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Alvarez FA, Ardiles V, Chara C, de Santibañes M, Sánchez Clariá R, Pekolj J, de Santibañes E. Adjuvant chemotherapy is associated with better oncological outcomes after ALPPS for colorectal liver metastases. Updates Surg 2024; 76:855-868. [PMID: 38647857 DOI: 10.1007/s13304-024-01835-1] [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] [Received: 12/11/2023] [Accepted: 03/15/2024] [Indexed: 04/25/2024]
Abstract
ALPPS enables complete tumor resection in a shorter interval and a larger number of patients than classic two-stage hepatectomies. However, there is little evidence regarding long-term outcomes in patients with colorectal liver metastases (CLM). This study aims to evaluate the short and long-term outcomes of ALPPS in patients with CRM. Single-cohort, prospective, observational study. Patients with unresectable CLM due to insufficient liver remnant who underwent ALPPS between June 2011 and June 2021 were included. Of 32 patients treated, 21 were male (66%) and the median age was 56 years (range = 29-81). Both stages were completed in 30 patients (93.7%), with an R0 rate of 75% (24/32). Major morbidity was 37.5% and the mortality nil. Median overall survival (OS) and recurrence-free survival (RFS) were 28.1 and 8.8 months, respectively. The 1-3, and 5-year OS was 86%, 45%, and 21%, and RFS was 42%, 14%, and 14%, respectively. The only independent risk factor associated with poor RFS (5.7 vs 11.6 months; p = 0.038) and OS (15 vs 37 months; p = 0.009) was not receiving adjuvant chemotherapy. KRAS mutation was associated with worse OS from disease diagnosis (24.3 vs. 38.9 months; p = 0.025). ALPPS is associated with favorable oncological outcomes, comparable to traditional strategies to increase resectability in patients with CLM and high tumor burden. Our results suggest for the first time that adjuvant chemotherapy is independently associated with better short- and long-term outcomes after ALPPS. Selection of patients with KRAS mutations should be performed with caution, as this could affect oncological outcomes.
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Affiliation(s)
- Fernando A Alvarez
- General Surgery Service, Hepato-Pancreato-Biliary Surgery Section and Liver Transplant Unit, Hospital Italiano de Buenos Aires, Juan D. Perón 4190, C1181AC, Buenos Aires, Argentina
| | - Victoria Ardiles
- General Surgery Service, Hepato-Pancreato-Biliary Surgery Section and Liver Transplant Unit, Hospital Italiano de Buenos Aires, Juan D. Perón 4190, C1181AC, Buenos Aires, Argentina
| | - Camila Chara
- General Surgery Service, Hepato-Pancreato-Biliary Surgery Section and Liver Transplant Unit, Hospital Italiano de Buenos Aires, Juan D. Perón 4190, C1181AC, Buenos Aires, Argentina
| | - Martin de Santibañes
- General Surgery Service, Hepato-Pancreato-Biliary Surgery Section and Liver Transplant Unit, Hospital Italiano de Buenos Aires, Juan D. Perón 4190, C1181AC, Buenos Aires, Argentina
| | - Rodrigo Sánchez Clariá
- General Surgery Service, Hepato-Pancreato-Biliary Surgery Section and Liver Transplant Unit, Hospital Italiano de Buenos Aires, Juan D. Perón 4190, C1181AC, Buenos Aires, Argentina
| | - Juan Pekolj
- General Surgery Service, Hepato-Pancreato-Biliary Surgery Section and Liver Transplant Unit, Hospital Italiano de Buenos Aires, Juan D. Perón 4190, C1181AC, Buenos Aires, Argentina
| | - Eduardo de Santibañes
- General Surgery Service, Hepato-Pancreato-Biliary Surgery Section and Liver Transplant Unit, Hospital Italiano de Buenos Aires, Juan D. Perón 4190, C1181AC, Buenos Aires, Argentina.
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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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Baumgart J, Hiller S, Stroh K, Kloth M, Lang H. Resection of Colorectal Liver Metastases with Major Vessel Involvement. Cancers (Basel) 2024; 16:571. [PMID: 38339321 PMCID: PMC10854547 DOI: 10.3390/cancers16030571] [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: 12/11/2023] [Revised: 01/15/2024] [Accepted: 01/23/2024] [Indexed: 02/12/2024] Open
Abstract
BACKGROUND Treatment of CRLM with major vessel involvement is still challenging and valid data on outcomes are still rare. We analyzed our experience of hepatectomies with resection and reconstruction of major hepatic vessels with regard to operative and perioperative details, histopathological findings and oncological outcome. METHODS Data of 32 hepatectomies with major hepatic vessel resections and reconstructions were included. Results were correlated with perioperative and oncological outcome. RESULTS Out of 1236 surgical resections due to CRLM, we performed 35 major hepatic vessel resections and reconstructions in 32 cases (2.6%) during the study period from January 2008 to March 2023. The vena cava inferior (VCI) was resected and reconstructed in 19, the portal vein (PV) in 6 and a hepatic vein (HV) in 10 cases. Histopathological examination confirmed a vascular infiltration in 6/32 patients (VCI 3/17, HV 2/10 and PV 1/6). There were 27 R0 and 5 R1 resections. All R1 situations affected the parenchymal margin. Vascular wall margins were R0. Ninety-day mortality was 0. The median overall survival (OS) for the patient group with vascular infiltration (V1) was 21 months and for the V0 group 33.3 months. CONCLUSION Liver resections with vascular resection and reconstruction are rare and histological vessel infiltration occurs seldom. In cases with presumed vascular wall infiltration, liver resection combined with major vessel resection and reconstruction can be performed with low morbidity and mortality. We prefer a parenchymal sparing liver resection with vascular resection and reconstruction to achieve negative resection margins, but in technically difficult cases with higher risk for postoperative complications, tumor detachment from vessels without resection is a most reasonable surgical alternative.
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Affiliation(s)
- Janine Baumgart
- Department of General, Visceral and Transplantation Surgery, Universitätsmedizin Mainz, 55131 Mainz, Germany; (J.B.); (S.H.)
| | - Sebastian Hiller
- Department of General, Visceral and Transplantation Surgery, Universitätsmedizin Mainz, 55131 Mainz, Germany; (J.B.); (S.H.)
| | - Kristina Stroh
- Department of Diagnostic and Interventional Radiology, Universitätsmedizin Mainz, 55131 Mainz, Germany;
| | - Michael Kloth
- Department of Pathology, Universitätsmedizin Mainz, 55131 Mainz, Germany;
| | - Hauke Lang
- Department of General, Visceral and Transplantation Surgery, Universitätsmedizin Mainz, 55131 Mainz, Germany; (J.B.); (S.H.)
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Lopez-Lopez V, Martínez-Caceres C, Gomez-Valles P, Cruz J, Caballero-Illanes A, Brusadin R, López-Conesa A, Pérez M, Miura K, de la Peña-Moral J, Robles-Campos R. Impact of rapid hypertrophy of tourniquet associating liver partition and portal vein ligation in the tumor progression pathways compared to two stage hepatectomy in patients with colorectal liver metastases. HPB (Oxford) 2023; 25:1235-1246. [PMID: 37407399 DOI: 10.1016/j.hpb.2023.06.005] [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: 09/11/2022] [Revised: 01/22/2023] [Accepted: 06/10/2023] [Indexed: 07/07/2023]
Abstract
BACKGROUND It is not known if the inflammatory phenomena related to highly accelerated regeneration activate any signaling pathways that are associated with a major stimulus to colorectal liver metastases (CRLM) disease in tourniquet associating liver partition and portal vein ligation for staged hepatectomy (T-ALPPS) compared to two stage hepatectomy (TSH). METHODS Between January 2012 and April 2018, we prospectively performed biopsies from future liver remnant and deportalized lobe in CRLM patients undergoing T-ALPPS in both stages. Immunohistopathological analysis was performed on the above tissue samples and compared to biopsy samples from patients who underwent TSH for CRLM at our center between September 2000 and August 2011. RESULTS A total of 42 patients (20 TSH and 22 T-ALPPS) were included. There were no differences in the rates of recurrence, overall survival or any of the factors analyzed relating to tumor progression between stages 1 and 2. Regarding the anti-tumor effect, there was a significant reduction in the number of T-CD8 infiltrates in the second stage of TSH (12.5 vs. 5.5, p = 0.02). CONCLUSION The results suggest that liver regeneration with T-ALPPS does not induce higher tumor progression or significant immunological changes in the tumor environment when compared to classical TSH.
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Affiliation(s)
- Victor Lopez-Lopez
- Department of General, Visceral and Transplantation Surgery, Clinic and University Hospital Virgen de La Arrixaca, IMIB-Arrixaca, Ctra. Madrid-Cartagena, s/n, 30120, El Palmar, Murcia, Spain
| | - Carlos Martínez-Caceres
- Investigation Support Platforms, IMIB-Arrixaca, Ctra. Madrid-Cartagena, s/n, 30120, El Palmar, Murcia, Spain
| | - Paula Gomez-Valles
- Department of General, Visceral and Transplantation Surgery, Clinic and University Hospital Virgen de La Arrixaca, IMIB-Arrixaca, Ctra. Madrid-Cartagena, s/n, 30120, El Palmar, Murcia, Spain
| | - Juan Cruz
- Group of Applied Mathematics in Science and Engineering, Faculty of Computer Science, University of Murcia, C. Campus Universitario, Edificio 32, 30100, Murcia, Spain
| | - Albert Caballero-Illanes
- Department of Pathology, Virgen de La Arrixaca University Hospital, IMIB-Arrixaca, Ctra. Madrid-Cartagena, s/n, 30120, El Palmar, Murcia, Spain
| | - Roberto Brusadin
- Department of General, Visceral and Transplantation Surgery, Clinic and University Hospital Virgen de La Arrixaca, IMIB-Arrixaca, Ctra. Madrid-Cartagena, s/n, 30120, El Palmar, Murcia, Spain
| | - Asuncion López-Conesa
- Department of General, Visceral and Transplantation Surgery, Clinic and University Hospital Virgen de La Arrixaca, IMIB-Arrixaca, Ctra. Madrid-Cartagena, s/n, 30120, El Palmar, Murcia, Spain
| | - María Pérez
- University of Lleida, Catalonia, Plaça de Víctor Siurana, 1, 25003, Lleida, Spain
| | - Kohei Miura
- Department of General, Visceral and Transplantation Surgery, Clinic and University Hospital Virgen de La Arrixaca, IMIB-Arrixaca, Ctra. Madrid-Cartagena, s/n, 30120, El Palmar, Murcia, Spain; Division of Digestive and General Surgery, Niigata University Graduate School of Medical and Dental Sciences, 1-757, Asahimachi-dori, Chuo-ku, Niigata City, 951-8510, Niigata, Japan
| | - Jesús de la Peña-Moral
- Group of Applied Mathematics in Science and Engineering, Faculty of Computer Science, University of Murcia, C. Campus Universitario, Edificio 32, 30100, Murcia, Spain
| | - Ricardo Robles-Campos
- Department of General, Visceral and Transplantation Surgery, Clinic and University Hospital Virgen de La Arrixaca, IMIB-Arrixaca, Ctra. Madrid-Cartagena, s/n, 30120, El Palmar, Murcia, Spain.
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Turk S, Plahuta I, Magdalenic T, Spanring T, Laufer K, Mavc Z, Potrc S, Ivanecz A. Two-stage hepatectomy in resection of colorectal liver metastases - a single-institution experience with case-control matching and review of the literature. Radiol Oncol 2023; 57:270-278. [PMID: 37341198 DOI: 10.2478/raon-2023-0026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2023] [Accepted: 05/15/2023] [Indexed: 06/22/2023] Open
Abstract
BACKGROUND Two-stage hepatectomy (TSH) has been proposed for patients with bilateral liver tumours who have a high risk of posthepatectomy liver failure after one-stage hepatectomy (OSH). This study aimed to determine the outcomes of TSH for extensive bilateral colorectal liver metastases. PATIENTS AND METHODS A retrospective review of a prospectively maintained database of liver resections for colorectal liver metastases was conducted. The TSH group was compared to the OSH group in terms of perioperative outcomes and survival. Case-control matching was performed. RESULTS A total of 632 consecutive liver resections for colorectal liver metastases were performed between 2000 and 2020. The study group (TSH group) consisted of 15 patients who completed TSH. The control group included 151 patients who underwent OSH. The case-control matching-OSH group consisted of 14 patients. The major morbidity and 90-day mortality rates were 40% and 13.3% in the TSH group, 20.5% and 4.6% in the OSH group and 28.6% and 7.1% in the case-control matching-OSH group, respectively. The recurrence-free survival, median overall survival, and 3- and 5-year survival rates were 5 months, 21 months, 33% and 13% in the TSH group; 11 months, 35 months, 49% and 27% in the OSH group; and 8 months, 23 months, 36% and 21%, respectively, in the case-control matching-OSH group, respectively. CONCLUSIONS TSH used to be a favourable therapeutic choice in a select population of patients. Now, OSH should be preferred whenever feasible because it has lower morbidity and equivalent oncological outcomes to those of completed TSH.
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Affiliation(s)
- Spela Turk
- Clinical Department of Abdominal and General Surgery, University Medical Centre Maribor, Maribor, Slovenia
- Department of Surgery, Faculty of Medicine, University of Maribor, Maribor, Slovenia
| | - Irena Plahuta
- Clinical Department of Abdominal and General Surgery, University Medical Centre Maribor, Maribor, Slovenia
- Department of Surgery, Faculty of Medicine, University of Maribor, Maribor, Slovenia
| | - Tomislav Magdalenic
- Clinical Department of Abdominal and General Surgery, University Medical Centre Maribor, Maribor, Slovenia
| | - Tajda Spanring
- Clinical Department of Abdominal and General Surgery, University Medical Centre Maribor, Maribor, Slovenia
- Department of Surgery, Faculty of Medicine, University of Maribor, Maribor, Slovenia
| | - Kevin Laufer
- Clinical Department of Abdominal and General Surgery, University Medical Centre Maribor, Maribor, Slovenia
- Department of Surgery, Faculty of Medicine, University of Maribor, Maribor, Slovenia
| | - Zan Mavc
- Clinical Department of Abdominal and General Surgery, University Medical Centre Maribor, Maribor, Slovenia
| | - Stojan Potrc
- Clinical Department of Abdominal and General Surgery, University Medical Centre Maribor, Maribor, Slovenia
- Department of Surgery, Faculty of Medicine, University of Maribor, Maribor, Slovenia
| | - Arpad Ivanecz
- Clinical Department of Abdominal and General Surgery, University Medical Centre Maribor, Maribor, Slovenia
- Department of Surgery, Faculty of Medicine, University of Maribor, Maribor, Slovenia
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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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Yi F, Zhang W, Feng L. Efficacy and safety of different options for liver regeneration of future liver remnant in patients with liver malignancies: a systematic review and network meta-analysis. World J Surg Oncol 2022; 20:399. [PMID: 36527081 PMCID: PMC9756618 DOI: 10.1186/s12957-022-02867-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 12/04/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Several treatments induce liver hypertrophy for patients with liver malignancies but insufficient future liver remnant (FLR). Herein, the aim of this study is to compare the efficacy and safety of existing surgical techniques using network meta-analysis (NMA). METHODS We searched PubMed, Web of Science, and Cochrane Library from databases for abstracts and full-text articles published from database inception through Feb 2022. The primary outcome was the efficacy of different procedures, including standardized FLR (sFLR) increase, time to hepatectomy, resection rate, and R0 resection margin. The secondary outcome was the safety of different treatments, including the rate of Clavien-Dindo≥3a and 90-day mortality. RESULTS Twenty-seven studies, including three randomized controlled trials (RCTs), three prospective trials (PTs), and twenty-one retrospective trials (RTs), and a total number of 2075 patients were recruited in this study. NMA demonstrated that the Associating Liver Partition and Portal vein ligation for Staged hepatectomy (ALPPS) had much higher sFLR increase when compared to portal vein embolization (PVE) (55.25%, 95% CI 45.27-65.24%), or liver venous deprivation(LVD) (43.26%, 95% CI 22.05-64.47%), or two-stage hepatectomy (TSH) (30.53%, 95% CI 16.84-44.21%), or portal vein ligation (PVL) (58.42%, 95% CI 37.62-79.23%). ALPPS showed significantly shorter time to hepatectomy when compared to PVE (-32.79d, 95% CI -42.92-22.66), or LVD (-34.02d, 95% CI -47.85-20.20), or TSH (-22.85d, 95% CI -30.97-14.72), or PVL (-43.37d, 95% CI -64.11-22.62); ALPPS was considered as the highest resection rate when compared to TSH (OR=6.09; 95% CI 2.76-13.41), or PVL (OR =3.52; 95% CI 1.16-10.72), or PVE (OR =4.12; 95% CI 2.19-7.77). ALPPS had comparable resection rate with LVD (OR =2.20; 95% CI 0.83-5.86). There was no significant difference between them when considering the R0 marge rate. ALPPS had a higher Clavien-Dindo≥3a complication rate and 90-day mortality compared to other treatments, although there were no significant differences between different procedures. CONCLUSIONS ALPPS demonstrated a higher regeneration rate, shorter time to hepatectomy, and higher resection rate than PVL, PVE, or TSH. There was no significant difference between them when considering the R0 marge rate. However, ALPPS developed the trend of higher Clavien-Dindo≥3a complication rate and 90-day mortality compared to other treatments.
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Affiliation(s)
- Fengming Yi
- grid.412455.30000 0004 1756 5980Department of Oncology, Second Affiliated Hospital of Nanchang University, Nanchang, 330006 People’s Republic of China ,JiangXi Key Laboratory of Clinical and Translational Cancer Research, Nanchang, 330006 People’s Republic of China
| | - Wei Zhang
- grid.412455.30000 0004 1756 5980Department of Obstetrics and Gynecology, Second Affiliated Hospital of Nanchang University, Nanchang, 330006 People’s Republic of China
| | - Long Feng
- grid.412455.30000 0004 1756 5980Department of Oncology, Second Affiliated Hospital of Nanchang University, Nanchang, 330006 People’s Republic of China ,JiangXi Key Laboratory of Clinical and Translational Cancer Research, Nanchang, 330006 People’s Republic of China
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Simultaneous portal and hepatic vein embolization is better than portal embolization or ALPPS for hypertrophy of future liver remnant before major hepatectomy: A systematic review and network meta-analysis. Hepatobiliary Pancreat Dis Int 2022; 22:221-227. [PMID: 36100542 DOI: 10.1016/j.hbpd.2022.08.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 08/24/2022] [Indexed: 02/05/2023]
Abstract
BACKGROUND Post-hepatectomy liver failure (PHLF) is the Achilles' heel of hepatic resection for colorectal liver metastases. The most commonly used procedure to generate hypertrophy of the functional liver remnant (FLR) is portal vein embolization (PVE), which does not always lead to successful hypertrophy. Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) has been proposed to overcome the limitations of PVE. Liver venous deprivation (LVD), a technique that includes simultaneous portal and hepatic vein embolization, has also been proposed as an alternative to ALPPS. The present study aimed to conduct a systematic review as the first network meta-analysis to compare the efficacy, effectiveness, and safety of the three regenerative techniques. DATA SOURCES A systematic search for literature was conducted using the electronic databases Embase, PubMed (MEDLINE), Google Scholar and Cochrane. RESULTS The time to operation was significantly shorter in the ALPPS cohort than in the PVE and LVD cohorts by 27 and 22 days, respectively. Intraoperative parameters of blood loss and the Pringle maneuver demonstrated non-significant differences between the PVE and LVD cohorts. There was evidence of a significantly higher FLR hypertrophy rate in the ALPPS cohort when compared to the PVE cohort, but non-significant differences were observed when compared to the LVD cohort. Notably, the LVD cohort demonstrated a significantly better FLR/body weight (BW) ratio compared to both the ALPPS and PVE cohorts. Both the PVE and LVD cohorts demonstrated significantly lower major morbidity rates compared to the ALPPS cohort. The LVD cohort also demonstrated a significantly lower 90-day mortality rate compared to both the PVE and ALPPS cohorts. CONCLUSIONS LVD in adequately selected patients may induce adequate and profound FLR hypertrophy before major hepatectomy. Present evidence demonstrated significantly lower major morbidity and mortality rates in the LVD cohort than in the ALPPS and PVE cohorts.
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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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10
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Link KH, Kornmann M, Staib L, Kreuser ED, Gaus W, Röttinger E, Suhr P, Maulbecker-Armstrong C, Danenberg P, Danenberg K, Schatz M, Sander S, Ji ZL, Li JT, Peng SY, Bittner R, Beger HG, Traub B. Patient-centered developments in colon- and rectal cancer with a multidisciplinary international team: From translational research to national guidelines. World J Gastrointest Surg 2021; 13:1597-1614. [PMID: 35070066 PMCID: PMC8727190 DOI: 10.4240/wjgs.v13.i12.1597] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 08/07/2021] [Accepted: 11/25/2021] [Indexed: 02/06/2023] Open
Abstract
Rarely, scientific developments centered around the patient as a whole are published. Our multidisciplinary group, headed by gastrointestinal surgeons, applied this research philosophy considering the most important aspects of the diseases “colon- and rectal cancer” in the long-term developments. Good expert cooperation/knowledge at the Comprehensive Cancer Center Ulm (CCCU) were applied in several phase III trials for multimodal treatments of primary tumors (MMT) and metastatic diseases (involving nearly 2000 patients and 64 centers), for treatment individualization of MMT and of metastatic disease, for psycho-oncology/quality of life involving the patients’ wishes, and for disease prevention. Most of the targets initially were heavily rejected/discussed in the scientific communities, but now have become standards in treatments and national guidelines or are topics in modern translational research protocols involving molecular biology for e.g., “patient centered individualized treatment”. In this context we also describe the paths we had to tread in order to realize our new goals, which at the end were highly beneficial for the patients from many points of view. This description is also important for students and young researchers who, with an actual view on our recent developments, might want to know how medical progress was achieved.
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Affiliation(s)
- Karl-Heinrich Link
- Asklepios Tumor Center (ATC) and Surgical Center, Asklepios Paulinen Klinik, Wiesbaden 65197, Germany
- FOGT (Multidisciplinary Study Group on Oncology of Gastrointestinal Tumors), University of Ulm, Ulm 89081, Germany
- Department of General and Visceral Surgery, University of Ulm, Ulm 89081, Germany
| | - Marko Kornmann
- FOGT (Multidisciplinary Study Group on Oncology of Gastrointestinal Tumors), University of Ulm, Ulm 89081, Germany
- Department of General and Visceral Surgery, University of Ulm, Ulm 89081, Germany
| | - Ludger Staib
- FOGT (Multidisciplinary Study Group on Oncology of Gastrointestinal Tumors), University of Ulm, Ulm 89081, Germany
- Department of General and Visceral Surgery, University of Ulm, Ulm 89081, Germany
| | - Ernst-Dietrich Kreuser
- FOGT (Multidisciplinary Study Group on Oncology of Gastrointestinal Tumors), University of Ulm, Ulm 89081, Germany
| | - Wilhelm Gaus
- FOGT (Multidisciplinary Study Group on Oncology of Gastrointestinal Tumors), University of Ulm, Ulm 89081, Germany
- Department of Biometry and Medical Documentation, University of Ulm, Ulm 89081, Germany
| | - Erwin Röttinger
- FOGT (Multidisciplinary Study Group on Oncology of Gastrointestinal Tumors), University of Ulm, Ulm 89081, Germany
- Department of Radiotherapy, University of Ulm, Ulm 89081, Germany
| | - Peter Suhr
- FOGT (Multidisciplinary Study Group on Oncology of Gastrointestinal Tumors), University of Ulm, Ulm 89081, Germany
- Department of Radiotherapy, University of Ulm, Ulm 89081, Germany
| | - Catharina Maulbecker-Armstrong
- Fachbereich Gesundheit, Medizinisches Management, Sozialversicherungssysteme, Internationales Versorgungsmanagement, e-Health, Technische Hochschule Mittelhessen, Giessen 35390, Germany
| | - Peter Danenberg
- Department of Biochemistry and Molecular Medicine, Keck-USC School of Medicine, Los Angeles, CA 90033, United States
| | - Kathleen Danenberg
- Norris Comprehensive Cancer Center, Keck-USC School of Medicine, Los Angeles, CA 90033, United States
| | - Miriam Schatz
- Private Practice for Psychology, Adelsdorf 91325, Germany
| | - Silvia Sander
- FOGT (Multidisciplinary Study Group on Oncology of Gastrointestinal Tumors), University of Ulm, Ulm 89081, Germany
- Department of Biometry and Medical Documentation, University of Ulm, Ulm 89081, Germany
| | - Zhen-Ling Ji
- Department of General Surgery, Southeast University, Nanjing 210009, Jiangsu Province, China
| | - Jiang-Tao Li
- Department of Surgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310009, Zhejiang Province, China
| | - Shu-You Peng
- Department of Surgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310009, Zhejiang Province, China
| | - Reinhard Bittner
- FOGT (Multidisciplinary Study Group on Oncology of Gastrointestinal Tumors), University of Ulm, Ulm 89081, Germany
- Surgical Clinic, Marienhospital, Stuttgart 70177, Germany
| | - Hans Günther Beger
- FOGT (Multidisciplinary Study Group on Oncology of Gastrointestinal Tumors), University of Ulm, Ulm 89081, Germany
- Department of General and Visceral Surgery, University of Ulm, Ulm 89081, Germany
| | - Benno Traub
- FOGT (Multidisciplinary Study Group on Oncology of Gastrointestinal Tumors), University of Ulm, Ulm 89081, Germany
- Department of General and Visceral Surgery, University of Ulm, Ulm 89081, Germany
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11
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Reese T, Makridis G, Raptis D, Malagó M, Hernandez-Alejandro R, Tun-Abraham M, Ardiles V, de Santibañes E, Fard-Aghaie M, Li J, Kuemmerli C, Petrowsky H, Linecker M, Clavien PA, Oldhafer KJ. Repeated hepatectomy after ALPPS for recurrence of colorectal liver metastasis: the edge of limits? HPB (Oxford) 2021; 23:1488-1495. [PMID: 33726975 DOI: 10.1016/j.hpb.2021.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Revised: 01/03/2021] [Accepted: 02/17/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Repeated liver resections for the recurrence of colorectal liver metastasis (CRLM) are described as safe and have similar oncological outcomes compared to first hepatectomy. Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) is performed in patients with conventionally non-resectable CRLM. Repeated resections after ALPPS has not yet been described. METHODS Patients that underwent repeated liver resection in recurrence of CRLM after ALPPS were included in this study. The primary endpoint was morbidity and secondary endpoints were mortality, resection margin and survival. RESULTS Thirty patients were included in this study. During ALPPS, most of the patients had classical split (60%, n = 18) and clearance of the FLR (77%, n = 23). Hepatic recurrence was treated with non-anatomical resection (57%, n = 17), resection combined with local ablation (13%, n = 4), open ablation (13%, n = 4), segmentectomy (10%, n = 3) or subtotal segmentectomy (7%, n = 2). Six patients (20%) developed complications (10% minor complications). No post-hepatectomy liver failure or perioperative mortality was observed. One-year patient survival was 87%. Five patients received a third hepatectomy. CONCLUSION Repeated resections after ALPPS for CRLM in selected patients are safe and feasible with low morbidity and no mortality. Survival seems to be comparable with repeated resections after conventional hepatectomy.
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Affiliation(s)
- Tim Reese
- Department of Surgery, Division of Hepatobiliary and Pancreatic Surgery, Asklepios Hospital Barmbek, Germany; Semmelweis University of Medicine, Asklepios Campus Hamburg, Hamburg, Germany.
| | - Georgios Makridis
- Department of Surgery, Division of Hepatobiliary and Pancreatic Surgery, Asklepios Hospital Barmbek, Germany; Semmelweis University of Medicine, Asklepios Campus Hamburg, Hamburg, Germany
| | - Dimitri Raptis
- Department of HPB and Liver Transplant Surgery, Royal Free Hospital, University College London, London, UK
| | - Massimo Malagó
- Department of HPB and Liver Transplant Surgery, Royal Free Hospital, University College London, London, UK
| | | | | | - Victoria Ardiles
- Department of Surgery, Division of HPB Surgery, Liver Transplant Unit, Italian Hospital Buenos Aires, Buenos Aires, Argentina
| | - Eduardo de Santibañes
- Department of Surgery, Division of HPB Surgery, Liver Transplant Unit, Italian Hospital Buenos Aires, Buenos Aires, Argentina
| | - Mohammad Fard-Aghaie
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jun Li
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christoph Kuemmerli
- Department of Surgery and Transplantation, Swiss HPB and Transplant Center, University Hospital Zurich, Zurich, Switzerland
| | - Henrik Petrowsky
- Department of Surgery and Transplantation, Swiss HPB and Transplant Center, University Hospital Zurich, Zurich, Switzerland
| | - Michael Linecker
- Department of Surgery and Transplantation, Swiss HPB and Transplant Center, University Hospital Zurich, Zurich, Switzerland
| | - Pierre-Alain Clavien
- Department of Surgery and Transplantation, Swiss HPB and Transplant Center, University Hospital Zurich, Zurich, Switzerland
| | - Karl J Oldhafer
- Department of Surgery, Division of Hepatobiliary and Pancreatic Surgery, Asklepios Hospital Barmbek, Germany; Semmelweis University of Medicine, Asklepios Campus Hamburg, Hamburg, Germany
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12
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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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13
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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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14
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The evolution of surgery for colorectal liver metastases: A persistent challenge to improve survival. Surgery 2021; 170:1732-1740. [PMID: 34304889 DOI: 10.1016/j.surg.2021.06.033] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Revised: 06/01/2021] [Accepted: 06/21/2021] [Indexed: 02/07/2023]
Abstract
Only a few decades ago, the opinion that colorectal liver metastases were a palliative diagnosis changed. In fact, previously, the prevailing view was strongly resistant against resecting colorectal liver metastases. Constant technical improvement of liver surgery and, much later, effective chemotherapy allowed for a successful wider application of surgery. The clinical use of portal vein embolization was the starting signal of regenerative liver surgery, where insufficient liver volume can be expanded to an extent where safe resection is possible. Today, a number of these techniques including portal vein ligation, associating liver partition and portal vein ligation for staged hepatectomy, and bi-embolization (portal and hepatic vein) can be successfully used to address an insufficient future liver remnant in staged resections. It turned out that the road to success is embedding surgery in a well-orchestrated oncological concept of controlling systemic disease. This concept was the prerequisite that meant liver transplantation could enter the treatment strategy for colorectal liver metastases, ending up with a 5-year overall survival of 80% in highly selected cases. In particular, techniques combining principles of 2-stage hepatectomy and liver transplantation, such as "resection and partial liver segment 2-3 transplantation with delayed total hepatectomy" (RAPID) are on the rise. These techniques enable the use of partial liver grafts with primarily insufficient liver volume. All this progress also prompted a number of innovative local therapies to address recurrences ultimately transferring colorectal liver metastases from instantly deadly into a chronic disease in some cases.
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15
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ALPPS Improves Survival Compared With TSH in Patients Affected of CRLM: Survival Analysis From the Randomized Controlled Trial LIGRO. Ann Surg 2021; 273:442-448. [PMID: 32049675 DOI: 10.1097/sla.0000000000003701] [Citation(s) in RCA: 58] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To evaluate the oncological outcome for patients with colorectal liver metastases (CRLM) randomized to associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) or 2-stage hepatectomy (TSH). BACKGROUND TSH with portal vein occlusion is an established method for patients with CRLM and a low volume of the future liver remnant (FLR). ALPPS is a less established method. The oncological outcome of these methods has not been previously compared in a randomized controlled trial. METHODS One hundred patients with CRLM and standardized FLR (sFLR) <30% were included and randomized to resection by ALPPS or TSH, with the option of rescue ALPPS in the TSH group, if the criteria for volume increase was not met. The first radiological follow-up was performed approximately 4 weeks postoperatively and then after 4, 8, 12, 18, and 24 months. At all the follow-ups, the remaining/recurrent tumor was noted. After the first follow-up, chemotherapy was administered, if indicated. RESULTS The resection rate, according to the intention-to-treat principle, was 92% (44 patients) for patients randomized to ALPPS compared with 80% (39 patients) for patients randomized to TSH (P = 0.091), including rescue ALPPS. At the first postoperative follow-up, 37 patients randomized to ALPPS were assessed as tumor free in the liver, and also 28 patients randomized to TSH (P = 0.028). The estimated median survival for patients randomized to ALPPS was 46 months compared with 26 months for patients randomized to TSH (P = 0.028). CONCLUSIONS ALPPS seems to improve survival in patients with CRLM and sFLR <30% compared with TSH.
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16
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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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17
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Lang H. Liver resection is beneficial for patients with colorectal liver metastases and extrahepatic disease. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:1122. [PMID: 33240971 PMCID: PMC7576061 DOI: 10.21037/atm-20-4416] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- Hauke Lang
- Department of General, Visceral and Transplantation Surgery, University Medical Center, Mainz, Germany
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18
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Heinrich S, Watzka F, Lang H. Integrative Concepts for Liver Surgery. Visc Med 2020; 36:351-358. [PMID: 33178731 PMCID: PMC7590779 DOI: 10.1159/000511043] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Accepted: 08/20/2020] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Surgery is the standard treatment for primary tumors and metastases. Due to improvements in surgical outcomes as well as the efficacy of systemic treatments, the role of surgery has changed in recent years. SUMMARY Liver surgery has become safe and efficient, with resectability being increased by multimodality concepts as well as staged liver resections and orthotopic liver transplantation. These concepts may be applied to primary liver tumors but also to selected patients with liver metastases from various diseases. In addition, even debulking surgery may be indicated for selected patients with endocrine metastases. While patient selection for liver resections was limited to clinical parameters in the past, histological and molecular characteristics have become increasingly important. Moreover, the response to regional or systemic chemotherapy has been demonstrated to be strong for a beneficial course of the disease even in advanced diseases. KEY-MESSAGES Due to the variety of available treatment options, optimal patient selection is crucial. Besides liver surgery, staged concepts as well as liver transplantation are curative tools for many patients.
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Affiliation(s)
| | | | - Hauke Lang
- General, Visceral and Transplantation Surgery, University Hospital, Mainz, Germany
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19
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Hepatobiliary scintigraphy and kinetic growth rate predict liver failure after ALPPS: a multi-institutional study. HPB (Oxford) 2020; 22:1420-1428. [PMID: 32057681 DOI: 10.1016/j.hpb.2020.01.010] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Revised: 01/14/2020] [Accepted: 01/19/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Post hepatectomy liver failure (PHLF) after ALPPS has been related to the discrepancy between liver volume and function. Pre-operative hepatobiliary scintigraphy (HBS) can predict post-operative liver function and guide when it is safe to proceed with major hepatectomy. Aim of this study was to evaluate the role of HBS in predicting PHLF after ALPPS, defining a safe cut-off. METHODS A multicenter retrospective study was approved by the ALPPS Registry. All patients selected for ALPPS between 2012 and 2018, were evaluated. Every patient underwent HBS during ALPPS evaluation. PHLF was reported according to ISGLS definition, considering grade B or C as clinically significant. RESULTS 98 patients were included. Thirteen patients experienced PHLF grade B or C (14%) following ALPPS-2. The HBS and the daily gain in volume (KGRFLR) of the future liver remnant (FLR) were significantly lower in PHLF B and C (p = .004 and .041 respectively). ROC curves indicated safe cut-offs of 4.1%/day (AUC = 0.68) for KGRFLR, and of 2.7 %/min/m2 (AUC = 0.75) for HBSFLR. Multivariate analysis confirmed these cut-offs as variables predicting PHLF after ALPPS-2. CONCLUSION Patients presenting a KGRFLR ≤4.1%/day and a HBSFLR ≤2.7%/min/m2 are at high risk of PHLF and their second stage should be re-discussed.
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20
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Gavriilidis P, Sutcliffe RP, Roberts KJ, Pai M, Spalding D, Habib N, Jiao LR, Sodergren MH. No difference in mortality among ALPPS, two-staged hepatectomy, and portal vein embolization/ligation: A systematic review by updated traditional and network meta-analyses. Hepatobiliary Pancreat Dis Int 2020; 19:411-419. [PMID: 32753333 DOI: 10.1016/j.hbpd.2020.07.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Accepted: 07/17/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND There is an ongoing debate on the feasibility, safety, and oncological efficacy of the associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) technique. The aim of this study was to compare ALPPS, two-staged hepatectomy (TSH), and portal vein embolization (PVE)/ligation (PVL) using updated traditional meta-analysis and network meta-analysis (NMA). DATA SOURCES Electronic databases were used in a systematic literature search. Updated traditional meta-analysis and NMA were performed and compared. Mortality and major morbidity were selected as primary outcomes. RESULTS Nineteen studies including 1200 patients were selected from the pool of 436 studies. Of these patients, 315 (31%) and 702 (69%) underwent ALPPS and portal vein occlusion (PVO), respectively. Ninety-day mortality based on updated traditional meta-analysis, subgroup analysis of the randomized controlled trials (RCTs), and both Bayesian and frequentist NMA did not demonstrate significant differences between the ALPPS cohort and the PVE, PVL, and TSH cohorts. Moreover, analysis of RCTs did not demonstrate significant differences of major morbidity between the ALPPS and PVO cohorts. The ALPPS cohort demonstrated significantly more favorable outcomes in hypertrophy parameters, time to operation, definitive hepatectomy, and R0 margins rates compared with the PVO cohort. In contrast, 1-year disease-free survival was significantly higher in the PVO cohort compared to the ALPPS cohort. CONCLUSIONS This study is the first to use updated traditional meta-analysis and both Bayesian and frequentist NMA and demonstrated no significant differences in 90-day mortality between the ALPPS and other hepatic hypertrophy approaches. Furthermore, two high quality RCTs including 147 patients demonstrated no significant differences in major morbidity between the ALPPS and PVO cohorts.
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Affiliation(s)
- Paschalis Gavriilidis
- Department of Hepatopanceaticobiliary Surgery, Imperial College Healthcare NHS Trust, Hammersmith Hospital, London W12 0HS, UK.
| | - Robert P Sutcliffe
- Department of Hepato-Pancreato-Biliary and Liver Transplant Surgery, Queen Elizabeth University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TH, UK
| | - Keith J Roberts
- Department of Hepato-Pancreato-Biliary and Liver Transplant Surgery, Queen Elizabeth University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TH, UK
| | - Madhava Pai
- Department of Hepatopanceaticobiliary Surgery, Imperial College Healthcare NHS Trust, Hammersmith Hospital, London W12 0HS, UK
| | - Duncan Spalding
- Department of Hepatopanceaticobiliary Surgery, Imperial College Healthcare NHS Trust, Hammersmith Hospital, London W12 0HS, UK
| | - Nagy Habib
- Department of Hepatopanceaticobiliary Surgery, Imperial College Healthcare NHS Trust, Hammersmith Hospital, London W12 0HS, UK
| | - Long R Jiao
- Department of Hepatopanceaticobiliary Surgery, Imperial College Healthcare NHS Trust, Hammersmith Hospital, London W12 0HS, UK
| | - Mikael H Sodergren
- Department of Hepatopanceaticobiliary Surgery, Imperial College Healthcare NHS Trust, Hammersmith Hospital, London W12 0HS, UK
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21
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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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22
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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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23
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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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