSH + PVE proceeded to second-stage hepatectomy, and ten patients (59%) finally completed second-stage hepatectomy. Median interval between stages was 5.6 weeks (4.0-20.1). One patient (10%) had a major morbidity after SSH, and there was no 90-day mortality. CONCLUSIONS FT-TSH is safe and allows for short intervals between hepatectomy stages while achieving favorable liver hypertrophy. Further investigation is needed to evaluate the true efficacy of FT-TSH.
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26
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Memeo R, Conticchio M, Deshayes E, Nadalin S, Herrero A, Guiu B, Panaro F. Optimization of the future remnant liver: review of the current strategies in Europe. Hepatobiliary Surg Nutr 2021; 10:350-363. [PMID: 34159162 DOI: 10.21037/hbsn-20-394] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Liver resection still represent the treatment of choice for liver malignancies, but in some cases inadequate future remnant liver (FRL) can lead to post hepatectomy liver failure (PHLF) that still represents the most common cause of death after hepatectomy. Several strategies in recent era have been developed in order to generate a compensatory hypertrophy of the FRL, reducing the risk of post hepatectomy liver failure. Portal vein embolization, portal vein ligation, and ALLPS are the most popular techniques historically adopted up to now. The liver venous deprivation and the radio-embolization are the most recent promising techniques. Despite even more precise tools to calculate the relationship among volume and function, such as scintigraphy with 99mTc-mebrofenin (HBS), no consensus is still available to define which of the above mentioned augmentation strategy is more adequate in terms of kind of surgery, complexity of the pathology and quality of liver parenchyma. The aim of this article is to analyse these different strategies to achieve sufficient FRL.
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Affiliation(s)
- Riccardo Memeo
- Division of Hepato-Pancreato-Biliary Surgery, Department of Surgery, "F. Miulli" General Hospital, Acquaviva delle Fonti, Bari, Italy
| | | | - Emmanuel Deshayes
- Department of Nuclear Medicine, Institute du Cancer de Montpellier (ICM), Montpellier, France.,INSERM U1194, Montpellier Cancer Research Institute, Montpellier University, Montpellier, France
| | - Silvio Nadalin
- Department of General, Visceral and Transplant Surgery, University Hospital Tübingen, Germany
| | - Astrid Herrero
- Department of Surgery, Division of HBP Surgery and Liver Transplantation, St-Eloi University Hospital, Montpellier, France
| | - Boris Guiu
- INSERM U1194, Montpellier Cancer Research Institute, Montpellier University, Montpellier, France.,Department of Radiology, St-Eloi University Hospital, Montpellier, France
| | - Fabrizio Panaro
- Department of Surgery, Division of HBP Surgery and Liver Transplantation, St-Eloi University Hospital, Montpellier, France
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27
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Marchese U, Seux H, Garnier J, Ewald J, Piana G, Lelong B, Chaisemartin CD, Meillat H, Delpero JR, Turrini O. Is percutaneous destruction of a solitary liver colorectal metastasis as effective as a resection? Ann Hepatobiliary Pancreat Surg 2021; 25:198-205. [PMID: 34053922 PMCID: PMC8180403 DOI: 10.14701/ahbps.2021.25.2.198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 10/14/2020] [Accepted: 10/15/2020] [Indexed: 11/17/2022] Open
Abstract
Backgrounds/Aims Surgical resection remains the gold standard in the treatment of colorectal liver metastasis. However, when a patient presents with a deep solitary colorectal liver metastasis (S-CLM), the balance between the hepatic volume sacrificed and the S-CLM volume is sometimes clearly unappropriated. Thus, alternatives to surgery, such as operative and percutaneous radiofrequency ablation (RFA) and microwave ablation (MWA), have been developed. This study aimed to identify the prognostic factors affecting survival of patients with S-CLM who undergo curative-intent liver resection or local destruction (RFA or MWA). Methods We retrospectively identified 211 patients with synchronous or metachronous S-CLM who underwent either surgical resection (n=182) or local destruction (RFA or MWA; n=29) according to the S-CLM size, location, and surrounding Glissonian structures. Results Patients who underwent RFA or MWA had S-CLM of a smaller size than those who underwent resection (mean 19.7 vs. 37.3 mm, p<.01). The 1-, 3-, and 5-year overall survival (OS) rates were 97.4%, 84.9%, and 74.9%, respectively. The 1-, 3-, and 5-year disease-free survival (DFS) rates were 77.9%, 47%, and 38.9%, respectively. S-CLM located in the left liver (p=.04), S-CLM KRAS mutation (p<.01), and extra-hepatic recurrence (p<.01) were identified as independent poor risk factors for overall survival (OS); the OS and DFS were comparable in patients with surgical procedure or percutaneous MWA. Conclusions In eligible S-CLM cases, percutaneous MWA seems to be as oncologically efficient as surgical resection and should be include in the decision-tree for treatment strategies.
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Affiliation(s)
- Ugo Marchese
- Department of Surgery, Institut Paoli-Calmettes, Aix-Marseille University, CNRS, Inserm, CRCM, Marseille, France
| | - Héloïse Seux
- Department of Surgery, Institut Paoli-Calmettes, Aix-Marseille University, CNRS, Inserm, CRCM, Marseille, France
| | - Jonathan Garnier
- Department of Surgery, Institut Paoli-Calmettes, Aix-Marseille University, CNRS, Inserm, CRCM, Marseille, France
| | - Jacques Ewald
- Department of Surgery, Institut Paoli-Calmettes, Aix-Marseille University, CNRS, Inserm, CRCM, Marseille, France
| | - Gilles Piana
- Department of Radiology, Institut Paoli-Calmettes, Aix-Marseille University, CNRS, Inserm, CRCM, Marseille, France
| | - Bernard Lelong
- Department of Surgery, Institut Paoli-Calmettes, Aix-Marseille University, CNRS, Inserm, CRCM, Marseille, France
| | - Cécile De Chaisemartin
- Department of Surgery, Institut Paoli-Calmettes, Aix-Marseille University, CNRS, Inserm, CRCM, Marseille, France
| | - Hélène Meillat
- Department of Surgery, Institut Paoli-Calmettes, Aix-Marseille University, CNRS, Inserm, CRCM, Marseille, France
| | - Jean-Robert Delpero
- Department of Surgery, Institut Paoli-Calmettes, Aix-Marseille University, CNRS, Inserm, CRCM, Marseille, France
| | - Olivier Turrini
- Department of Surgery, Institut Paoli-Calmettes, Aix-Marseille University, CNRS, Inserm, CRCM, Marseille, France
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28
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Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) in colorectal liver metastases: review of the literature. Clin Exp Hepatol 2021; 7:125-133. [PMID: 34295978 PMCID: PMC8284168 DOI: 10.5114/ceh.2021.106521] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Accepted: 02/26/2021] [Indexed: 02/08/2023] Open
Abstract
The liver is considered as one of the most common sites of metastasis and a key determining factor of survival in patients with isolated colorectal liver metastasis (CRLM). For longer survival of patients, surgical resection is the only available option. Especially in CRLM bilobar patients, to achieve R0 resection, maintaining an adequate volume of the future liver remnant (FLR) is the main technical challenge to avoid post-hepatectomy liver failure (PHLF). As standard procedures in the treatment of patients with severe metastatic liver disease, techniques such as portal vein embolization/portal vein ligation (PVE/PVL) accompanied by two-stage hepatectomy (TSH) have been introduced. These methods, however, have drawbacks depending on the severity of the disease and the capacity of the patient to expand the liver remnant. Eventually, implementation of the novel ALPPS technique ignited excitement among the community of hepatobiliary surgeons because ALPPS challenged the idea of unrespectability and extended the limit of liver surgery and it was reported that FLR hypertrophy of up to 80% was induced in a shorter time than PVL or PVE. Nonetheless, ALPPS techniques caused serious concerns due to the associated high morbidity and mortality levels of up to 40% and 15% respectively, and PHLF and bile leak are critical morbidity- and mortality-related factors. Carefully establishing the associated risk factors of ALPPS has opened up a new dimension in the field of ALPPS technique for improved surgical outcome by carefully choosing patients. The benefit of ALPPS technique is enhanced when performed for young patients with very borderline remnant volume. Adopting ALPPS technical modifications such as middle hepatic vein preservation, surgical management of the hepatoduodenal ligament, the anterior approach and partial ALPPS may lead to the improvement of ALPPS surgical performance. Research findings to validate the translatability of ALPPS’ theoretical advantages into real survival benefits are scarce.
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29
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Beppu T, Yamamura K, Okabe H, Imai K, Hayashi H. Oncological benefits of portal vein embolization for patients with hepatocellular carcinoma. Ann Gastroenterol Surg 2021; 5:287-295. [PMID: 34095718 PMCID: PMC8164464 DOI: 10.1002/ags3.12414] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 10/29/2020] [Accepted: 11/18/2020] [Indexed: 12/28/2022] Open
Abstract
Portal vein embolization (PVE) for hepatocellular carcinoma (HCC) was first introduced in 1986 and has been continuously developed throughout the years. Basically, PVE has been applied to expand the indication of liver resection for HCC patients of insufficient future liver remnant. Importantly, PVE can result in tumor progression in both embolized and non-embolized livers; however, long-term survival after liver resection following PVE is at least not inferior compared with liver resection alone despite the smaller future liver remnant volume. Five-year disease-free survival and 5-year overall survival were 17% to 49% and 12% to 53% in non-PVE patients, and 21% to 78% and 44% to 72% in PVE patients, respectively. At present, it has proven that PVE has multiple oncological advantages for both surgical and nonsurgical treatments. PVE can also enhance the anticancer effects of transarterial chemoembolization and can avoid intraportal tumor cell dissemination. Additional interventional transarterial chemoembolization and hepatic vein embolization as well as surgical two-stage hepatectomy and associated liver partition and portal vein ligation for staged hepatectomy can enhance the oncological benefit of PVE monotherapy. Taken together, PVE is an important treatment which we recommend for listing in the guidelines for HCC treatment strategies.
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Affiliation(s)
- Toru Beppu
- Department of SurgeryYamaga City Medical CenterKumamotoJapan
- Department of Gastroenterological SurgeryGraduate School of Life SciencesKumamoto UniversityKumamotoJapan
| | - Kensuke Yamamura
- Department of SurgeryYamaga City Medical CenterKumamotoJapan
- Department of Gastroenterological SurgeryGraduate School of Life SciencesKumamoto UniversityKumamotoJapan
| | - Hirohisa Okabe
- Department of Gastroenterological SurgeryGraduate School of Life SciencesKumamoto UniversityKumamotoJapan
| | - Katsunori Imai
- Department of Gastroenterological SurgeryGraduate School of Life SciencesKumamoto UniversityKumamotoJapan
| | - Hiromitsu Hayashi
- Department of Gastroenterological SurgeryGraduate School of Life SciencesKumamoto UniversityKumamotoJapan
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30
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Ono K, Abe T, Oshita A, Sumi Y, Yano T, Okuda H, Kurayoshi M, Kobayashi T, Ohdan H, Noriyuki T, Nakahara M. Efficacy of upfront hepatectomy without neoadjuvant chemotherapy for resectable colorectal liver metastasis. World J Surg Oncol 2021; 19:97. [PMID: 33820549 PMCID: PMC8022388 DOI: 10.1186/s12957-021-02210-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 03/22/2021] [Indexed: 12/17/2022] Open
Abstract
Background Hepatectomy for resectable colorectal liver metastasis (CRLM) is recommended. However, the efficacy of upfront hepatectomy without neoadjuvant chemotherapy (NAC) is unclear due to the uncertainty of perioperative systemic chemotherapy. Moreover, it is crucial to predict the prognosis when considering perioperative chemotherapy. This study evaluated the impact of neoadjuvant chemotherapy on the prognosis of patients with resectable CRLM and assessed the usefulness of Beppu’s nomogram for predicting prognosis. Methods This retrospective study identified 88 consecutive inpatients who underwent primary hepatic resection for CRLM; 58 received neoadjuvant chemotherapy and 30 underwent upfront surgery. Factors associated with recurrence-free survival were identified via univariate and multivariate analysis. Furthermore, propensity score analysis using inverse probability of treatment weighting (IPTW) was performed. Results On univariate analysis, poor recurrence-free survival was associated with multiple tumors, advanced primary tumor stage, vascular invasion by the primary tumor, a Beppu’s nomogram score ≥ 6, and neoadjuvant chemotherapy. On multivariate analysis, a Beppu’s nomogram score ≥ 6 and neoadjuvant chemotherapy were independent risk factors for recurrence. Neoadjuvant chemotherapy recipients had a higher incidence of lymph node metastasis and vascular invasion than non-recipients. Propensity score analysis revealed no significant difference in the recurrence-free survival rate between these groups. Conclusions Our results show that upfront hepatectomy without neoadjuvant chemotherapy can be considered for resectable CRLM treatment. Beppu’s nomogram score can be a tool for predicting the prognosis of patients with CRLM.
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Affiliation(s)
- Kosuke Ono
- Department of Surgery, Onomichi General Hospital, 1-10-23 Hirahara Onomichi, Hiroshima, 722-8508, Japan
| | - Tomoyuki Abe
- Department of Surgery, Onomichi General Hospital, 1-10-23 Hirahara Onomichi, Hiroshima, 722-8508, Japan.
| | - Akihiko Oshita
- Department of Surgery, Onomichi General Hospital, 1-10-23 Hirahara Onomichi, Hiroshima, 722-8508, Japan.,Department of Gastroenterological and Transplant Surgery, Applied Life Sciences, Institute of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Hiroshima, 734-8551, Japan
| | - Yusuke Sumi
- Department of Surgery, Onomichi General Hospital, 1-10-23 Hirahara Onomichi, Hiroshima, 722-8508, Japan
| | - Takuya Yano
- Department of Surgery, Hiroshima Citizens Hospital, 7-33 Motomachi, Hiroshima, 730-8518, Japan
| | - Hiroshi Okuda
- Department of Surgery, Onomichi General Hospital, 1-10-23 Hirahara Onomichi, Hiroshima, 722-8508, Japan
| | - Manabu Kurayoshi
- Department of Surgery, Onomichi General Hospital, 1-10-23 Hirahara Onomichi, Hiroshima, 722-8508, Japan
| | - Tsuyoshi Kobayashi
- Department of Gastroenterological and Transplant Surgery, Applied Life Sciences, Institute of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Hiroshima, 734-8551, Japan
| | - Hideki Ohdan
- Department of Gastroenterological and Transplant Surgery, Applied Life Sciences, Institute of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Hiroshima, 734-8551, Japan
| | - Toshio Noriyuki
- Department of Surgery, Onomichi General Hospital, 1-10-23 Hirahara Onomichi, Hiroshima, 722-8508, Japan.,Department of Gastroenterological and Transplant Surgery, Applied Life Sciences, Institute of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Hiroshima, 734-8551, Japan
| | - Masahiro Nakahara
- Department of Surgery, Onomichi General Hospital, 1-10-23 Hirahara Onomichi, Hiroshima, 722-8508, Japan
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31
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Elfrink AK, van Zwet EW, Swijnenburg RJ, den Dulk M, van den Boezem PB, Mieog JSD, te Riele WW, Patijn GA, Leclercq WK, Lips DJ, Rijken AM, Verhoef C, Kuhlmann KF, Buis CI, Bosscha K, Belt EJ, Vermaas M, van Heek NT, Oosterling SJ, Torrenga H, Eker HH, Consten EC, Marsman HA, Wouters MW, Kok NF, Grünhagen DJ, Klaase JM, Besselink MG, de Boer MT, Dejong CH, van Gulik TM, Hagendoorn J, Hoogwater FH, Molenaar IQ, Liem MS. Case-mix adjustment to compare nationwide hospital performances after resection of colorectal liver metastases. Eur J Surg Oncol 2021; 47:649-659. [DOI: 10.1016/j.ejso.2020.10.016] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 10/07/2020] [Accepted: 10/12/2020] [Indexed: 01/23/2023] Open
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32
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Chavez MI, Gholami S, Kim BJ, Margonis GA, Ethun CG, Tsai S, Christians KK, Clarke C, Mogal H, Maithel SK, Pawlik TM, D'Angelica MI, Aloia TA, Eastwood D, Gamblin TC. Two-Stage Hepatectomy for Bilateral Colorectal Liver Metastases: A Multi-institutional Analysis. Ann Surg Oncol 2021; 28:1457-1465. [PMID: 33393036 DOI: 10.1245/s10434-020-09459-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 10/17/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND Two-stage hepatectomy (TSH) is an important tool in the management of bilateral colorectal liver metastases (CRLM). This study sought to examine the presentation, management, and outcomes of patients completing TSH in major hepatobiliary centers in the United States (US). METHODS A retrospective review from five liver centers in the US identified patients who completed a TSH procedure for bilateral CRLM. RESULTS From December 2000 to March 2016, a total of 196 patients were identified. The majority of procedures were performed using an open technique (n = 194, 99.5%). The median number of tumors was 7 (range 2-33). One-hundred and twenty-eight (65.3%) patients underwent portal vein embolization. More patients received chemotherapy prior to the first stage than chemotherapy administration preceding the second stage (92% vs. 60%, p = 0.308). Median overall survival (OS) was 50 months, with a median follow-up of 28 months (range 2-143). Hepatic artery infusion chemotherapy was administered to 64 (32.7%) patients with similar OS as those managed without an infusion pump (p = 0.848). Postoperative morbidity following the second-stage resection was 47.4%. Chemotherapy prior to the second stage did not demonstrate an increased complication rate (p = 0.202). Readmission following the second stage was 10.3% and was associated with a decrease in disease-free survival (p = 0.003). OS was significantly decreased by positive resection margins and increased estimated blood loss (EBL; p = 0.036 and p = 0.05, respectively). CONCLUSION This is the largest TSH series in the US and demonstrates evidence of safety and feasibility in the management of bilateral CRLM. Outcomes are influenced by margin status and operative EBL.
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Affiliation(s)
- Mariana I Chavez
- Division of Surgical Oncology, Medical College of Wisconsin, Milwaukee, WI, USA
| | | | | | | | | | - Susan Tsai
- Division of Surgical Oncology, Medical College of Wisconsin, Milwaukee, WI, USA
| | | | - Callisia Clarke
- Division of Surgical Oncology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Harveshp Mogal
- Division of Surgical Oncology, Medical College of Wisconsin, Milwaukee, WI, USA
| | | | - Timothy M Pawlik
- The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | | | | | - Daniel Eastwood
- Division of Biostatistics at Medical College of Wisconsin, Milwaukee, WI, USA
| | - T Clark Gamblin
- Division of Surgical Oncology, Medical College of Wisconsin, Milwaukee, WI, USA.
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Wanis KN, Linecker M, Madenci AL, Müller PC, Nüssler N, Brusadin R, Robles-Campos R, Hahn O, Serenari M, Jovine E, Lehwald N, Knoefel WT, Reese T, Oldhafer K, de Santibañes M, Ardiles V, Lurje G, Capelli R, Enne M, Ratti F, Aldrighetti L, Zhurbin AS, Voskanyan S, Machado M, Kitano Y, Adam R, Chardarov N, Skipenko O, Ferri V, Vicente E, Tomiyama K, Hernandez-Alejandro R. Variation in complications and mortality following ALPPS at early-adopting centers. HPB (Oxford) 2021; 23:46-55. [PMID: 32456975 PMCID: PMC7680722 DOI: 10.1016/j.hpb.2020.04.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2019] [Accepted: 04/13/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Various, often conflicting, estimates for post-operative morbidity and mortality following ALPPS have been reported in the literature, suggesting that considerable center-level variation exists. Some of this variation may be related to center volume and experience. METHODS Using data from seventeen centers who were early adopters of the ALPPS technique, we estimated the variation, by center, in standardized 90-day mortality and comprehensive complication index (CCI) for patients treated between 2012 and 2018. RESULTS We estimated that center-specific 90-day mortality following treatment with ALPPS varied from 4.2% (95% CI: 0.8, 9.9) to 29.1% (95% CI: 13.9, 50.9), and that center-specific CCI following treatment with ALPPS varied from 17.0 (95% CI: 7.5, 26.5) to 49.8 (95% CI: 38.1, 61.8). Declines in estimated 90-day mortality and CCI were observed over time, and almost all individual centers followed this trend. Patients treated at centers with a higher number of ALPPS cases performed over the prior year had a lower risk of post-operative mortality. CONCLUSION Despite considerable center-level variation in ALPPS outcomes, perioperative outcomes following ALPPS have improved over time and treatment at higher volume centers results in a lower risk of 90-day mortality. Morbidity and mortality remain concerningly high at some centers.
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Affiliation(s)
- Kerollos N Wanis
- Department of Surgery, Western University, Ontario, Canada; Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA.
| | - Michael Linecker
- Department of Surgery and Transplantation, University Hospital Zurich, Switzerland
| | - Arin L Madenci
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Philip C Müller
- Department of Surgery and Transplantation, University Hospital Zurich, Switzerland
| | - Natascha Nüssler
- Department of Surgery, Klinikum Neuperlach, Städtisches Klinikum München, Munich, Germany
| | - Roberto Brusadin
- Department of Surgery and Liver and Pancreas Transplantation, Virgen de la Arrixaca Clinic and University Hospital, Murcia, Spain
| | - Ricardo Robles-Campos
- Department of Surgery and Liver and Pancreas Transplantation, Virgen de la Arrixaca Clinic and University Hospital, Murcia, Spain
| | - Oszkar Hahn
- Hepato-Pancreatico-Biliary (HPB) Surgical Research Center Hungary, 1st Department of Surgery, Semmelweis University, Budapest, Hungary
| | - Matteo Serenari
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Elio Jovine
- Department of Surgery, C. A. Pizzardi Maggiore Hospital, Bologna, Italy
| | - Nadja Lehwald
- Department of General, Visceral and Pediatric Surgery, Medical Faculty, University of Duesseldorf, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Wolfram T Knoefel
- Department of General, Visceral and Pediatric Surgery, Medical Faculty, University of Duesseldorf, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Tim Reese
- Department of General, Visceral and Oncological Surgery, Asklepios Klinik Barmbek, Hamburg, Germany
| | - Karl Oldhafer
- Department of General, Visceral and Oncological Surgery, Asklepios Klinik Barmbek, Hamburg, Germany
| | | | - Victoria Ardiles
- Department of Surgery, Hospital Italiano, Buenos Aires, Argentina
| | - Georg Lurje
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Germany; Department of Surgery, Charité Universitätsmedizin Berlin, Campus Charité Mitte I Campus Virchow Klinikum, Augustenburger Platz 1, 13353 Berlin, Germany
| | - Rafaela Capelli
- Hepatobiliary Surgery, Ipanema Federal Hospital, Health Ministry, Rio de Janeiro, Brazil
| | - Marcelo Enne
- Hepatobiliary Surgery, Ipanema Federal Hospital, Health Ministry, Rio de Janeiro, Brazil
| | | | | | - Alexey S Zhurbin
- Department of Surgery, A.I. Burnazyan FMBC Russian State Scientific Center of FMBA, Moscow, Russia
| | - Sergey Voskanyan
- Department of Surgery, A.I. Burnazyan FMBC Russian State Scientific Center of FMBA, Moscow, Russia
| | - Marcel Machado
- Department of Surgery, University of São Paulo, São Paulo, Brazil
| | - Yuki Kitano
- Hepato-Biliary Center, AP-HP Paul Brousse Hospital, University of Paris-Sud, Inserm U776, Villejuif, France
| | - René Adam
- Hepato-Biliary Center, AP-HP Paul Brousse Hospital, University of Paris-Sud, Inserm U776, Villejuif, France
| | - Nikita Chardarov
- Research Center of Surgery, Russian Academy of Medical Science, Moscow, Russia
| | - Oleg Skipenko
- Research Center of Surgery, Russian Academy of Medical Science, Moscow, Russia
| | - Valentina Ferri
- Department of General Surgery, HM Sanchinarro Hospital, Madrid, Spain
| | - Emilio Vicente
- Department of General Surgery, HM Sanchinarro Hospital, Madrid, Spain
| | - Koji Tomiyama
- Division of Transplantation/Hepatobiliary Surgery, Department of Surgery, University of Rochester, NY, USA
| | - Roberto Hernandez-Alejandro
- Department of Surgery, Western University, Ontario, Canada; Division of Transplantation/Hepatobiliary Surgery, Department of Surgery, University of Rochester, NY, USA
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Pavel MC, Casanova R, Estalella L, Memba R, Llàcer-Millán E, Achalandabaso M, Julià E, Geoghegan J, Jorba R. The effect of preoperative chemotherapy on liver regeneration after portal vein embolization/ligation or liver resection in patients with colorectal liver metastasis: a systematic review protocol. Syst Rev 2020; 9:279. [PMID: 33276812 PMCID: PMC7718667 DOI: 10.1186/s13643-020-01545-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 11/26/2020] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION Liver resection (LR) in patients with liver metastasis from colorectal cancer remains the only curative treatment. Perioperative chemotherapy improves prognosis of these patients. However, there are concerns regarding the effect of preoperative chemotherapy on liver regeneration, which is a key event in avoiding liver failure after LR. The primary objective of this systematic review is to assess the effect of neoadjuvant chemotherapy on liver regeneration after (LR) or portal vein embolization (PVE) in patients with liver metastasis from colorectal cancer. The secondary objectives are to evaluate the impact of the type of chemotherapy, number of cycles, and time between end of treatment and procedure (LR or PVE) and to investigate whether there is an association between degree of hypertrophy and postoperative liver failure. METHODS This meta-analysis will include studies reporting liver regeneration rates in patients submitted to LR or PVE. Pubmed, Scopus, Web of Science, Embase, and Cochrane databases will be searched. Only studies comparing neoadjuvant vs no chemotherapy, or comparing chemotherapy characteristics (bevacizumab administration, number of cycles, and time from finishing chemotherapy until intervention), will be included. We will select studies from 1990 to present. Two researchers will individually screen the identified records, according to a list of inclusion and exclusion criteria. Primary outcome will be future liver remnant regeneration rate. Bias of the studies will be evaluated with the ROBINS-I tool, and quality of evidence for all outcomes will be determined with the GRADE system. The data will be registered in a predesigned database. If selected studies are sufficiently homogeneous, we will perform a meta-analysis of reported results. In the event of a substantial heterogeneity, a qualitative systematic review will be performed. DISCUSSION The results of this systematic review may help to better identify the patients affected by liver metastasis that could present low regeneration rates after neoadjuvant chemotherapy. These patients are at risk to develop liver failure after extended hepatectomies and therefore are not good candidates for such aggressive procedures. SYSTEMATIC REVIEW REGISTRATION PROSPERO registration number: CRD42020178481 (July 5, 2020).
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Affiliation(s)
- Mihai-Calin Pavel
- HPB Unit, Department of General Surgery, Hospital Universitari de Tarragona Joan XXIII, C/ Dr. Mallafrè Guasch, 4, 43005, Tarragona, Spain. .,Departament de Medicina i Cirugia, Universitat Rovira i Virgili, Reus, Spain.
| | - Raquel Casanova
- HPB Unit, Department of General Surgery, Hospital Universitari de Tarragona Joan XXIII, C/ Dr. Mallafrè Guasch, 4, 43005, Tarragona, Spain
| | - Laia Estalella
- HPB Unit, Department of General Surgery, Hospital Universitari de Tarragona Joan XXIII, C/ Dr. Mallafrè Guasch, 4, 43005, Tarragona, Spain.,Departament de Medicina i Cirugia, Universitat Rovira i Virgili, Reus, Spain
| | - Robert Memba
- HPB Unit, Department of General Surgery, Hospital Universitari de Tarragona Joan XXIII, C/ Dr. Mallafrè Guasch, 4, 43005, Tarragona, Spain.,Departament de Medicina i Cirugia, Universitat Rovira i Virgili, Reus, Spain
| | - Erik Llàcer-Millán
- HPB Unit, Department of General Surgery, Hospital Universitari de Tarragona Joan XXIII, C/ Dr. Mallafrè Guasch, 4, 43005, Tarragona, Spain.,Departament de Medicina i Cirugia, Universitat Rovira i Virgili, Reus, Spain
| | - Mar Achalandabaso
- HPB Unit, Department of General Surgery, Hospital Universitari de Tarragona Joan XXIII, C/ Dr. Mallafrè Guasch, 4, 43005, Tarragona, Spain
| | - Elisabet Julià
- HPB Unit, Department of General Surgery, Hospital Universitari de Tarragona Joan XXIII, C/ Dr. Mallafrè Guasch, 4, 43005, Tarragona, Spain
| | - Justin Geoghegan
- HPB and Liver Transplant Surgery Department, St. Vincent's University Hospital, Dublin, Ireland
| | - Rosa Jorba
- HPB Unit, Department of General Surgery, Hospital Universitari de Tarragona Joan XXIII, C/ Dr. Mallafrè Guasch, 4, 43005, Tarragona, Spain.,Departament de Medicina i Cirugia, Universitat Rovira i Virgili, Reus, Spain
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Abstract
Abstract
Purpose of Review
Accumulating evidence suggest that selected patients with nonresectable liver only metastases from colorectal cancer can be offered liver transplantation with acceptable outcome. This review provides an update on the scientific literature.
Recent Findings
The SECA-I study showed an estimated 5-year survival of 60% in a heterogenous patient population and guided the development of the first clinical selection criteria. In the sequel SECA-II trial, an estimated 5-year survival of 83% was obtained. A recent study shows that an Oslo score of 0–2, a metabolic tumor volume below 70 cm3 on PET-CT or Fong score of 0–2 at time of listing, can stratify patients with superior survival. Recurrence is common, but about 70% are slow-growing lung metastases, whereof the majority are resectable.
Summary
Liver transplantation for colorectal liver metastasis is an option in highly selected patients. Futile use of grafts can be avoided by applying stringent selection criteria.
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Zhang J, Huang H, Bian J, Sang X, Xu Y, Lu X, Zhao H. Safety, feasibility, and efficacy of associating liver partition and portal vein ligation for staged hepatectomy in treating hepatocellular carcinoma: a systematic review. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:1246. [PMID: 33178778 PMCID: PMC7607135 DOI: 10.21037/atm-20-2214] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) allows radical resection of colorectal liver metastasis (CRLM). However, the effect of ALPPS on hepatocellular carcinoma (HCC) is not completely understood. This systematic review aimed to examine the existing data on the safety, feasibility, and oncologic effect of ALPPS on HCC. Electronic databases, including PubMed, Web of Science, and Embase, were systemically searched to identify articles on ALPPS and HCC. Additional articles were identified manually. The feasibility (liver hypertrophy between two stages), safety (90-day mortality), and therapeutic effect (long-term survival) were analyzed. Nine published articles that satisfied the retrieval standards were included, and these studies involved 176 patients. The evidence level of the enrolled studies was low, among which, the greatest Oxford evidence level was 2c. Additionally, the average median increase in future liver volume was 178 mL, the average interval between two stages was 11.2 days, the interval was remarkably longer in radiofrequency-assisted ALPPS (RALPPS) patients (28 days), and the average 90-day mortality was 17.6% (range, 0–50%). However, the oncological outcomes were not well documented. Survival following ALPPS was evidently improved compared with that after transcatheter arterial chemoembolization (TACE). This value was comparable to that following the one-stage hepatectomy and portal vein embolization (PVE), and it was similar to that in CRLM patients over the long term. Publication biases caused by case series and single-center reports are common in the review. It is concluded in this review that ALPPS is a safe and feasible approach to treat selected patients with unresectable HCC, but its oncological outcome requires further study. RALPPS is not recommended for HCC patients because of the long waiting time between the two stages.
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Affiliation(s)
- Junwei Zhang
- Department of Liver Surgery, Peking Union Medical College (PUMC) Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hanchun Huang
- Department of Liver Surgery, Peking Union Medical College (PUMC) Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jin Bian
- Department of Liver Surgery, Peking Union Medical College (PUMC) Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xinting Sang
- Department of Liver Surgery, Peking Union Medical College (PUMC) Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yiyao Xu
- Department of Liver Surgery, Peking Union Medical College (PUMC) Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xin Lu
- Department of Liver Surgery, Peking Union Medical College (PUMC) Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Haitao Zhao
- Department of Liver Surgery, Peking Union Medical College (PUMC) Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Burlaka AA, Paliichuk AV, Iatsyna OI, Kolesnik ОО. Colorectal cancer liver metastases within the central and peripheral segments: Parenchymal sparing surgery adaptation. Ann Med Surg (Lond) 2020; 58:8-13. [PMID: 32874570 PMCID: PMC7452121 DOI: 10.1016/j.amsu.2020.07.052] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 07/27/2020] [Accepted: 07/30/2020] [Indexed: 02/06/2023] Open
Abstract
Background The debate over the surgical strategy optimization in colorectal cancer patients with liver metastases (mCRC) has been ongoing in the last 20 years. However, parenchyma sparing surgery (PPS) in cases of hard to reach liver cites (HTRLC) remain to be controversial. Methods A prospective analysis of 185 mCRC patients performed who were devided in two groups depending by predominant liver cite localization. Peripherally localized metastases (PLM) (n = 107) (S2, S3, S6, S7, Spiegel lobe and subcapsular area 1-2 cm below the liver surface). Group 2 included those with metastases localized in HTRLC (n = 78) - metastatic lesions of the "right venous core", portal and caval hilum, paracaval part of S1, "deep" parenchyma cites of S5, S8 and S4. Results In 26 (33,3%) and 32 (29,9%) patients of HTRLC and PLM, respectively, performed one liver re-resection (0,62). In HTRLC group 2 and more re-resection were performed in 7 (8,9%) cases while in PLM in 11 (10,3%), p = 0,76. Postoperative major morbidity was 24,4%, 21,8% (p = 0,15) and mortality 8,9%, 4,6% for HTRLC and PLM groups, respectively. R1v principles were implemented in 24 (30,7%) cases with centrally located metastases and in only 6 cases (5.6%) with peripheral localized metastases (p = 0,001). Cumulative 3-year disease-free survival (DSF) for PLM and HTRLC groups was 63% and 41% (p = 0,008). DFS for R1v (n = 24) and R0 (54) cochorts in HTRLC group was 33% and 43%, respeсtively (p = 0,44). Conclusions Principles of the PPS tactic provides an adequate removal of metastatic lesions in hard to reach liver cites allowing to maintain organ functions and increases the feasibility of the repeated liver resections in case of the initial disease progression.
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Affiliation(s)
- A A Burlaka
- Colorectal Cancer Department of National Cancer Institute, Ukraine
| | | | - O I Iatsyna
- Medical Director of National Cancer Institute, Ukraine
| | - О О Kolesnik
- Main Researcher of Colorectal Cancer Department of National Cancer Institute, Ukraine
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Simultaneous portal and hepatic vein embolization before major liver resection. Langenbecks Arch Surg 2020; 406:1295-1305. [PMID: 32839889 PMCID: PMC8370912 DOI: 10.1007/s00423-020-01960-6] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 08/06/2020] [Indexed: 11/17/2022]
Abstract
Background Regenerative liver surgery expands the limitations of technical resectability by increasing the future liver remnant (FLR) volume before extended resections in order to avoid posthepatectomy liver failure (PHLF). Portal vein rerouting with ligation of one branch of the portal vein bifurcation (PVL) or embolization (PVE) leads to a moderate liver volume increase over several weeks with a clinical dropout rate of 20–40%, mostly due to tumor progression during the waiting period. Accelerated liver regeneration by the Associating Liver Partition and Portal vein Ligation for Staged hepatectomy (ALPPS) was poised to overcome this limitation by reduction of the waiting time, but failed due increased perioperative complications. Simultaneous portal and hepatic vein embolization (PVE/HVE) is a novel minimal invasive way to induce rapid liver growth without the need of two surgeries. Purpose This article summarizes published results of PVE/HVE and analyzes what is known about its efficacy to achieve resection, safety, and the volume changes induced. Conclusions PVE/HVE holds promise to induce accelerated liver regeneration in a similar safety profile to PVE. The demonstrated accelerated hypertrophy may increase resectability. Randomized trials will have to compare PVE/HVE and PVE to determine if PVE/HVE is superior to PVE.
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Zhang L, Yang Z, Zhang S, Wang W, Zheng S. Conventional Two-Stage Hepatectomy or Associating Liver Partitioning and Portal Vein Ligation for Staged Hepatectomy for Colorectal Liver Metastases? A Systematic Review and Meta-Analysis. Front Oncol 2020; 10:1391. [PMID: 32974141 PMCID: PMC7471772 DOI: 10.3389/fonc.2020.01391] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Accepted: 07/01/2020] [Indexed: 12/14/2022] Open
Abstract
Background: Pushing the surgical limits for initially unresectable colorectal liver metastases (CRLM) are two approaches for sequential liver resection: two-stage hepatectomy (TSH) and associating liver partitioning and portal vein ligation for staged hepatectomy (ALPPS). However, the role of each treatment modality remains ill-defined. The present meta-analysis was designed to compare the safety, efficacy, and oncological benefits between ALPPS and TSH in the management of advanced CRLM. Methods: A systematic literature search was conducted from online databases through to February 2020. Single-arm synthesis and cumulative meta-analysis were performed. Results: Eight studies were included, providing a total of 409 subjects for analysis (ALPPS: N = 161; TSH: N = 248). The completions of the second stage of the hepatectomy [98 vs. 78%, odds ratio (OR) 5.75, p < 0.001] and R0 resection (66 vs. 37%; OR 4.68; p < 0.001) were more frequent in patients receiving ALPPS than in those receiving TSH, and the waiting interval was dramatically shortened in ALPPS (11.6 vs. 45.7 days, weighted mean difference = −35.3 days, p < 0.001). Nevertheless, the rate of minor complications was significantly higher in ALPPS (59 vs. 18%, OR 6.5, p < 0.001) than in TSH. The two treatments were similar in 90-day mortality (7 vs. 5%, p = 0.43), major complications (29 vs. 22%, p = 0.08), posthepatectomy liver failure (PHLF; 9 vs. 9%, p = 0.3), biliary leakage (11 vs. 14%, p = 0.86), length of hospital stay (27.95 vs. 26.88 days, p = 0.8), 1-year overall survival (79 vs. 84%, p = 0.61), 1-year recurrence (49 vs. 39%, p = 0.32), and 1-year disease-free survival (34 vs. 39%, p = 0.66). Cumulative meta-analyses indicated chronological stability for the pooled effect sizes of resection rate, 90-day mortality, major complications, and PHLF. Conclusions: Compared with TSH, ALPPS for advanced CRLM resulted in superior surgical efficacy with comparable perioperative mortality rate and short-term oncological outcomes, while this was at the cost of increased perioperative minor complications.
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Affiliation(s)
- Liang Zhang
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, School of Medicine, The First Affiliated Hospital, Zhejiang University, Hangzhou, China
- NHC Key Laboratory of Combined Multi-Organ Transplantation, Key Laboratory of the Diagnosis and Treatment of Organ Transplantation, CAMS, Hangzhou, China
| | - Zhentao Yang
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, School of Medicine, The First Affiliated Hospital, Zhejiang University, Hangzhou, China
- NHC Key Laboratory of Combined Multi-Organ Transplantation, Key Laboratory of the Diagnosis and Treatment of Organ Transplantation, CAMS, Hangzhou, China
| | - Shiyu Zhang
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, School of Medicine, The First Affiliated Hospital, Zhejiang University, Hangzhou, China
- NHC Key Laboratory of Combined Multi-Organ Transplantation, Key Laboratory of the Diagnosis and Treatment of Organ Transplantation, CAMS, Hangzhou, China
| | - Wenchao Wang
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, School of Medicine, The First Affiliated Hospital, Zhejiang University, Hangzhou, China
- NHC Key Laboratory of Combined Multi-Organ Transplantation, Key Laboratory of the Diagnosis and Treatment of Organ Transplantation, CAMS, Hangzhou, China
| | - Shusen Zheng
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, School of Medicine, The First Affiliated Hospital, Zhejiang University, Hangzhou, China
- NHC Key Laboratory of Combined Multi-Organ Transplantation, Key Laboratory of the Diagnosis and Treatment of Organ Transplantation, CAMS, Hangzhou, China
- *Correspondence: Shusen Zheng
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Pérez-Santiago L, Dorcaratto D, Garcés-Albir M, Muñoz-Forner E, Huerta Álvaro M, Roselló Keranën S, Sabater L. The actual management of colorectal liver metastases. MINERVA CHIR 2020; 75:328-344. [PMID: 32773753 DOI: 10.23736/s0026-4733.20.08436-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Colorectal cancer is one of the most frequent cancers in the world and between 50% and 60% of patients will develop colorectal liver metastases (CRLM) during the disease. There have been great improvements in the management of CRLM during the last decades. The combination of modern chemotherapeutic and biological systemic treatments with aggressive surgical resection strategies is currently the base for the treatment of patients considered unresectable until few years ago. Furthermore, several new treatments for the local control of CRLM have been developed and are now part of the arsenal of multidisciplinary teams for the treatment of these complex patients. The aim of this review was to summarize and update the management of CRLM, its controversies and relevant evidence.
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Affiliation(s)
- Leticia Pérez-Santiago
- Unit of Liver, Biliary and Pancreatic Surgery, Department of Surgery, Clinic Hospital, INCLIVA Biomedical Research Institute, University of Valencia, Valencia, Spain
| | - Dimitri Dorcaratto
- Unit of Liver, Biliary and Pancreatic Surgery, Department of Surgery, Clinic Hospital, INCLIVA Biomedical Research Institute, University of Valencia, Valencia, Spain -
| | - Marina Garcés-Albir
- Unit of Liver, Biliary and Pancreatic Surgery, Department of Surgery, Clinic Hospital, INCLIVA Biomedical Research Institute, University of Valencia, Valencia, Spain
| | - Elena Muñoz-Forner
- Unit of Liver, Biliary and Pancreatic Surgery, Department of Surgery, Clinic Hospital, INCLIVA Biomedical Research Institute, University of Valencia, Valencia, Spain
| | - Marisol Huerta Álvaro
- Department of Medical Oncology, Clinic Hospital, INCLIVA Biomedical Research Institute, University of Valencia, Valencia, Spain
| | - Susana Roselló Keranën
- Department of Medical Oncology, Clinic Hospital, INCLIVA Biomedical Research Institute, University of Valencia, Valencia, Spain
| | - Luis Sabater
- Unit of Liver, Biliary and Pancreatic Surgery, Department of Surgery, Clinic Hospital, INCLIVA Biomedical Research Institute, University of Valencia, Valencia, Spain
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41
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Affiliation(s)
- Juan Manuel O'Connor
- GI Clinical Oncology & GI Surgical Oncology, Instituto Alexander Fleming, Av Cramer 1180, Buenos Aires, C1426ANZ, Argentina
| | - Fernando Sanchez Loria
- GI Clinical Oncology & GI Surgical Oncology, Instituto Alexander Fleming, Av Cramer 1180, Buenos Aires, C1426ANZ, Argentina
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Bednarsch J, Czigany Z, Sharmeen S, van der Kroft G, Strnad P, Ulmer TF, Isfort P, Bruners P, Lurje G, Neumann UP. ALPPS versus two-stage hepatectomy for colorectal liver metastases--a comparative retrospective cohort study. World J Surg Oncol 2020; 18:140. [PMID: 32580729 PMCID: PMC7315489 DOI: 10.1186/s12957-020-01919-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Accepted: 06/15/2020] [Indexed: 02/07/2023] Open
Abstract
Abstract Background Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) and two stage hepatectomy with inter-stage portal vein embolization (TSH/PVE) are surgical maneuvers applied in patients with advanced malignancies considered unresectable by means of conventional liver surgery. The aim of this report is to compare the oncologic outcome and technical feasibility of ALPPS and TSH/PVE in the scenario of colorectal liver metastases (CRLM). Methods All consecutive patients who underwent either ALPPS or TSH/PVE for CRLM between 2011 and 2017 in one hepatobiliary center were analyzed and compared regarding perioperative and long-term oncologic outcome. Results A cohort of 58 patients who underwent ALPPS (n = 21) or TSH/PVE (n = 37) was analyzed. The median overall survival (OS) was 28 months and 34 months after ALPPS and TSH/PVE (p = 0.963), respectively. The median recurrence-free survival (RFS) was higher following ALPPS with 19 months than following TSH/PVE with 10 months, but marginally failed to achieve statistical significance (p = 0.05). There were no differences in morbidity and mortality after stages 1 and 2. Patients undergoing ALPPS due to insufficient hypertrophy after TSH/PVE (rescue-ALPPS) displayed similar oncologic outcome as patients treated by conventional ALPPS or TSH/PVE (p = 0.971). Conclusions ALPPS and TSH/PVE show excellent technical feasibility and comparable long-term oncologic outcome in CRLM. Rescue ALPPS appears to be a viable option for patients displaying insufficient hypertrophy after a TSH/PVE approach.
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Affiliation(s)
- Jan Bednarsch
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Pauwelsstrasse 30, 52074, Aachen, Germany
| | - Zoltan Czigany
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Pauwelsstrasse 30, 52074, Aachen, Germany
| | - Samara Sharmeen
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Pauwelsstrasse 30, 52074, Aachen, Germany
| | - Gregory van der Kroft
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Pauwelsstrasse 30, 52074, Aachen, Germany
| | - Pavel Strnad
- Department of Medicine III, University Hospital RWTH Aachen, Aachen, Germany
| | - Tom Florian Ulmer
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Pauwelsstrasse 30, 52074, Aachen, Germany
| | - Peter Isfort
- Department of Radiology, University Hospital RWTH Aachen, Aachen, Germany
| | - Philipp Bruners
- Department of Radiology, University Hospital RWTH Aachen, Aachen, Germany
| | - Georg Lurje
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Pauwelsstrasse 30, 52074, Aachen, Germany. .,Department of Surgery, Campus Charité Mitte
- Campus Virchow-Klinikum, Charité-Universitätsmedizin Berlin, Berlin, Germany.
| | - Ulf Peter Neumann
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Pauwelsstrasse 30, 52074, Aachen, Germany.,Department of Surgery, Maastricht University Medical Centre (MUMC), Maastricht, Netherlands
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Kabir T, Syn N, Goh BKP. Current status of laparoscopic liver resection for the management of colorectal liver metastases. J Gastrointest Oncol 2020; 11:526-539. [PMID: 32655931 PMCID: PMC7340801 DOI: 10.21037/jgo.2020.02.05] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2019] [Accepted: 01/22/2020] [Indexed: 12/11/2022] Open
Abstract
Colorectal cancer (CRC) is one of the most prevalent malignancies worldwide. The commonest site of spread is the liver, with up to 40% of patients developing colorectal liver metastasis (CLRM) during the course of their lifetime. Significant advances in surgical techniques, as well as breakthroughs in chemotherapy and biologic agents, have resulted in dramatic improvements in prognosis. A multimodal approach comprising of liver resection coupled with systemic therapy offers these patients the best chance of cure. The arrival of laparoscopic liver resection (LLR) within the last 3 decades has added a whole new dimension to the management of this condition. Today, CLRM is one of the most frequent indications for LLR globally. Meta-analyses of retrospective studies and two randomized trials have demonstrated superior short-term outcomes following LLR, with no differences in mortality rates. Oncologically, R0 resection rates are comparable to the open approach, while overall and disease-free survival rates are also similar. As surgeons gain confidence, boundaries are pushed even further. High-volume centers have published their early experiences with complex LLR of recurrent CLRM as well as totally laparoscopic synchronous resection of CRC and liver metastases, with very encouraging results. In the presence of extensive bilobar CLRM, two-stage hepatectomy (TSH) and associating liver partition with portal vein ligation (ALPPS) may be adopted to augment an inadequate future liver remnant to facilitate metastasectomy. Interestingly, the adoption of LLR for these techniques also seem to confer additional benefits. Despite the plethora of advantages, LLR comes with its own unique set of limitations such as a steep learning curve and high cost. The surgical world eagerly awaits the results of prospective trials currently underway in order to further advance the management of this disease.
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Affiliation(s)
- Tousif Kabir
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore, Singapore
- Department of General Surgery, Sengkang General Hospital, Singapore, Singapore
| | - Nicholas Syn
- Yong Loo Lin School of Medicine, Singapore, Singapore
| | - Brian K. P. Goh
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore, Singapore
- Duke NUS Medical School, Singapore, Singapore
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Tsilimigras DI, Bagante F, Moris D, Hyer JM, Sahara K, Paredes AZ, Mehta R, Ratti F, Marques HP, Soubrane O, Lam V, Poultsides GA, Popescu I, Alexandrescu S, Martel G, Workneh A, Guglielmi A, Hugh T, Aldrighetti L, Endo I, Pawlik TM. Recurrence Patterns and Outcomes after Resection of Hepatocellular Carcinoma within and beyond the Barcelona Clinic Liver Cancer Criteria. Ann Surg Oncol 2020; 27:2321-2331. [PMID: 32285278 DOI: 10.1245/s10434-020-08452-3] [Citation(s) in RCA: 69] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2019] [Indexed: 01/27/2023]
Abstract
BACKGROUND Several investigators have advocated for extending the Barcelona Clinic Liver Cancer (BCLC) resection criteria to select patients with BCLC-B and even BCLC-C hepatocellular carcinoma (HCC). The objective of the current study was to define the outcomes and recurrence patterns after resection within and beyond the current resection criteria. PATIENTS AND METHODS Patients who underwent resection for HCC within (i.e., BCLC 0/A) and beyond (i.e. BCLC B/C) the current resection criteria between 2005 and 2017 were identified from an international multi-institutional database. Overall survival (OS), disease-free survival (DFS), as well as patterns of recurrence of patients undergoing HCC resection within and beyond the BCLC guidelines were examined. RESULTS Among 756 patients, 602 (79.6%) patients were BCLC 0/A and 154 (20.4%) were BCLC B/C. Recurrences were mostly intrahepatic (within BCLC: 74.3% versus beyond BCLC: 70.8%, p = 0.80), with BCLC B/C patients more often having multiple tumors at relapse (69.6% versus 49.4%, p = 0.001) and higher rates of early (< 2 years) recurrence (88.0% versus 75.5%, p = 0.011). During the first postoperative year, annual recurrence was 38.3% and 21.3% among BCLC B/C and BCLC 0/A patients, respectively; 5-year OS among BCLC 0/A and BCLC B/C patients was 76.9% versus 51.6% (p = 0.003). On multivariable analysis, only a-fetoprotein (AFP) > 400 ng/mL (HR = 1.84, 95% CI 1.07-3.15) and R1 resection (HR = 2.36, 95% CI 1.32-4.23) were associated with higher risk of recurrence among BCLC B/C patients. CONCLUSIONS Surgery can provide acceptable outcomes among select patients with BCLC B/C HCC. The data emphasize the need to further refine the BCLC treatment algorithm as well as highlight the need for surveillance protocols with a particular focus on the liver, especially for patients undergoing resection outside the BCLC criteria.
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Affiliation(s)
| | - Fabio Bagante
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA.,Department of Surgery, University of Verona, Verona, Italy
| | - Dimitrios Moris
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - J Madison Hyer
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Kota Sahara
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Anghela Z Paredes
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Rittal Mehta
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | | | - Hugo P Marques
- Department of Surgery, Curry Cabral Hospital, Lisbon, Portugal
| | - Olivier Soubrane
- Department of Hepatobiliopancreatic Surgery, APHP, Beaujon Hospital, Clichy, France
| | - Vincent Lam
- Department of Surgery, Westmead Hospital, Sydney, Australia
| | | | - Irinel Popescu
- Department of Surgery, Fundeni Clinical Institute, Bucharest, Romania
| | | | | | - Aklile Workneh
- Department of Surgery, University of Ottawa, Ottawa, Canada
| | | | - Tom Hugh
- Department of Surgery, The University of Sydney, School of Medicine, Sydney, Australia
| | | | - Itaru Endo
- Yokohama City University School of Medicine, Yokohama, Japan
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA.
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45
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Rassam F, Olthof PB, van Lienden KP, Bennink RJ, Erdmann JI, Swijnenburg RJ, Busch OR, Besselink MG, van Gulik TM. Comparison of functional and volumetric increase of the future remnant liver and postoperative outcomes after portal vein embolization and complete or partial associating liver partition and portal vein ligation for staged hepatectomy (ALPPS). ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:436. [PMID: 32395480 PMCID: PMC7210209 DOI: 10.21037/atm.2020.03.191] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Background Portal vein embolization (PVE) is performed to induce hypertrophy of an insufficient future remnant liver (FRL) before major liver resection. Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) aims to offer a more rapid and increased hypertrophy response. The first stage can be performed with complete or partial (laparoscopic) transection of the liver parenchyma. This study aimed to investigate the increase in FRL volume and function, as well as postoperative outcomes after PVE or complete- or partial-ALPPS1. Methods Patients with insufficient FRL undergoing either PVE or ALPPS underwent CT-volumetry and functional assessment using 99mTc-mebrofenin hepatobiliary scintigraphy (HBS). Severe complications and 90-day mortality were evaluated after liver resection. Results Seventy-two patients were included; 51 underwent PVE, 12 complete-ALPPS1 and 9 partial-ALPPS1 of which 7 laparoscopic. The median increase in FRL function was 1.5-, 1.7- and 1.3-fold higher, respectively, than the increase in volume; (P<0.01, P<0.01 and P=0.44). The target hypertrophy response did not differ between the groups, but was reached earlier in both ALPPS1 groups (8 and 10 days) compared to the PVE group (23 days). Of the resected patients, 18%, 30% and 17% had severe postoperative complications and the 90-day mortality was 2%, 25% and 0%, respectively. Conclusions Increase of FRL function exceeded increase of volume after both PVE and ALPPS1. The target hypertrophy response was reached earlier in ALPPS. Complete and partial-ALPPS1 showed comparable functional and volumetric hypertrophy responses. A (laparoscopic) partial-ALPPS1 is preferred considering lower morbidity and mortality rates after resection.
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Affiliation(s)
- Fadi Rassam
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, The Netherlands
| | - Pim B Olthof
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, The Netherlands
| | - Krijn P van Lienden
- Departments of Radiology and Nuclear Medicine, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, The Netherlands
| | - Roel J Bennink
- Departments of Radiology and Nuclear Medicine, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, The Netherlands
| | - Joris I Erdmann
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, The Netherlands
| | - Rutger-Jan Swijnenburg
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, The Netherlands
| | - Olivier R Busch
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, The Netherlands
| | - Marc G Besselink
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, The Netherlands
| | - Thomas M van Gulik
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, The Netherlands
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Kim D, Cornman-Homonoff J, Madoff DC. Preparing for liver surgery with "Alphabet Soup": PVE, ALPPS, TAE-PVE, LVD and RL. Hepatobiliary Surg Nutr 2020; 9:136-151. [PMID: 32355673 DOI: 10.21037/hbsn.2019.09.10] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Future liver remnant (FLR) size and function is a critical limiting factor for treatment eligibility and postoperative prognosis when considering surgical hepatectomy. Pre-operative portal vein embolization (PVE) has been proven effective in modulating FLR and now widely accepted as a standard of care. However, PVE is not always effective due to potentially inadequate augmentation of the FLR as well as tumor progression while awaiting liver growth. These concerns have prompted exploration of alternative techniques: associating liver partition and portal vein ligation for staged hepatectomy (ALPPS), transarterial embolization-portal vein embolization (TAE-PVE), liver venous deprivation (LVD), and radiation lobectomy (RL). The article aims to review the principles and applications of PVE and these newer hepatic regenerative techniques.
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Affiliation(s)
- DaeHee Kim
- Department of Radiology, Division of Interventional Radiology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Joshua Cornman-Homonoff
- Department of Radiology and Biomedical Imaging, Section of Interventional Radiology, Yale School of Medicine, New Haven, CT, USA
| | - David C Madoff
- Department of Radiology and Biomedical Imaging, Section of Interventional Radiology, Yale School of Medicine, New Haven, CT, USA
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Ren L, Zhu D, Benson AB, Nordlinger B, Koehne CH, Delaney CP, Kerr D, Lenz HJ, Fan J, Wang J, Gu J, Li J, Shen L, Tsarkov P, Tejpar S, Zheng S, Zhang S, Gruenberger T, Qin X, Wang X, Zhang Z, Poston GJ, Xu J. Shanghai international consensus on diagnosis and comprehensive treatment of colorectal liver metastases (version 2019). Eur J Surg Oncol 2020; 46:955-966. [PMID: 32147426 DOI: 10.1016/j.ejso.2020.02.019] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2020] [Accepted: 02/17/2020] [Indexed: 12/17/2022] Open
Abstract
The liver is the most common anatomical site for hematogenous metastases from colorectal cancer. Therefore effective treatment of liver metastases is one of the most challenging elements in the management of colorectal cancer. However, there is rare available clinical consensus or guideline only focusing on colorectal liver metastases. After six rounds of discussion by 195 clinical experts of the Shanghai International Consensus Expert Group on Colorectal Liver Metastases (SINCE) from 29 countries or regions, the Shanghai Consensus has been finally completed, based on current research and expert experience. The consensus emphasized the principle of multidisciplinary team, provided detailed diagnosis approaches, and guided precise local and systemic treatments. This Shanghai Consensus might be of great significance to standardized diagnosis and treatment of colorectal liver metastases all over the world.
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Affiliation(s)
- Li Ren
- Department of Colorectal Surgery, Colorectal Cancer Center, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Dexiang Zhu
- Department of Colorectal Surgery, Colorectal Cancer Center, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Al B Benson
- Division of Hematology/Oncology, Northwestern Medical Group, Chicago, USA
| | - Bernard Nordlinger
- Surgery Department, Hospital Ambroise-Pare, Boulogne-Billancourt, France
| | | | - Conor P Delaney
- Department of Colorectal Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - David Kerr
- Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - Heinz-Josef Lenz
- Division of Medical Oncology, Norris Comprehensive Cancer Center, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Jia Fan
- Department of Liver Surgery and Transplantation, Liver Cancer Institute, Zhongshan Hospital, Key Laboratory of Carcinogenesis and Cancer Invasion of Ministry of Education, Fudan University, Shanghai, China
| | - Jianping Wang
- Department of Colorectal Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Jin Gu
- Department of Colorectal Surgery, Peking University Cancer Hospital, Beijing, China; Department of Colorectal Surgery, Peking University Shougang Hospital, Beijing, China
| | - Jin Li
- Department of Oncology, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
| | - Lin Shen
- Department of Gastrointestinal Oncology, Key Laboratory of Carcinogenesis and Translational Research, Peking University Cancer Hospital and Institute, Beijing, China
| | - Petrv Tsarkov
- Clinic of Colorectal and Minimally Invasive Surgery, Sechenov First Moscow State Medical University, Moscow, Russia
| | - Sabine Tejpar
- Department of Gastroenterology, University Hospitals Leuven, Leuven, Belgium
| | - Shu Zheng
- Key Laboratory of Cancer Prevention and Intervention, China National Ministry of Education, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Suzhan Zhang
- Department of Surgical Oncology, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | | | - Xinyu Qin
- Department of Colorectal Surgery, Colorectal Cancer Center, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Xishan Wang
- Department of Colorectal Surgery, National Cancer Center, National Clinical Research Center for Cancer, Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zhongtao Zhang
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University, National Clinical Research Center of Digestive Diseases, Beijing, China
| | - Graeme John Poston
- Surgery Department, Aintree University Hospital, School of Translational Studies, University of Liverpool, Liverpool, UK.
| | - Jianmin Xu
- Department of Colorectal Surgery, Colorectal Cancer Center, Zhongshan Hospital, Fudan University, Shanghai, China.
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Chan KS, Low JK, Shelat VG. Associated liver partition and portal vein ligation for staged hepatectomy: a review. Transl Gastroenterol Hepatol 2020; 5:37. [PMID: 32632388 PMCID: PMC7063517 DOI: 10.21037/tgh.2019.12.01] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Accepted: 11/30/2019] [Indexed: 02/05/2023] Open
Abstract
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.
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Affiliation(s)
- Kai Siang Chan
- Department of Medicine, Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | - Jee Keem Low
- Department of General Surgery, Tan Tock Seng Hospital, Singapore
| | - Vishal G. Shelat
- Department of General Surgery, Tan Tock Seng Hospital, Singapore
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Robles-Campos R, Brusadin R, López-Conesa A, López-López V, Navarro-Barrios Á, López-Espín JJ, Arévalo-Pérez J, Parrilla P. Long-Term Outcome After Conventional Two-Stage Hepatectomy Versus Tourniquet-ALPPS in Colorectal Liver Metastases: A Propensity Score Matching Analysis. World J Surg 2019; 43:2281-2289. [PMID: 31119359 DOI: 10.1007/s00268-019-05031-w] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND To compare the overall survival (OS) and disease-free survival (DFS) of Tourniquet-ALPPS (T-ALPPS) and conventional two-stage hepatectomy (TSH) in patients with colorectal liver metastases (CRLM). METHODS A retrospective study from a prospectively collected database was performed between October 2000 and July 2016. TSH was performed before September 2011, after which time T-ALPPS became the technique of choice. A propensity score matching (PSM) was performed based on a 1:1 ratio with consideration of the following variables: number and size of metastases, bilobar disease presence, and chemotherapy received. RESULTS Thirty-four patients received T-ALPPS; 41 patients received TSH. After PSM, 21 patients remained in each group, with 100% resectability in the T-ALPPS group and 90.5% resectability in the TSH group. The median OS for TSH was 41 months; for T-ALPPS, the median OS was 36 months (P = 0.925). The median DFS was 16 months in the TSH group; the median DFS was 9 months in the T-ALPPS group (P = 0.930). The 1-, 3-, and 5-year OS for TSH was 81%, 66.7%, and 23.8% vs. 76.2%, 57.1%, and 22.9% for T-ALPPS, respectively. The 1-, 3-, and 5-year DFS for TSH was 66.7%, 9.5%, and 5% vs. 44.6%, 11.1%, and 11.1% for T-ALPPS, respectively. The volume increase with T-ALPPS was superior to that with TSH (68% vs. 39%; P = 0.018). There were no differences in morbidity and mortality after stages 1 and 2. CONCLUSIONS T-ALPPS produces a similar outcome to TSH, indicating that it could be a safe and effective alternative for curative hepatectomy for all patients.
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Affiliation(s)
- Ricardo Robles-Campos
- Department of Liver Surgery and Transplantation, Virgen de La Arrixaca Clinic, University Hospital, IMIB-Arrixaca, Murcia, Spain. .,Department of Surgery, Virgen de La Arrixaca Clinic, University Hospital, El Palmar, Murcia, Spain.
| | - Roberto Brusadin
- Department of Liver Surgery and Transplantation, Virgen de La Arrixaca Clinic, University Hospital, IMIB-Arrixaca, Murcia, Spain
| | - Asunción López-Conesa
- Department of Liver Surgery and Transplantation, Virgen de La Arrixaca Clinic, University Hospital, IMIB-Arrixaca, Murcia, Spain
| | - Víctor López-López
- Department of Liver Surgery and Transplantation, Virgen de La Arrixaca Clinic, University Hospital, IMIB-Arrixaca, Murcia, Spain
| | - Álvaro Navarro-Barrios
- Department of Liver Surgery and Transplantation, Virgen de La Arrixaca Clinic, University Hospital, IMIB-Arrixaca, Murcia, Spain
| | | | | | - Pascual Parrilla
- Department of Liver Surgery and Transplantation, Virgen de La Arrixaca Clinic, University Hospital, IMIB-Arrixaca, Murcia, Spain
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50
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Two-Stage Hepatectomy and ALPPS for Advanced Bilateral Liver Metastases: a Tailored Approach Balancing Risk and Outcome. J Gastrointest Surg 2019; 23:2391-2400. [PMID: 30820795 DOI: 10.1007/s11605-019-04145-9] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Accepted: 01/29/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND AND AIM Two-stage hepatectomy (TSH) with or without portal vein ligation (PVL) or portal vein embolization (PVE) and associated liver partition and portal vein ligation for staged hepatectomy (ALPPS) are surgical strategies in the treatment of advanced colorectal liver metastases (CRLM). The role of each strategy is yet ill defined. The aim of this analysis is to share our center experience with conventional TSH with or without PVL/PVE and ALPPS in patients with advanced bilateral CRLM. PATIENTS AND METHODS Data were extracted from a prospectively collected institutional database. Complication rates according to the Dindo-Clavien classification, overall and recurrence-free survival data were analyzed. RESULTS Between 2008 and 2017, 790 liver resections were performed in 611 patients with CRLM. Out of 320 patients with bilateral disease, TSH (as right or extended right hepatectomy) with or without PVL/PVE was performed in 50 patients and ALPPS in 8. Stage 2 was completed in 36 (72%) out of 50 TSH/PVL/PVE and in all ALPPS patients (100%). Median follow-up was 15.8 months (0.9 to 111.9 months). On an intention-to-treat basis, the median overall survival was 26.7 (21.8-35.1 range) months after TSH/PVL/PVE and 36.2 months (11.3-61.2 range) after ALPPS (p = 0.809). In the TSH/PVL/PVE cohort, the median overall survival was 29.9 (19.0-40.3) months in patients who completed stage 2 compared to 13.8 months in patients who did not (p < 0.001). Disease recurred in 60% in the TSH/PVL/PVE cohort and in 87.5% in the ALPPS cohort (p = 0.777). The median recurrence-free survival was 5.9 (1.7-18.6) months after TSH/PVL/PVE and 3 (1.6-14.8) months after ALPPS (p = 0.680). CONCLUSION The treatment of advanced bilateral CRLM remains a surgical and oncological challenge. A tailored approach to bilateral CRLM uses TSH/PVL/PVE as first and ALPPS as second rescue treatment in order to achieve resectability in patients with extensive tumor burden not amenable to one-stage resection. ALPPS should be reserved for patients with no other surgical options.
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