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Barcena AJR, Owens TC, Melancon S, Workeneh I, Tran Cao HS, Vauthey JN, Huang SY. Current Perspectives and Progress in Preoperative Portal Vein Embolization with Stem Cell Augmentation (PVESA). Stem Cell Rev Rep 2024; 20:1236-1251. [PMID: 38613627 DOI: 10.1007/s12015-024-10719-1] [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] [Accepted: 04/03/2024] [Indexed: 04/15/2024]
Abstract
Portal vein embolization with stem cell augmentation (PVESA) is an emerging approach for enhancing the growth of the liver segment that will remain after surgery (i.e., future liver remnant, FLR) in patients with liver cancer. Conventional portal vein embolization (PVE) aims to induce preoperative FLR growth, but it has a risk of failure in patients with underlying liver dysfunction and comorbid illnesses. PVESA combines PVE with stem cell therapy to potentially improve FLR size and function more effectively and efficiently. Various types of stem cells can help improve liver growth by secreting paracrine signals for hepatocyte growth or by transforming into hepatocytes. Mesenchymal stem cells (MSCs), unrestricted somatic stem cells, and small hepatocyte-like progenitor cells have been used to augment liver growth in preclinical animal models, while clinical studies have demonstrated the benefit of CD133 + bone marrow-derived MSCs and hematopoietic stem cells. These investigations have shown that PVESA is generally safe and enhances liver growth after PVE. However, optimizing the selection, collection, and application of stem cells remains crucial to maximize benefits and minimize risks. Additionally, advanced stem cell technologies, such as priming, genetic modification, and extracellular vesicle-based therapy, that could further enhance efficacy outcomes should be evaluated. Despite its potential, PVESA requires more investigations, particularly mechanistic studies that involve orthotopic animal models of liver cancer with concomitant liver injury as well as larger human trials.
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Affiliation(s)
- Allan John R Barcena
- Department of Interventional Radiology, Division of Diagnostic Imaging, The University of Texas MD Anderson Cancer Center, 1400 Pressler St, Unit, Houston, TX, 1471, 77030, United States
- College of Medicine, University of the Philippines Manila, Manila, NCR, 1000, Philippines
| | - Tyler C Owens
- Department of Interventional Radiology, Division of Diagnostic Imaging, The University of Texas MD Anderson Cancer Center, 1400 Pressler St, Unit, Houston, TX, 1471, 77030, United States
| | - Sophie Melancon
- Department of Interventional Radiology, Division of Diagnostic Imaging, The University of Texas MD Anderson Cancer Center, 1400 Pressler St, Unit, Houston, TX, 1471, 77030, United States
| | - Isias Workeneh
- Department of Interventional Radiology, Division of Diagnostic Imaging, The University of Texas MD Anderson Cancer Center, 1400 Pressler St, Unit, Houston, TX, 1471, 77030, United States
| | - Hop S Tran Cao
- Department of Surgical Oncology, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, 77030, United States
| | - Jean-Nicolas Vauthey
- Department of Surgical Oncology, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, 77030, United States
| | - Steven Y Huang
- Department of Interventional Radiology, Division of Diagnostic Imaging, The University of Texas MD Anderson Cancer Center, 1400 Pressler St, Unit, Houston, TX, 1471, 77030, United States.
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Magistri P, Guidetti C, Catellani B, Caracciolo D, Odorizzi R, Frassoni S, Bagnardi V, Guerrini GP, Di Sandro S, Di Benedetto F. Robotic ALPPS for primary and metastatic liver tumours: short-term outcomes versus open approach. Updates Surg 2024; 76:435-445. [PMID: 38326663 DOI: 10.1007/s13304-023-01680-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 10/25/2023] [Indexed: 02/09/2024]
Abstract
Associating Liver Partition and Portal vein ligation for Staged hepatectomy (ALPPS) is one of the strategies available for patients initially unresectable. High risk of peri-operative morbidity and mortality limited its application and diffusion. We aimed to analyse short-term outcomes of robotic ALPPS versus open approach, to assess safety and reproducibility of this technique. A retrospective analysis of prospectively maintained databases at University of Modena and Reggio Emilia on patients that underwent ALPPS between January 2015 and September 2022 was conducted. The main aim of the study was to evaluate safety and feasibility of robotic approach, either full robotic or only first-stage robotic, compared to a control group of patients who underwent open ALPPS in the same Institution. 23 patients were included. Nine patients received a full open ALPPS (O-ALPPS), 7 received a full robotic ALPPS (R-ALPPS), and 7 underwent a robotic approach for stage 1, followed by an open approach for stage 2 (R + O-ALPPS). PHLF grade B-C after stage 1 was 0% in all groups, rising to 58% in the R + O-ALPPS group after stage 2 and remaining 0% in the R-ALPPS group. 86% of R-ALPPS cases were discharged from the hospital between stages 1 and 2, and median total in-hospital stay and ICU stay favoured full robotic approach as well. This contemporary study represents the largest series of robotic ALPPS, showing potential advantages from full robotic ALPPS over open approach, resulting in reduced hospital stay and complications and lower incidence of 90-day mortality.
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Affiliation(s)
- Paolo Magistri
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University Hospital of Modena "Policlinico", University of Modena and Reggio Emilia, 41124, Modena, Italy
| | - Cristiano Guidetti
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University Hospital of Modena "Policlinico", University of Modena and Reggio Emilia, 41124, Modena, Italy
| | - Barbara Catellani
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University Hospital of Modena "Policlinico", University of Modena and Reggio Emilia, 41124, Modena, Italy
| | - Daniela Caracciolo
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University Hospital of Modena "Policlinico", University of Modena and Reggio Emilia, 41124, Modena, Italy
| | - Roberta Odorizzi
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University Hospital of Modena "Policlinico", University of Modena and Reggio Emilia, 41124, Modena, Italy
| | - Samuele Frassoni
- Department of Statistics and Quantitative Methods, University of Milan-Bicocca, Milan, Italy
| | - Vincenzo Bagnardi
- Department of Statistics and Quantitative Methods, University of Milan-Bicocca, Milan, Italy
| | - Gian Piero Guerrini
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University Hospital of Modena "Policlinico", University of Modena and Reggio Emilia, 41124, Modena, Italy
| | - Stefano Di Sandro
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University Hospital of Modena "Policlinico", University of Modena and Reggio Emilia, 41124, Modena, Italy
| | - Fabrizio Di Benedetto
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University Hospital of Modena "Policlinico", University of Modena and Reggio Emilia, 41124, Modena, Italy.
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Wang J, Xu J, Liu Z. Laparoscopic Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy (L-ALPPS) After Conversion Therapy for BCLC-B Hepatocellular Carcinoma: A Video Article. Ann Surg Oncol 2023; 30:7360-7361. [PMID: 37501052 DOI: 10.1245/s10434-023-13946-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 07/03/2023] [Indexed: 07/29/2023]
Abstract
BACKGROUND Despite the ALPPS technique remains a controversy, various ALPPS techniques have made many attempts.1-6 This video discusses the technical tips for L-ALPPS after conversion therapy. METHODS A 56-year-old, HCC patient who performed the abdominal CT showed a 6.0*5.7-cm-sized mass with intrahepatic metastasis. After four cycles of conversion therapy, the patient achieved a radiologic complete response. However, the standardized, remnant liver volume ratio (SRLVR) was only 34%. Thus, L-ALPPS was contemplated. RESULTS After full mobilization, intraoperative ultrasonography marked the main trunk of MHV. The concept of "Laennec membrane anatomy" was introduced.7 The anterior pedicle (AP) and the posterior pedicle (PP) were elastically suspended along the Laennec membrane. The conventional hilar dissection approach was used to isolate and suspend RHA and the right portal vein (RPV). Then, IRHV and short hepatic vein were clipped and cut. The Pringle maneuver was used intermittently during the parenchymal transection. Hepatic resection was performed from the caudal to the cranial side along MHV after RPV was ligated. The RHV was elastically suspended after hepatic resection. The omentum was used to cover the resection surface. Stage 2, preoperative SRLVR increased to 68.3%. The adhesion of the right hemiliver was bluntly separated. AP, PP, and RHV were divided by the stapler respectively. Operation time and bleeding volume for stage-1 surgery and stage-2 surgery were 240 min and 80 min, 200 ml and 250 ml, respectively. The postoperative recovery was uneventful. CONCLUSIONS L-ALPPS as a surgical option seems to be feasible and safe for intermediate-advanced HCC after conversion therapy.
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Affiliation(s)
- Jiaguo Wang
- Department of Hepatobiliary Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Jie Xu
- Department of Hepatobiliary Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Zuojin Liu
- Department of Hepatobiliary Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China.
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John N, Montorfano L, Nagarajan A, Simpfendorfer CH, Wexner SD, Amin P, Roy M. Liver Venous Deprivation for Rapid Liver Hypertrophy Before Major Hepatectomy: A Case Report. Am Surg 2023; 89:4944-4948. [PMID: 38050321 DOI: 10.1177/00031348221135787] [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] [Indexed: 12/06/2023]
Abstract
Liver venous deprivation (LVD) is an emerging, minimally invasive strategy to induce rapid liver hypertrophy of the future liver remnant (FLR) before a major hepatectomy. LVD (aka "double vein embolization") entails same-session percutaneous embolization of the portal and hepatic veins of the planned liver resection. This report discusses LVD's utilization and technical challenges in managing a 49-year-old male with recurrent multifocal colorectal liver metastases (CRLM). The patient initially underwent neoadjuvant FOLFOX chemotherapy followed by a simultaneous laparoscopic sigmoid colectomy and liver surgery (microwave ablation of segment V and wedge resections of segment one and IVb), followed by completion of chemotherapy. The patient had an R0 resection with clear colon and liver surgical margins. Nine months after the initial surgery, the patient had a rise in tumor markers, and surveillance imaging demonstrated recurrence of liver metastases in segments I and V. LVD was performed by interventional radiology, which led to a 28% increase in FLR (segments II, III, and IV); initially measuring 464 cm3 before LVD and measuring 594 cm3 on post-procedure day 21. The patient underwent right hemi-hepatectomy and caudate resection on post-procedure day 29. The patient did not have any complications and was discharged on postoperative day 6. The patient remains disease-free with no evidence of recurrence at 12 months follow-up.
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Affiliation(s)
- Nathan John
- Department of General Surgery, Section of Hepatobiliary and Pancreatic Surgery, Digestive Disease Institute, Cleveland Clinic Florida, Weston, FL, USA
| | - Lisandro Montorfano
- Department of General Surgery, Section of Hepatobiliary and Pancreatic Surgery, Digestive Disease Institute, Cleveland Clinic Florida, Weston, FL, USA
| | - Arun Nagarajan
- Department of Hematology and Medical Oncology, Cleveland Clinic Florida, Weston, FL, USA
| | - Conrad H Simpfendorfer
- Department of General Surgery, Section of Hepatobiliary and Pancreatic Surgery, Digestive Disease Institute, Cleveland Clinic Florida, Weston, FL, USA
| | - Steven D Wexner
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic Florida, Weston, FL, USA
| | - Parag Amin
- Department of Imaging, Section of Interventional Radiology, Cleveland Clinic Florida, Weston, FL, USA
| | - Mayank Roy
- Department of General Surgery, Section of Hepatobiliary and Pancreatic Surgery, Digestive Disease Institute, Cleveland Clinic Florida, Weston, FL, USA
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Liu R, Abu Hilal M, Wakabayashi G, Han HS, Palanivelu C, Boggi U, Hackert T, Kim HJ, Wang XY, Hu MG, Choi GH, Panaro F, He J, Efanov M, Yin XY, Croner RS, Fong YM, Zhu JY, Wu Z, Sun CD, Lee JH, Marino MV, Ganpati IS, Zhu P, Wang ZZ, Yang KH, Fan J, Chen XP, Lau WY. International experts consensus guidelines on robotic liver resection in 2023. World J Gastroenterol 2023; 29:4815-4830. [PMID: 37701136 PMCID: PMC10494765 DOI: 10.3748/wjg.v29.i32.4815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 07/22/2023] [Accepted: 08/09/2023] [Indexed: 08/25/2023] Open
Abstract
The robotic liver resection (RLR) has been increasingly applied in recent years and its benefits shown in some aspects owing to the technical advancement of robotic surgical system, however, controversies still exist. Based on the foundation of the previous consensus statement, this new consensus document aimed to update clinical recommendations and provide guidance to improve the outcomes of RLR clinical practice. The guideline steering group and guideline expert group were formed by 29 international experts of liver surgery and evidence-based medicine (EBM). Relevant literature was reviewed and analyzed by the evidence evaluation group. According to the WHO Handbook for Guideline Development, the Guidance Principles of Development and Amendment of the Guidelines for Clinical Diagnosis and Treatment in China 2022, a total of 14 recommendations were generated. Among them were 8 recommendations formulated by the GRADE method, and the remaining 6 recommendations were formulated based on literature review and experts' opinion due to insufficient EBM results. This international experts consensus guideline offered guidance for the safe and effective clinical practice and the research direction of RLR in future.
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Affiliation(s)
- Rong Liu
- Faculty of Hepato-Pancreato-Biliary Surgery, The First Medical Center of Chinese PLA General Hospital, Beijing 100000, China
| | - Mohammed Abu Hilal
- Hepatobiliary Pancreatic, Robotic & Laparoscopic Surgery, Poliambulanza Foundation Hospital, Brescia 25100, Italy
| | - Go Wakabayashi
- Center for Advanced Treatment of HBP Diseases, Ageo Central General Hospital, Saitama 362-0075, Japan
| | - Ho-Seong Han
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seoul 03080, South Korea
| | - Chinnusamy Palanivelu
- GEM Hospital & Research Centre, GEM Hospital & Research Centre, Coimbatore 641045, India
| | - Ugo Boggi
- Division of General and Transplant Surgery, University of Pisa, Pisa 56126, Italy
| | - Thilo Hackert
- Department of General, Visceral and Thoracic Surgery, University Hospital Hamburg-Eppendorf, Hamburg 20251, Germany
| | - Hong-Jin Kim
- Department of Surgery, Yeungnam University Hospital, Daegu 42415, South Korea
| | - Xiao-Ying Wang
- Department of Liver Surgery and Transplantation, Liver Cancer Institute, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Ming-Gen Hu
- Faculty of Hepato-Pancreato-Biliary Surgery, The First Medical Center of Chinese PLA General Hospital, Beijing 100000, China
| | - Gi Hong Choi
- Division of Hepato-Biliary-Pancreatic Surgery, Department of Surgery, Severance Hospital, Yonsei University, College of Medicine, Seoul 03722, South Korea
| | - Fabrizio Panaro
- Department of Surgery/Division of Robotic and HBP Surgery, Montpellier University Hospital-School of Medicine, Montpellier 34090, France
| | - Jin He
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD 21218, United States
| | - Mikhail Efanov
- Department of Hepato-Pancreato-Biliary Surgery, Moscow Clinical Scientific Center, Moscow 111123, Russia
| | - Xiao-Yu Yin
- Department of Pancreatobiliary Surgery, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou 510080, Guangdong Province, China
| | - Roland S Croner
- Department of General, Visceral, Vascular and Transplant Surgery, University Hospital Magdeburg, Magdeburg 39120, Germany
| | - Yu-Man Fong
- Department of Surgery, City of Hope Medical Center, Duarte, CA 91010, United States
| | - Ji-Ye Zhu
- Department of Hepatobiliary Surgery, Peking University People’s Hospital, Beijing 100000, China
| | - Zheng Wu
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an 710061, Shaanxi Province, China
| | - Chuan-Dong Sun
- Department of Hepatobiliary and Pancreatic Surgery, The Affiliated Hospital of Qingdao University, Qingdao 266000, Shandong Province, China
| | - Jae Hoon Lee
- Division of Hepatobiliary & Pancreatic surgery, Asan Medical Center, University of Ulsan College of Medicine, Ulsan 682, South Korea
| | - Marco V Marino
- General Surgery Department, F. Tappeiner Hospital, Merano 39012, Italy
| | - Iyer Shridhar Ganpati
- Hepatobiliary and Pancreatic Surgery, National University Hospital, Singapore 189969, Singapore
| | - Peng Zhu
- Hepatic Surgery Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430000, Hubei Province, China
| | - Zi-Zheng Wang
- Department of Hepatobiliary Surgery, Senior Department of Hepatology, The Fifth Medical Center of Chinese PLA General Hospital, Beijing 100000, China
| | - Ke-Hu Yang
- Evidence-Based Medicine Center, Lanzhou University, Lanzhou 730000, Gansu Province, China
| | - Jia Fan
- Zhongshan Hospital, Fudan University, Shanghai 200000, China
| | - Xiao-Ping Chen
- Hepatic Surgery Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430000, Hubei Province, China
| | - Wan Yee Lau
- Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong 999077, China
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Campos-Varela I, Rammohan A, Chadha R, Alconchel F, Hakeem AR, Mathew JS, Goldaracena N, Syn N, Shankar S, Patel D, Keskin O, Liu J, Nasralla D, Mazzola A, Shingina A, Spiro M, Patel MS, Tanaka T, Victor D, Yoon U, Yoon YI, Shaker T, Vinaixa C, Kirchner VA, De Martin E. Proceedings of the 27th Annual Congress of the International Liver Transplantation Society. Transplantation 2023; 107:1226-1231. [PMID: 37220340 DOI: 10.1097/tp.0000000000004637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
After a virtual congress in 2021 and a previous absence in 2020 because of the coronavirus disease 2019 pandemic, the 27th Annual Congress of the International Liver Transplantation Society was held from May 4 to 7, 2022, in a hybrid format in Istanbul, with 1123 (58% on-site) liver transplant professionals from 61 countries attending the meeting. The hybrid format successfully achieved a balance of much yearned-for "in-person interaction" and global online participation. Almost 500 scientific abstracts were presented. In this report, the Vanguard Committee aims to present a summary of key invited lectures and selected abstracts for the liver transplant community.
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Affiliation(s)
- Isabel Campos-Varela
- Liver Unit, Vall d'Hebron Hospital Universitari, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain
| | - Ashwin Rammohan
- Institute of Liver Disease and Transplantation, Dr Rela Institute and Medical Centre, Bharath Institute of Higher Education and Research, Chennai, India
| | - Ryan Chadha
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, FL
| | | | - Abdul R Hakeem
- Department of Hepatobiliary and Liver Transplant Surgery, St James's University Hospital NHS Trust, Leeds, United Kingdom
| | | | - Nicolas Goldaracena
- Abdominal Organ Transplant and Hepatobiliary Surgery, University of Virginia Health System, Charlottesville, VA
| | | | - Sadhana Shankar
- The Liver Unit, King's College Hospital, London, United Kingdom
| | - Dhupal Patel
- Addenbrookes Hospital, Cambridge, United Kingdom
| | - Onur Keskin
- Department of Gastroenterology, Hacettepe University Medical School, Ankara, Turkey
| | - Jiang Liu
- Hepato-Pancreato-Biliary Center, Beijing Tsinghua Changgung Hospital, Tsinghua University, Beijing, China
| | - David Nasralla
- Department of HPB and Liver Transplant Surgery, The Royal Free Hospital, London, United Kingdom
| | - Alessandra Mazzola
- Sorbonne Université, Unité médicale de transplantation hépatique, AP-HP, Hôpital Pitié-Salpêtrière, Paris, France
| | - Alexandra Shingina
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Michael Spiro
- Anesthesia and Intensive Care Medicine, Royal Free Hospital, London, United Kingdom
| | | | - Tomohiro Tanaka
- Department of Internal Medicine, Gastroenterology and Hepatology, University of Iowa, Iowa City, IA
| | - David Victor
- Sherrie and Alan Conover Center for Liver Disease and Transplantation. Houston Methodist Hospital, Houston, TX
| | - Uzung Yoon
- Thomas Jefferson University Hospital, Philadelphia, PA
| | | | - Tamer Shaker
- Division of Transplantation, Department of Surgery, University of Minnesota Medical School, Minneapolis, MN
| | - Carmen Vinaixa
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain
- Hepatology and Liver Transplantation Unit, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Varvara A Kirchner
- Division of Abdominal Transplantation, Department of Surgery, Stanford University, Stanford, CA
| | - Eleonora De Martin
- AP-HP, Hôpital Paul-Brousse, Centre Hépato- Biliaire, Unité INSERM 1193, Villejuif, France
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Bozkurt E, Sijberden JP, Abu Hilal M. Safety and Feasibility of Laparoscopic Right or Extended Right Hemi Hepatectomy Following Modulation of the Future Liver Remnant in Patients with Colorectal Liver Metastases: A Systematic Review. J Laparoendosc Adv Surg Tech A 2023. [PMID: 37015071 DOI: 10.1089/lap.2022.0609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/06/2023] Open
Abstract
Background: Major hepatectomies after future liver remnant (FLR) modulation are technically demanding procedures, especially when performed as minimally invasive surgery. The aim of this systematic review is to assess current evidence regarding the safety and feasibility of laparoscopic right or extended right hemihepatectomies after FLR modulation. Materials and Methods: The Medline, PubMed, Cochrane Library, and Embase databases were searched for studies involving laparoscopic right or extended right hemihepatectomies after FLR modulation, from their inception to December 2021. Two reviewers independently selected eligible articles and assessed their quality using the Newcastle-Ottawa Quality Assessment Scale (NOS). Baseline characteristics and outcomes were extracted from the included studies and summarized. Results: Six studies were included. In these studies, the median length of stay after the second stage ranged from 4.5 to 15.5 days and postoperative complication rates between 4.5% and 42.8%. Overall, 7.4% of patients developed liver failure, and 90-day mortality occurred in 3.2% of patients. The R0 resection rate was 93.5%. Only one study reported long-term outcomes, describing comparable 3-year overall survival rates following laparoscopic and open surgery (80% versus 54%, P = .154). Conclusions: The current evidence is scarce, but it suggests that in experienced centers, laparoscopic right or extended right hemihepatectomy, following FLR modulation, is a safe and feasible procedure.
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Affiliation(s)
- Emre Bozkurt
- Department of Surgery, Poliambulanza Foundation Hospital, Brescia, Italy
- Hepatopancreatobiliary Surgery Division, Department of Surgery, Koç University Hospital, Istanbul, Turkey
| | - Jasper P Sijberden
- Department of Surgery, Poliambulanza Foundation Hospital, Brescia, Italy
- Department of Surgery, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - 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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8
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Cheng J, Hong DF, Zhang CW, Fan XM, Luo ZY, Yao WF, Jin LM. Transcatheter arterial chemoembolization after percutaneous microwave ablation and portal vein embolization for advanced hepatocellular carcinoma. Hepatobiliary Pancreat Dis Int 2023; 22:213-216. [PMID: 35780016 DOI: 10.1016/j.hbpd.2022.06.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 06/23/2022] [Indexed: 02/05/2023]
Affiliation(s)
- Jian Cheng
- General Surgery, Cancer Center, Department of Hepatobiliary & Pancreatic Surgery and Minimally Invasive Surgery, Zhejiang Provincial People's Hospital, Affiliated People's Hospital of Hangzhou Medical College, Hangzhou 310014, China
| | - De-Fei Hong
- Department of General Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou 310020, China
| | - Cheng-Wu Zhang
- General Surgery, Cancer Center, Department of Hepatobiliary & Pancreatic Surgery and Minimally Invasive Surgery, Zhejiang Provincial People's Hospital, Affiliated People's Hospital of Hangzhou Medical College, Hangzhou 310014, China
| | - Xiao-Ming Fan
- General Surgery, Cancer Center, Department of Hepatobiliary & Pancreatic Surgery and Minimally Invasive Surgery, Zhejiang Provincial People's Hospital, Affiliated People's Hospital of Hangzhou Medical College, Hangzhou 310014, China
| | - Zu-Yan Luo
- General Surgery, Cancer Center, Department of Hepatobiliary & Pancreatic Surgery and Minimally Invasive Surgery, Zhejiang Provincial People's Hospital, Affiliated People's Hospital of Hangzhou Medical College, Hangzhou 310014, China
| | - Wei-Feng Yao
- General Surgery, Cancer Center, Department of Hepatobiliary & Pancreatic Surgery and Minimally Invasive Surgery, Zhejiang Provincial People's Hospital, Affiliated People's Hospital of Hangzhou Medical College, Hangzhou 310014, China
| | - Li-Ming Jin
- General Surgery, Cancer Center, Department of Hepatobiliary & Pancreatic Surgery and Minimally Invasive Surgery, Zhejiang Provincial People's Hospital, Affiliated People's Hospital of Hangzhou Medical College, Hangzhou 310014, China.
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9
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Serenari M, Ratti F, Guglielmo N, Zanello M, Mocchegiani F, Lenzi J, Colledan M, Mazzaferro V, Cillo U, Ferrero A, Cescon M, Di Benedetto F, Massani M, Grazi G, Valle RD, Vivarelli M, Ettorre GM, Aldrighetti L, Jovine E. Evolution of minimally invasive techniques and surgical outcomes of ALPPS in Italy: a comprehensive trend analysis over 10 years from a national prospective registry. Surg Endosc 2023:10.1007/s00464-023-09937-4. [PMID: 36976422 DOI: 10.1007/s00464-023-09937-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 02/05/2023] [Indexed: 03/29/2023]
Abstract
BACKGROUND Since 2012, Associating Liver Partition and Portal vein ligation for Staged hepatectomy (ALPPS) has encountered several modifications of its original technique. The primary endpoint of this study was to analyze the trend of ALPPS in Italy over a 10-year period. The secondary endpoint was to evaluate factors affecting the risk of morbidity/mortality/post-hepatectomy liver failure (PHLF). METHODS Data of patients submitted to ALPPS between 2012 and 2021 were identified from the ALPPS Italian Registry and evaluation of time trends was performed. RESULTS From 2012 to 2021, a total of 268 ALPPS were performed within 17 centers. The number of ALPPS divided by the total number of liver resections performed by each center slightly declined (APC = - 2.0%, p = 0.111). Minimally invasive (MI) approach significantly increased over the years (APC = + 49.5%, p = 0.002). According to multivariable analysis, MI completion of stage 1 was protective against 90-day mortality (OR = 0.05, p = 0.040) as well as enrollment within high-volume centers for liver surgery (OR = 0.32, p = 0.009). Use of interstage hepatobiliary scintigraphy (HBS) and biliary tumors were independent predictors of PHLF. CONCLUSIONS This national study showed that use of ALPPS only slightly declined over the years with an increased use of MI techniques, leading to lower 90-day mortality. PHLF still remains an open issue.
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Affiliation(s)
- Matteo Serenari
- General Surgery and Transplant Unit, IRCCS, Azienda Ospedaliero-Universitaria di Bologna, Sant'Orsola-Malpighi Hospital, Bologna, Italy
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Francesca Ratti
- Hepatobiliary Surgery Division, San Raffaele Hospital, Milan, Italy
| | - Nicola Guglielmo
- Division of General Surgery and Liver Transplantation, S. Camillo Hospital, Rome, Italy
| | - Matteo Zanello
- Department of General Surgery, IRCCS, Azienda Ospedaliero-Universitaria di Bologna, Maggiore Hospital, Bologna, Italy
| | - Federico Mocchegiani
- HPB Surgery and Transplantation Unit, Department of Clinical and Experimental Medicine, Polytechnic University of Marche, Ancona, Italy
| | - Jacopo Lenzi
- Department of Biomedical and Neuromotor Sciences, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Michele Colledan
- Department of Organ Failure and Transplantation, ASST Giovanni XXIII, Bergamo, Italy
- Department of Medicine and Surgery, Università di Milano, Bicocca, Italy
| | - Vincenzo Mazzaferro
- Department of Surgery, Division of HPB Surgery and Liver Transplantation, Fondazione IRCCS Istituto Nazionale Tumori di Milano, Milan, Italy
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | - Umberto Cillo
- General Surgery 2 - Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, Padua University Hospital, Padua, Italy
| | - Alessandro Ferrero
- Department of General and Oncological Surgery, Mauriziano Hospital Umberto I, Turin, Italy
| | - Matteo Cescon
- General Surgery and Transplant Unit, IRCCS, Azienda Ospedaliero-Universitaria di Bologna, Sant'Orsola-Malpighi Hospital, Bologna, Italy
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Fabrizio Di Benedetto
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University of Modena and Reggio Emilia, Modena, Italy
| | - Marco Massani
- Regional Center for HPB Surgery, Regional Hospital of Treviso, Treviso, Italy
| | - Gianluca Grazi
- Division of Hepatobiliarypancreatic Unit, IRCCS, Regina Elena National Cancer Institute, Rome, Italy
| | | | - Marco Vivarelli
- HPB Surgery and Transplantation Unit, Department of Clinical and Experimental Medicine, Polytechnic University of Marche, Ancona, Italy
| | | | - Luca Aldrighetti
- Hepatobiliary Surgery Division, San Raffaele Hospital, Milan, Italy
| | - Elio Jovine
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Bologna, Italy.
- Department of General Surgery, IRCCS, Azienda Ospedaliero-Universitaria di Bologna, Maggiore Hospital, Bologna, Italy.
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10
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Morise Z. Current status of minimally invasive liver surgery for cancers. World J Gastroenterol 2022; 28:6090-6098. [PMID: 36483154 PMCID: PMC9724486 DOI: 10.3748/wjg.v28.i43.6090] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 10/23/2022] [Accepted: 11/07/2022] [Indexed: 11/16/2022] Open
Abstract
Hepatocellular carcinoma (HCC) patients have chronic liver disease with functional deterioration and multicentric oncogenicity. Liver surgeries for the patients should be planned on both oncological effects and sparing liver function. In colorectal patients with post-chemotherapy liver injury and multiple bilateral tumors, handling multiple tumors in a fragile/easy-to-bleed liver is an important issue. Liver surgery for biliary tract cancers is often performed as a resection of large-volume functioning liver with extensive lymphadenectomy and bile duct resection/reconstruction. Minimally invasive liver surgery (MILS) for HCC is applied with the advantages of laparoscopic for cases of cirrhosis or repeat resections. Small anatomical resections using the Glissonian, indocyanine green-guided, and hepatic vein-guided approaches are under discussion. In many cases of colorectal liver metastases, MILS is applied combined with chemotherapy owing to its advantage of better hemostasis. Two-stage hepatectomy and indocyanine green-guided tumor identification for multiple bilateral tumors are under discussion. In the case of biliary tract cancers, MILS with extensive lymphadenectomy and bile duct resection/reconstruction are developing. A robot-assisted procedure for dissection of major vessels and handling fragile livers may have advantages, and well-simulated robot-assisted procedure may decrease the difficulty for biliary tract cancers.
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Affiliation(s)
- Zenichi Morise
- Department of Surgery, Fujita Health University School of Medicine Okazaki Medical Center, Okazaki 444-0827, Aichi, Japan
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11
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Chan KM, Hung HC, Lee JC, Wu TH, Wang YC, Cheng CH, Lee CF, Wu TJ, Chou HS, Lee WC. Individualized Selection Criteria Based on Tumor Burden in Future Remnant Liver for Staged Hepatectomy of Advanced CRLM: Conventional TSH or ALPPS. Cancers (Basel) 2022; 14:cancers14143553. [PMID: 35884613 PMCID: PMC9324888 DOI: 10.3390/cancers14143553] [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: 06/08/2022] [Revised: 07/08/2022] [Accepted: 07/19/2022] [Indexed: 02/05/2023] Open
Abstract
Staged hepatectomy is a promising strategy for curative resection of advanced colorectal liver metastasis (CRLM) to prevent inadequate future remnant liver (FRL). However, the selection criteria for conventional two-stage hepatectomy (cTSH) and associating liver partitioning and portal vein ligation for staged hepatectomy (ALPPS) remain unclear. This study aimed to propose a selection criterion for determining the optimal staged hepatectomy for patients with advanced CRLM. A selection criterion based on the degree of metastatic tumors within the FRL was established to determine staged hepatectomy approaches. Generally, ALPPS is recommended for patients with ≤3 metastatic nodules and whose nodules do not measure >3 cm in the FRL. cTSH is performed for patients whose tumor burden in FRL beyond the selection criteria. Data of 37 patients who underwent staged hepatectomy and curative intent of CRLM were analyzed. The clinical characteristics and outcomes of the two approaches were compared. Overall, cTSH and ALPPS were performed for 27 (73.0%) and 10 (27.0%) patients, respectively. Of those, 20 patients in the cTSH group and all patients in the ALPPS group had completed staged hepatectomy. The 1-, 3-, and 5-year survival rates were 91.6%, 62.4%, and 45.4% for all patients, respectively. The outcomes of patients who had successfully completed the staged hepatectomy were significantly better than those of other patients who failed to achieve staged hepatectomy. However, no significant difference was observed in the overall survival of patients who underwent staged hepatectomy between the two groups, but those in the ALPPS group had 100% survival at the end of this study. The individualized selection criteria based on tumor burden in the FRL that could balance the operative risk and oncologic outcome appear to be a promising strategy for achieving complete staged hepatectomy in patients with advanced CRLM.
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Affiliation(s)
- Kun-Ming Chan
- Correspondence: ; Tel.: +886-3-3281200 (ext. 3366); Fax: +886-3-3285818
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12
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Evolution of associating liver partition and portal vein ligation for staged hepatectomy from 2012 to 2021: A bibliometric analysis. Review. Int J Surg 2022; 103:106648. [PMID: 35513249 DOI: 10.1016/j.ijsu.2022.106648] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 04/15/2022] [Accepted: 04/19/2022] [Indexed: 02/08/2023]
Abstract
BACKGROUND Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) has become increasingly popular during the past few decades, and its indications have extended from patients with normal liver to post-chemotherapy patients and even patients with cirrhosis. However, few studies have assessed the publications in relation to ALPPS. METHODS Web of Science was searched to identify studies related to ALPPS published from 2012 to 2021. The analysis was performed using the bibliometric package (Version 3.1.0) in R software. RESULTS In total, 486 publications were found. These articles were published in 159 journals and authored by 2157 researchers from 694 organizations. The most prolific journal was Annals of Surgery (24 articles and 1170 citations). The most frequently cited article was published in Annals of Surgery (average citations, 72.7; total citations, 727). China was the most productive country for ALPPS publications but had comparatively less interaction with other countries. Both thematic evolution and co-occurrence network analysis showed low numbers of topics such as failure, resection, and safety among the publications but large numbers of highly cited papers on outcomes, prediction, mechanisms, multicenter analysis, and novel procedures such as liver venous deprivation. A total of 196 studies focused the clinical application of ALPPS, and most studies were IDEAL Stages I and II. The specific mechanism of ALPPS liver regeneration remains unclear. CONCLUSIONS This is the first bibliometric analysis offering an overview of the development of ALPPS research publications. Our findings identified prominent studies, countries, institutions, journals, and authors to indicate the future direction of ALPPS research. The role of ALPPS in liver regeneration and the long-term results of ALPPS need further study. Future research directions include comparison of ALPPS with portal vein embolization, liver venous deprivation, and other two-stage hepatectomies as well as patients' quality of life after ALPPS.
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13
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Aliseda D, Martí-Cruchaga P, Zozaya G, Benito A, Lopez-Olaondo L, Rodríguez-Fraile M, Bilbao JI, Hidalgo F, Iñarrairaegui M, Ciria R, Pardo F, Sangro B, Rotellar F. Pure laparoscopic major liver resection after yttrium 90 radioembolization: a case-matched series analysis of feasibility and outcomes. Langenbecks Arch Surg 2022; 407:1099-1111. [PMID: 35229168 PMCID: PMC9151566 DOI: 10.1007/s00423-022-02474-z] [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: 09/14/2021] [Accepted: 02/15/2022] [Indexed: 11/29/2022]
Abstract
Background Liver surgery after radioembolization (RE) entails highly demanding and challenging procedures due to the frequent combination of large tumors, severe RE-related adhesions, and the necessity of conducting major hepatectomies. Laparoscopic liver resection (LLR) and its associated advantages could provide benefits, as yet unreported, to these patients. The current study evaluated feasibility, morbidity, mortality, and survival outcomes for major laparoscopic liver resection after radioembolization. Material and methods In this retrospective, single-center study patients diagnosed with hepatocellular carcinoma, intrahepatic cholangiocarcinoma or metastases from colorectal cancer undergoing major laparoscopic hepatectomy after RE were identified from institutional databases. They were matched (1:2) on several pre-operative characteristics to a group of patients that underwent major LLR for the same malignancies during the same period but without previous RE. Results From March 2011 to November 2020, 9 patients underwent a major LLR after RE. No differences were observed in intraoperative blood loss (50 vs. 150 ml; p = 0.621), operative time (478 vs. 407 min; p = 0.135) or pedicle clamping time (90.5 vs 74 min; p = 0.133) between the post-RE LLR and the matched group. Similarly, no differences were observed on hospital stay (median 3 vs. 4 days; p = 0.300), Clavien–Dindo ≥ III complications (2 vs. 1 cases; p = 0.250), specific liver morbidity (1 vs. 1 case p = 1.000), or 90 day mortality (0 vs. 0; p = 1.000). Conclusion The laparoscopic approach for post radioembolization patients may be a feasible and safe procedure with excellent surgical and oncological outcomes and meets the current standards for laparoscopic liver resections. Further studies with larger series are needed to confirm the results herein presented. Supplementary Information The online version contains supplementary material available at 10.1007/s00423-022-02474-z.
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Affiliation(s)
- Daniel Aliseda
- HPB and Liver Transplant Unit, Department of General Surgery, Clinica Universidad de Navarra, University of Navarra, Av. Pío XII, 36, 31008, Pamplona, Spain
| | - Pablo Martí-Cruchaga
- HPB and Liver Transplant Unit, Department of General Surgery, Clinica Universidad de Navarra, University of Navarra, Av. Pío XII, 36, 31008, Pamplona, Spain.,Institute of Health Research of Navarra (IdisNA), Pamplona, Spain
| | - Gabriel Zozaya
- HPB and Liver Transplant Unit, Department of General Surgery, Clinica Universidad de Navarra, University of Navarra, Av. Pío XII, 36, 31008, Pamplona, Spain.,Institute of Health Research of Navarra (IdisNA), Pamplona, Spain
| | - Alberto Benito
- Institute of Health Research of Navarra (IdisNA), Pamplona, Spain.,Interventional Radiology, Department of Radiology, Clinica Universidad de Navarra, University of Navarra, Av. Pío XII, 36, 31008, Pamplona, Spain
| | - Luis Lopez-Olaondo
- Institute of Health Research of Navarra (IdisNA), Pamplona, Spain.,Anesthesiology Unit, Clínica Universidad de Navarra, University of Navarra, Av. Pío XII, 36, 31008, Pamplona, Spain
| | - Macarena Rodríguez-Fraile
- Institute of Health Research of Navarra (IdisNA), Pamplona, Spain.,Nuclear Medicine Department, Clinica Universidad de Navarra, University of Navarra, Av. Pío XII, 36, 31008, Pamplona, Spain
| | - José I Bilbao
- Institute of Health Research of Navarra (IdisNA), Pamplona, Spain.,Interventional Radiology, Department of Radiology, Clinica Universidad de Navarra, University of Navarra, Av. Pío XII, 36, 31008, Pamplona, Spain
| | - Francisco Hidalgo
- Institute of Health Research of Navarra (IdisNA), Pamplona, Spain.,Anesthesiology Unit, Clínica Universidad de Navarra, University of Navarra, Av. Pío XII, 36, 31008, Pamplona, Spain
| | - Mercedes Iñarrairaegui
- Institute of Health Research of Navarra (IdisNA), Pamplona, Spain.,Liver Unit and HPB Oncology Area, Clinica Universidad de Navarra and CIBEREHD, Pamplona, Spain
| | - Rubén Ciria
- Unit of Hepatobiliary Surgery and Liver Transplantation, IMIBIC, University Hospital Reina Sofía, University of Cordoba, Cordoba, Spain
| | - Fernando Pardo
- HPB and Liver Transplant Unit, Department of General Surgery, Clinica Universidad de Navarra, University of Navarra, Av. Pío XII, 36, 31008, Pamplona, Spain.,Institute of Health Research of Navarra (IdisNA), Pamplona, Spain
| | - Bruno Sangro
- Institute of Health Research of Navarra (IdisNA), Pamplona, Spain.,Liver Unit and HPB Oncology Area, Clinica Universidad de Navarra and CIBEREHD, Pamplona, Spain
| | - Fernando Rotellar
- HPB and Liver Transplant Unit, Department of General Surgery, Clinica Universidad de Navarra, University of Navarra, Av. Pío XII, 36, 31008, Pamplona, Spain. .,Institute of Health Research of Navarra (IdisNA), Pamplona, Spain.
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14
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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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15
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Di Benedetto F, Magistri P, Guerrini GP, Di Sandro S. Robotic liver partition and portal vein embolization for staged hepatectomy for perihilar cholangiocarcinoma. Updates Surg 2021; 74:773-777. [PMID: 34846695 PMCID: PMC8630284 DOI: 10.1007/s13304-021-01209-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Accepted: 11/18/2021] [Indexed: 12/31/2022]
Abstract
Perihilar cholangiocarcinoma (pCCA) is one of the most complex challenges for hepatobiliary surgeons. Poor results and high incidence of morbidity after Associating Liver Partition and Portal vein ligation for Staged hepatectomy (ALPPS) for pCCA discouraged this indication. It has been proposed that minimally invasive approach for ALPPS first stage, as well as combination of surgical liver partition and radiologic portal vein embolization (PVE), may improve outcomes reducing interstage morbidity. We report a case of right trisectionectomy with enbloc caudatectomy ALPPS scheduled for pCCA with robotic approach at stage-1, the full video is provided as supplementary material. Due to intraoperative presence of portal vein tumor infiltration during hilar dissection (no evidence in the pre-operative work-up), a radiologic right PVE was performed after stage-1 instead of portal vein ligation, followed by portal vein resection and biductal hepatico-jejunostomy at stage-2 with open approach. The patient was a 74-year-old female diagnosed with 3-cm mass-forming pCCA. The total clean liver volume was 1231 cc, with future liver remnant (FLR) volume of 25.1% (segments II and III). She was discharged in the interstage interval on postoperative day (POD) 4; CT scan on POD 12 showed that FLR increased up to 33% (369 cc) (Fig. 1). ALPPS was completed on POD 17, the postoperative course was uneventful, and the patient was discharged in good general condition on POD 19 after stage-2. Besides the already demonstrated advantages in terms of reduced interstage morbidity, robotic ALPPS represents a promising strategy to expand surgical indication in patients with pCCA. The combination of liver partition and PVE may increase the opportunities to perform radical resections in selected patients with pCCA and portal vein infiltration.
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Affiliation(s)
- Fabrizio Di Benedetto
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University of Modena and Reggio Emilia, Largo del Pozzo 71, 41124, Modena, Italy.
| | - Paolo Magistri
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University of Modena and Reggio Emilia, Largo del Pozzo 71, 41124, Modena, Italy
| | - Gian Piero Guerrini
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University of Modena and Reggio Emilia, Largo del Pozzo 71, 41124, Modena, Italy
| | - Stefano Di Sandro
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University of Modena and Reggio Emilia, Largo del Pozzo 71, 41124, Modena, Italy
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16
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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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17
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Torzilli G. Parenchyma-sparing vessel-guided major hepatectomy: nonsense or new paradigm in liver surgery? Br J Surg 2021; 108:109-111. [PMID: 33711137 DOI: 10.1093/bjs/znaa112] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Accepted: 11/06/2020] [Indexed: 12/12/2022]
Abstract
Advanced liver surgery.
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Affiliation(s)
- G Torzilli
- Department of Surgery, Division of Hepatobiliary & General Surgery, Humanitas Clinical & Research Hospital, IRCCS - Department of Biomedical Sciences, Humanitas university - Via Manzoni, 56, 20089 Rozzano, Milan, Italy
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18
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Fernandes EDSM, de Barros F, Magistri P, Di Sandro S, Rezende de Carvalho P, Roza da Silva F, Andrade RO, Pimentel LS, Girão CL, Pedreira de Mello F, Torres OJM, Di Benedetto F. Total robotic ALPPS approach for hepatocellular carcinoma in cirrhotic liver. Int J Med Robot 2021; 17:e2238. [PMID: 33522077 DOI: 10.1002/rcs.2238] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 01/25/2021] [Accepted: 01/26/2021] [Indexed: 12/27/2022]
Abstract
BACKGROUND Hepatocellular carcinoma (HCC) is a common indication for associating liver partition with portal vein ligation for staged hepatectomy (ALPPS). Robotic liver resection has been done for HCC, but robotic ALPPS is a rare procedure. METHODS To present three cases of totally robotic ALPPS in cirrhotic patients with HCC. RESULTS Three cirrhotic male patients with HCC underwent ALPPS; the mean age was 54.3 years. MELD score was ≤9 and tumour size between 90 and 140 mm. The mean hypertrophy of the future liver remnant after the first stage was 77.5% and no postoperative liver failure was reported. Mean operative time of stage 1 was 7:30 h and of stage 2 was 4:37 h, without blood transfusion. The mean hospital stay for the first stage was 10 days and for the second stage was 9.3 days. No postoperative complication was recorded. CONCLUSIONS Robotic ALPPS in cirrhotic patients with HCC is safe and feasible.
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Affiliation(s)
- Eduardo de Souza M Fernandes
- Department of Hepatopancreatobiliary and Transplant Surgery, Rio de Janeiro Federal University, Rio de Janeiro, Brazil.,Department of Surgery, San Lucas Hospital, Rio de Janeiro, Brazil
| | | | - Paolo Magistri
- Department of Hepatopancreatobiliary Surgery and Liver Transplant, Maranhão Federal University, São Luís, Brazil.,Hepatopancreatobiliary Surgery and Transplant, Modena University Hospital, Modena, Italy
| | - Stefano Di Sandro
- Department of Hepatopancreatobiliary Surgery and Liver Transplant, Maranhão Federal University, São Luís, Brazil.,Hepatopancreatobiliary Surgery and Transplant, Modena University Hospital, Modena, Italy
| | | | | | | | | | - Camila L Girão
- Department of Surgery, San Lucas Hospital, Rio de Janeiro, Brazil
| | | | - Orlando Jorge M Torres
- Department of Hepatopancreatobiliary Surgery and Liver Transplant, Maranhão Federal University, São Luís, Brazil
| | - Fabrizio Di Benedetto
- Hepatopancreatobiliary Surgery and Transplant, Modena University Hospital, Modena, Italy
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19
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Fiorentini G, Ratti F, Cipriani F, Quattromani R, Catena M, Paganelli M, Aldrighetti L. The SMART-ALPPS Protocol: Strategy to Minimize ALPPS Risks by Targeting Invasiveness. Ann Surg Oncol 2021; 28:6826-6827. [PMID: 33625636 DOI: 10.1245/s10434-021-09711-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/27/2021] [Indexed: 01/24/2023]
Abstract
BACKGROUND The range of procedures with documented feasibility by laparoscopic approach is widening in the setting of liver resections. Many technical limits have been overcome in the attempt to reduce the biological impact of major procedures [1-8]. Similarly, associated liver partition and portal vein ligation for staged hepatectomy (ALPPS)-which could be assumed as the paradigm of maxi-invasiveness-has recently been proposed in a minimally invasive fashion to reduce the impact of this procedure [9-12]. Technical insights to perform laparoscopic ALPPS are provided. METHODS Perioperative and intraoperative tips for laparoscopic ALPPS are provided within a SMART (Strategy to Minimize ALPPS Risks by Targeting invasiveness) protocol. Stage 1: After volumetric and functional assessment, partial liver transection is performed, keeping intact both the hilum and the caval plane (to prevent adhesions), therefore avoiding portal ligation. No inert material is left inside the abdominal cavity at the end of procedure to keep the liver surfaces apart. Radiologic portography with portal vein embolization is scheduled on postoperative day (POD) 1. Liver volume (pre-PVE: 29%; post-PVE: 52%) and liver function measured through a Technetium-99 hepatobiliary scintigraphy [13] (pre-PVE: 2.15%/min/sqm; post-PVE: 3.67%/min/sqm) of the future remnant liver are reassessed within 10 days to verify whether size and function are adequate. Stage 2: After 2 weeks from the first stage, laparoscopic right hepatectomy is performed following an anterior approach. RESULTS No conversion to open was required. Operative time was 100 and 300 minutes for stage 1 and 2, respectively. Intraoperative blood loss was 50 and 300 ml for the two procedures. Postoperative course was uneventful; patient was discharged on POD 6 of the second operation. CONCLUSIONS The implementation of a perioperative protocol to prevent the risk of liver failure by both assessing volume and function of FLR and targeting the invasiveness of the surgical procedure may allow to minimize and control risks of a maximally invasive procedure, such as ALPPS.
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Affiliation(s)
- G Fiorentini
- Hepatobiliary Surgery Division, IRCCS San Raffaele Hospital, Milan, Italy. .,PhD School in Experimental Medicine, University of Pavia, Pavia, Italy.
| | - F Ratti
- Hepatobiliary Surgery Division, IRCCS San Raffaele Hospital, Milan, Italy
| | - F Cipriani
- Hepatobiliary Surgery Division, IRCCS San Raffaele Hospital, Milan, Italy
| | - R Quattromani
- Hepatobiliary Surgery Division, IRCCS San Raffaele Hospital, Milan, Italy
| | - M Catena
- Hepatobiliary Surgery Division, IRCCS San Raffaele Hospital, Milan, Italy
| | - M Paganelli
- Hepatobiliary Surgery Division, IRCCS San Raffaele Hospital, Milan, Italy
| | - L Aldrighetti
- Hepatobiliary Surgery Division, IRCCS San Raffaele Hospital, Milan, Italy.,University Vita-Salute San Raffaele, Milan, Italy
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Heinrich S, Lang H. [Evidence of minimally invasive oncological surgery of the liver]. Chirurg 2021; 92:316-325. [PMID: 33449156 DOI: 10.1007/s00104-020-01338-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/14/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND The evidence for minimally invasive surgery (MIS) of the liver has significantly increased with the increasing number of publications on this topic in recent years; however, this technique has not yet gained broad acceptance among surgeons. OBJECTIVE Analysis and presentation of the current literature on MIS of the liver. MATERIAL UND METHODS Structured PubMed literature search and analysis. RESULTS According to the literature, MIS and open liver surgery are equivalent regarding the oncological quality. In addition to parenchyma-preserving resections, major hepatectomies (e.g. hemihepatectomy and sectorectomy), two-stage concepts and re-resections have increasingly been reported. The MIS of the liver is associated with less blood loss and other immunological advantages in addition to a shorter hospital stay. The highest level of evidence has been achieved for colorectal liver metastases for which a systematic review even revealed a survival benefit for patients undergoing MIS surgery. From an oncological perspective, laparoscopic and robotic liver surgery are considered to be equivalent. CONCLUSION According to the current literature MIS of the liver is recommended for the resection of colorectal liver metastases and hepatocellular carcinoma.
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Affiliation(s)
- Stefan Heinrich
- Klinik f. Allgemein‑, Viszeral- und Transplantationschirurgie, Universitätsmedizin Mainz, Langenbeckstraße 1, 55131, Mainz, Deutschland
| | - Hauke Lang
- Klinik f. Allgemein‑, Viszeral- und Transplantationschirurgie, Universitätsmedizin Mainz, Langenbeckstraße 1, 55131, Mainz, Deutschland.
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21
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Martin J, Petrillo A, Smyth EC, Shaida N, Khwaja S, Cheow HK, Duckworth A, Heister P, Praseedom R, Jah A, Balakrishnan A, Harper S, Liau S, Kosmoliaptsis V, Huguet E. Colorectal liver metastases: Current management and future perspectives. World J Clin Oncol 2020; 11:761-808. [PMID: 33200074 PMCID: PMC7643190 DOI: 10.5306/wjco.v11.i10.761] [Citation(s) in RCA: 100] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 05/14/2020] [Accepted: 08/31/2020] [Indexed: 02/06/2023] Open
Abstract
The liver is the commonest site of metastatic disease for patients with colorectal cancer, with at least 25% developing colorectal liver metastases (CRLM) during the course of their illness. The management of CRLM has evolved into a complex field requiring input from experienced members of a multi-disciplinary team involving radiology (cross sectional, nuclear medicine and interventional), Oncology, Liver surgery, Colorectal surgery, and Histopathology. Patient management is based on assessment of sophisticated clinical, radiological and biomarker information. Despite incomplete evidence in this very heterogeneous patient group, maximising resection of CRLM using all available techniques remains a key objective and provides the best chance of long-term survival and cure. To this end, liver resection is maximised by the use of downsizing chemotherapy, optimisation of liver remnant by portal vein embolization, associating liver partition and portal vein ligation for staged hepatectomy, and combining resection with ablation, in the context of improvements in the functional assessment of the future remnant liver. Liver resection may safely be carried out laparoscopically or open, and synchronously with, or before, colorectal surgery in selected patients. For unresectable patients, treatment options including systemic chemotherapy, targeted biological agents, intra-arterial infusion or bead delivered chemotherapy, tumour ablation, stereotactic radiotherapy, and selective internal radiotherapy contribute to improve survival and may convert initially unresectable patients to operability. Currently evolving areas include biomarker characterisation of tumours, the development of novel systemic agents targeting specific oncogenic pathways, and the potential re-emergence of radical surgical options such as liver transplantation.
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Affiliation(s)
- Jack Martin
- Department of Surgery, Addenbrookes Hospital, NIHR Comprehensive Biomedical Research and Academic Health Sciences Centre, Cambridge University Hospitals NHS Foundation Trust, Cambridge CB2 0QQ, United Kingdom
| | - Angelica Petrillo
- Department of Precision Medicine, Division of Medical Oncology, University of Campania "L. Vanvitelli", Napoli 80131, Italy, & Medical Oncology Unit, Ospedale del Mare, 80147 Napoli Italy
| | - Elizabeth C Smyth
- Department of Oncology, Addenbrookes Hospital, NIHR Comprehensive Biomedical Research and Academic Health Sciences Centre, Cambridge University Hospitals NHS Foundation Trust, Cambridge CB2 0QQ, United Kingdom
| | - Nadeem Shaida
- Department of Radiology, Addenbrookes Hospital, NIHR Comprehensive Biomedical Research and Academic Health Sciences Centre, Cambridge University Hospitals NHS Foundation Trust, Cambridge CB22 0QQ, United Kingdom
| | - Samir Khwaja
- Department of Radiology, Addenbrookes Hospital, NIHR Comprehensive Biomedical Research and Academic Health Sciences Centre, Cambridge University Hospitals NHS Foundation Trust, Cambridge CB22 0QQ, United Kingdom
| | - HK Cheow
- Department of Nuclear Medicine, Addenbrookes Hospital, NIHR Comprehensive Biomedical Research and Academic Health Sciences Centre, Cambridge University Hospitals NHS Foundation Trust, Cambridge CB2 0QQ, United Kingdom
| | - Adam Duckworth
- Department of Pathology, Addenbrookes Hospital, NIHR Comprehensive Biomedical Research and Academic Health Sciences Centre, Cambridge University Hospitals NHS Foundation Trust, Cambridge CB2 0QQ, United Kingdom
| | - Paula Heister
- Department of Pathology, Addenbrookes Hospital, NIHR Comprehensive Biomedical Research and Academic Health Sciences Centre, Cambridge University Hospitals NHS Foundation Trust, Cambridge CB2 0QQ, United Kingdom
| | - Raaj Praseedom
- Department of Surgery, Addenbrookes Hospital, NIHR Comprehensive Biomedical Research and Academic Health Sciences Centre, Cambridge University Hospitals NHS Foundation Trust, Cambridge CB2 0QQ, United Kingdom
| | - Asif Jah
- Department of Surgery, Addenbrookes Hospital, NIHR Comprehensive Biomedical Research and Academic Health Sciences Centre, Cambridge University Hospitals NHS Foundation Trust, Cambridge CB2 0QQ, United Kingdom
| | - Anita Balakrishnan
- Department of Surgery, Addenbrookes Hospital, NIHR Comprehensive Biomedical Research and Academic Health Sciences Centre, Cambridge University Hospitals NHS Foundation Trust, Cambridge CB2 0QQ, United Kingdom
| | - Simon Harper
- Department of Surgery, Addenbrookes Hospital, NIHR Comprehensive Biomedical Research and Academic Health Sciences Centre, Cambridge University Hospitals NHS Foundation Trust, Cambridge CB2 0QQ, United Kingdom
| | - Siong Liau
- Department of Surgery, Addenbrookes Hospital, NIHR Comprehensive Biomedical Research and Academic Health Sciences Centre, Cambridge University Hospitals NHS Foundation Trust, Cambridge CB2 0QQ, United Kingdom
| | - Vasilis Kosmoliaptsis
- Department of Surgery, Addenbrookes Hospital, NIHR Comprehensive Biomedical Research and Academic Health Sciences Centre, Cambridge University Hospitals NHS Foundation Trust, Cambridge CB2 0QQ, United Kingdom
| | - Emmanuel Huguet
- Department of Surgery, Addenbrookes Hospital, NIHR Comprehensive Biomedical Research and Academic Health Sciences Centre, Cambridge University Hospitals NHS Foundation Trust, Cambridge CB2 0QQ, United Kingdom
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Serenari M, Ratti F, Zanello M, Guglielmo N, Mocchegiani F, Di Benedetto F, Nardo B, Mazzaferro V, Cillo U, Massani M, Colledan M, Dalla Valle R, Cescon M, Vivarelli M, Colasanti M, Ettorre GM, Aldrighetti L, Jovine E. Minimally Invasive Stage 1 to Protect Against the Risk of Liver Failure: Results from the Hepatocellular Carcinoma Series of the Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy Italian Registry. J Laparoendosc Adv Surg Tech A 2020; 30:1082-1089. [PMID: 32907480 DOI: 10.1089/lap.2020.0563] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Introduction: Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) has been described to treat hepatocellular carcinoma (HCC) but burdened, in its pioneering phase, by high morbidity and mortality. With the advent of minimally invasive (MI) techniques in liver surgery, surgical complications, including posthepatectomy liver failure (PHLF), have been dramatically reduced. The primary endpoint of this study was to compare the short-term outcomes of MI- versus open-ALPPS for HCC, with specific focus on PHLF. Methods: Data of patients submitted to ALPPS for HCC between 2012 and 2020 were identified from the ALPPS Italian Registry. Patients receiving an MI Stage 1 (MI-ALPPS) constituted the study group, whereas the patients who received an open Stage 1 (open-ALPPS) constituted the control group. Results: Sixty-six patients were enrolled from 12 Italian centers. Stage 1 of ALPPS was performed in 14 patients using an MI approach (21.2%). MI-ALPPS patients were discharged after Stage 1 at a significantly higher rate compared with open-ALPPS (78.6% versus 9.6%, P < .001). After Stage 2, major morbidity after MI-ALPPS was 8.3% compared with 28.6% reported after open-ALPPS. Mortality was nil after MI-ALPPS. Length of hospital stay was significantly shorter in MI-ALPPS (12 days versus 22 days, P < .001). Univariate logistic regression analysis (Firth method) found that both MI-ALPPS (odds ratio [OR] = 0.05, P = .040) and partial parenchymal transection (OR = 0.04, P = .027) were protective against PHLF. Conclusion: This national multicenter study showed that a less invasive approach to ALPPS first stage was associated with a lower overall risk of PHLF.
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Affiliation(s)
- Matteo Serenari
- General Surgery and Transplantation Unit, Azienda Ospedaliero-Universitaria di Bologna, Sant'Orsola-Malpighi Hospital, Bologna, Italy
| | - Francesca Ratti
- Hepatobiliary Surgery Division, San Raffaele Hospital, Milan, Italy
| | - Matteo Zanello
- Department of General Surgery, Azienda Ospedaliero-Universitaria di Bologna, Maggiore Hospital, Bologna, Italy
| | - Nicola Guglielmo
- Division of General Surgery and Liver Transplantation, S. Camillo Hospital, Rome, Italy
| | - Federico Mocchegiani
- HPB Surgery and Transplantation Unit, Department of Clinical and Experimental Medicine, Polytechnic University of Marche, Ancona, Italy
| | - Fabrizio Di Benedetto
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University of Modena and Reggio Emilia, Modena, Italy
| | - Bruno Nardo
- Department of Surgery, UOC Chirurgia Generale "Falcone," Cosenza, Italy
| | - Vincenzo Mazzaferro
- Division of HPB, General Surgery and Liver Transplantation, Department of Surgery, Fondazione IRCCS Istituto Nazionale Tumori di Milano, Milan, Italy
| | - Umberto Cillo
- Hepatobiliary and Liver Transplantation Unit, University of Padua, Padua, Italy
| | - Marco Massani
- Regional Center for HPB Surgery, Regional Hospital of Treviso, Treviso, Italy
| | - Michele Colledan
- Unit of Hepato-biliary Surgery and Liver Transplantation, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Raffaele Dalla Valle
- Hepatobiliary Surgery Unit, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Matteo Cescon
- General Surgery and Transplantation Unit, Azienda Ospedaliero-Universitaria di Bologna, Sant'Orsola-Malpighi Hospital, Bologna, Italy
| | - Marco Vivarelli
- HPB Surgery and Transplantation Unit, Department of Clinical and Experimental Medicine, Polytechnic University of Marche, Ancona, Italy
| | - Marco Colasanti
- Division of General Surgery and Liver Transplantation, S. Camillo Hospital, Rome, Italy
| | | | - Luca Aldrighetti
- Hepatobiliary Surgery Division, San Raffaele Hospital, Milan, Italy
| | - Elio Jovine
- Department of General Surgery, Azienda Ospedaliero-Universitaria di Bologna, Maggiore Hospital, Bologna, Italy
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Masetti M, Lombardi R, Romboli A, Jovine E. Fully Robotic ALPPS and Simultaneous Left Colectomy for Synchronous Colorectal Liver Metastases. J Laparoendosc Adv Surg Tech A 2020; 30:1106-1109. [PMID: 32762603 DOI: 10.1089/lap.2020.0589] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) is a recent surgical advancement for increasing the rate of successful liver resection. This technique is particularly important for patients with advanced tumor burden in whom future liver remnant volume is estimated to be too small to meet hepatic metabolic demands. With increasing acceptance of laparoscopic liver surgery and the related experience, even complex liver resection techniques such as ALPPS have been performed laparoscopically to improve patient outcomes. However, conventional laparoscopy has certain technical limitations that can result in a lack of dexterity. By overcoming these limitations, robot-assisted laparoscopy could become the preferred procedure for complex liver resection. In this study, we describe the technique of fully robotic ALPPS with simultaneous left colectomy in a patient with stage IV colorectal cancer. We emphasize on the performance of the robotic platform during certain difficult steps of the procedure.
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Affiliation(s)
- Michele Masetti
- General Surgery Unit, Department of Surgery, Maggiore Hospital of Bologna, Bologna, Italy
| | - Raffaele Lombardi
- General Surgery Unit, Department of Surgery, Maggiore Hospital of Bologna, Bologna, Italy
| | - Andrea Romboli
- General Surgery Unit, Department of Surgery, Maggiore Hospital of Bologna, Bologna, Italy
| | - Elio Jovine
- General Surgery Unit, Department of Surgery, Maggiore Hospital of Bologna, Bologna, Italy
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24
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Di Benedetto F, Magistri P. First Case of Full Robotic ALPPS for Intrahepatic Cholangiocarcinoma. Ann Surg Oncol 2020; 28:865. [PMID: 32638168 DOI: 10.1245/s10434-020-08794-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) for intrahepatic cholangiocarcinoma (ICC) demonstrated good long-term outcomes1 and can increase the rate of resectability in locally advanced ICC;2 however, the rates of postoperative complications (Clavien-Dindo grade III) and mortality range between 13.6 and 44% and 0 and 29%, respectively.3 Minimally invasive strategies may reduce the risk of postoperative morbidity, with the same oncologic outcomes.4,5 We report the first case of full robotic ALPPS for advanced ICC. METHODS The patient was a 61-year-old male diagnosed with a 6.5 cm ICC involving segments IV, V, and VIII. The total clean liver volume was 1553 cc3, with a future liver remnant (FLR) volume of 21.6% (segments I, II, and III: 337 cc3). The procedure was performed by a senior hepato-pancreato-biliary (HPB) surgeon at the robotic console and a junior HPB surgeon at the table side. RESULTS Computed tomography scan on postoperative day (POD) 9 after stage 1 showed that FLR increased up to 38%. The indocyanine green clearance test showed a plasma disappearance rate of 19.8%/min and a retention rate at 15 min of 5.1%; complete blood tests are available at the end of the video. ALPPS was completed on POD 14, the postoperative course was uneventful, and the patient was discharged in good general condition on POD 5. Final pathology showed a 6 cm ICC, G3, R0 margin (10 mm), T2-N0-M0. The patient started adjuvant capecitabine, and after 6 months was in good general condition without signs of local or systemic recurrence. CONCLUSIONS Robotic ALPPS combines the opportunity to perform a curative resection in patients presenting with insufficient FLR with the advantages of a minimally invasive approach. It is feasible and oncologically accurate for ICC when performed in fully trained HPB centers.
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Affiliation(s)
- Fabrizio Di Benedetto
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University of Modena and Reggio Emilia, Modena, MO, Italy.
| | - Paolo Magistri
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University of Modena and Reggio Emilia, Modena, MO, Italy
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25
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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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26
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Hernandez-Alejandro R, Ruffolo LI, Alikhanov R, Björnsson B, Torres OJM, Serrablo A. Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy (ALPPS) procedure for colorectal liver metastasis. Int J Surg 2020; 82S:103-108. [PMID: 32305531 DOI: 10.1016/j.ijsu.2020.04.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 03/24/2020] [Accepted: 04/01/2020] [Indexed: 12/24/2022]
Abstract
Since first described, Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy (ALPPS) has garnered boisterous praise and fervent criticism. Its rapid adoption and employment for a variety of indications resulted in high perioperative morbidity and mortality. However recent risk stratification, refinement of technique to reduce the impact of stage I and progression along the learning curve have resulted in improved outcomes. The first randomized trial comparing ALPPS to two stage hepatectomy (TSH) for colorectal liver metastases (CRLM) was recently published demonstrating comparable perioperative morbidity and mortality with improved resectability and survival following ALPPS. In this review, as ALPPS enters the thirteenth year since conception, the current status of this contentious two stage technique is presented and best practices for deployment in the treatment of CRLM is codified.
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Affiliation(s)
- Roberto Hernandez-Alejandro
- Department of Surgery and Division of Abdominal Transplantation and Hepatobiliary Surgery, University of Rochester Medical Center, Rochester, USA.
| | - Luis I Ruffolo
- Department of Surgery and Division of Abdominal Transplantation and Hepatobiliary Surgery, University of Rochester Medical Center, Rochester, USA
| | - Ruslan Alikhanov
- Department of Liver and Pancreatic Surgery, Clinical Research Center of Moscow, Moscow, Russia
| | - Bergthor Björnsson
- Department of Surgery in Linköping, And Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Orlando Jorge M Torres
- Department of Gastrointestinal Surgery, Hepatopancreatobiliary Unit, University Hospital and School of Medicine, Federal University of Maranhão, São Luís, Brazil
| | - Alejandro Serrablo
- Division of Surgery, Miguel Servet University Hospital and University of Zaragoza School of Medicine, Zaragoza, Spain
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Di Benedetto F, Assirati G, Magistri P. Full robotic ALPPS for HCC with intrahepatic portal vein thrombosis. Int J Med Robot 2020; 16:e2087. [DOI: 10.1002/rcs.2087] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Revised: 01/08/2020] [Accepted: 01/27/2020] [Indexed: 12/18/2022]
Affiliation(s)
- Fabrizio Di Benedetto
- Hepato‐Pancreato‐Biliary Surgery and Liver Transplantation UnitUniversity of Modena and Reggio Emilia Modena Italy
| | - Giacomo Assirati
- Hepato‐Pancreato‐Biliary Surgery and Liver Transplantation UnitUniversity of Modena and Reggio Emilia Modena Italy
| | - Paolo Magistri
- Hepato‐Pancreato‐Biliary Surgery and Liver Transplantation UnitUniversity of Modena and Reggio Emilia Modena Italy
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