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Sun HC, Zhou J, Wang Z, Liu X, Xie Q, Jia W, Zhao M, Bi X, Li G, Bai X, Ji Y, Xu L, Zhu XD, Bai D, Chen Y, Chen Y, Dai C, Guo R, Guo W, Hao C, Huang T, Huang Z, Li D, Li G, Li T, Li X, Li G, Liang X, Liu J, Liu F, Lu S, Lu Z, Lv W, Mao Y, Shao G, Shi Y, Song T, Tan G, Tang Y, Tao K, Wan C, Wang G, Wang L, Wang S, Wen T, Xing B, Xiang B, Yan S, Yang D, Yin G, Yin T, Yin Z, Yu Z, Zhang B, Zhang J, Zhang S, Zhang T, Zhang Y, Zhang Y, Zhang A, Zhao H, Zhou L, Zhang W, Zhu Z, Qin S, Shen F, Cai X, Teng G, Cai J, Chen M, Li Q, Liu L, Wang W, Liang T, Dong J, Chen X, Wang X, Zheng S, Fan J. Chinese expert consensus on conversion therapy for hepatocellular carcinoma (2021 edition). Hepatobiliary Surg Nutr 2022; 11:227-252. [PMID: 35464283 PMCID: PMC9023831 DOI: 10.21037/hbsn-21-328] [Citation(s) in RCA: 56] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 11/18/2021] [Indexed: 01/27/2023]
Abstract
Recent advances in systemic and locoregional treatments for patients with unresectable or advanced hepatocellular carcinoma (HCC) have resulted in improved response rates. This has provided an opportunity for selected patients with initially unresectable HCC to achieve adequate tumor downstaging to undergo surgical resection, a 'conversion therapy' strategy. However, conversion therapy is a new approach to the treatment of HCC and its practice and treatment protocols are still being developed. Review the evidence for conversion therapy in HCC and develop consensus statements to guide clinical practice. Evidence review: Many research centers in China have accumulated significant experience implementing HCC conversion therapy. Preliminary findings and data have shown that conversion therapy represents an important strategy to maximize the survival of selected patients with intermediate stage to advanced HCC; however, there are still many urgent clinical and scientific challenges for this therapeutic strategy and its related fields. In order to summarize and learn from past experience and review current challenges, the Chinese Expert Consensus on Conversion Therapy for Hepatocellular Carcinoma (2021 Edition) was developed based on a review of preliminary experience and clinical data from Chinese and non-Chinese studies in this field and combined with recommendations for clinical practice. Sixteen consensus statements on the implementation of conversion therapy for HCC were developed. The statements generated in this review are based on a review of clinical evidence and real clinical experience and will help guide future progress in conversion therapy for patients with HCC.
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Affiliation(s)
- Hui-Chuan Sun
- Department of Liver Surgery and Transplantation, Liver Cancer Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jian Zhou
- Department of Liver Surgery and Transplantation, Liver Cancer Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Zheng Wang
- Department of Liver Surgery and Transplantation, Liver Cancer Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Xiufeng Liu
- Department of Medical Oncology of PLA Cancer Center, Jinling Hospital, Nanjing, China
| | - Qing Xie
- Department of Infectious Disease, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Weidong Jia
- Department of Liver Surgery, The First Affiliated Hospital of USTC, Hefei, China
| | - Ming Zhao
- Minimally Invasive Interventional Division, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Xinyu Bi
- Department of Hepatobiliary Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Gong Li
- Department of Radiation Oncology, Beijing Tsinghua Changgung Hospital, Beijing, China
| | - Xueli Bai
- Department of Hepatobiliary and Pancreatic Surgery, the First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Yuan Ji
- Department of Pathology, Fudan University Shanghai Cancer Centre, Shanghai, China
| | - Li Xu
- Department of Liver Surgery, Sun Yat-sen University Cancer Centre, Guangzhou, China
| | - Xiao-Dong Zhu
- Department of Liver Surgery and Transplantation, Liver Cancer Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Dousheng Bai
- Department of Hepatobiliary Surgery, Clinical Medical College, Yangzhou University, Yangzhou, China
| | - Yajin Chen
- Department of Hepatobiliopancreatic Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Yongjun Chen
- Division of Hepatobiliary Surgery, Department of General Surgery, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Chaoliu Dai
- Department of Hepatobiliary and Splenic Surgery, Shengjing Hospital Affiliated to China Medical University, Shenyang, China
| | - Rongping Guo
- The Department of Hepatobiliary Oncology of Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Wenzhi Guo
- Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Chunyi Hao
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Sarcoma Center, Peking University Cancer Hospital and Institute, Beijing, China
| | - Tao Huang
- Department of Hepatobiliary Surgery, Affiliated Tumour Hospital of Zhengzhou University, Zhengzhou, China
| | - Zhiyong Huang
- Hepatic Surgery Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Deyu Li
- Department of Hepato-Biliary Pancreatic Surgery, Henan Provincial People's Hospital, Zhengzhou, China
| | - Gang Li
- Department of Hepatobiliary Pancreatic Surgery, Changhai Hospital, Naval Military Medical University (Second Military Medical University), Shanghai, China
| | - Tao Li
- Department of general surgery, Qilu Hospital, Shandong University, Jinan, China
| | - Xiangcheng Li
- Department of Liver Transplantation Center, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Guangming Li
- Center of General Surgery, Beijing YouAn Hospital, Capital Medical University, Beijing, China
| | - Xiao Liang
- Department of General Surgery, Zhejiang University, School of Medicine, Sir Run Run Shaw Hospital, Hangzhou, China
| | - Jingfeng Liu
- The United Innovation of Mengchao Hepatobiliary Technology Key Laboratory of Fujian Province, Mengchao Hepatobiliary Hospital of Fujian Medical University, Fuzhou, China
| | - Fubao Liu
- Division of General Surgery, First Affiliated Hospital, Anhui Medical University, Hefei, China
| | - Shichun Lu
- Department of Hepatobiliary Surgery, First Medical Center of Chinese People's Liberation Army (PLA) General Hospital, Beijing, China
| | - Zheng Lu
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Bengbu Medical College Bengbu, China
| | - Weifu Lv
- Department of Interventional Radiology, The Anhui Provincial Hospital, Hefei, China
| | - Yilei Mao
- Department of Liver Surgery, Peking Union Medical College (PUMC) Hospital, PUMC & Chinese Academy of Medical Sciences (CAMS), Beijing, China
| | - Guoliang Shao
- Department of Intervention, Zhejiang Cancer Hospital, Hangzhou, China
| | - Yinghong Shi
- Department of Liver Surgery and Transplantation, Liver Cancer Institute, Zhongshan Hospital, Fudan University, Shanghai, China
- Key Laboratory of Carcinogenesis and Cancer Invasion of Ministry of Education, Shanghai, China
| | - Tianqiang Song
- Department of Hepatobiliary Cancer, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin, Tianjin's Clinical Research Center for Cancer, Tianjin, China
| | - Guang Tan
- Department of Hepatobiliary Surgery, First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Yunqiang Tang
- Department of Hepatic-Biliary Surgery, The Affiliated Cancer Hospital of Guangzhou Medical University, Guangzhou, China
| | - Kaishan Tao
- Department of Hepatobiliary Surgery, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Chidan Wan
- Department of Hepatobiliary Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Guangyi Wang
- Department of Hepatobiliary and Pancreatic Surgery, The First Hospital of Jilin University, Changchun, China
| | - Lu Wang
- Liver Surgery Department, Shanghai Cancer Center, Fudan University, Shanghai, China
| | - Shunxiang Wang
- Department of Hepatobiliary Surgery, The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
| | - Tianfu Wen
- Department of Liver Surgery & Liver Transplantation Centre, West China Hospital of Sichuan University, Chengdu, China
| | - Baocai Xing
- Hepatopancreatobiliary Surgery Department I, Key Laboratory of Carcinogenesis and Translational Research, Ministry of Education, Peking University School of Oncology, Beijing Cancer Hospital and Institute, Beijing, China
| | - Bangde Xiang
- Hepatobiliary Surgery Department, Guangxi Liver Cancer Diagnosis and Treatment Engineering and Technology Research Center, Key Laboratory for High-Incidence Tumor Prevention and Treatment, Ministry of Education, Guangxi Medical University Cancer Hospital, Nanning, China
| | - Sheng Yan
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Dinghua Yang
- Unit of Hepatobiliary Surgery, Department of General Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Guowen Yin
- Department of Intervention, Cancer Hospital of Jiangsu, Nanjing, China
| | - Tao Yin
- Department of Hepatic & Biliary & Pancreatic Surgery, Hubei Cancer Hospital, Affiliated Hubei Cancer Hospital of Huazhong University of Science and Technology, Wuhan, China
| | - Zhenyu Yin
- Department of Hepatobiliary Surgery, Zhongshan Hospital, Xiamen University, Fujian Provincial Key Laboratory of Chronic Liver Disease and Hepatocellular Carcinoma, Xiamen, China
| | - Zhengping Yu
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Bixiang Zhang
- Hepatic Surgery Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jialin Zhang
- Department of Hepatobiliary Surgery, the First Hospital of China Medical University, Shenyang, China
| | - Shuijun Zhang
- Key Laboratory of Hepatobiliary and Pancreatic Surgery and Digestive Organ Transplantation of Henan Province, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Ti Zhang
- Department of Hepatic Surgery, Fudan University Shanghai Cancer Center, Shanghai Medical College, Fudan University, Shanghai, China
| | - Yamin Zhang
- Department of Hepatobiliary Surgery, Tianjin First Central Hospital, Tianjin, China
| | - Yubao Zhang
- Department of Hepatobiliary Pancreatic Surgery, Harbin Medical University Cancer Hospital, Harbin, China
| | - Aibin Zhang
- Department of Hepatobiliary Pancreatic Surgery, The First Affiliated Hospital of College of Medicine, Zhejiang University, Hangzhou, China
| | - Haitao Zhao
- Department of Liver Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ledu Zhou
- Department of Liver Surgery, Xiangya Hospital, Central South University, Changsha, China
| | - Wu Zhang
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Key Laboratory of Combined Multi-Organ Transplantation, Zhejiang Province, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Zhenyu Zhu
- Hepatoliliary Surgery Center, 302 Hospital of PLA, Beijing, China
| | - Shukui Qin
- Qinhuai Medical Area, Eastern Theater General Hospital of PLA China, Nanjing, China
| | - Feng Shen
- Department of Hepatic Surgery IV, the Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, Shanghai, China
| | - Xiujun Cai
- Department of General Surgery, Sir Run-Run Shaw Hospital, Zhejiang University, Hangzhou, China
| | - Gaojun Teng
- Center of Interventional Radiology and Vascular Surgery, Department of Radiology, Zhongda Hospital, Medical School, Southeast University, Nanjing, China
| | - Jianqiang Cai
- Department of Hepatobiliary Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Minshan Chen
- Department of Liver Surgery, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Qiang Li
- Department of Hepatobiliary Surgery, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin's Clinical Research Center for Cancer, Tianjin, China
| | - Lianxin Liu
- Department of Hepatobiliary Surgery, Anhui Province Key Laboratory of Hepatopancreatobiliary Surgery, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
| | - Weilin Wang
- Department of Hepatobiliary and Pancreatic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Tingbo Liang
- Department of Hepatobiliary and Pancreatic Surgery, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Jiahong Dong
- Hepatopancreatobiliary Center, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Changping, Beijing, China
| | - Xiaoping Chen
- Hepatic Surgery Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xuehao Wang
- Hepatobiliary Center, The First Affiliated Hospital of Nanjing Medical University, Key Laboratory of Liver Transplantation, Chinese Academy of Medical Sciences, NHC Key Laboratory of Living Donor Liver Transplantation (Nanjing Medical University), Nanjing, China
| | - Shusen Zheng
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, Zhejiang University, School of Medicine, Hangzhou, China
| | - Jia Fan
- Department of Liver Surgery and Transplantation, Liver Cancer Institute, Zhongshan Hospital, Fudan University, Shanghai, China
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State-of-the-art surgery for hepatocellular carcinoma. Langenbecks Arch Surg 2021; 406:2151-2162. [PMID: 34405284 DOI: 10.1007/s00423-021-02298-3] [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: 08/05/2021] [Accepted: 08/06/2021] [Indexed: 12/22/2022]
Abstract
BACKGROUND Hepatocellular carcinoma (HCC) is the most commonly diagnosed primary liver tumor with an increasing incidence worldwide. Management of patients with HCC is largely dictated by the presence of cirrhosis, disease stage, underlying liver function, and patient performance status. PURPOSE We provide an update on key aspects of surgical treatment options for patients with HCC. RESULTS & CONCLUSIONS: Liver resection and transplantation remain cornerstone treatment options for patients with early-stage disease and constitute the only potentially curative options for HCC. Selection of patients for surgical treatment should include a thorough evaluation of tumor characteristics and biology, as well as evidence-based use of various available treatment options to achieve optimal long-term outcomes for patients with HCC.
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Qin JM. Conversion therapy for primary liver cancer: Indications and selective strategies. Shijie Huaren Xiaohua Zazhi 2021; 29:501-510. [DOI: 10.11569/wcjd.v29.i10.501] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Primary liver cancer has an insidious onset and no specific symptoms at early stage. Most patients are in the middle or advanced stage when diagnosed, and only 20%-40% of patients meet the criteria for radical resection. At present, surgical resection is still the main radical treatment for primary liver cancer, but factors such as liver function decompensation, too large tumor volume, too small future liver remnant, intrahepatic multiple metastasis, tumor thrombus invading the large vessels or bile duct, and distant metastasis limit the application of surgical resection or liver transplantation. In recent years, with the advances of basic research of primary liver cancer, the development of surgical techniques and equipment, as well as the development of new molecular targeted drugs and immunotherapy drugs, a part of unresectable patients with primary liver cancer can receive conversion therapy to improve liver function, minimize tumor volume, minimize or inactivate tumor thrombus, and increase the residual liver volume. Following conversion therapy, patients with primary liver cancer can undergo surgical resection or liver transplantation, which greatly improve the therapeutic efficacy and patient survival.
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Affiliation(s)
- Jian-Min Qin
- Department of General Surgery, the Third Hospital Affiliated to Naval Military Medical University, Shanghai 201805, China
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Efficacy of the association liver partition and portal vein ligation for staged hepatectomy for the treatment of solitary huge hepatocellular carcinoma: a retrospective single-center study. World J Surg Oncol 2021; 19:95. [PMID: 33785022 PMCID: PMC8011225 DOI: 10.1186/s12957-021-02199-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Accepted: 03/17/2021] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND The feasibility of association liver partition and portal vein ligation for staged hepatectomy (ALPPS) for solitary huge hepatocellular carcinoma (HCC, maximal diameter ≥ 10 cm) remains uncertain. This study aims to evaluate the safety and the efficacy of ALPPS for patients with solitary huge HCC. METHODS Twenty patients with solitary huge HCC who received ALPPS during January 2017 and December 2019 were retrospectively analyzed. The oncological characteristics of contemporaneous patients who underwent one-stage resection and transcatheter arterial chemoembolization (TACE) were compared using propensity score matching (PSM). RESULTS All patients underwent complete two-staged ALPPS. The median future liver remnant from the ALPPS-I stage to the ALPPS-II stage increased by 64.5% (range = 22.3-221.9%) with a median interval of 18 days (range = 10-54 days). The 90-day mortality rate after the ALPPS-II stage was 5%. The 1- and 3-year overall survival (OS) rates were 70.0% and 57.4%, respectively, whereas the 1- and 3-year progression-free survival (PFS) rates were 60.0% and 43.0%, respectively. In the one-to-one PSM analysis, the long-term survival of patients who received ALPPS was significantly better than those who received TACE (OS, P = 0.007; PFS, P = 0.011) but comparable with those who underwent one-stage resection (OS, P = 0.463; PFS, P = 0.786). CONCLUSION The surgical outcomes of ALPPS were superior to those of TACE and similar to those of one-stage resection. ALPPS is a safe and effective treatment strategy for patients with unresectable solitary huge HCC.
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Chan KS, Low JK, Shelat VG. Associated liver partition and portal vein ligation for staged hepatectomy: a review. Transl Gastroenterol Hepatol 2020; 5:37. [PMID: 32632388 PMCID: PMC7063517 DOI: 10.21037/tgh.2019.12.01] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Accepted: 11/30/2019] [Indexed: 02/05/2023] Open
Abstract
Outcomes of liver resection have improved with advances in surgical techniques, improvements in critical care and expansion of resectability criteria. However, morbidity and mortality following liver resection continue to plague surgeons. Post-hepatectomy liver failure (PHLF) due to inadequate future liver remnant (FLR) is an important cause of morbidity and mortality following liver resection. Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) is a novel two-staged procedure described in 2012, which aims to induce rapid hypertrophy of the FLR unlike conventional two-stage hepatectomy, which require a longer time for FLR hypertrophy. Careful patient selection and modifications in surgical technique has improved morbidity and mortality rates in ALPPS. Colorectal liver metastases (CRLM) confers the best outcomes post-ALPPS. Patients <60 years old and low-grade fibrosis with underlying hepatocellular carcinoma (HCC) are also eligible for ALPPS. Evidence for other types of cancers is less promising. Current studies, though limited, demonstrate that ALPPS has comparable oncological outcomes with conventional two-stage hepatectomy. Modifications such as partial-ALPPS and mini-ALPPS have shown improved morbidity and mortality compared to classic ALPPS. ALPPS may be superior to conventional two-stage hepatectomy in carefully selected groups of patients and has a promising outlook in liver surgery.
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Affiliation(s)
- Kai Siang Chan
- Department of Medicine, Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | - Jee Keem Low
- Department of General Surgery, Tan Tock Seng Hospital, Singapore
| | - Vishal G. Shelat
- Department of General Surgery, Tan Tock Seng Hospital, Singapore
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Au KP, Chan ACY. Current status of associating liver partition with portal vein ligation for staged hepatectomy: Comparison with two-stage hepatectomy and strategies for better outcomes. World J Gastroenterol 2019; 25:6373-6385. [PMID: 31798275 PMCID: PMC6881507 DOI: 10.3748/wjg.v25.i43.6373] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2019] [Revised: 07/31/2019] [Accepted: 08/07/2019] [Indexed: 02/06/2023] Open
Abstract
Since its introduction in 2012, associating liver partition with portal vein ligation for staged hepatectomy (ALPPS) has significantly expanded the pool of candidates for liver resection. It offers patients with insufficient liver function a chance of a cure. ALPPS is most controversial when its high morbidity and mortality is concerned. Operative mortality is usually a result of post-hepatectomy liver failure and can be minimized with careful patient selection. Elderly patients have limited reserve for tolerating the demanding operation. Patients with colorectal liver metastasis have normal liver and are ideal candidates. ALPPS for cholangiocarcinoma is technically challenging and associated with fair outcomes. Patients with hepatocellular carcinoma have chronic liver disease and limited parenchymal hypertrophy. However, in selected patients with limited hepatic fibrosis satisfactory outcomes have been produced. During the inter-stage period, serum bilirubin and creatinine level and presence of surgical complication predict mortality after stage II. Kinetic growth rate and hepatobiliary scintigraphy also guide the decision whether to postpone or omit stage II surgery. The outcomes of ALPPS have been improved by a combination of technical modifications. In patients with challenging anatomy, partial ALPPS potentially reduces morbidity, but remnant hypertrophy may compare unfavorably to a complete split. When compared to conventional two-stage hepatectomy with portal vein embolization or portal vein ligation, ALPPS offers a higher resection rate for colorectal liver metastasis without increased morbidity or mortality. While ALPPS has obvious theoretical oncological advantages over two-stage hepatectomy, the long-term outcomes are yet to be determined.
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Affiliation(s)
- Kin Pan Au
- Department of Surgery, Queen Mary Hospital, Hong Kong, China
| | - Albert Chi Yan Chan
- Department of Surgery and State Key Laboratory for Liver Research, The University of Hong Kong, Hong Kong, China
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Tustumi F, Ernani L, Coelho FF, Bernardo WM, Junior SS, Kruger JAP, Fonseca GM, Jeismann VB, Cecconello I, Herman P. Preoperative strategies to improve resectability for hepatocellular carcinoma: a systematic review and meta-analysis. HPB (Oxford) 2018; 20:1109-1118. [PMID: 30057123 DOI: 10.1016/j.hpb.2018.06.1798] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Revised: 06/14/2018] [Accepted: 06/16/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND Preoperative strategies to increase the future liver remnant are useful methods to improve resectability rates for patients with hepatocellular carcinoma (HCC). The aim of this study was to perform a systematic review and meta-analysis of the main strategies used for this purpose. METHODS A systematic review was performed in PubMed, EMBASE, Cochrane and Scielo/LILACS. The procedures included for analysis were portal vein embolization or ligation (PVE/PVL), sequential transarterial embolization and PVE (TACE + PVE), radioembolization (RE) and associated liver partition and portal vein ligation for staged hepatectomy (ALPPS). Perioperative morbidity and mortality, post-hepatectomy liver failure (PHLF), and survival rates were evaluated. RESULTS A total of 46 studies were included in the systematic review (1284 patients). Resection rate was higher in TACE + PVE (90%; N = 315) when compared to PVE/PVL (75%; N = 254; P = <0.001) and similar to ALPPS (84%; N = 43; P = 0.374) and RE (100%; N = 28; P = 0.14). ALPPS was associated with higher PHLF and perioperative mortality rates when compared to PVE/PVL and TACE + PVE. ALPPS and RE showed higher risk of major complications than PVE/PVL and TACE + PVE. CONCLUSION Preoperative strategies to increase liver volume are effective in achieving resectability of HCC. TACE + PVE is as safe as PVL/PVE providing higher OS. ALPPS is associated with a higher risk of PHLF, major complications, and mortality. RE despite the small experience seems to present similar resection rate and OS as TACE + PVE with higher rate of major complications.
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Affiliation(s)
- Francisco Tustumi
- Department of Gastroenterology, Digestive Surgery Division, Sao Paulo School of Medicine, Brazil.
| | - Lucas Ernani
- Department of Gastroenterology, Digestive Surgery Division, Sao Paulo School of Medicine, Brazil
| | - Fabricio F Coelho
- Department of Gastroenterology, Digestive Surgery Division, Sao Paulo School of Medicine, Brazil
| | - Wanderley M Bernardo
- Department of Gastroenterology, Digestive Surgery Division, Sao Paulo School of Medicine, Brazil
| | - Sérgio S Junior
- Department of Gastroenterology, Digestive Surgery Division, Sao Paulo School of Medicine, Brazil
| | - Jaime A P Kruger
- Department of Gastroenterology, Digestive Surgery Division, Sao Paulo School of Medicine, Brazil
| | - Gilton M Fonseca
- Department of Gastroenterology, Digestive Surgery Division, Sao Paulo School of Medicine, Brazil
| | - Vagner B Jeismann
- Department of Gastroenterology, Digestive Surgery Division, Sao Paulo School of Medicine, Brazil
| | - Ivan Cecconello
- Department of Gastroenterology, Digestive Surgery Division, Sao Paulo School of Medicine, Brazil
| | - Paulo Herman
- Department of Gastroenterology, Digestive Surgery Division, Sao Paulo School of Medicine, Brazil
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Fernandes EDSM, de Mello FPT, Andrade RO, Girao CL, Pimentel LS, Cesar C, Sousa CC, Brito-Azevedo A, Basto ST, Torres OJM. Living Donor Liver Transplant as Rescue Surgery for a Patient with Hepatocellular Carcinoma Who Underwent Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy (ALPPS). AMERICAN JOURNAL OF CASE REPORTS 2018; 19:1338-1341. [PMID: 30409960 PMCID: PMC6238545 DOI: 10.12659/ajcr.911694] [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] [Indexed: 11/09/2022]
Abstract
BACKGROUND The associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) is an important tool to induce fast liver hypertrophy. The degree of hepatic fibrosis/cirrhosis in patients with HCC negatively impacts their health, and the risk of liver failure is always present. In these cases, liver transplantation may be necessary as a rescue procedure. We present the case of a patient with HCC who underwent ALPPS and developed liver failure. A living donor liver transplant was performed as a rescue procedure. CASE REPORT A 49-year-old man with chronic hepatitis B without cirrhosis underwent computed tomography, which revealed an expansive lesion in the right lobe of his liver that was diagnosed as hepatocellular carcinoma. Liver resection was indicated and liver cirrhosis was observed with high portal pressure after transection. The treatment strategy was switched from right hepatectomy to ALPPS. The patient developed severe liver dysfunction and liver transplantation was indicated. His postoperative course was uneventful and 3 months after the procedure the patient was without complications. CONCLUSIONS Living donor liver transplantation may be necessary as a rescue procedure for patients who underwent ALPPS and develop liver dysfunction.
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Affiliation(s)
- Eduardo de Souza Martins Fernandes
- Department of Gastrointestinal and Liver Transplant Surgery, Rio de Janeiro Adventista Hospital, Rio de Janeiro, RJ, Brazil.,Department of Surgery, Faculty of Medicine, Federal University of Rio de Janeiro, Rio de Janeiro, RJ, Brazil
| | | | - Ronaldo Oliveira Andrade
- Department of Gastrointestinal and Liver Transplant Surgery, Rio de Janeiro Adventista Hospital, Rio de Janeiro, RJ, Brazil
| | - Camila Liberato Girao
- Department of Gastrointestinal and Liver Transplant Surgery, Rio de Janeiro Adventista Hospital, Rio de Janeiro, RJ, Brazil
| | - Leandro Savattone Pimentel
- Department of Gastrointestinal and Liver Transplant Surgery, Rio de Janeiro Adventista Hospital, Rio de Janeiro, RJ, Brazil
| | - Camilla Cesar
- Department of Gastrointestinal and Liver Transplant Surgery, Rio de Janeiro Adventista Hospital, Rio de Janeiro, RJ, Brazil
| | - Claudia Cristina Sousa
- Department of Gastrointestinal and Liver Transplant Surgery, Rio de Janeiro Adventista Hospital, Rio de Janeiro, RJ, Brazil
| | - Anderson Brito-Azevedo
- Department of Gastrointestinal and Liver Transplant Surgery, Rio de Janeiro Adventista Hospital, Rio de Janeiro, RJ, Brazil
| | - Samanta Teixeira Basto
- Department of Gastrointestinal and Liver Transplant Surgery, Rio de Janeiro Adventista Hospital, Rio de Janeiro, RJ, Brazil
| | - Orlando Jorge Martins Torres
- Department of Gastrointestinal and Liver Transplant Surgery, University Hospital, Federal University of Maranhão, São Luis, MA, Brazil
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Papa S, Bubici C. Feeding the Hedgehog: A new meaning for JNK signalling in liver regeneration. J Hepatol 2018; 69:572-574. [PMID: 29870764 DOI: 10.1016/j.jhep.2018.05.026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Accepted: 05/24/2018] [Indexed: 12/13/2022]
Affiliation(s)
- Salvatore Papa
- Cell Signaling and Cancer Laboratory, Leeds Institute of Cancer and Pathology, Faculty of Medicine and Health, University of Leeds, St James' University Hospital, Beckett Street, Leeds LS9 7TF, United Kingdom.
| | - Concetta Bubici
- College of Health and Life Sciences, Department of Life Sciences, Institute of Environment, Health and Societies, Division of Biosciences, Brunel University London, Uxbridge UB8 3PH, United Kingdom.
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Braunwarth E, Stättner S, Fodor M, Cardini B, Resch T, Oberhuber R, Putzer D, Bale R, Maglione M, Margreiter C, Schneeberger S, Öfner D, Primavesi F. Surgical techniques and strategies for the treatment of primary liver tumours: hepatocellular and cholangiocellular carcinoma. Eur Surg 2018; 50:100-112. [PMID: 29875798 PMCID: PMC5968076 DOI: 10.1007/s10353-018-0537-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2018] [Accepted: 05/02/2018] [Indexed: 12/14/2022]
Abstract
Background Owing to remarkable improvements of surgical techniques and associated specialities, liver surgery has become the standard of care for hepatocellular carcinoma and cholangiocarcinoma. Although applied with much greater safety, hepatic resections for primary liver tumours remain challenging and need to be integrated in a complex multidisciplinary treatment approach. Methods This literature review gives an update on the recent developments regarding basics of open and laparoscopic liver surgery and surgical strategies for primary liver tumours. Results Single-centre reports and multicentre registries mainly from Asia and Europe dominate the surgical literature on primary liver tumours, but the numbers of randomized trials are slowly increasing. Perioperative outcomes of open liver surgery for hepatocellular and cholangiocellular carcinoma have vastly improved over the last decades, accompanied by some progress in terms of oncological outcome. The laparoscopic approach is increasingly being applied in many centres, even for patients with underlying liver disease, and may result in decreased morbidity. Liver transplantation represents a cornerstone in the treatment of early hepatocellular carcinoma and is indispensable to achieve long-term survival. In contrast, resection remains the gold standard for cholangiocarcinoma in most countries, but interventional techniques are on the rise. Conclusion Liver surgery for primary tumours is complex, with a need for high expertise in a multidisciplinary team to achieve acceptable outcomes. Technical developments and clinical stratification tools have optimized individual care, but further improvements in oncological survival will likely require enhanced pre- and postoperative systemic and local treatment options.
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Affiliation(s)
- Eva Braunwarth
- Department of Visceral, Transplantation and Thoracic Surgery, Medical University of Innsbruck, Anichstraße 35, 6020 Innsbruck, Austria
| | - Stefan Stättner
- Department of Visceral, Transplantation and Thoracic Surgery, Medical University of Innsbruck, Anichstraße 35, 6020 Innsbruck, Austria
| | - Margot Fodor
- Department of Visceral, Transplantation and Thoracic Surgery, Medical University of Innsbruck, Anichstraße 35, 6020 Innsbruck, Austria
| | - Benno Cardini
- Department of Visceral, Transplantation and Thoracic Surgery, Medical University of Innsbruck, Anichstraße 35, 6020 Innsbruck, Austria
| | - Thomas Resch
- Department of Visceral, Transplantation and Thoracic Surgery, Medical University of Innsbruck, Anichstraße 35, 6020 Innsbruck, Austria
| | - Rupert Oberhuber
- Department of Visceral, Transplantation and Thoracic Surgery, Medical University of Innsbruck, Anichstraße 35, 6020 Innsbruck, Austria
| | - Daniel Putzer
- Department of Radiology, Medical University of Innsbruck, Anichstraße 35, 6020 Innsbruck, Austria
| | - Reto Bale
- Department of Radiology, Medical University of Innsbruck, Anichstraße 35, 6020 Innsbruck, Austria
| | - Manuel Maglione
- Department of Visceral, Transplantation and Thoracic Surgery, Medical University of Innsbruck, Anichstraße 35, 6020 Innsbruck, Austria
| | - Christian Margreiter
- Department of Visceral, Transplantation and Thoracic Surgery, Medical University of Innsbruck, Anichstraße 35, 6020 Innsbruck, Austria
| | - Stefan Schneeberger
- Department of Visceral, Transplantation and Thoracic Surgery, Medical University of Innsbruck, Anichstraße 35, 6020 Innsbruck, Austria
| | - Dietmar Öfner
- Department of Visceral, Transplantation and Thoracic Surgery, Medical University of Innsbruck, Anichstraße 35, 6020 Innsbruck, Austria
| | - Florian Primavesi
- Department of Visceral, Transplantation and Thoracic Surgery, Medical University of Innsbruck, Anichstraße 35, 6020 Innsbruck, Austria
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Sheng RF, Yang L, Jin KP, Wang HQ, Liu H, Ji Y, Fu CX, Zeng MS. Assessment of liver regeneration after associating liver partition and portal vein ligation for staged hepatectomy: a comparative study with portal vein ligation. HPB (Oxford) 2018; 20:305-312. [PMID: 29046260 DOI: 10.1016/j.hpb.2017.09.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Revised: 06/02/2017] [Accepted: 09/17/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND To investigate the diagnostic value of diffusion kurtosis imaging (DKI) and diffusion-weighted imaging (DWI) in assessing liver regeneration after associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) compared with portal vein ligation (PVL). METHODS Thirty rats were divided into the ALPPS, PVL, and control groups. DKI and DWI were performed before and 7 days after surgery. Corrected apparent diffusion (D), kurtosis (K) and apparent diffusion coefficient (ADC) were calculated and compared, radiologic-pathologic correlations were evaluated. RESULTS The volume of the right median lobe increased significantly after ALPPS. There were larger cellular diameters after ALPPS and PVL (P = 0.0003). The proliferative indexes of Ki-67 and hepatocyte growth factor were higher after ALPPS (P = 0.0024/0.0433). D, K and ADC values differed between the groups (P = 0.021/0.0015/0.0008). A significant correlation existed between D and the hepatocyte size (r = -0.523), no correlations existed in ADC and K (P = 0.159/0.111). The proliferative indexes showed moderate negative correlations with ADC (r = -0.484/-0.537) and no correlations with D and K (P = 0.100-0.877). DISCUSSION Liver regeneration after ALPPS was effective and superior to PVL. DKI, especially the D map, may provide added value in evaluating the microstructure of liver regeneration after ALPPS, but this model alone may perform no better than the standard monoexponential model of DWI.
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Affiliation(s)
- Ruo-Fan Sheng
- Department of Radiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Medical Imaging, Shanghai, China
| | - Li Yang
- Department of Radiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Medical Imaging, Shanghai, China
| | - Kai-Pu Jin
- Department of Radiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Medical Imaging, Shanghai, China
| | - He-Qing Wang
- Department of Radiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Medical Imaging, Shanghai, China
| | - Hao Liu
- Department of Radiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Medical Imaging, Shanghai, China
| | - Yuan Ji
- Department of Pathology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Cai-Xia Fu
- MR Collaboration NEA, Siemens Ltd., China
| | - Meng-Su Zeng
- Department of Radiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Medical Imaging, Shanghai, China.
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Lau WY, Lai EC. Modifications of ALPPS - from complex to more complex or from complex to less complex operations. Hepatobiliary Pancreat Dis Int 2017; 16:346-352. [PMID: 28823363 DOI: 10.1016/s1499-3872(17)60034-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Accepted: 05/12/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) has recently been developed to induce rapid liver hypertrophy to reduce the chance of post-hepatectomy liver failure in patients with borderline or insufficient future liver remnant. ALPPS is still in an early developmental stage and its techniques have not been standardized. This study aimed to review the technical modifications of the conventional ALPPS procedure. DATA SOURCES Studies were identified by searching MEDLINE and PubMed for articles published from January 2007 to December 2016 using the keywords "associating liver partition and portal vein ligation for staged hepatectomy" and "ALPPS". Additional articles were identified by a manual search of references from key articles. RESULTS There have been a lot of modifications of the conventional ALPPS. These are classified as: (1) modifications aiming to improve surgical results; (2) modifications aiming to expand surgical indications; (3) salvage ALPPS; (4) ALPPS using the minimally invasive approach. Some of these modifications have made the conventional ALPPS procedure to become even more complex, although there have also been other attempts to make the procedure less complex. The results of most of these modifications have been reported in small case series or case reports. We need better well-designed studies to establish the true roles of these modifications. However, it is interesting to see how this conventional ALPPS procedure has evolved since its introduction. CONCLUSIONS There is a trend for the use of minimally invasive procedure in the phase 1 or 2 of the conventional ALPPS procedure. Some of these modifications have expanded the use of ALPPS in patients who have been considered to have unresectable liver tumors. The long-term oncological outcomes of these modifications are still unknown.
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Affiliation(s)
- Wan Yee Lau
- Faculty of Medicine, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong SAR, China.
| | - Eric Ch Lai
- Faculty of Medicine, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong SAR, China; Department of Surgery, Pamela Youde Nethersole Eastern Hospital, Hong Kong SAR, China
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Sheng RF, Wang HQ, Jin KP, Yang L, Liu H, Ji Y, Fu CX, Zeng MS. Histogram analyses of diffusion kurtosis indices and apparent diffusion coefficient in assessing liver regeneration after ALPPS and a comparative study with portal vein ligation. J Magn Reson Imaging 2017. [PMID: 28640476 DOI: 10.1002/jmri.25793] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Affiliation(s)
- Ruo-fan Sheng
- Department of Radiology, Zhongshan Hospital; Fudan University; Shanghai Institute of Medical Imaging; Shanghai P.R. China
| | - He-qing Wang
- Department of Radiology, Zhongshan Hospital; Fudan University; Shanghai Institute of Medical Imaging; Shanghai P.R. China
| | - Kai-pu Jin
- Department of Radiology, Zhongshan Hospital; Fudan University; Shanghai Institute of Medical Imaging; Shanghai P.R. China
| | - Li Yang
- Department of Radiology, Zhongshan Hospital; Fudan University; Shanghai Institute of Medical Imaging; Shanghai P.R. China
| | - Hao Liu
- Department of Radiology, Zhongshan Hospital; Fudan University; Shanghai Institute of Medical Imaging; Shanghai P.R. China
| | - Yuan Ji
- Department of Pathology, Zhongshan Hospital; Fudan University; Shanghai P.R. China
| | | | - Meng-su Zeng
- Department of Radiology, Zhongshan Hospital; Fudan University; Shanghai Institute of Medical Imaging; Shanghai P.R. China
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Levi Sandri GB, Vennarecci G, Lepiane P, Ettorre GM. Associating liver partition and portal vein ligation for bleeding hepatocellular carcinoma in HBV cirrhosis: a safety strategy. Transl Gastroenterol Hepatol 2017; 2:20. [PMID: 28447055 DOI: 10.21037/tgh.2017.03.08] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2017] [Accepted: 02/13/2017] [Indexed: 11/06/2022] Open
Abstract
The incidence of hepatocellular carcinoma (HCC) spontaneous tumor rupture varies between 3% and 26%. For resectable HCC ruptures, emergency hepatectomy or staged hepatectomy after transcatheter arterial embolization (TAE) are life-saving procedures, and efficient therapeutic methods. We report a multimodal therapy including TAE, associating liver partition and portal vein ligation (ALPPS) and immunoglobuline infusion for a huge bleeding HCC with portal vein tumor thrombosis (PVTT) in hepatitis B virus (HBV) cirrhosis. ALPPS first step began with an abdominal toilette due to the massive hemoperitoneum and a portal vein incision at the bifurcation of the right and left portal veins was performed. A freely floating left part of the thrombus was extracted from the left portal vein in order to restore the left portal vein. The right portal vein with complete thrombosis was closed. Liver partition was then performed. The second step was performed without complications. A HCC Edmondson grade 4 (pT3b) and a cirrhotic liver parenchyma were described. Postoperative ascites decompensation was treated and patient was discharged in postoperative day 21. The reported triple strategy allowed us to prolong patient live. A multimodal therapy including TAE, ALPPS and immunoglobuline is a good option for a life treatment in case of huge bleeding hepatocellular carcinoma with PVTT in HBV cirrhosis.
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Affiliation(s)
| | - Giovanni Vennarecci
- Division of General Surgery and Liver Transplantation, S. Camillo Hospital, Rome, Lazio, Italy
| | - Pasquale Lepiane
- Division of General Surgery and Liver Transplantation, S. Camillo Hospital, Rome, Lazio, Italy
| | - Giuseppe Maria Ettorre
- Division of General Surgery and Liver Transplantation, S. Camillo Hospital, Rome, Lazio, Italy
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Wang Q, Yan J, Feng X, Chen G, Xia F, Li X, Ma K, Bie P. Safety and efficacy of radiofrequency-assisted ALPPS (RALPPS) in patients with cirrhosis-related hepatocellular carcinoma. Int J Hyperthermia 2017; 33:846-852. [PMID: 28540784 DOI: 10.1080/02656736.2017.1303752] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND AND AIMS Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) has high morbidity and mortality. In this study, the safety and efficacy of a modification of ALPPS (radiofrequency-assisted ALPPS, RALPPS) were assessed in patients with hepatocellular carcinoma (HCC). MATERIALS AND METHODS Patients who were diagnosed with HCC and were considered to have an insufficient future liver remnant (FLR) were enrolled. In stage I, a radiofrequency ablation (RFA) device was used to cauterise along the planned transection plane to form a coagulum avascular area. When the FLR reached above 40%, hepatectomy was performed in stage II along the coagulum area established previously. After two stages, operative morbidity, mortality, per cent increase in FLR, operative time and blood loss were evaluated. RESULTS Between July 2014 and September 2015, 10 patients with HCC (9 with hepatitis-related cirrhosis) were treated with the RALPPS procedure. The incidence of severe complications (Clavien-Dindo ≥ IIIb) was 20% (2/10). One patient died. No biliary leakage, intraperitoneal infection or post-hepatectomy liver failure (PHLF) occurred after both stages. The median FLR before stage I was 31% (364 ml). This increased to 47% (632 ml) before stage II after a median interval of 28 days. The median percentage increase in FLR was 53% (210 ml). Additionally, the median operative time during the first and second stages was 214 and 281 min, respectively. The corresponding median blood loss was 200 and 550 ml, respectively. CONCLUSIONS RALPPS has a potential advantage in eliminating serious complications of biliary leakage and PHLF associated with classic ALPPS. On the basis of rigorous patient selection criteria, RALPPS may achieve the same effect of promoting significant growth of the FLR in patients with cirrhosis-related HCC and insufficient FLR volume, albeit at the cost of a longer interval time.
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Affiliation(s)
- Qiang Wang
- a Institute of Hepatobiliary Surgery, Southwest Hospital , Third Military Medical University , Chongqing , P.R. China
| | - Jun Yan
- a Institute of Hepatobiliary Surgery, Southwest Hospital , Third Military Medical University , Chongqing , P.R. China
| | - Xiaobin Feng
- a Institute of Hepatobiliary Surgery, Southwest Hospital , Third Military Medical University , Chongqing , P.R. China
| | - Geng Chen
- a Institute of Hepatobiliary Surgery, Southwest Hospital , Third Military Medical University , Chongqing , P.R. China
| | - Feng Xia
- a Institute of Hepatobiliary Surgery, Southwest Hospital , Third Military Medical University , Chongqing , P.R. China
| | - Xiaowu Li
- a Institute of Hepatobiliary Surgery, Southwest Hospital , Third Military Medical University , Chongqing , P.R. China
| | - Kuansheng Ma
- a Institute of Hepatobiliary Surgery, Southwest Hospital , Third Military Medical University , Chongqing , P.R. China
| | - Ping Bie
- a Institute of Hepatobiliary Surgery, Southwest Hospital , Third Military Medical University , Chongqing , P.R. China
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Lau WY, Lai EC, Lau SH. Associating liver partition and portal vein ligation for staged hepatectomy: the current role and development. Hepatobiliary Pancreat Dis Int 2017; 16:17-26. [PMID: 28119254 DOI: 10.1016/s1499-3872(16)60174-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) has recently been developed to induce rapid liver hypertrophy and reduce post-hepatectomy liver failure in patients with insufficient future liver remnant (FLR). ALPPS is still considered to be in an early developmental phase because surgical indications and techniques have not been standardized. This article aimed to review the current role and future developments of ALPPS. DATA SOURCES Studies were identified by searching MEDLINE and PubMed for articles from January 2007 to October 2016 using the keywords "associating liver partition and portal vein ligation for staged hepatectomy" and "ALPPS". Additional papers were identified by a manual search of references from key articles. RESULTS ALPPS induces more hypertrophy of the FLR in less time than portal vein embolization or portal vein ligation. The benefits of ALPPS include rapid hypertrophy 47%-110% of the liver over a median of 6-16.4 days, and 95%-100% completion rate of the second stage of ALPPS. The main criticisms of ALPPS are centered on its high morbidity and mortality rates. Morbidity rates after ALPPS have been reported to be 15.3%-100%, with ≥ the Clavien-Dindo grade III morbidity of 13.6%-44%. Mortality rates have been reported to be 0%-29%. The important questions to ask even if oncologic long-term results are acceptable are: whether the gain in quality and quantity of life can be off balance by the substantial risks of morbidity and mortality, and whether stimulation of rapid liver hypertrophy also accelerates rapid tumor progression and spread. Up till now, the documentations of the ALPPS procedure come mainly from case series, and most of these series include heterogeneous groups of malignancies. The numbers are also too small to separately evaluate survival for different tumor etiologies. CONCLUSIONS Currently, knowledge on ALPPS is limited, and prospective randomized studies are lacking. From the reported preliminary results, safety of the ALPPS procedure remains questionable. ALPPS should only be used in experienced, high-volume hepatobiliary centers.
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Affiliation(s)
- Wan Yee Lau
- Faculty of Medicine, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong, China.
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Levi Sandri GB, de Werra E, Mascianà G, Colasanti M, Santoro R, D'Andrea V, Ettorre GM. Laparoscopic and robotic approach for hepatocellular carcinoma-state of the art. Hepatobiliary Surg Nutr 2016; 5:478-484. [PMID: 28124002 DOI: 10.21037/hbsn.2016.05.05] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Hepatocellular carcinoma (HCC) is the sixth most common malignant tumor worldwide and the most common primary liver cancer, in over 80% of cases HCC grown on a cirrhotic liver. Laparoscopic liver resection (LLR) is now worldwide accepted considering the excellent results shown. Minimally invasive surgical approach for HCC is increasing continuously and in specialized centers seems to become the first-line approach for those patients. The aim of this review presents and discusses state of the art in the laparoscopic and robotic surgical treatment of HCC. An electronic search was performed to identify all studies dealing with HCC resected with laparoscopy or robotic approach. Indications for laparoscopic resection, robotic assisted and totally robotic resection of HCC will be doubtless increased in future years. LLR and robotic approach for HCC is safe and feasible.
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Affiliation(s)
- Giovanni Battista Levi Sandri
- Division of General Surgery and Liver Transplantation, S. Camillo Hospital, Rome, Lazio, Italy;; Department of Surgical Sciences, Sapienza University of Rome, Rome, Italy
| | - Edoardo de Werra
- Division of General Surgery and Liver Transplantation, S. Camillo Hospital, Rome, Lazio, Italy
| | - Gianluca Mascianà
- Division of General Surgery and Liver Transplantation, S. Camillo Hospital, Rome, Lazio, Italy
| | - Marco Colasanti
- Division of General Surgery and Liver Transplantation, S. Camillo Hospital, Rome, Lazio, Italy
| | - Roberto Santoro
- Division of General Surgery and Liver Transplantation, S. Camillo Hospital, Rome, Lazio, Italy
| | - Vito D'Andrea
- Department of Surgical Sciences, Sapienza University of Rome, Rome, Italy
| | - Giuseppe Maria Ettorre
- Division of General Surgery and Liver Transplantation, S. Camillo Hospital, Rome, Lazio, Italy
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Chen XB, Zheng XB, Cai ZX, Lin XJ, Xu MQ. MicroRNA-203 promotes liver regeneration after partial hepatectomy in cirrhotic rats. J Surg Res 2016; 211:53-63. [PMID: 28501131 DOI: 10.1016/j.jss.2016.11.043] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Revised: 11/06/2016] [Accepted: 11/23/2016] [Indexed: 02/05/2023]
Abstract
BACKGROUND Liver resection or partial hepatectomy (PH) is still the most commonly used therapeutic option for hepatocellular carcinoma (HCC) at present. However, the impaired regenerative ability induced by the accompanied liver cirrhosis is an important risk factor of posthepatectomy liver failure, and posthepatectomy liver failure is a feared complication that accounts for up to 75% of mortality after extensive liver resection. MicroRNA(miR)-203 is a tumor suppressor of HCC and may act as a positive intermediary in A20-enhanced interleukin (IL-6)/signal transducer and activator of transcription 3 (STAT3) pro-proliferative signals, which may promote liver regeneration after PH. However, its direct pro-proliferative effect on cirrhotic liver after hepatectomy is unknown. MATERIALS AND METHODS Liver cirrhosis was induced by intraperitoneal injection of 50% CCl4-olive oil solution in adult male Wistar rat. Rats with liver cirrhosis received portal vein injection of physiological saline, miR-203 lentivirus, or control empty lentivirus, and then 70% PH was performed under ether anesthesia 7 d later. Liver samples were harvested at 0, 24, 36, and 72 h after 70% PH. Hepatic expressions of cyclin D1 and Ki67 were checked to evaluate the liver regenerative ability. Hepatic expressions of IL-6, suppressor of cytokine signaling 3 (SOCS3), and phospho-STAT3 were also tested to clarify the mechanisms of miR-203 in liver regeneration. RESULTS The regeneration of miR-203 overexpression cirrhotic liver after 70% PH was enhanced and peaked at 24 and 36 h after 70% PH. The cyclin D1-positive liver cells/high-power field (HPF) in miR-203 overexpression liver markedly increased at 24 and 36 h after 70% PH compared with 0-h samples. When comparing with the control groups, cyclin D1-positive liver cells/HPF in miR-203 overexpression liver were also significantly increased at 24 and 36 h after 70% PH. A similar result of the Ki67-positive liver cells/HPF was achieved at 36 h after 70% PH. The hepatic expression of IL-6 showed a rising tendency after 70% PH, and the levels of IL-6 are significantly higher in miR-203 overexpression livers. Hepatic expression of SOCS3 was negatively expressed with hepatic miR-203 expression level, and the reduced expression of SOCS3 facilitated the phosphorylation of STAT3. CONCLUSIONS By targeting SOCS3 and then enhancing proliferating IL-6/STAT3 signaling pathway, hepatic overexpression of miR-203 can facilitate the initiation of liver regeneration and enhance the potency of liver regeneration after 70% PH in cirrhotic rat. Together with the tumor suppressive effect on HCC, miR-203 would be an ideal candidate for promoting liver regeneration in HCC patients undergoing liver resection without the risk of tumorigenesis or cancer recurrence.
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Affiliation(s)
- Xiao-Bo Chen
- Department of Liver Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Xiao-Bo Zheng
- Department of Liver Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Zhen-Xing Cai
- Department of Liver Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Xian-Jian Lin
- Department of Liver Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Ming-Qing Xu
- Department of Liver Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China.
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Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) in colorectal liver metastasis: the radiologist's perspective. Abdom Radiol (NY) 2016; 41:2150-2160. [PMID: 27377899 DOI: 10.1007/s00261-016-0832-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE Hepatic resection is the only potentially curative treatment for patients with colorectal liver metastasis (CRLM). Many multidisciplinary approaches, including the associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) procedure, have been proposed to increase the resectability rate in these patients. ALPPS is the most recently described staged liver resection technique, representing an advantageous strategy to induce a rapid and marked increase in the future liver remnant (FLR) volume. The aim of this article is to describe the radiological evaluation of this procedure and its variation. METHODS This retrospective study included 9 patients with CRLM who underwent the ALPPS procedure. Abdominal imaging studies were reviewed, with an emphasis on a rational radiological approach. The number of liver metastases, the FLR volume (pre- and postportal vein ligation), anatomical variations, potential pitfalls related to disease progression, and postoperative complications were evaluated. RESULTS The types of hepatic resection included 4 classical ALPPS cases, 3 right ALPPS variations, and 2 left ALPPS variations. The mean FLR volume calculated in the initial evaluation was 453 mL (213-790 mL). Following the first surgery, the mean FLR volume increased to 634 mL (410-957 mL), which indicated a mean volume increase of 181.1 mL (95% CI 149.7-212.5 mL; p < 0.001) and a mean absolute volume increase of 48% (19%-88%). CONCLUSION The ALPPS procedure is an emerging form of two-stage hepatectomy. In this context, radiologists should provide crucial preoperative and perioperative information that may change surgical planning and contribute to an improvement in the oncologic outcome.
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Vennarecci G, Grazi GL, Sperduti I, Busi Rizzi E, Felli E, Antonini M, D'Offizi G, Ettorre GM. ALPPS for primary and secondary liver tumors. Int J Surg 2016; 30:38-44. [DOI: 10.1016/j.ijsu.2016.04.031] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Revised: 03/24/2016] [Accepted: 04/05/2016] [Indexed: 12/16/2022]
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Papamichail M, Pizanias M, Yip V, Prassas E, Prachalias A, Quaglia A, Peddu P, Heaton N, Srinivasan P. Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) procedure for hepatocellular carcinoma with chronic liver disease: a case report and review of literature. KOREAN JOURNAL OF HEPATO-BILIARY-PANCREATIC SURGERY 2016; 20:75-80. [PMID: 27212995 PMCID: PMC4874049 DOI: 10.14701/kjhbps.2016.20.2.75] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/07/2015] [Revised: 02/10/2016] [Accepted: 02/18/2016] [Indexed: 12/29/2022]
Abstract
The incidence of complications after liver resection is closely related to functional future liver remnant (FLR). The standard approach to augment FLR is surgical or radiological occlusion of the artery or portal vein on the tumor side. Associated liver partition and portal vein ligation for staged hepatectomy (ALLPS) has been introduced as an alternative method to augment FLR. It offers rapid and effective hypertrophy for resecting liver metastases. However, data regarding its application in patients with hepatocellular carcinoma (HCC) with a background of chronic liver disease are limited. Here we describe the use of ALPPS procedure to manage a large solitary HCC with a background of chronic liver disease. The rising incidence of HCC has increased the number of surgical resections in patients with advanced stage liver disease not considered for liver transplantation. We reviewed reported experience of ALPPS in established chronic liver disease and current therapeutic modalities for HCC on a background of chronic liver disease in patients with potential liver insufficiency where tumor burden is beyond liver transplant criteria.
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Affiliation(s)
- Michail Papamichail
- Institute of Liver Studies, Kings Health Partners of King's College Hospital, NHS Foundation Trust, London, United Kingdom
| | - Michail Pizanias
- Institute of Liver Studies, Kings Health Partners of King's College Hospital, NHS Foundation Trust, London, United Kingdom
| | - Vincent Yip
- Institute of Liver Studies, Kings Health Partners of King's College Hospital, NHS Foundation Trust, London, United Kingdom
| | - Evangellos Prassas
- Institute of Liver Studies, Kings Health Partners of King's College Hospital, NHS Foundation Trust, London, United Kingdom
| | - Andreas Prachalias
- Institute of Liver Studies, Kings Health Partners of King's College Hospital, NHS Foundation Trust, London, United Kingdom
| | - Alberto Quaglia
- Institute of Liver Studies, Kings Health Partners of King's College Hospital, NHS Foundation Trust, London, United Kingdom
| | - Praveen Peddu
- Institute of Liver Studies, Kings Health Partners of King's College Hospital, NHS Foundation Trust, London, United Kingdom
| | - Nigel Heaton
- Institute of Liver Studies, Kings Health Partners of King's College Hospital, NHS Foundation Trust, London, United Kingdom
| | - Parthi Srinivasan
- Institute of Liver Studies, Kings Health Partners of King's College Hospital, NHS Foundation Trust, London, United Kingdom
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Serenari M, Zanello M, Schadde E, Toschi E, Ratti F, Gringeri E, Masetti M, Cillo U, Aldrighetti L, Jovine E. Importance of primary indication and liver function between stages: results of a multicenter Italian audit of ALPPS 2012-2014. HPB (Oxford) 2016; 18:419-27. [PMID: 27154805 PMCID: PMC4857064 DOI: 10.1016/j.hpb.2016.02.003] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2016] [Accepted: 02/02/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND Posthepatectomy liver failure is one of the most feared complications in extended hepatic resections. In 2012, a novel two-stage liver resection was developed, able to induce rapid and extensive hypertrophy by portal vein ligation and in situ liver splitting - Associating Liver Partition and Portal vein ligation for Staged hepatectomy (ALPPS). The technique became more widely employed but its use remained controversial due to reporting of high complication and mortality rates. METHOD A national audit was performed to gather information about the safety of the procedure and to better understand the complications. The audit was offered to all high-volume hepatobiliary centers in Italy. RESULTS Of all Italian centers approached in January 2012, 12 centers with experience in ALPPS enrolled and participated in collection of data. Fifty patients underwent ALPPS between 2012 and 2014. In 48/50 patients completion of hepatectomy was performed successfully. Major morbidity occurred in 54% with a 20% 90-day mortality. Uni- and multivariate analysis showed that ALPPS for cholangiocarcinoma and a peak of bilirubin over 5 mg/dl between stages was associated with increase of 90-day mortality and worse survival. DISCUSSION It is proposed that a moratorium be introduced for classic ALPPS in cholangiocarcinoma and to abort ALPPS in patients who develop an interstage increase in bilirubin, due to the high risk of liver failure and mortality.
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Affiliation(s)
- Matteo Serenari
- Division of General Surgery, Maggiore Hospital, Bologna, Italy
| | - Matteo Zanello
- Division of General Surgery, Maggiore Hospital, Bologna, Italy
| | - Erik Schadde
- Department of Surgery, Cantonal Hospital Winterthur and Institute of Physiology, University of Zurich, Zurich, Switzerland
| | - Elena Toschi
- Division of General Surgery, Maggiore Hospital, Bologna, Italy
| | - Francesca Ratti
- Department of Surgery, Hepatobiliary Surgery Unit, Vita-Salute San Raffaele University, Milan, Italy
| | - Enrico Gringeri
- General Surgery and Organ Transplantation Hepatobiliary Surgery and Liver Transplant Unit, University of Padua, Padua, Italy
| | - Michele Masetti
- Division of General Surgery, Maggiore Hospital, Bologna, Italy
| | - Umberto Cillo
- General Surgery and Organ Transplantation Hepatobiliary Surgery and Liver Transplant Unit, University of Padua, Padua, Italy
| | - Luca Aldrighetti
- Department of Surgery, Hepatobiliary Surgery Unit, Vita-Salute San Raffaele University, Milan, Italy
| | - Elio Jovine
- Division of General Surgery, Maggiore Hospital, Bologna, Italy.
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Abstract
The nuances of determining resectability for liver tumors can be difficult to navigate, owing to the variety of primary and secondary malignancies involving the liver, the range of patient-specific factors to consider, and the hepatic anatomic and functional variability that seems inevitable. The basic principles, however, are simple;if surgery is deemed appropriate from an oncologic standpoint, the patient is in reasonably good health, and the tumor can be safely removed without compromising the integrity of the future remnant, nearly all patients will be candidates for resection.
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Affiliation(s)
- Cecilia G Ethun
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, 1365C Clifton Road NE, Building C, 2nd Floor, Atlanta, GA 30322, USA
| | - Shishir K Maithel
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, 1365C Clifton Road NE, Building C, 2nd Floor, Atlanta, GA 30322, USA.
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Edmondson MJ, Sodergren MH, Pucher PH, Darzi A, Li J, Petrowsky H, Campos RR, Serrablo A, Jiao LR. Variations and adaptations of associated liver partition and portal vein ligation for staged hepatectomy (ALPPS): Many routes to the summit. Surgery 2015; 159:1058-72. [PMID: 26747229 DOI: 10.1016/j.surg.2015.11.013] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Revised: 10/19/2015] [Accepted: 11/11/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND Our aim was to review variations from the originally described associated liver partition and portal vein ligation for staged hepatectomy (ALPPS) procedure and relevant clinical outcomes. METHODS A systematic review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (ie, PRISMA) guidelines. A search of PubMed and Google Scholar was conducted until March 2015. Inclusion criteria were any publications reporting technical variations and descriptions of ALPPS. Exclusion criteria were insufficient technical description, data repeated elsewhere, or data that could not be accessed in English. RESULTS Initial search results returned 790 results; 46 studies were included in the final qualitative analysis. There were several alternatives described to the first stage of complete parenchymal split. Variations included partial ALPPS (partial split; hypertrophy of future liver remnant [FLR] 80-90%), radiofrequency-assisted liver partition and portal vein ligation (mean FLR hypertrophy 62%), laparoscopic microwave ablation and portal vein ligation (FLR hypertrophy 78-90%), associating liver tourniquet and portal ligation for staged hepatectomy (median FLR hypertrophy 61%), and sequential associating liver tourniquet and portal ligation for staged hepatectomy (FLR hypertrophy 77%) with a potential decrease in morbidity particularly after stage I. We analyzed several other variations, including considerations for segment IV, operative maneuvers, use of laparoscopy, identification of biliary complications, and liver containment. CONCLUSION The current literature demonstrates a large variability in techniques of ALPPS that limits meaningful statistical comparisons of outcomes. Not physically splitting the liver at the first stage may decrease morbidity; however, randomized controlled trials are needed to determine benefits in technical variations.
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Affiliation(s)
- Matthew J Edmondson
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom
| | - Mikael H Sodergren
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom.
| | - Philip H Pucher
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom
| | - Ara Darzi
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom
| | - Jun Li
- Department of Hepatobiliary Surgery and Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Henrik Petrowsky
- Swiss HPB and Transplant Center, University Hospital Zurich, Zurich, Switzerland
| | - Ricardo Robles Campos
- Department of General Surgery, Liver Transplant Unit, Virgen De La Arrixaca University Hospital, Murcia, Spain
| | | | - Long R Jiao
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom
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Vivarelli M, Vincenzi P, Montalti R, Fava G, Tavio M, Coletta M, Vecchi A, Nicolini D, Agostini A, Ali Ahmed E, Giovagnoni A, Mocchegiani F. ALPPS Procedure for Extended Liver Resections: A Single Centre Experience and a Systematic Review. PLoS One 2015; 10:e0144019. [PMID: 26700646 PMCID: PMC4689524 DOI: 10.1371/journal.pone.0144019] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2015] [Accepted: 11/12/2015] [Indexed: 02/06/2023] Open
Abstract
Aim To report a single-centre experience with the novel Associating Liver Partition and Portal vein ligation for Staged hepatectomy (ALPPS) technique and systematically review the related literature. Methods Since January 2013, patients with extended primary or secondary liver tumors whose future liver remnant (FLR) was considered too small to allow hepatic resection were prospectively assessed for the ALPPS procedure. A systematic literature search was performed using PubMed, Scopus and the Cochrane Library Central. Results Until July 2014 ALPPS was completed in 9 patients whose mean age was 60±8 years. Indications for surgical resection were metastases from colorectal cancer in 3 cases, perihilar cholangiocarcinoma in 3 cases, intrahepatic cholangiocarcinoma in 2 cases and hepatocellular carcinoma without chronic liver disease in 1 case. The calculated FLR volume was 289±122 mL (21.1±5.5%) before ALPPS-1 and 528±121 mL (32.2±5.7%) before ALLPS-2 (p<0.001). The increase in FLR between the two procedures was 96±47% (range: 24–160%, p<0.001). Additional interventions were performed in 4 cases: 3 patients underwent Roux-en-Y hepaticojejunostomy, and one case underwent wedge resection of a residual tumor in the FLR. The average time between the first and second step of the procedure was 10.8±2.9 days. The average hospital stay was 24.1±13.3 days. There was 1 postoperative death due to hepatic failure in the oldest patient of this series who had a perihilar cholangiocarcinoma and concomitant liver fibrosis; 11 complications occurred in 6 patients, 4 of whom had grade III or above disease. After a mean follow-up of 17.1±8.5 months, the overall survival was 89% at 3–6 and 12 months. The recurrence-free survival was 100%, 87.5% and 75% at 3-6-12 months respectively. The literature search yielded 148 articles, of which 22 articles published between 2012 and 2015 were included in this systematic review. Conclusion The ALPPS technique effectively increased the resectability of otherwise inoperable liver tumors. The postoperative morbidity in our series was high in accordance with the data from the systematic review. Age, liver fibrosis and presence of biliary stenting were predisposing factors for postoperative morbidity and mortality.
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Affiliation(s)
- Marco Vivarelli
- Hepatobiliary and Abdominal Transplantation Surgery, Department of Experimental and Clinical Medicine, Polytechnic University of Marche, Ancona, Italy
| | - Paolo Vincenzi
- Hepatobiliary and Abdominal Transplantation Surgery, Department of Experimental and Clinical Medicine, Polytechnic University of Marche, Ancona, Italy
| | - Roberto Montalti
- Hepatobiliary and Abdominal Transplantation Surgery, Department of Experimental and Clinical Medicine, Polytechnic University of Marche, Ancona, Italy
- * E-mail:
| | - Giammarco Fava
- Department of Gastroenterology, Polytechnic University of Marche, Ancona, Italy
| | - Marcello Tavio
- Unit of Emerging and Immunosuppressed Infectious Diseases, Department of Gastroenterology and Transplantation, Polytechnic University of Marche, Ancona, Italy
| | - Martina Coletta
- Hepatobiliary and Abdominal Transplantation Surgery, Department of Experimental and Clinical Medicine, Polytechnic University of Marche, Ancona, Italy
| | - Andrea Vecchi
- Hepatobiliary and Abdominal Transplantation Surgery, Department of Experimental and Clinical Medicine, Polytechnic University of Marche, Ancona, Italy
| | - Daniele Nicolini
- Hepatobiliary and Abdominal Transplantation Surgery, Department of Experimental and Clinical Medicine, Polytechnic University of Marche, Ancona, Italy
| | - Andrea Agostini
- Unit of General and Paediatric Radiology, Department of Radiology, Polytechnic University of Marche, Ancona, Italy
| | - Emad Ali Ahmed
- Hepatobiliary and Abdominal Transplantation Surgery, Department of Experimental and Clinical Medicine, Polytechnic University of Marche, Ancona, Italy
- Department of Gastroenterology, Polytechnic University of Marche, Ancona, Italy
- Unit of Emerging and Immunosuppressed Infectious Diseases, Department of Gastroenterology and Transplantation, Polytechnic University of Marche, Ancona, Italy
- Unit of General and Paediatric Radiology, Department of Radiology, Polytechnic University of Marche, Ancona, Italy
- Hepatobiliary and Pancreatic Surgery Unit, Department of General Surgery, Faculty of Medicine, Sohag University, Sohag, Egypt
| | - Andrea Giovagnoni
- Unit of General and Paediatric Radiology, Department of Radiology, Polytechnic University of Marche, Ancona, Italy
| | - Federico Mocchegiani
- Hepatobiliary and Abdominal Transplantation Surgery, Department of Experimental and Clinical Medicine, Polytechnic University of Marche, Ancona, Italy
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A preliminary study of ALPPS procedure in a rat model. Sci Rep 2015; 5:17567. [PMID: 26631552 PMCID: PMC4668375 DOI: 10.1038/srep17567] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Accepted: 11/02/2015] [Indexed: 12/18/2022] Open
Abstract
Associating Liver Partition and Portal vein ligation for Staged hepatectomy (ALPPS) has been reported to be a novel surgical technique that provides fast and effective growth of liver remnant. Despite occasional reports on animal studies, the mechanisms of rapid liver regeneration in ALPPS remains unclear. In the present study, we intend to develop a reproducible rat model to mimick ALPPS and to explore the underlying mechanisms. Rats assigned to the portal vein ligation (PVL), left lateral lobe (LLL) resection, transection and sham groups served as controls. Results indicated that the regeneration rate in the remnant liver after ALPPS was two times relative to PVL, whereas rats with transection alone showed minimal volume increase. The expression levels of Ki-67 and PCNA were about ten-fold higher after ALPPS compared with the transection and LLL resection groups, and four-fold higher compared with the PVL group. The levels of TNF-α, IL-6 and HGF in the regenerating liver remnant were about three-fold higher after ALPPS than the controls. There was a more significant activation of NF-κB p65, STAT3 and Yap after ALPPS, suggesting synergistic activation of the pathways by PVL and transection, which might play an important role in liver regeneration after ALPPS.
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Galun D, Basaric D, Zuvela M, Bulajic P, Bogdanovic A, Bidzic N, Milicevic M. Hepatocellular carcinoma: From clinical practice to evidence-based treatment protocols. World J Hepatol 2015; 7:2274-91. [PMID: 26380652 PMCID: PMC4568488 DOI: 10.4254/wjh.v7.i20.2274] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2014] [Revised: 07/06/2015] [Accepted: 08/30/2015] [Indexed: 02/06/2023] Open
Abstract
Hepatocellular carcinoma (HCC) is one of the major malignant diseases in many healthcare systems. The growing number of new cases diagnosed each year is nearly equal to the number of deaths from this cancer. Worldwide, HCC is a leading cause of cancer-related deaths, as it is the fifth most common cancer and the third most important cause of cancer related death in men. Among various risk factors the two are prevailing: viral hepatitis, namely chronic hepatitis C virus is a well-established risk factor contributing to the rising incidence of HCC. The epidemic of obesity and the metabolic syndrome, not only in the United States but also in Asia, tend to become the leading cause of the long-term rise in the HCC incidence. Today, the diagnosis of HCC is established within the national surveillance programs in developed countries while the diagnosis of symptomatic, advanced stage disease still remains the characteristic of underdeveloped countries. Although many different staging systems have been developed and evaluated the Barcelona-Clinic Liver Cancer staging system has emerged as the most useful to guide HCC treatment. Treatment allocation should be decided by a multidisciplinary board involving hepatologists, pathologists, radiologists, liver surgeons and oncologists guided by personalized -based medicine. This approach is important not only to balance between different oncologic treatments strategies but also due to the complexity of the disease (chronic liver disease and the cancer) and due to the large number of potentially efficient therapies. Careful patient selection and a tailored treatment modality for every patient, either potentially curative (surgical treatment and tumor ablation) or palliative (transarterial therapy, radioembolization and medical treatment, i.e., sorafenib) is mandatory to achieve the best treatment outcome.
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Affiliation(s)
- Danijel Galun
- Danijel Galun, Dragan Basaric, Marinko Zuvela, Predrag Bulajic, Aleksandar Bogdanovic, Nemanja Bidzic, Miroslav Milicevic, Clinic of Digestive Surgery, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Dragan Basaric
- Danijel Galun, Dragan Basaric, Marinko Zuvela, Predrag Bulajic, Aleksandar Bogdanovic, Nemanja Bidzic, Miroslav Milicevic, Clinic of Digestive Surgery, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Marinko Zuvela
- Danijel Galun, Dragan Basaric, Marinko Zuvela, Predrag Bulajic, Aleksandar Bogdanovic, Nemanja Bidzic, Miroslav Milicevic, Clinic of Digestive Surgery, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Predrag Bulajic
- Danijel Galun, Dragan Basaric, Marinko Zuvela, Predrag Bulajic, Aleksandar Bogdanovic, Nemanja Bidzic, Miroslav Milicevic, Clinic of Digestive Surgery, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Aleksandar Bogdanovic
- Danijel Galun, Dragan Basaric, Marinko Zuvela, Predrag Bulajic, Aleksandar Bogdanovic, Nemanja Bidzic, Miroslav Milicevic, Clinic of Digestive Surgery, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Nemanja Bidzic
- Danijel Galun, Dragan Basaric, Marinko Zuvela, Predrag Bulajic, Aleksandar Bogdanovic, Nemanja Bidzic, Miroslav Milicevic, Clinic of Digestive Surgery, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Miroslav Milicevic
- Danijel Galun, Dragan Basaric, Marinko Zuvela, Predrag Bulajic, Aleksandar Bogdanovic, Nemanja Bidzic, Miroslav Milicevic, Clinic of Digestive Surgery, University Clinical Center of Serbia, 11000 Belgrade, Serbia
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Ettorre GM, Guglielmo N, Felli E, Meniconi RL, Colasanti M, Lepiane P, Santoro R, Vennarecci G. Is there still a room to improve the safety of ALPPS procedure? A new technical note. Eur J Surg Oncol 2015; 41:1556-7. [PMID: 26346182 DOI: 10.1016/j.ejso.2015.06.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2015] [Accepted: 06/19/2015] [Indexed: 10/23/2022] Open
Affiliation(s)
- G M Ettorre
- Division of Surgical Oncology and Liver Transplantation, San Camillo Hospital, INMI Lazzaro Spallanzani, Rome, Italy
| | - N Guglielmo
- Division of Surgical Oncology and Liver Transplantation, San Camillo Hospital, INMI Lazzaro Spallanzani, Rome, Italy.
| | - E Felli
- Division of Surgical Oncology and Liver Transplantation, San Camillo Hospital, INMI Lazzaro Spallanzani, Rome, Italy
| | - R L Meniconi
- Division of Surgical Oncology and Liver Transplantation, San Camillo Hospital, INMI Lazzaro Spallanzani, Rome, Italy
| | - M Colasanti
- Division of Surgical Oncology and Liver Transplantation, San Camillo Hospital, INMI Lazzaro Spallanzani, Rome, Italy
| | - P Lepiane
- Division of Surgical Oncology and Liver Transplantation, San Camillo Hospital, INMI Lazzaro Spallanzani, Rome, Italy
| | - R Santoro
- Division of Surgical Oncology and Liver Transplantation, San Camillo Hospital, INMI Lazzaro Spallanzani, Rome, Italy
| | - G Vennarecci
- Division of Surgical Oncology and Liver Transplantation, San Camillo Hospital, INMI Lazzaro Spallanzani, Rome, Italy
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Chiu CC, Wang JJ, Chen YS, Chen JJ, Tsai TC, Lai CC, Sun DP, Shi HY. Trends and predictors of outcomes after surgery for hepatocellular carcinoma: A nationwide population-based study in Taiwan. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2015; 41:1170-8. [PMID: 26048295 DOI: 10.1016/j.ejso.2015.04.023] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2014] [Revised: 04/19/2015] [Accepted: 04/27/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND Despite the huge and growing global burden of hepatocellular carcinoma (HCC), high-quality population-based studies of HCC prevalence and outcomes are scarce. PURPOSE To analyze trends and predictors of hospital resource utilization and mortality rates in a population of patients who had received HCC surgery. PATIENTS AND MATERIALS This population-based patient cohort study retrospectively analyzed 23,107 patients who had received surgical treatment for HCC from 1998 to 2009. RESULTS The prevalence rate of surgical treatment in HCC patients significantly increased by 167.4% from 4.857 per 100,000 persons in 1998 to 12.989 per 100,000 persons in 2009 (P < 0.001). Age, gender, Deyo-Charlson co-morbidity index score, hospital volume, surgeon volume, digestive system disease, hepatitis type and liver cirrhosis were significantly associated with HCC surgical outcomes (P < 0.05). Over the 12-year period analyzed, the estimated mean hospital treatment cost increased 9.4% whereas mean length of stay (LOS) decreased 25.3%. The estimated mean overall survival time after HCC surgery was 40.9 months (SD 1.2 months), and the overall in-hospital 1-, 3-, and 5-year survival rates were 97.2%, 79.9%, 61.1%, and 54.6%, respectively. CONCLUSIONS These population-based data reveal that the prevalence of HCC has increased, especially in older patients. Additionally, hospital treatment costs for HCC have increased despite decreases in LOS. These analytical results should be applicable to most countries with relatively small populations. Additionally, healthcare providers and patients should recognize that attributes of both the patient and the hospital may affect outcomes.
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Affiliation(s)
- C-C Chiu
- Department of General Surgery, Chi Mei Medical Center, Tainan and Liouying, Taiwan; Department of Electrical Engineering, Southern Taiwan University of Science and Technology, Tainan, Taiwan
| | - J-J Wang
- Department of Medical Research, Chi Mei Medical Center, Tainan, Taiwan
| | - Y-S Chen
- Department of Surgery, E-Da Hospital, Kaohsiung, Taiwan
| | - J-J Chen
- Department of Gastroenterology & Hepatology, Chi Mei Medical Center, Tainan and Liouying, Taiwan
| | - T-C Tsai
- Department of General Surgery, Chi Mei Medical Center, Tainan and Liouying, Taiwan
| | - C-C Lai
- Department of Intensive Care Medicine, Chi Mei Medical Center, Tainan and Liouying, Taiwan
| | - D-P Sun
- Department of General Surgery, Chi Mei Medical Center, Tainan and Liouying, Taiwan
| | - H-Y Shi
- Department of Healthcare Administration and Medical Informatics, Kaohsiung Medical University, Kaohsiung, Taiwan.
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She WH, Chok KSH. Strategies to increase the resectability of hepatocellular carcinoma. World J Hepatol 2015; 7:2147-2154. [PMID: 26328026 PMCID: PMC4550869 DOI: 10.4254/wjh.v7.i18.2147] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2015] [Revised: 08/10/2015] [Accepted: 08/21/2015] [Indexed: 02/06/2023] Open
Abstract
Hepatocellular carcinoma (HCC) is best treated by liver transplantation, but the applicability of transplantation is greatly limited. Tumor resection in partial hepatectomy is hence resorted to. However, in most parts of the world, only 20%-30% of HCCs are resectable. The main reason for such a low resectability is a future liver remnant too small to be sufficient for the patient. To allow more HCC patients to undergo curative hepatectomy, a variety of ways have been developed to increase the resectability of HCC, mainly ways to increase the future liver remnants in patients through hypertrophy. They include portal vein embolization, sequential transarterial chemoembolization and portal vein embolization, staged hepatectomy, two-staged hepatectomy with portal vein ligation, and Associating Liver Partition and Portal Vein Ligation in Staged Hepatectomy. Herein we review, describe and evaluate these different ways, ways that can be life-saving.
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Li Y, Xia Y, Li J, Wu D, Wan X, Wang K, Wu M, Liu J, Lau WY, Shen F. Prognostic Nomograms for Pre- and Postoperative Predictions of Long-Term Survival for Patients Who Underwent Liver Resection for Huge Hepatocellular Carcinoma. J Am Coll Surg 2015; 221:962-974.e4. [PMID: 26382973 DOI: 10.1016/j.jamcollsurg.2015.08.003] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2015] [Revised: 08/01/2015] [Accepted: 08/03/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND Liver resection is an effective treatment in select patients with huge hepatocellular carcinoma (HCC, diameter ≥10 cm). This study aimed to develop nomograms for pre- and postoperative predictions of overall survival (OS) for these patients. STUDY DESIGN There were 464 consecutive patients who underwent liver resection for huge HCC at the Eastern Hepatobiliary Surgery Hospital (EHBH) between January 2008 and December 2009. They were collected and divided into a training cohort (n = 310) and an internal validation cohort (n = 154). Another 90 patients who were operated on at the Fujian Medical University (FMU) between January 2008 and April 2010 served as an external validation cohort. The surgical morbidity, mortality, time to recurrence, and OS were observed. Two prognostic nomograms were developed based separately on the data obtained before and after surgery. Discrimination and predictive accuracy of the models were measured using concordance index (C-index), calibration curves, and validation study. RESULTS The postoperative 4-year tumor recurrence and OS rates were, respectively, 79.0% and 41.2% in the patients from the EHBH and 78.8% and 37.6% in those from the FMU. Independent predictors of OS on multivariable analysis using pre- and postoperative data were respectively incorporated into the 2 nomograms. In the training cohort, calibration curves for the probability of 4-year postoperative survival fitted well. The C-indexes of the pre- and postoperative nomograms in predicting OS were 0.75 (95% CI 0.72 to 0.78) and 0.78 (95% CI 0.75 to 0.81), respectively. The internal and external validation studies optimally supported these results. CONCLUSIONS The 2 nomograms achieved accurate pre- or postoperative predictions of long-term survival for patients with huge HCC after liver resection.
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Affiliation(s)
- Yuntong Li
- Department of Hepatobiliary Surgery, the Mengchao Hepatobiliary Surgery Hospital, Fujian Medical University, Fuzhou, China; Department of Hepatic Surgery, the Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, Shanghai, China
| | - Yong Xia
- Department of Hepatic Surgery, the Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, Shanghai, China
| | - Jun Li
- Department of Hepatic Surgery, the Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, Shanghai, China
| | - Dong Wu
- Department of Hepatic Surgery, the Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, Shanghai, China
| | - Xuying Wan
- Department of Hepatic Surgery, the Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, Shanghai, China
| | - Kui Wang
- Department of Hepatic Surgery, the Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, Shanghai, China
| | - Mengchao Wu
- Department of Hepatobiliary Surgery, the Mengchao Hepatobiliary Surgery Hospital, Fujian Medical University, Fuzhou, China; Department of Hepatic Surgery, the Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, Shanghai, China
| | - Jingfeng Liu
- Department of Hepatobiliary Surgery, the Mengchao Hepatobiliary Surgery Hospital, Fujian Medical University, Fuzhou, China
| | - Wan Yee Lau
- Department of Hepatic Surgery, the Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, Shanghai, China; Faculty of Medicine, the Chinese University of Hong Kong, Hong Kong, SAR, China
| | - Feng Shen
- Department of Hepatic Surgery, the Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, Shanghai, China.
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Mei Y, Peng CJ, Li WN, Li XX, Xie WT, Shu DJ, Zhang JG. Surgical treatment of hilar cholangiocarcinoma: New advances. Shijie Huaren Xiaohua Zazhi 2015; 23:2907-2912. [DOI: 10.11569/wcjd.v23.i18.2907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Hilar cholangiocarcinoma, a malignant tumor that occurs in the left and right hepatic duct, is the most common form of bile duct carcinoma. Early diagnosis of hilar cholangiocarcinoma is difficult, and the majority of patients are diagnosed in advanced stages. Therefore, surgery for this malignancy is difficult, has high risk, and is associated with a poor prognosis. In recent years, with the development of imaging technology and extended radical surgery, the preoperative diagnosis and surgical treatment of hilar cholangiocarcinoma have been improved. However, hilar cholangiocarcinoma still has a low cure rate, high complication rate, and poor prognosis. Therefore, we should strengthen the research on the susceptible factors and biological characteristics of hilar cholangiocarcinoma, and improve early diagnosis. Currently, although there has been no unified standard for the resectability of the tumor, surgery combined with partial hepatectomy is strongly recommended in patients without surgical contraindication. This paper reviews the recent progress in surgical treatment of hilar cholangiocarcinoma.
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Reply to: "ALPPS procedure for hepatocellular carcinoma with macrovascular thrombosis: a new opportunity?". J Hepatol 2015; 62:243. [PMID: 25200904 DOI: 10.1016/j.jhep.2014.09.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2014] [Accepted: 09/01/2014] [Indexed: 12/04/2022]
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Levi Sandri GB, Lai Q, Rayar M, Sulpice L. ALPPS procedure for hepatocellular carcinoma with macrovascular thrombosis: a new opportunity? J Hepatol 2015; 62:241-2. [PMID: 25200909 DOI: 10.1016/j.jhep.2014.08.048] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2014] [Revised: 06/27/2014] [Accepted: 08/17/2014] [Indexed: 12/13/2022]
Affiliation(s)
- Giovanni Battista Levi Sandri
- Department of General Surgery and Organ Transplantation, Umberto I Policlinic of Rome, Sapienza University of Rome, Rome, Italy; Service de Chirurgie Hépatobiliaire et Digestive, Centre Hospitalier Universitaire de Rennes, Université de Rennes 1, France.
| | - Quirino Lai
- Service de Chirurgie Hépatobiliaire et Digestive, Centre Hospitalier Universitaire de Rennes, Université de Rennes 1, France
| | - Michel Rayar
- Department of General Surgery and Organ Transplantation, Umberto I Policlinic of Rome, Sapienza University of Rome, Rome, Italy
| | - Laurent Sulpice
- Department of General Surgery and Organ Transplantation, Umberto I Policlinic of Rome, Sapienza University of Rome, Rome, Italy
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Bertens KA, Hawel J, Lung K, Buac S, Pineda-Solis K, Hernandez-Alejandro R. ALPPS: challenging the concept of unresectability--a systematic review. Int J Surg 2014; 13:280-287. [PMID: 25496851 DOI: 10.1016/j.ijsu.2014.12.008] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2014] [Accepted: 12/07/2014] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Hepatic resection for malignancy is limited by the amount of liver parenchyma left behind. As a result, two-staged hepatectomy and portal vein occlusion (PVO) have become part of the treatment algorithm. Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) has been recently described as a method to stimulate rapid and profound hypertrophy. MATERIALS AND METHODS A systematic review of the literature pertaining to ALPPS was undertaken. Peer-reviewed articles relating to portal vein ligation (PVL) and in situ split (ISS) of the parenchyma were included. RESULTS To date, ALPPS has been employed for a variety of primary and metastatic liver tumors. In early case series, the perioperative morbidity and mortality was unacceptably high. However with careful patient selection and improved technique, many centers have reported a 0% 90-day mortality. The benefits of ALPPS include hypertrophy of 61-93% over a median 9-14 days, 95-100% completion of the second stage, and high likelihood of R0 resection (86-100%). DISCUSSION ALPPS is only indicated when a two-stage hepatectomy is necessary and the future liver remnant (FLR) is deemed inadequate (<30%). Use in patients with poor functional status, or advanced age (>70 years) is cautioned. Discretion should be used when considering this in patients with pathology other than colorectal liver metastases (CRLM), especially hilar tumors requiring biliary reconstruction. Biliary ligation during the first stage and routine lymphadenectomy of the hepatoduodenal ligament should be avoided. CONCLUSIONS A consensus on the indications and contraindications for ALPPS and a standardized operative protocol are needed.
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Affiliation(s)
- Kimberly A Bertens
- Department of Surgery, Schulich School of Medicine & Dentistry, University of Western Ontario, 339 Windermere Road, London, ON, Canada N6A 5A5
| | - Jeffrey Hawel
- Department of Surgery, Schulich School of Medicine & Dentistry, University of Western Ontario, 339 Windermere Road, London, ON, Canada N6A 5A5
| | - Kalvin Lung
- Department of Surgery, Schulich School of Medicine & Dentistry, University of Western Ontario, 339 Windermere Road, London, ON, Canada N6A 5A5
| | - Suzana Buac
- Department of Surgery, Schulich School of Medicine & Dentistry, University of Western Ontario, 339 Windermere Road, London, ON, Canada N6A 5A5
| | - Karen Pineda-Solis
- Department of Surgery, Schulich School of Medicine & Dentistry, University of Western Ontario, 339 Windermere Road, London, ON, Canada N6A 5A5; Multi-Organ Transplant Program, London Health Sciences Centre, 339 Windermere Road, London, ON, Canada N6A 5A5
| | - Roberto Hernandez-Alejandro
- Department of Surgery, Schulich School of Medicine & Dentistry, University of Western Ontario, 339 Windermere Road, London, ON, Canada N6A 5A5; Multi-Organ Transplant Program, London Health Sciences Centre, 339 Windermere Road, London, ON, Canada N6A 5A5.
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Vennarecci G, Grazi GL, Santoro R, Ettorre GM. A room for the alpps procedure in patients with HCC. Int J Surg 2014; 13:90-91. [PMID: 25500565 DOI: 10.1016/j.ijsu.2014.11.054] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2014] [Accepted: 11/30/2014] [Indexed: 01/03/2023]
Affiliation(s)
- Giovanni Vennarecci
- Department of General Surgery and Organ Transplantation, San Camillo Hospital, Rome, Italy.
| | - Gian Luca Grazi
- Department of Hepatobiliary Surgery, Regina Elena Cancer Institute, Rome, Italy
| | - Roberto Santoro
- Department of General Surgery and Organ Transplantation, San Camillo Hospital, Rome, Italy
| | - Giuseppe Maria Ettorre
- Department of General Surgery and Organ Transplantation, San Camillo Hospital, Rome, Italy
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Heterogeneity of intermediate-stage HCC necessitates personalized management including surgery. Nat Rev Clin Oncol 2014; 12:10. [PMID: 25421283 DOI: 10.1038/nrclinonc.2014.122-c1] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Kauffmann R, Fong Y. Post-hepatectomy liver failure. Hepatobiliary Surg Nutr 2014; 3:238-46. [PMID: 25392835 DOI: 10.3978/j.issn.2304-3881.2014.09.01] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2014] [Accepted: 08/21/2014] [Indexed: 12/11/2022]
Abstract
Hepatectomies are among some of the most complex operative interventions performed. Mortality rates after major hepatectomy are as high as 30%, with post-hepatic liver failure (PHLF) representing the major source of morbidity and mortality. We present a review of PHLF, including the current definition, predictive factors, pre-operative risk assessment, techniques to prevent PHLF, identification and management. Despite great improvements in morbidity and mortality, liver surgery continues to demand excellent clinical judgement in selecting patients for surgery. Appropriate choice of pre-operative techniques to improve the functional liver remnant (FLR), fastidious surgical technique, and excellent post-operative management are essential to optimize patient outcomes.
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Affiliation(s)
- Rondi Kauffmann
- Department of Surgery, City of Hope National Medical Center, Duarte, CA, USA
| | - Yuman Fong
- Department of Surgery, City of Hope National Medical Center, Duarte, CA, USA
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Chia NH, Lai ECH, Lau WY. Associating liver partition and portal vein ligation for a patient with hepatocellular carcinoma with a background of hepatitis B related fibrotic liver. Int J Surg Case Rep 2014; 5:1077-81. [PMID: 25460479 PMCID: PMC4275789 DOI: 10.1016/j.ijscr.2014.11.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2014] [Revised: 10/30/2014] [Accepted: 11/02/2014] [Indexed: 01/20/2023] Open
Abstract
Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) has rarely been reported for patients with hepatocellular carcinoma (HCC). ALPPS is feasible even in the context of HCC with a background of chronic hepatitis B related liver fibrosis. The hypertrophy rate of the liver remnant was slower and the time needed between the two stages of the operation was longer.
INTRODUCTION Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) has recently been developed for patients with predicted insufficient future liver remnant volumes to induce more rapid hepatic hypertrophy and increase resectability. In the medical literature, the use of ALPPS in hepatocellular carcinoma (HCC) has rarely been reported. PRESENTATION OF CASE We reported the use of ALPPS in a patient with primarily unresectable HCC arising from a background of hepatitis B related liver fibrosis. Preoperative computed tomography (CT) showed 2 large conglomerated tumors measuring 16 cm × 10.5 cm in liver segments 5, 6, 7 and 8, and at least 3 satellite nodules with the largest one measuring 3 cm around the main tumor and another 4 cm tumor in segment 4. Right trisectionectomy after ALPPS was successfully performed. He was discharged from hospital on postoperative day 13 after the second operation. Follow-up CT scan at 6 weeks after the second operation showed further hypertrophy of the liver remnant and no liver recurrence. DISCUSSION Our case showed that this novel strategy is feasible even in the context of a background of chronic hepatitis B related liver fibrosis, although the hypertrophy rate was a little bit slower and the time needed was longer. CONCLUSION ALPPS is also feasible in liver fibrosis. It gives hope to patients with HCC who previously were considered as having unresectable diseases. More studies are needed to further evaluate the effectiveness and oncological outcomes of ALPPS from these patients.
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Affiliation(s)
- Nam Hung Chia
- Department of Surgery, Queen Elizabeth Hospital, Hong Kong SAR, China
| | - Eric C H Lai
- Department of Surgery, Pamela Youde Nethersole Eastern Hospital, Hong Kong SAR, China
| | - Wan Yee Lau
- Faculty of Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, China.
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