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Boubaddi M, Marichez A, Adam JP, Lapuyade B, Debordeaux F, Tlili G, Chiche L, Laurent C. Comprehensive Review of Future Liver Remnant (FLR) Assessment and Hypertrophy Techniques Before Major Hepatectomy: How to Assess and Manage the FLR. Ann Surg Oncol 2024:10.1245/s10434-024-16108-9. [PMID: 39230854 DOI: 10.1245/s10434-024-16108-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2024] [Accepted: 08/16/2024] [Indexed: 09/05/2024]
Abstract
BACKGROUND The regenerative capacities of the liver and improvements in surgical techniques have expanded the possibilities of resectability. Liver resection is often the only curative treatment for primary and secondary malignancies, despite the risk of post-hepatectomy liver failure (PHLF). This serious complication (with a 50% mortality rate) can be avoided by better assessment of liver volume and function of the future liver remnant (FLR). OBJECTIVE The aim of this review was to understand and assess clinical, biological, and imaging predictors of PHLF risk, as well as the various hypertrophy techniques, to achieve an adequate FLR before hepatectomy. METHOD We reviewed the state of the art in liver regeneration and FLR hypertrophy techniques. RESULTS The use of new biological scores (such as the aspartate aminotransferase/platelet ratio index + albumin-bilirubin [APRI+ALBI] score), concurrent utilization of 99mTc-mebrofenin scintigraphy (HBS), or dynamic hepatocyte contrast-enhanced MRI (DHCE-MRI) for liver volumetry helps predict the risk of PHLF. Besides portal vein embolization, there are other FLR optimization techniques that have their indications in case of risk of failure (e.g., associating liver partition and portal vein ligation for staged hepatectomy, liver venous deprivation) or in specific situations (transarterial radioembolization). CONCLUSION There is a need to standardize volumetry and function measurement techniques, as well as FLR hypertrophy techniques, to limit the risk of PHLF.
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Affiliation(s)
- Mehdi Boubaddi
- Hepatobiliary and Pancreatic Surgery Department, Bordeaux University Hospital Center, Bordeaux, France.
- Bordeaux Institute of Oncology, BRIC U1312, INSERM, Bordeaux University, Bordeaux, France.
| | - Arthur Marichez
- Hepatobiliary and Pancreatic Surgery Department, Bordeaux University Hospital Center, Bordeaux, France
- Bordeaux Institute of Oncology, BRIC U1312, INSERM, Bordeaux University, Bordeaux, France
| | - Jean-Philippe Adam
- Hepatobiliary and Pancreatic Surgery Department, Bordeaux University Hospital Center, Bordeaux, France
| | - Bruno Lapuyade
- Radiology Department, Bordeaux University Hospital Center, Bordeaux, France
| | - Frederic Debordeaux
- Nuclear Medicine Department, Bordeaux University Hospital Center, Bordeaux, France
| | - Ghoufrane Tlili
- Nuclear Medicine Department, Bordeaux University Hospital Center, Bordeaux, France
| | - Laurence Chiche
- Hepatobiliary and Pancreatic Surgery Department, Bordeaux University Hospital Center, Bordeaux, France
| | - Christophe Laurent
- Hepatobiliary and Pancreatic Surgery Department, Bordeaux University Hospital Center, Bordeaux, France
- Bordeaux Institute of Oncology, BRIC U1312, INSERM, Bordeaux University, Bordeaux, France
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Hung KC, Wang HP, Li WF, Lin YC, Wang CC. Single center experience with ALPPS and timing with stage 2 in patients with fibrotic/cirrhotic liver. Updates Surg 2024; 76:1213-1221. [PMID: 38494567 PMCID: PMC11341627 DOI: 10.1007/s13304-024-01782-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Accepted: 02/03/2024] [Indexed: 03/19/2024]
Abstract
Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) is a novel procedure for major resection in patients with insufficient future liver remnant (FLR). Effective FLR augmentation is pivotal in the completion of ALPPS. Liver fibrosis/cirrhosis associated with chronic viral hepatitis impairs liver regeneration. To investigate the augmentation of FLR in associating ALPPS between patients with fibrotic/cirrhotic livers (FL) and non-fibrotic livers (NFL) and compare their short-term clinical outcomes and long-term survival. Patients were divided into two groups based on the Ishak modified staging: non-fibrotic liver group (NFL, stage 0) and fibrotic/cirrhotic liver group (FL, stage 1-5/6). Weekly liver regeneration in FLR, perioperative data, and survival outcomes were investigated. Twenty-seven patients with liver tumors underwent ALPPS (NFL, n = 7; FL, n = 20). NFL and FL patients had viral hepatitis (28.6% [n = 2] and 95% [n = 19]), absolute FLR volume increments of 134.90 ml and 161.85 ml (p = 0.825), and rates of hypertrophy were 16.46 ml/day and 13.66 ml/day (p = 0.507), respectively. In the FL group, baseline FLR volume was 360.13 ml, postoperatively it increased to a plateau (542.30 ml) in week 2 and declined (378.45 ml) in week 3. One patient (3.7%) with cirrhotic liver (stage 6) failed to proceed to ALPPS-II. The overall ALPPS-related major complication rate was 7.4%. ALPPS is feasible for fibrotic liver patients classified by Ishak modified stages ≤ 5. After ALPPS-I, 14 days for FLR augmentation seems an appropriate waiting time to reach a maximum FLR volume in these patients.
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Affiliation(s)
- Kuo-Chen Hung
- Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, 123 Ta-Pei Road, Niao-Song, Kaohsiung, 833, Taiwan
- Chang Gung University College of Medicine, Taoyüan, Taiwan
| | - Hao-Ping Wang
- Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, 123 Ta-Pei Road, Niao-Song, Kaohsiung, 833, Taiwan
- Chang Gung University College of Medicine, Taoyüan, Taiwan
| | - Wei-Feng Li
- Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, 123 Ta-Pei Road, Niao-Song, Kaohsiung, 833, Taiwan
- Chang Gung University College of Medicine, Taoyüan, Taiwan
| | - Yu-Cheng Lin
- Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, 123 Ta-Pei Road, Niao-Song, Kaohsiung, 833, Taiwan
- Chang Gung University College of Medicine, Taoyüan, Taiwan
| | - Chih-Chi Wang
- Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, 123 Ta-Pei Road, Niao-Song, Kaohsiung, 833, Taiwan.
- Chang Gung University College of Medicine, Taoyüan, Taiwan.
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Heil J, Augath M, Kurtcuoglu V, Hohmann J, Bechstein WO, Olthof P, Schnitzbauer AA, Seebeck P, Schiesser M, Schläpfer M, Beck-Schimmer B, Schadde E. Assessment of liver function by gadoxetic acid avidity in MRI in a model of rapid liver regeneration in rats. HPB (Oxford) 2024; 26:521-529. [PMID: 38185541 DOI: 10.1016/j.hpb.2023.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 11/18/2023] [Accepted: 12/18/2023] [Indexed: 01/09/2024]
Abstract
BACKGROUND This animal study investigates the hypothesis of an immature liver growth following ALPPS (associating liver partition and portal vein ligation for staged hepatectomy) by measuring liver volume and function using gadoxetic acid avidity in magnetic resonance imaging (MRI) in models of ALPPS, major liver resection (LR) and portal vein ligation (PVL). METHODS Wistar rats were randomly allocated to ALPPS, LR or PVL. In contrast-enhanced MRI scans with gadoxetic acid (Primovist®), liver volume and function of the right median lobe (=future liver remnant, FLR) and the deportalized lobes (DPL) were assessed until post-operative day (POD) 5. Liver functionFLR/DPL was defined as the inverse value of time from injection of gadoxetic acid to the blood pool-corrected maximum signal intensityFLR/DPL multiplied by the volumeFLR/DPL. RESULTS In ALPPS (n = 6), LR (n = 6) and PVL (n = 6), volumeFLR and functionFLR increased proportionally, except on POD 1. Thereafter, functionFLR exceeded volumeFLR increase in LR and ALPPS, but not in PVL. Total liver function was significantly reduced after LR until POD 3, but never undercuts 60% of its pre-operative value following ALPPS and PVL. DISCUSSION This study shows for the first time that functional increase is proportional to volume increase in ALPPS using gadoxetic acid avidity in MRI.
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Affiliation(s)
- Jan Heil
- Institute of Physiology, University of Zurich, Zurich, Switzerland; Goethe University Frankfurt, University Hospital, Department of General, Visceral, Transplant and Thoracic Surgery, Germany
| | - Mark Augath
- Institute for Biomedical Engineering, ETH Zurich, Zurich, Switzerland
| | - Vartan Kurtcuoglu
- The Interface Group, Institute of Physiology, University of Zurich, Zurich, Switzerland
| | - Joachim Hohmann
- Department of Radiology and Nuclear Medicine, Cantonal Hospital Winterthur, Winterthur, Switzerland; Medical Faculty, University of Basel, Basel, Switzerland
| | - Wolf O Bechstein
- Goethe University Frankfurt, University Hospital, Department of General, Visceral, Transplant and Thoracic Surgery, Germany
| | - Pim Olthof
- Department of Surgery, Erasmus MC, Rotterdam, the Netherlands; Department of Surgery, Amsterdam UMC, Amsterdam, the Netherlands
| | - Andreas A Schnitzbauer
- Goethe University Frankfurt, University Hospital, Department of General, Visceral, Transplant and Thoracic Surgery, Germany
| | - Petra Seebeck
- Zurich Integrative Rodent Physiology (ZIRP), University of Zurich, Zurich, Switzerland
| | - Marc Schiesser
- Chirurgisches Zentrum Zürich (CZZ), Klinik Hirslanden Zurich, Zurich, Switzerland; Chirurgie Zentrum Zentralschweiz (CZZ) Hirslanden St. Anna, Lucerne, Switzerland
| | - Martin Schläpfer
- Institute of Physiology, University of Zurich, Zurich, Switzerland; Institute of Anesthesiology, University Hospital of Zurich, University of Zurich, Zurich, Switzerland
| | - Beatrice Beck-Schimmer
- Institute of Physiology, University of Zurich, Zurich, Switzerland; Institute of Anesthesiology, University Hospital of Zurich, University of Zurich, Zurich, Switzerland
| | - Erik Schadde
- Institute of Physiology, University of Zurich, Zurich, Switzerland; Chirurgisches Zentrum Zürich (CZZ), Klinik Hirslanden Zurich, Zurich, Switzerland; Chirurgie Zentrum Zentralschweiz (CZZ) Hirslanden St. Anna, Lucerne, Switzerland; Department of Surgery, Rush University Medical Center Chicago, IL, USA.
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Magistri P, Guidetti C, Catellani B, Caracciolo D, Odorizzi R, Frassoni S, Bagnardi V, Guerrini GP, Di Sandro S, Di Benedetto F. Robotic ALPPS for primary and metastatic liver tumours: short-term outcomes versus open approach. Updates Surg 2024; 76:435-445. [PMID: 38326663 DOI: 10.1007/s13304-023-01680-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 10/25/2023] [Indexed: 02/09/2024]
Abstract
Associating Liver Partition and Portal vein ligation for Staged hepatectomy (ALPPS) is one of the strategies available for patients initially unresectable. High risk of peri-operative morbidity and mortality limited its application and diffusion. We aimed to analyse short-term outcomes of robotic ALPPS versus open approach, to assess safety and reproducibility of this technique. A retrospective analysis of prospectively maintained databases at University of Modena and Reggio Emilia on patients that underwent ALPPS between January 2015 and September 2022 was conducted. The main aim of the study was to evaluate safety and feasibility of robotic approach, either full robotic or only first-stage robotic, compared to a control group of patients who underwent open ALPPS in the same Institution. 23 patients were included. Nine patients received a full open ALPPS (O-ALPPS), 7 received a full robotic ALPPS (R-ALPPS), and 7 underwent a robotic approach for stage 1, followed by an open approach for stage 2 (R + O-ALPPS). PHLF grade B-C after stage 1 was 0% in all groups, rising to 58% in the R + O-ALPPS group after stage 2 and remaining 0% in the R-ALPPS group. 86% of R-ALPPS cases were discharged from the hospital between stages 1 and 2, and median total in-hospital stay and ICU stay favoured full robotic approach as well. This contemporary study represents the largest series of robotic ALPPS, showing potential advantages from full robotic ALPPS over open approach, resulting in reduced hospital stay and complications and lower incidence of 90-day mortality.
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Affiliation(s)
- Paolo Magistri
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University Hospital of Modena "Policlinico", University of Modena and Reggio Emilia, 41124, Modena, Italy
| | - Cristiano Guidetti
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University Hospital of Modena "Policlinico", University of Modena and Reggio Emilia, 41124, Modena, Italy
| | - Barbara Catellani
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University Hospital of Modena "Policlinico", University of Modena and Reggio Emilia, 41124, Modena, Italy
| | - Daniela Caracciolo
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University Hospital of Modena "Policlinico", University of Modena and Reggio Emilia, 41124, Modena, Italy
| | - Roberta Odorizzi
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University Hospital of Modena "Policlinico", University of Modena and Reggio Emilia, 41124, Modena, Italy
| | - Samuele Frassoni
- Department of Statistics and Quantitative Methods, University of Milan-Bicocca, Milan, Italy
| | - Vincenzo Bagnardi
- Department of Statistics and Quantitative Methods, University of Milan-Bicocca, Milan, Italy
| | - Gian Piero Guerrini
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University Hospital of Modena "Policlinico", University of Modena and Reggio Emilia, 41124, Modena, Italy
| | - Stefano Di Sandro
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University Hospital of Modena "Policlinico", University of Modena and Reggio Emilia, 41124, Modena, Italy
| | - Fabrizio Di Benedetto
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University Hospital of Modena "Policlinico", University of Modena and Reggio Emilia, 41124, Modena, Italy.
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5
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Mehrabi A, Golriz M, Ramouz A, Khajeh E, Hammad A, Hackert T, Müller-Stich B, Strobel O, Ali-Hasan-Al-Saegh S, Ghamarnejad O, Al-Saeedi M, Springfeld C, Rupp C, Mayer P, Mieth M, Goeppert B, Hoffmann K, Büchler MW. Promising Outcomes of Modified ALPPS for Staged Hepatectomy in Cholangiocarcinoma. Cancers (Basel) 2023; 15:5613. [PMID: 38067316 PMCID: PMC10705795 DOI: 10.3390/cancers15235613] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Revised: 11/13/2023] [Accepted: 11/22/2023] [Indexed: 09/14/2024] Open
Abstract
Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) is a two-stage procedure that can potentially cure patients with large cholangiocarcinoma. The current study evaluates the impact of modifications on the outcomes of ALPPS in patients with cholangiocarcinoma. In this single-center study, a series of 30 consecutive patients with cholangiocarcinoma (22 extrahepatic and 8 intrahepatic) who underwent ALPPS between 2011 and 2021 was evaluated. The ALPPS procedure in our center was modified in 2016 by minimizing the first stage of the surgical procedure through biliary externalization after the first stage, antibiotic administration during the interstage phase, and performing biliary reconstructions during the second stage. The rate of postoperative major morbidity and 90-day mortality, as well as the one- and three-year disease-free and overall survival rates were calculated and compared between patients operated before and after 2016. The ALPPS risk score before the second stage of the procedure was lower in patients who were operated on after 2016 (before 2016: median 6.4; after 2016: median 4.4; p = 0.010). Major morbidity decreased from 42.9% before 2016 to 31.3% after 2016, and the 90-day mortality rate decreased from 35.7% before 2016 to 12.5% after 2016. The three-year survival rate increased from 40.8% before 2016 to 73.4% after 2016. Our modified ALPPS procedure improved perioperative and postoperative outcomes in patients with extrahepatic and intrahepatic cholangiocarcinoma. Minimizing the first step of the ALPPS procedure was key to these improvements.
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Affiliation(s)
- Arianeb Mehrabi
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, 69120 Heidelberg, Germany
- Liver Cancer Center Heidelberg (LCCH), Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Mohammad Golriz
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, 69120 Heidelberg, Germany
- Liver Cancer Center Heidelberg (LCCH), Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Ali Ramouz
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, 69120 Heidelberg, Germany
| | - Elias Khajeh
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, 69120 Heidelberg, Germany
| | - Ahmed Hammad
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, 69120 Heidelberg, Germany
| | - Thilo Hackert
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, 69120 Heidelberg, Germany
- Liver Cancer Center Heidelberg (LCCH), Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Beat Müller-Stich
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, 69120 Heidelberg, Germany
- Liver Cancer Center Heidelberg (LCCH), Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Oliver Strobel
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, 69120 Heidelberg, Germany
- Liver Cancer Center Heidelberg (LCCH), Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Sadeq Ali-Hasan-Al-Saegh
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, 69120 Heidelberg, Germany
| | - Omid Ghamarnejad
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, 69120 Heidelberg, Germany
| | - Mohammed Al-Saeedi
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, 69120 Heidelberg, Germany
| | - Christoph Springfeld
- Liver Cancer Center Heidelberg (LCCH), Heidelberg University Hospital, 69120 Heidelberg, Germany
- Department of Medical Oncology, National Center for Tumor Diseases, Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Christian Rupp
- Department of Internal Medicine, Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Philipp Mayer
- Department of Interventional Radiology, Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Markus Mieth
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, 69120 Heidelberg, Germany
| | - Benjamin Goeppert
- Liver Cancer Center Heidelberg (LCCH), Heidelberg University Hospital, 69120 Heidelberg, Germany
- Institute of Pathology, Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Katrin Hoffmann
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, 69120 Heidelberg, Germany
- Liver Cancer Center Heidelberg (LCCH), Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Markus W. Büchler
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, 69120 Heidelberg, Germany
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Kambakamba P, Schneider MA, Linecker M, Kirimker EO, Moeckli B, Graf R, Reiner CS, Nguyen-Kim TDL, Kologlu M, Karayalcin K, Clavien PA, Balci D, Petrowsky H. Early Postoperative Serum Phosphate Drop Predicts Sufficient Hypertrophy After Liver Surgery. Ann Surg 2023; 278:763-771. [PMID: 37465990 DOI: 10.1097/sla.0000000000006013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/20/2023]
Abstract
OBJECTIVE The aim of this study was to assess the impact of postoperative hypophosphatemia on liver regeneration after major liver surgery in the scenario of Associating Liver Partition with Portal vein ligation for Staged hepatectomy (ALPPS) and living liver donation (LLD). BACKGROUND Hypophosphatemia has been described to reflect the metabolic demands of regenerating hepatocytes. Both ALPPS and LLD are characterized by an exceptionally strong liver regeneration and may be of particular interest in the context of posthepatectomy hypophosphatemia. METHODS Serum phosphate changes within the first 7 postoperative days after ALPPS (n=61) and LLD (n=54) were prospectively assessed and correlated with standardized volumetry after 1 week. In a translational approach, postoperative phosphate changes were investigated in mice and in vitro . RESULTS After ALPPS stage 1 and LLD, serum phosphate levels significantly dropped from a preoperative median of 1.08 mmol/L [interquartile range (IQR) 0.92-1.23] and 1.07 mmol/L (IQR 0.91-1.21) to a postoperative median nadir of 0.68 and 0.52 mmol/L, respectively. A pronounced phosphate drop correlated well with increased liver hypertrophy ( P <0.001). Patients with a low drop of phosphate showed a higher incidence of posthepatectomy liver failure after ALPPS (7% vs 31%, P =0.041). Like in humans, phosphate drop correlated significantly with degree of hypertrophy in murine ALPPS and hepatectomy models ( P <0.001). Blocking phosphate transporter (Slc20a1) inhibited cellular phosphate uptake and hepatocyte proliferation in vitro. CONCLUSION Phosphate drop after hepatectomy is a direct surrogate marker for liver hypertrophy. Perioperative implementation of serum phosphate analysis has the potential to detect patients with insufficient regenerative capacity at an early stage.
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Affiliation(s)
- Patryk Kambakamba
- Department of Surgery and Transplantation, University Hospital Zürich, Zürich, Switzerland
- Hepatobiliary Group, St. Vincents's University Hospital, Dublin, Ireland
- Department of Surgery, Cantonal Hospital Winterthur, Winterthur, Switzerland
| | - Marcel A Schneider
- Department of Surgery and Transplantation, University Hospital Zürich, Zürich, Switzerland
| | - Michael Linecker
- Department of Surgery and Transplantation, University Hospital Zürich, Zürich, Switzerland
- Department of Surgery and Transplantation, University Hospital Schleswig Holstein, Kiel, Germany
| | - Elvan Onur Kirimker
- Department of Surgery and Transplantation, Ankara University School of Medicine, Ankara, Turkey
| | - Beat Moeckli
- Department of Surgery and Transplantation, University Hospital Zürich, Zürich, Switzerland
| | - Rolf Graf
- Department of Surgery and Transplantation, University Hospital Zürich, Zürich, Switzerland
| | - Cäcilia S Reiner
- Diagnostic and Interventional Radiology, University Hospital Zürich, Zürich, Switzerland
| | | | - Meltem Kologlu
- Department of Surgery and Transplantation, Ankara University School of Medicine, Ankara, Turkey
| | - Kaan Karayalcin
- Department of Surgery and Transplantation, Ankara University School of Medicine, Ankara, Turkey
| | - Pierre-Alain Clavien
- Department of Surgery and Transplantation, University Hospital Zürich, Zürich, Switzerland
| | - Deniz Balci
- Department of Surgery and Transplantation, Ankara University School of Medicine, Ankara, Turkey
- Department of Surgery and Solid Organ Transplantation, Bahcesehir University School of Medicine, Istanbul, Turkey
| | - Henrik Petrowsky
- Department of Surgery and Transplantation, University Hospital Zürich, Zürich, Switzerland
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Parente A, Cho HD, Kim KH, Schlegel A. Association between Hepatocellular Carcinoma Recurrence and Graft Size in Living Donor Liver Transplantation: A Systematic Review. Int J Mol Sci 2023; 24:ijms24076224. [PMID: 37047199 PMCID: PMC10093934 DOI: 10.3390/ijms24076224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 03/21/2023] [Accepted: 03/22/2023] [Indexed: 03/29/2023] Open
Abstract
The aim of this work was to assess the association between graft-to-recipient weight ratio (GRWR) in adult-to-adult living donor liver transplantation (LDLT) and hepatocellular carcinoma (HCC) recurrence. A search of the MEDLINE and EMBASE databases was performed until December 2022 for studies comparing different GRWRs in the prognosis of HCC recipients in LDLT. Data were pooled to evaluate 1- and 3-year survival rates. We identified three studies, including a total of 782 patients (168 GRWR < 0.8 vs. 614 GRWR ≥ 0.8%). The pooled overall survival was 85% and 77% at one year and 90% and 83% at three years for GRWR < 0.8 and GRWR ≥ 0.8, respectively. The largest series found that, in patients within Milan criteria, the GRWR was not associated with lower oncological outcomes. However, patients with HCC outside the Milan criteria with a GRWR < 0.8% had lower survival and higher tumor recurrence rates. The GRWR < 0.8% appears to be associated with lower survival rates in HCC recipients, particularly for candidates with tumors outside established HCC criteria. Although the data are scarce, the results of this study suggest that considering the individual GRWR not only as risk factor for small-for-size-syndrome but also as contributor to HCC recurrence in patients undergoing LDLT would be beneficial. Novel perfusion technologies and pharmacological interventions may contribute to improving outcomes.
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Cioffi L, Belli G, Izzo F, Fantini C, D’Agostino A, Russo G, Patrone R, Granata V, Belli A. Minimally Invasive ALPPS Procedure: A Review of Feasibility and Short-Term Outcomes. Cancers (Basel) 2023; 15:cancers15061700. [PMID: 36980586 PMCID: PMC10046857 DOI: 10.3390/cancers15061700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 02/27/2023] [Accepted: 03/05/2023] [Indexed: 03/12/2023] Open
Abstract
Background: Associated liver partition with portal vein ligation for staged hepatectomy (ALPPS) represents a recent strategy to improve resectability of extensive hepatic malignancies. Recent surgical advances, such as the application of technical variants and use of a mini-invasive approach (MI-ALPPS), have been proposed to improve clinical outcomes in terms of morbidity and mortality. Methods: A total of 119 MI-ALPPS cases from 6 series were identified and discussed to evaluate the feasibility of the procedure and short-term clinical outcomes. Results: Hepatocellular carcinoma were widely the most common indication for MI-ALPPS. The median estimated blood loss was 260 mL during Stage 1 and 1625 mL in Stage 2. The median length of the procedures was 230 min in Stage 1 and 184 in Stage 2. The median increase ratio of future liver remnant volume was 87.8%. The median major morbidity was 8.14% in Stage 1 and 23.39 in Stage 2. The mortality rate was 0.6%. Conclusions: MI-ALPPS appears to be a feasible and safe procedure, with potentially better short-term outcomes in terms of blood loss, morbidity, and mortality rate if compared with those of open series.
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Affiliation(s)
- Luigi Cioffi
- Department of General Surgery, Ospedale del Mare, 80147 Naples, Italy
- Correspondence: ; Tel.: +39-81-18775110
| | - Giulio Belli
- Department of General and HPB Surgery, Loreto Nuovo Hospital, 80127 Naples, Italy
| | - Francesco Izzo
- Division of Epatobiliary Surgical Oncology, Istituto Nazionale Tumori IRCCS Fondazione Pascale-IRCCS di Napoli, 80131 Naples, Italy
| | - Corrado Fantini
- Department of General Surgery, Pellegrini Hospital, 80134 Naples, Italy
| | | | - Gianluca Russo
- Department of General Surgery, Pellegrini Hospital, 80134 Naples, Italy
- Department of General Surgery, University of Campania Luigi Vanvitelli, 80131 Naples, Italy
| | - Renato Patrone
- Division of Epatobiliary Surgical Oncology, Istituto Nazionale Tumori IRCCS Fondazione Pascale-IRCCS di Napoli, 80131 Naples, Italy
| | - Vincenza Granata
- Division of Radiology, Istituto Nazionale Tumori IRCCS Fondazione Pascale-IRCCS di Napoli, 80131 Naples, Italy
| | - Andrea Belli
- Division of Epatobiliary Surgical Oncology, Istituto Nazionale Tumori IRCCS Fondazione Pascale-IRCCS di Napoli, 80131 Naples, Italy
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Khajeh E, Ramouz A, Dooghaie Moghadam A, Aminizadeh E, Ghamarnejad O, Ali-Hassan-Al-Saegh S, Hammad A, Shafiei S, Abbasi Dezfouli S, Nickkholgh A, Golriz M, Goncalves G, Rio-Tinto R, Carvalho C, Hoffmann K, Probst P, Mehrabi A. Efficacy of Technical Modifications to the Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy (ALPPS) Procedure: A Systematic Review and Meta-Analysis. ANNALS OF SURGERY OPEN 2022; 3:e221. [PMID: 37600287 PMCID: PMC10406102 DOI: 10.1097/as9.0000000000000221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Accepted: 09/30/2022] [Indexed: 11/11/2022] Open
Abstract
To compare the outcomes of modified-Associating Liver Partition and Portal vein Ligation for Staged hepatectomy (ALPPS) techniques with those of conventional-ALPPS. Background ALPPS is an established technique for treating advanced liver tumors. Methods PubMed, Web of Science, and Cochrane databases were searched. The outcomes were assessed by single-arm and 2-arm analyses. Results Seventeen studies containing 335 modified-ALPPS patients were included in single-arm meta-analysis. The estimated blood loss was 267 ± 29 mL (95% confidence interval [CI], 210-324 mL) during the first and 662 ± 51 mL (95% CI, 562-762 mL) during the second stage. The operation time was 166 ± 18 minutes (95% CI, 131-202 minutes) during the first and 225 ± 19 minutes (95% CI, 188-263 minutes) during the second stage. The major morbidity rate was 14% (95% CI, 9%-22%) after the first stage. The future liver remnant hypertrophy rate was 65.2% ± 5% (95% CI, 55%-75%) and the interstage interval was 16 ± 1 days (95% CI, 14-17 days). The dropout rate was 9% (95% CI, 5%-15%). The overall complication rate was 46% (95% CI, 37%-56%) and the major complication rate was 20% (95% CI, 14%-26%). The postoperative mortality rate was 7% (95% CI, 4%-11%). Seven studies containing 215 patients were included in comparative analysis. The hypertrophy rate was not different between 2 methods (mean difference [MD], -5.01; 95% CI, -19.16 to 9.14; P = 0.49). The interstage interval was shorter for partial-ALPPS (MD, 9.43; 95% CI, 3.29-15.58; P = 0.003). The overall complication rate (odds ratio [OR], 10.10; 95% CI, 2.11-48.35; P = 0.004) and mortality rate (OR, 3.74; 95% CI, 1.36-10.26; P = 0.01) were higher in the conventional-ALPPS. Conclusions The hypertrophy rate in partial-ALPPS was similar to conventional-ALPPS. This shows that minimizing the first stage of the operation does not affect hypertrophy. Moreover, the postoperative overall morbidity and mortality rates were lower following partial-ALPPS.
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Affiliation(s)
- Elias Khajeh
- From the Department of General, Visceral, and Transplantation Surgery, Ruprecht-Karls University, Heidelberg, Germany
- Department of Digestive Surgery, Hepato-Pancreato-Biliary Surgery Unit, Champalimaud Foundation, Lisbon, Portugal
| | - Ali Ramouz
- From the Department of General, Visceral, and Transplantation Surgery, Ruprecht-Karls University, Heidelberg, Germany
| | - Arash Dooghaie Moghadam
- From the Department of General, Visceral, and Transplantation Surgery, Ruprecht-Karls University, Heidelberg, Germany
| | - Ehsan Aminizadeh
- From the Department of General, Visceral, and Transplantation Surgery, Ruprecht-Karls University, Heidelberg, Germany
| | - Omid Ghamarnejad
- From the Department of General, Visceral, and Transplantation Surgery, Ruprecht-Karls University, Heidelberg, Germany
| | - Sadeq Ali-Hassan-Al-Saegh
- From the Department of General, Visceral, and Transplantation Surgery, Ruprecht-Karls University, Heidelberg, Germany
| | - Ahmed Hammad
- From the Department of General, Visceral, and Transplantation Surgery, Ruprecht-Karls University, Heidelberg, Germany
| | - Saeed Shafiei
- From the Department of General, Visceral, and Transplantation Surgery, Ruprecht-Karls University, Heidelberg, Germany
| | - Sepehr Abbasi Dezfouli
- From the Department of General, Visceral, and Transplantation Surgery, Ruprecht-Karls University, Heidelberg, Germany
| | - Arash Nickkholgh
- From the Department of General, Visceral, and Transplantation Surgery, Ruprecht-Karls University, Heidelberg, Germany
| | - Mohammad Golriz
- From the Department of General, Visceral, and Transplantation Surgery, Ruprecht-Karls University, Heidelberg, Germany
| | - Gil Goncalves
- Department of Digestive Surgery, Hepato-Pancreato-Biliary Surgery Unit, Champalimaud Foundation, Lisbon, Portugal
| | - Ricardo Rio-Tinto
- Department of Gastroenterology, Digestive Oncology Unit, Champalimaud Foundation, Lisbon, Portugal
| | - Carlos Carvalho
- Department of Clinical Oncology, Digestive Unit, Champalimaud Clinical Centre, Lisbon, Portugal
| | - Katrin Hoffmann
- From the Department of General, Visceral, and Transplantation Surgery, Ruprecht-Karls University, Heidelberg, Germany
| | - Pascal Probst
- From the Department of General, Visceral, and Transplantation Surgery, Ruprecht-Karls University, Heidelberg, Germany
| | - Arianeb Mehrabi
- From the Department of General, Visceral, and Transplantation Surgery, Ruprecht-Karls University, Heidelberg, Germany
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10
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Tang JC, Suolang WJ, Yang C, Wang Y, Tian MW, Zhang Y. Monosegmental ALPPS combined with ante-situm liver resection: A novel strategy for end-stage hepatic alveolar echinococcosis. Hepatobiliary Pancreat Dis Int 2022; 21:186-189. [PMID: 33879408 DOI: 10.1016/j.hbpd.2021.03.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Accepted: 03/18/2021] [Indexed: 02/08/2023]
Affiliation(s)
- Ji-Chao Tang
- Organ Transplantation Center, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu 610072, China; School of Clinical Medical Sciences, Southwest Medical University, Luzhou 646000, China
| | - Wang-Jie Suolang
- NHC Key Laboratory of Echinococcosis Prevention and Control, Lhasa 850000, China
| | - Chong Yang
- Organ Transplantation Center, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu 610072, China
| | - Yi Wang
- Organ Transplantation Center, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu 610072, China
| | - Ming-Wu Tian
- Organ Transplantation Center, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu 610072, China; School of Clinical Medical Sciences, Southwest Medical University, Luzhou 646000, China
| | - Yu Zhang
- Organ Transplantation Center, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu 610072, China.
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11
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Parente A, Tirotta F, Ronca V, Schlegel A, Muiesan P. Donation after Circulatory Death Liver Transplantation in Paediatric Recipients. TRANSPLANTOLOGY 2022; 3:91-102. [DOI: 10.3390/transplantology3010009] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/13/2024] Open
Abstract
Waiting list mortality together, with limited availability of organs, are one of the major challenges in liver transplantation (LT). Especially in the paediatric population, another limiting factor is the scarcity of transplantable liver grafts due to additional concerns regarding graft size matching. In adults, donation after circulatory death (DCD) liver grafts have been used to expand the donor pool with satisfactory results. Although several studies suggest that DCD livers could also be used in paediatric recipients with good outcomes, their utilisation in children is still limited to a small number of reports. Novel organ perfusion strategies could be used to improve organ quality and help to increase the number of DCD grafts utilised for children. With the current manuscript, we present the available literature of LT using DCD grafts in paediatric recipients, discussing current challenges with the use of these livers in children and how machine perfusion technologies could be of impact in the future.
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12
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Acciuffi S, Meyer F, Bauschke A, Croner R, Settmacher U, Altendorf-Hofmann A. Solitary colorectal liver metastasis: overview of treatment strategies and role of prognostic factors. J Cancer Res Clin Oncol 2021; 148:657-665. [PMID: 34914005 PMCID: PMC8881245 DOI: 10.1007/s00432-021-03880-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2021] [Accepted: 12/07/2021] [Indexed: 12/09/2022]
Abstract
The following is an overview of the treatment strategies and the prognostic factors to consider in the therapeutic choice of patients characterized by solitary colorectal liver metastasis. Liver resection is the only potential curative option; nevertheless, only 25% of the patients are considered to be eligible for surgery. To expand the potentially resectable pool of patients, surgeons developed multidisciplinary techniques like portal vein embolization, two-stage hepatectomy or associating liver partition and portal vein ligation for staged hepatectomy. Moreover, mini-invasive surgery is gaining support, since it offers lower post-operative complication rates and shorter hospital stay with no differences in long-term outcomes. In case of unresectable disease, various techniques of local ablation have been developed. Radiofrequency ablation is the most commonly used form of thermal ablation: it is widely used for unresectable patients and is trying to find its role in patients with small resectable metastasis. The identification of prognostic factors is crucial in the choice of the treatment strategy. Previous works that focused on patients with solitary colorectal liver metastasis obtained trustable negative predictive factors such as presence of lymph-node metastasis in the primary tumour, synchronous metastasis, R status, right-sided primary colon tumor, and additional presence of extrahepatic tumour lesion. Even the time factor could turn into a predictor of tumour biology as well as further clinical course, and could be helpful to discern patients with worse prognosis.
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Affiliation(s)
- S Acciuffi
- Department of General, Abdominal and Vascular Surgery, University Hospital, Leipziger Str. 44, 39120, Magdeburg, Germany
| | - F Meyer
- Department of General, Abdominal and Vascular Surgery, University Hospital, Leipziger Str. 44, 39120, Magdeburg, Germany
| | - A Bauschke
- Department of General, Abdominal and Vascular Surgery, University Hospital, Am Klinikum 1, 07747, Jena, Germany
| | - R Croner
- Department of General, Abdominal and Vascular Surgery, University Hospital, Leipziger Str. 44, 39120, Magdeburg, Germany
| | - U Settmacher
- Department of General, Abdominal and Vascular Surgery, University Hospital, Am Klinikum 1, 07747, Jena, Germany
| | - A Altendorf-Hofmann
- Department of General, Abdominal and Vascular Surgery, University Hospital, Am Klinikum 1, 07747, Jena, Germany.
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13
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Lang H, Baumgart J, Mittler J. Associated Liver Partition and Portal Vein Ligation for Staged Hepatectomy (ALPPS) Registry: What Have We Learned? Gut Liver 2021; 14:699-706. [PMID: 32036644 PMCID: PMC7667932 DOI: 10.5009/gnl19233] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Revised: 10/01/2019] [Accepted: 10/24/2019] [Indexed: 12/15/2022] Open
Abstract
In 2007, the first associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) procedure was performed in Regensburg, Germany. ALPPS is a variation of two-stage hepatectomy to induce rapid liver hypertrophy allowing the removal of large tumors otherwise considered irresectable due to a too small future liver remnant. In 2012, the international ALPPS registry was created, and it now contains more than 1,000 cases. During the past years, improved patient selection and refinements in operative techniques, in particular, less invasive approaches such as Partial ALPPS, Tourniquet ALPPS, Ablation-assisted ALPPS, Hybrid ALPPS or Laparoscopic or Robotic approaches, have resulted in significant improvements in safety. The most frequent indication for ALPPS is colorectal liver metastases. In the first randomized controlled study, ALPPS provided a higher resectability rate than conventional two-stage hepatectomy, with similar complication rates. Long-term outcome data are still missing. The initial results of ALPPS for hepatocellular carcinoma and for perihilar cholangiocarcinoma were devastating, but with progress in surgical technic and better patient selection, ALPPS could serve as a treatment alternative in carefully selected cases, even for these tumors. ALPPS has enlarged the armamentarium of hepato-pancreato-biliary surgeons, but there is still discussion regarding how to use this novel technique, which may allow resection of tumors that are otherwise deemed irresectable.
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Affiliation(s)
- Hauke Lang
- Department of General, Visceral, and Transplant Surgery, University Medical Center, Mainz, Germany
| | - Janine Baumgart
- Department of General, Visceral, and Transplant Surgery, University Medical Center, Mainz, Germany
| | - Jens Mittler
- Department of General, Visceral, and Transplant Surgery, University Medical Center, Mainz, Germany
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14
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The evolution of surgery for colorectal liver metastases: A persistent challenge to improve survival. Surgery 2021; 170:1732-1740. [PMID: 34304889 DOI: 10.1016/j.surg.2021.06.033] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Revised: 06/01/2021] [Accepted: 06/21/2021] [Indexed: 02/07/2023]
Abstract
Only a few decades ago, the opinion that colorectal liver metastases were a palliative diagnosis changed. In fact, previously, the prevailing view was strongly resistant against resecting colorectal liver metastases. Constant technical improvement of liver surgery and, much later, effective chemotherapy allowed for a successful wider application of surgery. The clinical use of portal vein embolization was the starting signal of regenerative liver surgery, where insufficient liver volume can be expanded to an extent where safe resection is possible. Today, a number of these techniques including portal vein ligation, associating liver partition and portal vein ligation for staged hepatectomy, and bi-embolization (portal and hepatic vein) can be successfully used to address an insufficient future liver remnant in staged resections. It turned out that the road to success is embedding surgery in a well-orchestrated oncological concept of controlling systemic disease. This concept was the prerequisite that meant liver transplantation could enter the treatment strategy for colorectal liver metastases, ending up with a 5-year overall survival of 80% in highly selected cases. In particular, techniques combining principles of 2-stage hepatectomy and liver transplantation, such as "resection and partial liver segment 2-3 transplantation with delayed total hepatectomy" (RAPID) are on the rise. These techniques enable the use of partial liver grafts with primarily insufficient liver volume. All this progress also prompted a number of innovative local therapies to address recurrences ultimately transferring colorectal liver metastases from instantly deadly into a chronic disease in some cases.
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15
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Induction of liver hypertrophy for extended liver surgery and partial liver transplantation: State of the art of parenchyma augmentation-assisted liver surgery. Langenbecks Arch Surg 2021; 406:2201-2215. [PMID: 33740114 PMCID: PMC8578101 DOI: 10.1007/s00423-021-02148-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 03/03/2021] [Indexed: 12/17/2022]
Abstract
Background Liver surgery and transplantation currently represent the only curative treatment options for primary and secondary hepatic malignancies. Despite the ability of the liver to regenerate after tissue loss, 25–30% future liver remnant is considered the minimum requirement to prevent serious risk for post-hepatectomy liver failure. Purpose The aim of this review is to depict the various interventions for liver parenchyma augmentation–assisting surgery enabling extended liver resections. The article summarizes one- and two-stage procedures with a focus on hypertrophy- and corresponding resection rates. Conclusions To induce liver parenchymal augmentation prior to hepatectomy, most techniques rely on portal vein occlusion, but more recently inclusion of parenchymal splitting, hepatic vein occlusion, and partial liver transplantation has extended the technical armamentarium. Safely accomplishing major and ultimately total hepatectomy by these techniques requires integration into a meaningful oncological concept. The advent of highly effective chemotherapeutic regimen in the neo-adjuvant, interstage, and adjuvant setting has underlined an aggressive surgical approach in the given setting to convert formerly “palliative” disease into a curative and sometimes in a “chronic” disease.
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16
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Sparrelid E, Hasselgren K, Røsok BI, Larsen PN, Schultz NA, Carling U, Fallentin E, Gilg S, Sandström P, Lindell G, Björnsson B. How should liver hypertrophy be stimulated? A comparison of upfront associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) and portal vein embolization (PVE) with rescue possibility. Hepatobiliary Surg Nutr 2021; 10:1-8. [PMID: 33575285 DOI: 10.21037/hbsn.2019.10.36] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2019] [Accepted: 10/08/2019] [Indexed: 12/17/2022]
Abstract
Background The role of associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) in comparison to portal vein embolization (PVE) is debated. The aim of this study was to compare successful resection rates (RR) with upfront ALPPS vs. PVE with rescue ALPPS on demand and to compare the hypertrophy of the liver between ALPPS and PVE plus subsequent rescue ALPPS. Methods A retrospective analysis of all patients treated with PVE for colorectal liver metastasis (CRLM) or ALPPS (any diagnosis, rescue ALPPS included) at five Scandinavian university hospitals during the years 2013-2016 was conducted. A Chi-square test and a Mann-Whitney U test were used to assess the difference between the groups. A successful RR was defined as liver resection without a 90-day mortality. Results A total of 189 patients were included. Successful RR was in 84.5% of the patients with ALPPS upfront and in 73.3% of the patients with PVE and rescue ALPPS on demand (P=0.080). The hypertrophy of the future liver remnants (FLRs) with ALPPS upfront was 71% (48-97%) compared to 96% (82-113%) after PVE and rescue ALPPS (P=0.010). Conclusions Upfront ALPPS offers a somewhat higher successful RR than PVE with rescue ALPPS on demand. The sequential combination of PVE and ALPPS leads to a higher overall degree of hypertrophy than upfront ALPPS.
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Affiliation(s)
- Ernesto Sparrelid
- Department of Clinical Science, Intervention and Technology, Division of Surgery, Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden
| | - Kristina Hasselgren
- Department of Surgery and Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Bård Ingvald Røsok
- Department of Hepato-Pancreato-Biliary Surgery, Oslo University Hospital, Oslo, Norway
| | - Peter Nørgaard Larsen
- Department of Surgical Gastroenterology and Transplantation, Rigshospitalet, University of Copenhagen, Denmark
| | - Nicolai Aagaard Schultz
- Department of Surgical Gastroenterology and Transplantation, Rigshospitalet, University of Copenhagen, Denmark
| | - Ulrik Carling
- Department of Radiology and Nuclear Medicin, Rikshospitalet, Oslo University Hospital, Oslo, Norway
| | - Eva Fallentin
- Department of Radiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Stefan Gilg
- Department of Clinical Science, Intervention and Technology, Division of Surgery, Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden
| | - Per Sandström
- Department of Surgery and Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Gert Lindell
- Department of Surgery, Skane University Hospital, Lund, Sweden
| | - Bergthor Björnsson
- Department of Surgery and Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
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17
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Modern therapeutic approaches for the treatment of malignant liver tumours. Nat Rev Gastroenterol Hepatol 2020; 17:755-772. [PMID: 32681074 DOI: 10.1038/s41575-020-0314-8] [Citation(s) in RCA: 113] [Impact Index Per Article: 28.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/05/2020] [Indexed: 02/06/2023]
Abstract
Malignant liver tumours include a wide range of primary and secondary tumours. Although surgery remains the mainstay of curative treatment, modern therapies integrate a variety of neoadjuvant and adjuvant strategies and have achieved dramatic improvements in survival. Extensive tumour loads, which have traditionally been considered unresectable, are now amenable to curative treatment through systemic conversion chemotherapies followed by a variety of interventions such as augmentation of the healthy liver through portal vein occlusion, staged surgeries or ablation modalities. Liver transplantation is established in selected patients with hepatocellular carcinoma but is now emerging as a promising option in many other types of tumour such as perihilar cholangiocarcinomas, neuroendocrine or colorectal liver metastases. In this Review, we summarize the available therapies for the treatment of malignant liver tumours, with an emphasis on surgical and ablative approaches and how they align with other therapies such as modern anticancer drugs or radiotherapy. In addition, we describe three complex case studies of patients with malignant liver tumours. Finally, we discuss the outlook for future treatment, including personalized approaches based on molecular tumour subtyping, response to targeted drugs, novel biomarkers and precision surgery adapted to the specific tumour.
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18
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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: 22] [Impact Index Per Article: 5.5] [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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19
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Madoff DC, Odisio BC, Schadde E, Gaba RC, Bennink RJ, van Gulik TM, Guiu B. Improving the Safety of Major Resection for Hepatobiliary Malignancy: Portal Vein Embolization and Recent Innovations in Liver Regeneration Strategies. Curr Oncol Rep 2020; 22:59. [PMID: 32415401 DOI: 10.1007/s11912-020-00922-x] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE OF REVIEW For three decades, portal vein embolization (PVE) has been the "gold-standard" strategy to hypertrophy the anticipated future liver remnant (FLR) in advance of major hepatectomy. During this time, CT volumetry was the most common method to preoperatively assess FLR quality and function and used to determine which patients are appropriate surgical candidates. This review provides the most up-to-date methods for preoperatively assessing the anticipated FLR and summarizes data from the currently available strategies used to induce FLR hypertrophy before surgery for hepatobiliary malignancy. RECENT FINDINGS Functional and physiological imaging is increasingly replacing standard CT volumetry as the method of choice for preoperative FLR assessment. PVE, associating liver partition and portal vein ligation, radiation lobectomy, and liver venous deprivation are all currently available techniques to hypertrophy the FLR. Each strategy has pros and cons based on tumor type, extent of resection, presence or absence of underlying liver disease, age, performance status, complication rates, and other factors. Numerous strategies can lead to FLR hypertrophy and improve the safety of major hepatectomy. Which is best has yet to be determined.
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Affiliation(s)
- David C Madoff
- Department of Radiology and Biomedical Imaging, Section of Interventional Radiology, Yale School of Medicine, New Haven, CT, USA.
| | - Bruno C Odisio
- Department of Interventional Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Erik Schadde
- Department of Surgery, Rush University Medical Center, Chicago, IL, USA.,Department of Surgery, Cantonal Hospital Winterthur, Zurich, Switzerland.,Institute of Physiology, Center for Integrative Human Physiology, University of Zurich, Zurich, Switzerland
| | - Ron C Gaba
- Department of Radiology, Interventional Radiology Section, University of Illinois Hospital, Chicago, IL, USA
| | - Roelof J Bennink
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Thomas M van Gulik
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Boris Guiu
- Department of Radiology, St-Eloi University Hospital-Montpellier, Montpellier, France
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20
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Hernandez-Alejandro R, Ruffolo LI, Alikhanov R, Björnsson B, Torres OJM, Serrablo A. Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy (ALPPS) procedure for colorectal liver metastasis. Int J Surg 2020; 82S:103-108. [PMID: 32305531 DOI: 10.1016/j.ijsu.2020.04.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 03/24/2020] [Accepted: 04/01/2020] [Indexed: 12/24/2022]
Abstract
Since first described, Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy (ALPPS) has garnered boisterous praise and fervent criticism. Its rapid adoption and employment for a variety of indications resulted in high perioperative morbidity and mortality. However recent risk stratification, refinement of technique to reduce the impact of stage I and progression along the learning curve have resulted in improved outcomes. The first randomized trial comparing ALPPS to two stage hepatectomy (TSH) for colorectal liver metastases (CRLM) was recently published demonstrating comparable perioperative morbidity and mortality with improved resectability and survival following ALPPS. In this review, as ALPPS enters the thirteenth year since conception, the current status of this contentious two stage technique is presented and best practices for deployment in the treatment of CRLM is codified.
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Affiliation(s)
- Roberto Hernandez-Alejandro
- Department of Surgery and Division of Abdominal Transplantation and Hepatobiliary Surgery, University of Rochester Medical Center, Rochester, USA.
| | - Luis I Ruffolo
- Department of Surgery and Division of Abdominal Transplantation and Hepatobiliary Surgery, University of Rochester Medical Center, Rochester, USA
| | - Ruslan Alikhanov
- Department of Liver and Pancreatic Surgery, Clinical Research Center of Moscow, Moscow, Russia
| | - Bergthor Björnsson
- Department of Surgery in Linköping, And Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Orlando Jorge M Torres
- Department of Gastrointestinal Surgery, Hepatopancreatobiliary Unit, University Hospital and School of Medicine, Federal University of Maranhão, São Luís, Brazil
| | - Alejandro Serrablo
- Division of Surgery, Miguel Servet University Hospital and University of Zaragoza School of Medicine, Zaragoza, Spain
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21
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Abstract
BACKGROUND Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) has gained both interest and controversy, as an alternative to portal vein embolisation (PVE) by inducing future liver remnant hypertrophy in patients at risk of liver failure following major hepatectomy. Open ALPPS induces more extensive hypertrophy in a shorter timespan than PVE; however, it is also associated with higher complication rates and mortality. Minimally invasive surgery (MIS), with its known benefits, has been applied to ALPPS in the hope of reducing the surgical insult and improving functional recovery time while preserving the extensive FLR hypertrophy. METHODS A search of the PubMed, Medline, EMBASE and Cochrane Library databases was conducted on 10 July 2019. 1231 studies were identified and screened. 19 open ALPPS studies, 3 MIS ALPPS and 1 study reporting on both were included in the analysis. RESULTS 1088 open and 46 MIS-ALPPS cases were included in the analysis. There were significant differences in the baseline characteristic: open ALPPS patients had a more diverse profile of underlying pathologies (p = 0.028) and comparatively more right extended hepatectomies (p = 0.006) as compared to right hepatectomy and left extended hepatectomy performed. Operative parameters (time and blood loss) did not differ between the two groups. MIS ALPPS had a lower rate of severe Clavien-Dindo complications (≥ IIIa) following stage 1 (p = 0.063) and significantly lower median mortality (0.00% vs 8.45%) (p = 0.007) compared to open ALPPS. CONCLUSION Although MIS ALPPS would seem to be better than open ALPPS with reduced morbidity and mortality rates, there is still limited evidence on MIS ALPPS. There is a need for a higher quality of evidence on MIS ALPPS vs. open ALPPS to answer whether MIS ALPPS can replace open ALPPS.
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Rassam F, Olthof PB, van Lienden KP, Bennink RJ, Erdmann JI, Swijnenburg RJ, Busch OR, Besselink MG, van Gulik TM. Comparison of functional and volumetric increase of the future remnant liver and postoperative outcomes after portal vein embolization and complete or partial associating liver partition and portal vein ligation for staged hepatectomy (ALPPS). ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:436. [PMID: 32395480 PMCID: PMC7210209 DOI: 10.21037/atm.2020.03.191] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Background Portal vein embolization (PVE) is performed to induce hypertrophy of an insufficient future remnant liver (FRL) before major liver resection. Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) aims to offer a more rapid and increased hypertrophy response. The first stage can be performed with complete or partial (laparoscopic) transection of the liver parenchyma. This study aimed to investigate the increase in FRL volume and function, as well as postoperative outcomes after PVE or complete- or partial-ALPPS1. Methods Patients with insufficient FRL undergoing either PVE or ALPPS underwent CT-volumetry and functional assessment using 99mTc-mebrofenin hepatobiliary scintigraphy (HBS). Severe complications and 90-day mortality were evaluated after liver resection. Results Seventy-two patients were included; 51 underwent PVE, 12 complete-ALPPS1 and 9 partial-ALPPS1 of which 7 laparoscopic. The median increase in FRL function was 1.5-, 1.7- and 1.3-fold higher, respectively, than the increase in volume; (P<0.01, P<0.01 and P=0.44). The target hypertrophy response did not differ between the groups, but was reached earlier in both ALPPS1 groups (8 and 10 days) compared to the PVE group (23 days). Of the resected patients, 18%, 30% and 17% had severe postoperative complications and the 90-day mortality was 2%, 25% and 0%, respectively. Conclusions Increase of FRL function exceeded increase of volume after both PVE and ALPPS1. The target hypertrophy response was reached earlier in ALPPS. Complete and partial-ALPPS1 showed comparable functional and volumetric hypertrophy responses. A (laparoscopic) partial-ALPPS1 is preferred considering lower morbidity and mortality rates after resection.
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Affiliation(s)
- Fadi Rassam
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, The Netherlands
| | - Pim B Olthof
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, The Netherlands
| | - Krijn P van Lienden
- Departments of Radiology and Nuclear Medicine, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, The Netherlands
| | - Roel J Bennink
- Departments of Radiology and Nuclear Medicine, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, The Netherlands
| | - Joris I Erdmann
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, The Netherlands
| | - Rutger-Jan Swijnenburg
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, The Netherlands
| | - Olivier R Busch
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, The Netherlands
| | - Marc G Besselink
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, The Netherlands
| | - Thomas M van Gulik
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, The Netherlands
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Kawka M, Gall TMH, Jiao LR. Minimum invasive associating liver partition and portal vein ligation for staged hepatectomy. LAPAROSCOPIC, ENDOSCOPIC AND ROBOTIC SURGERY 2020. [DOI: 10.1016/j.lers.2019.08.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
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24
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Affiliation(s)
- Hauke Lang
- Department of General, Visceral, and Transplant Surgery, University Medical Center, Mainz, Germany.
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25
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Kron P, Kimura N, Farid S, Lodge JPA. Current role of trisectionectomy for hepatopancreatobiliary malignancies. Ann Gastroenterol Surg 2019; 3:606-619. [PMID: 31788649 PMCID: PMC6875946 DOI: 10.1002/ags3.12292] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Revised: 09/24/2019] [Accepted: 09/30/2019] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Trisectionectomy is a treatment option in extensive liver malignancy, including colorectal liver metastases (CRLM). However, the reported experience of this procedure is limited. Therefore, we present our experience with right hepatic trisectionectomy (RHT) for CRLM as an example and discuss the changing role of trisectionectomy in the context of modern treatment alternatives based on a literature review. METHODS Between January 1993 and December 2014 all patients undergoing RHT at a single center in the UK for CRLM were included. Patient and tumor characteristics were reviewed and a multivariate analysis was done. Based on a literature review the role of trisectionectomy in the treatment of HPB malignancies was discussed. RESULTS A total of 211 patients undergoing RHT were included. Overall perioperative morbidity was 40.3%. Overall 90-day mortality was 7.6% but reduced to 2.8% over time. Multivariate analysis identified additional organ resection (P = .040) and blood transfusion (P = .028) as independent risk factors for morbidity. Multiple tumors, total hepatic vascular exclusion, and R1 resection were independent risk factors for significantly decreased disease-free and disease-specific survival. Further surgery for recurrence after RHT significantly prolonged survival compared with palliative chemotherapy only. CONCLUSION With the further development of surgical and multimodal treatment strategies in CRLM the indications for trisectionectomy are decreasing. Having being formerly associated with high rates of perioperative morbidity and mortality, this single-center experience clearly shows that these concomitant risks decrease with experience, liberal use of portal vein embolization and improved patient selection. Trisectionectomy remains relevant in selected patients.
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Affiliation(s)
- Philipp Kron
- Department of HPB and Transplant SurgerySt. James's University HospitalLeedsUK
| | - Norihisa Kimura
- Department of HPB and Transplant SurgerySt. James's University HospitalLeedsUK
| | - Shahid Farid
- Department of HPB and Transplant SurgerySt. James's University HospitalLeedsUK
| | - J. Peter A. Lodge
- Department of HPB and Transplant SurgerySt. James's University HospitalLeedsUK
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26
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Dili A, Bertrand C, Lebrun V, Pirlot B, Leclercq IA. Hypoxia protects the liver from Small For Size Syndrome: A lesson learned from the associated liver partition and portal vein ligation for staged hepatectomy (ALPPS) procedure in rats. Am J Transplant 2019; 19:2979-2990. [PMID: 31062475 DOI: 10.1111/ajt.15420] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Revised: 04/23/2019] [Accepted: 04/24/2019] [Indexed: 02/07/2023]
Abstract
Portal hyperperfusion and "dearterialization" of the liver remnant are the main pathogenic mechanisms for Small For Size syndrome (SFSS). Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) induces rapid remnant hypertrophy. We hypothesized a similar increase in portal pressure/flow into the future liver remnant in ALPPS and SFSS-setting hepatectomies. In a rodent model, ALPPS was compared to SFSS-setting hepatectomy. We assessed mortality, remnant hypertrophy, hepatocyte proliferation, portal and hepatic artery flow, hypoxia-induced response, and liver sinusoidal morphology. SFSS-hepatectomy rats were subjected to local (hepatic artery ligation) or systemic (Dimethyloxalylglycine) hypoxia. ALLPS prevented mortality in SFSS-setting hepatectomies. Portal hyperperfusion per liver mass was similar in ALLPS and SFSS. Compared to SFSS, efficient arterial perfusion of the remnant was significantly lower in ALPPS causing pronounced hypoxia confirmed by pimonidazole immunostaining, activation of hypoxia sensors and upregulation of neo-angiogenic genes. Liver sinusoids, larger in ALPPS, collapsed in SFSS. Induction of hypoxia in SFSS reduced mortality. Hypoxia had no impact on hepatocyte proliferation but contributed to the integrity of sinusoidal morphology. ALPPS hemodynamically differ from SFSS by a much lower arterial flow in ALPPS's FLR. We show that the ensuing hypoxic response is essential for the function of the regenerating liver by preserving sinusoidal morphology.
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Affiliation(s)
- Alexandra Dili
- Institut de Recherche Expérimentale et Clinique, Laboratory of Hepato-Gastroenterology, Université Catholique de Louvain, Brussels, Belgium.,Department of Surgery, Centre Hospitalier Universitaire UCLouvain-Namur, Yvoir, Belgium
| | - Claude Bertrand
- Department of Surgery, Centre Hospitalier Universitaire UCLouvain-Namur, Yvoir, Belgium
| | - Valérie Lebrun
- Institut de Recherche Expérimentale et Clinique, Laboratory of Hepato-Gastroenterology, Université Catholique de Louvain, Brussels, Belgium
| | - Boris Pirlot
- Institut de Recherche Expérimentale et Clinique, Laboratory of Hepato-Gastroenterology, Université Catholique de Louvain, Brussels, Belgium
| | - Isabelle A Leclercq
- Institut de Recherche Expérimentale et Clinique, Laboratory of Hepato-Gastroenterology, Université Catholique de Louvain, Brussels, Belgium
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Wu X, Rao J, Zhou X, Deng R, Ma Y. Partial ALPPS versus complete ALPPS for staged hepatectomy. BMC Gastroenterol 2019; 19:170. [PMID: 31655548 PMCID: PMC6815396 DOI: 10.1186/s12876-019-1090-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Accepted: 10/07/2019] [Indexed: 12/17/2022] Open
Abstract
Background Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) can induce a stronger regenerative ability than traditional 2-stage hepatectomy (TSH). ALPPS has become popular for achieving fast hypertrophy in patients with an insufficient future liver remnant (FLR). However, ALPPS is associated with high morbidity and mortality. Partial ALPPS is a variation that may decrease the morbidity and mortality. The purpose of this study was to perform a meta-analysis comparing outcomes of ALLPS and partial ALLPS. Methods PubMed, Embase, and Cochrane Library databases were searched for studies comparing partial ALPPS and complete ALPPS up to April 2019. Included studies were assessed by the Newcastle-Ottawa Scale (NOS). Weighted mean difference (WMD)/standard mean difference (SMD) and odds ratios (OR) with 95% confidence intervals (CIs) were calculated to compare FLR, time interval between stages, postoperative complications, and mortality between partial and complete ALPPS. Results Four studies including 124 patients were included. FLR hypertrophy of partial ALPPS was comparable to complete ALPPS (p = 0.09). The time interval between stages was not different between the 2 procedures (p = 0.57). The postoperative complications rate of partial ALPPS was significantly lower than that of complete ALPPS (OR = 0.38; p = 0.03). The mortality rate of partial ALLPS (4.9%) was lower than that of complete ALLPS (18.9%), but the difference was not significant (OR = 0.37; p = 0.12). Conclusions Partial ALLPS is associated with similar FLR hypertrophy and time interval between stages as complete ALLPS, and a lower complication rate. Further studies are needed to examine patient selection and outcomes of the 2 procedures.
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Affiliation(s)
- Xukun Wu
- Department of Organ Transplantation, First Affiliated Hospital of Sun, Yat-sen University, No. 58 Zhongshan 2nd Road, Guangzhou, 510080, China
| | - Jiawei Rao
- Department of Organ Transplantation, First Affiliated Hospital of Sun, Yat-sen University, No. 58 Zhongshan 2nd Road, Guangzhou, 510080, China
| | - Xiaozhuan Zhou
- Department of Organ Transplantation, First Affiliated Hospital of Sun, Yat-sen University, No. 58 Zhongshan 2nd Road, Guangzhou, 510080, China
| | - Ronghai Deng
- Department of Organ Transplantation, First Affiliated Hospital of Sun, Yat-sen University, No. 58 Zhongshan 2nd Road, Guangzhou, 510080, China.
| | - Yi Ma
- Department of Organ Transplantation, First Affiliated Hospital of Sun, Yat-sen University, No. 58 Zhongshan 2nd Road, Guangzhou, 510080, China.
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28
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Huang HC, Bian J, Bai Y, Lu X, Xu YY, Sang XT, Zhao HT. Complete or partial split in associating liver partition and portal vein ligation for staged hepatectomy: A systematic review and meta-analysis. World J Gastroenterol 2019; 25:6016-6024. [PMID: 31660037 PMCID: PMC6815793 DOI: 10.3748/wjg.v25.i39.6016] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2019] [Revised: 09/17/2019] [Accepted: 09/28/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) has been adopted by liver surgeons in recent years. However, high morbidity and mortality rates have limited the promotion of this technique. Some recent studies have suggested that ALPPS with a partial split can effectively induce the growth of future liver remnant (FLR) similar to a complete split with better postoperative safety profiles. However, some others have suggested that ALPPS can induce more rapid and adequate FLR growth, but with the same postoperative morbidity and mortality rates as in partial split of the liver parenchyma in ALPPS (p-ALPPS).
AIM To perform a systematic review and meta-analysis on ALPPS and p-ALPPS.
METHODS A systematic literature search of PubMed, Embase, the Cochrane Library, and ClinicalTrials.gov was performed for articles published until June 2019. Studies comparing the outcomes of p-ALPPS and ALPPS for a small FLR in consecutive patients were included. Our main endpoints were the morbidity, mortality, and FLR hypertrophy rates. We performed a subgroup analysis to evaluate patients with and without liver cirrhosis. We assessed pooled data using a random-effects model.
RESULTS Four studies met the inclusion criteria. Four studies reported data on morbidity and mortality, and two studies reported the FLR hypertrophy rate and one study involved patients with cirrhosis. In the non-cirrhotic group, p-ALPPS-treated patients had significantly lower morbidity and mortality rates than ALPPS-treated patients [odds ratio (OR) = 0.2; 95% confidence interval (CI): 0.07–0.57; P = 0.003 and OR = 0.16; 95%CI: 0.03-0.9; P = 0.04]. No significant difference in the FLR hypertrophy rate was observed between the two groups (P > 0.05). The total effects indicated no difference in the FLR hypertrophy rate or perioperative morbidity and mortality rates between the ALPPS and p-ALPPS groups. In contrast, ALPPS seemed to have a better outcome in the cirrhotic group.
CONCLUSION The findings of our study suggest that p-ALPPS is safer than ALPPS in patients without cirrhosis and exhibits the same rate of FLR hypertrophy.
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Affiliation(s)
- Han-Chun Huang
- Department of Liver Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Jin Bian
- Department of Liver Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Yi Bai
- Department of Liver Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Xin Lu
- Department of Liver Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Yi-Yao Xu
- Department of Liver Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Xin-Ting Sang
- Department of Liver Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Hai-Tao Zhao
- Department of Liver Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
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29
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Abstract
OBJECTIVE Associating Liver Partition and Portal vein ligation for Staged hepatectomy (ALPPS) has been tested in various indications and clinical scenarios, leading to steady improvements in safety. This report presents the current status of ALPPS. SUMMARY BACKGROUND DATA ALPPS offers improved resectability, but drawbacks are regularly pointed out regarding safety and oncologic benefits. METHODS During the 12th biennial congress of the European African-Hepato-Pancreato-Biliary Association (Mainz, Germany, May 23-26, 2017) an expert meeting "10th anniversary of ALPP" was held to discuss indications, management, mechanisms of regeneration, as well as pitfalls of this novel technique. The aim of the meeting was to make an inventory of what has been achieved and what remains unclear in ALPPS. RESULTS Precise knowledge of liver anatomy and its variations is paramount for success in ALPPS. Technical modifications, mainly less invasive approaches like partial, mini- or laparoscopic ALPPS, mostly aiming at minimizing the extensiveness of the first-stage procedure, are associated with improved safety. In fibrotic/cirrhotic livers the degree of future liver remnant hypertrophy after ALPPS appears some less than that in noncirrhotic. Recent data from the only prospective randomized controlled trial confirmed significant higher resection rates in ALPPS with similar peri-operative morbidity and mortality rates compared with conventional 2-stage hepatectomy including portal vein embolization. ALPPS is effective reliably even after failure of portal vein embolization. CONCLUSIONS Although ALPPS is now an established 2-stage hepatectomy additional data are warranted to further refine indication and technical aspects. Long-term oncological outcome results are needed to establish the place of ALPPS in patients with initially nonresectable liver tumors.
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30
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Kron P, Linecker M, Jones RP, Toogood GJ, Clavien PA, Lodge JPA. Ablation or Resection for Colorectal Liver Metastases? A Systematic Review of the Literature. Front Oncol 2019; 9:1052. [PMID: 31750233 PMCID: PMC6843026 DOI: 10.3389/fonc.2019.01052] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Accepted: 09/27/2019] [Indexed: 12/12/2022] Open
Abstract
Background: Successful use of ablation for small hepatocellular carcinomas (HCC) has led to interest in the role of ablation for colorectal liver metastases (CRLM). However, there remains a lack of clarity about the use of ablation for colorectal liver metastases (CRLM), specifically its efficacy compared with hepatic resection. Methods: A systematic review of the literature on ablation or resection of colorectal liver metastases was performed using MEDLINE, Cochrane Library, and Embase until December 2018. The aim of this study was to summarize the evidence for ablation vs. resection in the treatment of CRLM. Results: This review identified 1,773 studies of which 18 were eligible for inclusion. In the majority of the studies, overall survival (OS) and disease-free survival (DFS) were significantly higher and local recurrence (LR) rates were significantly lower in the resection groups. On subgroup analysis of solitary CRLM, resection was associated with improved OS, DFS, and reduced LR. Three series assessed the outcome of resection vs. ablation for technically resectable CRLM, and showed improved outcome in the resection group. In fact, there were no studies showing a survival advantage of ablation compared to resection in the treatment of CRLM. Conclusions: Resection remains the "gold standard" in the treatment of CRLM and should not be replaced by ablation at present. This review supports the use of ablation only as an adjunct to resection and as a single treatment option when resection is not safely possible.
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Affiliation(s)
- Philipp Kron
- Department of HPB and Transplant Surgery, St. James's University Hospital, NHS Trust, Leeds, United Kingdom
| | - Michael Linecker
- Department of Surgery and Transplantation, Swiss HPB and Transplant Center, University Hospital Zurich, Zurich, Switzerland
| | - Robert P Jones
- Department of HPB and Transplant Surgery, St. James's University Hospital, NHS Trust, Leeds, United Kingdom
| | - Giles J Toogood
- Department of HPB and Transplant Surgery, St. James's University Hospital, NHS Trust, Leeds, United Kingdom
| | - Pierre-Alain Clavien
- Department of Surgery and Transplantation, Swiss HPB and Transplant Center, University Hospital Zurich, Zurich, Switzerland
| | - J P A Lodge
- Department of HPB and Transplant Surgery, St. James's University Hospital, NHS Trust, Leeds, United Kingdom
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31
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ALPPS Improves Resectability Compared With Conventional Two-stage Hepatectomy in Patients With Advanced Colorectal Liver Metastasis: Results From a Scandinavian Multicenter Randomized Controlled Trial (LIGRO Trial). Ann Surg 2019; 267:833-840. [PMID: 28902669 PMCID: PMC5916470 DOI: 10.1097/sla.0000000000002511] [Citation(s) in RCA: 201] [Impact Index Per Article: 40.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Objective: The aim of the study was to evaluate if associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) could increase resection rates (RRs) compared with two-stage hepatectomy (TSH) in a randomized controlled trial (RCT). Background: Radical liver metastasis resection offers the only chance of a cure for patients with metastatic colorectal cancer. Patients with colorectal liver metastasis (CRLM) and an insufficient future liver remnant (FLR) volume are traditionally treated with chemotherapy with portal vein embolization or ligation followed by hepatectomy (TSH). This treatment sometimes fails due to insufficient liver growth or tumor progression. Methods: A prospective, multicenter RCT was conducted between June 2014 and August 2016. It included 97 patients with CRLM and a standardized FLR (sFLR) of less than 30%. Primary outcome—RRs were measured as the percentages of patients completing both stages of the treatment. Secondary outcomes were complications, radicality, and 90-day mortality measured from the final intervention. Results: Baseline characteristics, besides body mass index, did not differ between the groups. The RR was 92% [95% confidence interval (CI) 84%–100%] (44/48) in the ALPPS arm compared with 57% (95% CI 43%–72%) (28/49) in the TSH arm [rate ratio 8.25 (95% CI 2.6–26.6); P < 0.0001]. No differences in complications (Clavien–Dindo ≥3a) [43% (19/44) vs 43% (12/28)] [1.01 (95% CI 0.4–2.6); P = 0.99], 90-day mortality [8.3% (4/48) vs 6.1% (3/49)] [1.39 [95% CI 0.3–6.6]; P = 0.68] or R0 RRs [77% (34/44) vs 57% (16/28)] [2.55 [95% CI 0.9–7.1]; P = 0.11)] were observed. Of the patients in the TSH arm that failed to reach an sFLR of 30%, 12 were successfully treated with ALPPS. Conclusion: ALPPS is superior to TSH in terms of RR, with comparable surgical margins, complications, and short-term mortality.
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32
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Schlegel A, Sakuraoka Y, Kalisvaart M, Coldham C, Isaac J, Muiesan P. Future liver remnant portal or hepatic vein reconstruction at stage I of ALPPS-How far can we push the boundaries? J Surg Oncol 2019; 120:654-660. [PMID: 31309549 DOI: 10.1002/jso.25618] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Accepted: 06/21/2019] [Indexed: 12/12/2022]
Abstract
Preservation of the future liver remnant (FLR) vascular integrity has always been considered crucial to achieving successful liver growths after major hepatectomies. Most surgeons appeared therefore reluctant to combine stage I of associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) with vascular reconstructions. Here we describe a case series, where we combine parenchymal transection and venous in- or outflow reconstruction of the FLR at stage I of ALPPS. In addition, the cold flush of the FLR or delayed portal vein embolization is applied in selected cases.
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Affiliation(s)
- Andrea Schlegel
- The Liver Unit, Queen Elizabeth Hospital Birmingham, University of Birmingham, Birmingham, United Kingdom.,NIHR Liver Biomedical Research Unit, University Hospitals Birmingham, Birmingham, United Kingdom
| | - Yuhki Sakuraoka
- The Liver Unit, Queen Elizabeth Hospital Birmingham, University of Birmingham, Birmingham, United Kingdom.,Second Department of Surgery, Dokkyo Medical University, Tokyo, Japan
| | - Marit Kalisvaart
- The Liver Unit, Queen Elizabeth Hospital Birmingham, University of Birmingham, Birmingham, United Kingdom
| | - Chris Coldham
- The Liver Unit, Queen Elizabeth Hospital Birmingham, University of Birmingham, Birmingham, United Kingdom
| | - John Isaac
- The Liver Unit, Queen Elizabeth Hospital Birmingham, University of Birmingham, Birmingham, United Kingdom
| | - Paolo Muiesan
- The Liver Unit, Queen Elizabeth Hospital Birmingham, University of Birmingham, Birmingham, United Kingdom.,Department of Liver Surgery, Birmingham Children's Hospital NHS Foundation Trust, Birmingham, United Kingdom
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Xiang F, Hu ZM. Chance and challenge of associating liver partition and portal vein ligation for staged hepatectomy. Hepatobiliary Pancreat Dis Int 2019; 18:214-222. [PMID: 31056484 DOI: 10.1016/j.hbpd.2019.04.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Accepted: 04/18/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND The associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) was first performed in 2007. The critical patient selection, timing to perform the second stage operation, and minimally invasive technique are three key factors for patient outcomes. The aim of this review is to summarize published data on these three aspects. DATA SOURCES Studies were identified by searching PubMed for articles published from January 2007 to October 2018, using the keywords "associating liver partition and portal vein ligation for staged hepatectomy" or "ALPPS" or "in situ split". Studies on colorectal liver metastasis (CRLM), perihilar cholangiocarcinoma (PHC), and hepatocellular carcinoma (HCC) indicated for ALPPS, cutoff values to determine the timing of stage 2, as well as modifications of ALPPS were included. RESULTS The mortality of ALPPS for CRLM is declining, for PHC is high. In patients with HCC, essential hypertrophy makes the ALPPS safer. However, the degrees of fibrosis affect the hypertrophy. The future liver remnant volume is still the gold standard to start the second stage. Hepatobiliary scintigraphy plays an important role in quantitatively assessing liver function, whereas cutoff values need to be further calibrated. Less-invasive ALPPS modifications have increased and led to a decreased mortality. CONCLUSIONS ALLPS improved the CRLM outcomes; ALPPS is feasible in patients with PHC after failure of portal vein embolization; ALPPS may be an option for HCC patients with major vascular invasion and thrombosis. The simplified and less-invasive ALPPS is the trend.
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Affiliation(s)
- Fei Xiang
- Department of General Surgery, Jiangning Hospital of Nanjing Medical University, Nanjing 211100, China; Department of General Surgery, Zhongshan People's Hospital, Zhongshan 528403, China.
| | - Ze-Min Hu
- Department of General Surgery, Zhongshan People's Hospital, Zhongshan 528403, China
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Sulieman I, Elmoghazy W, Ghali MS, Mahfouz A, Elaffandi A, Khalaf H. Associating liver partition and portal vein ligation for staged hepatectomy in Qatar: Initial experience with two case series and review of the literature. Int J Surg Case Rep 2019; 58:108-116. [PMID: 31029782 PMCID: PMC6487366 DOI: 10.1016/j.ijscr.2019.03.060] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Revised: 03/14/2019] [Accepted: 03/31/2019] [Indexed: 01/07/2023] Open
Abstract
INTRODUCTION Associating Liver Partition and Portal Vein Ligation for Staged -hepatectomy (ALPPS) is an evolving procedure that allows rapid hypertrophy of the future liver remnant (FLR). We describe the first two cases performed in Qatar. CASE PRESENTATIONS Case 1: A 53 -year old male with sarcoma metastases to the liver 8 years after resection of an abdominal wall tumor, requiring an extended right hepatectomy but with in an inadequate FLR. ALPPS was done and he achieved 147% increase in the volume of the FLR within 6 days (from 15.9%-34.2%). The second stage was completed successfully on day 7. Case 2: A 59-year old male patient had colorectal liver metastases that required an extended right liver resection and had inadequate FLR of 19.8%. Seven days after the first stage, the FLR hypertrophied to 37.7% (90.2% increase in volume) and the second stage was completed successfully on day 8. Both patients had uneventful recovery and no recurrence or complications on follow up. DISCUSSION ALPPS allows large liver resections while circumventing the long delay in the conventional two staged hepatectomy and portal vein ligation/embolization. The reported morbidity and mortality in earlier series was high, but recent selection criteria and technique refinements reduce this morbidity. Many variations are still being reported. CONCLUSION ALPPS is an evolving technique that adds to the armamentarium of the liver surgeon to allow larger liver resections in a timely manner. It is feasible and safe to be performed with careful selection.
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Affiliation(s)
- Ibnouf Sulieman
- Department of Surgery, Division of Organ Transplant, Hamad General Hospital, Doha, PO Box 3050, Qatar.
| | - Walid Elmoghazy
- Department of Surgery, Division of Organ Transplant, Hamad General Hospital, Doha, PO Box 3050, Qatar; Department of Surgery, Sohag University, Sohag, Egypt.
| | - Mohammed Said Ghali
- Department of Surgery, Division of Organ Transplant, Hamad General Hospital, Doha, PO Box 3050, Qatar; Department of Surgery, Ain Shams University, Cairo, Egypt.
| | - Ahmed Mahfouz
- Department of Radiology, Hamad General Hospital, Doha, PO Box 3050, Qatar.
| | - Ahmed Elaffandi
- Department of Surgery, Division of Organ Transplant, Hamad General Hospital, Doha, PO Box 3050, Qatar; Department of Surgical Oncology, National Cancer Institute, Cairo University, Egypt.
| | - Hatem Khalaf
- Department of Surgery, Division of Organ Transplant, Hamad General Hospital, Doha, PO Box 3050, Qatar.
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Linecker M, Kuemmerli C, Clavien PA, Petrowsky H. Dealing with insufficient liver remnant: Associating liver partition and portal vein ligation for staged hepatectomy. J Surg Oncol 2019; 119:604-612. [PMID: 30847941 DOI: 10.1002/jso.25435] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2019] [Revised: 02/16/2019] [Accepted: 02/18/2019] [Indexed: 12/12/2022]
Abstract
Liver resection for colorectal liver metastases has emerged to highly successful treatment in the last decades. Key to this success is complete hepatic tumor removal and systemic disease control by chemotherapy. Associating liver partition and portal vein ligation for staged hepatectomy is the most recent two-stage resection strategy for patients with very small future liver remnant making complete tumor removal possible within 1 to 2 weeks. Oncological outcome data are being collected at the moment and first results from small series reveal promising results.
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Affiliation(s)
- Michael Linecker
- Department of Surgery and Transplantation, Swiss HPB and Transplantation Center, University Hospital Zürich, Zürich, Switzerland
| | - Christoph Kuemmerli
- Department of Surgery and Transplantation, Swiss HPB and Transplantation Center, University Hospital Zürich, Zürich, Switzerland
| | - Pierre-Alain Clavien
- Department of Surgery and Transplantation, Swiss HPB and Transplantation Center, University Hospital Zürich, Zürich, Switzerland
| | - Henrik Petrowsky
- Department of Surgery and Transplantation, Swiss HPB and Transplantation Center, University Hospital Zürich, Zürich, Switzerland
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Hepatic regeneration by associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) is feasible but attenuated in rat liver with thioacetamide-induced fibrosis. Surgery 2018; 165:345-352. [PMID: 30249433 DOI: 10.1016/j.surg.2018.08.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Revised: 08/05/2018] [Accepted: 08/08/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND The associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) procedure promotes the proliferation of the future liver remnant, but evidence to support the feasibility of ALPPS in livers with fibrosis is needed. Therefore the aim of this study was to establish a fibrotic ALPPS model in the rat to compare the capacity of regeneration in the remnant liver with or without fibrosis. METHODS In our study we first established a thioacetamide-induced fibrotic ALPPS model in rats. Then the ALPPS-induced regenerative capacities of normal and fibrotic liver were compared in this animal model. In addition, markers of regeneration, including the proliferative index and cyclin D1 and proliferating cell nuclear antigen levels, as well as various indicators of liver function were determined to evaluate the quality of the hepatic regeneration. RESULTS Compared with that of the sham group (opening of the peritoneal cavity with no further operative manipulation), the proliferation of the future liver remnant in fibrotic rat liver after the ALPPS procedure was increased on postoperative days 1, 2, and 5 (P < .039 each). In addition, the proliferative response was greater in the ALPPS group than in the ligation group subjected only to portal vein ligation of the left lateral, left middle, right, and caudate lobes (P = .099, P = .006, and P = .020 on postoperative days 1, 2, and 5, respectively). In contrast, the ALPPS-induced regenerative capacity in the fibrotic rat livers was attenuated compared with that in the normal liver on postoperative days 1, 2, and 5 (P < .031 for each) after stage I and on postoperative day 5 after stage II of the ALPPS procedure (P < .005). This attenuated the recovery of liver function, and the greater mortality rate indicated that functional proliferation was either delayed or not as extensive in the fibrotic rat livers. CONCLUSION Through establishing a rat model of thioacetamide-induced liver fibrosis, we found that ALPPS-derived liver regeneration was present and feasible in fibrotic livers, but this effect was attenuated compared with that in normal liver.
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López-López V, Robles-Campos R, Brusadin R, López-Conesa A, Navarro Á, Arevalo-Perez J, Gil PJ, Parrilla P. Tourniquet-ALPPS is a promising treatment for very large hepatocellular carcinoma and intrahepatic cholangiocarcinoma. Oncotarget 2018; 9:28267-28280. [PMID: 29963276 PMCID: PMC6021344 DOI: 10.18632/oncotarget.25538] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Accepted: 05/12/2018] [Indexed: 02/06/2023] Open
Abstract
When very large hepatocellular carcinomas (HCCs) and intrahepatic cholangiocarcinoma (IHCCs) with insufficient future liver remnants are treated using associating liver partition and portal vein ligation for staged hepatectomy (ALPPS), the outcome is often poor. We therefore tested the efficacy of a modified version of that technique, tourniquet-ALPPS. A review of the literature examining outcomes of HCC and IHCC patients treated with ALPPS revealed the incidences of morbidity ≥ III and postoperative mortality to be respectively 20.7% and 16.1% among HCC patients and 50% and 45.4% among IHCC patients. In the present case series, in which HCC and IHCC patients were treated with tourniquet-ALPPS, median tumor size was 100 mm (range: 70–200 mm). After surgical stage I, there was no morbidity, no mortality and the median future liver remnant had increased at day 7 by 76%. In surgical stage II, 100% of tumors were resectable (8 right trisectionectomies, 5 with inferior vena cava resection). Two patients experienced serious morbidity ≥ IIIB and 1 patient died (11%). One- and 3-year overall survival was 75% and 60%, respectively. Thus tourniquet-ALPPS appears to be an effective alternative to classical ALPPS for the treatment of patients with HCC or IHCC.
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Affiliation(s)
- Victor López-López
- Virgen de la Arrixaca Clinic and University Hospital, IMIB, Murcia, Spain
| | | | - Robeto Brusadin
- Virgen de la Arrixaca Clinic and University Hospital, IMIB, Murcia, Spain
| | | | - Álvaro Navarro
- Virgen de la Arrixaca Clinic and University Hospital, IMIB, Murcia, Spain
| | - Julio Arevalo-Perez
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Pedro Jose Gil
- Virgen de la Arrixaca Clinic and University Hospital, IMIB, Murcia, Spain
| | - Pascual Parrilla
- Virgen de la Arrixaca Clinic and University Hospital, IMIB, Murcia, Spain
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Lang H, Baumgart J, Mittler J. Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy in the Treatment of Colorectal Liver Metastases: Current Scenario. Dig Surg 2018; 35:294-302. [PMID: 29621745 DOI: 10.1159/000488097] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2018] [Accepted: 02/20/2018] [Indexed: 12/13/2022]
Abstract
Associating Liver Partition and Portal vein ligation for Staged hepatectomy (ALPPS) has expanded the surgical armamentarium for patients with advanced and bilateral colorectal liver metastases. However, the enthusiasm that the medical fraternity had about ALPPS was hampered by a high mortality rate and early and frequent tumor recurrence. While surgical safety has improved, mainly due to technical refinements and a better patient selection, the oncological value in the face of early tumor recurrence remains unclear. The only randomized controlled trial on ALPPS versus two-stage hepatectomy (TSH) so far confirmed that ALPPS led to higher resectability with comparable perioperative complication rate, but oncological outcome was not measured. Robust data regarding long-term outcome are still missing. TSH and ALPPS might be complementary strategies for the resection of colorectal liver metatsases (CRLM) with ALPPS being reserved for patients with no other surgical option, that is, after failed portal vein embolization or those with an extremely small future liver remnant. In other words, ALPPS can be considered a supplementary tool and a last resort in the liver surgeon's hand to offer resectability in otherwise nonresectable CRLM. In these individual cases, and always embedded into a multimodal treatment setting, ALPPS may offer a chance of complete tumor removal and prolonged survival and even a chance for cure.
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Tong YF, Meng N, Chen MQ, Ying HN, Xu M, Lu B, Hong JJ, Wang YF, Cai XJ. Maturity of associating liver partition and portal vein ligation for staged hepatectomy-derived liver regeneration in a rat model. World J Gastroenterol 2018; 24:1107-1119. [PMID: 29563755 PMCID: PMC5850130 DOI: 10.3748/wjg.v24.i10.1107] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2017] [Revised: 02/04/2018] [Accepted: 02/09/2018] [Indexed: 02/06/2023] Open
Abstract
AIM To establish a rat model for evaluating the maturity of liver regeneration derived from associating liver partition and portal vein ligation for staged hepatectomy (ALPPS).
METHODS In the present study, ALPPS, partial hepatecotmy (PHx), and sham rat models were established initially, which were validated by significant increase of proliferative markers including Ki-67, proliferating cell nuclear antigen, and cyclin D1. In the setting of accelerated proliferation in volume at the second and fifth day after ALPPS, the characteristics of newborn hepatocytes, as well as specific markers of progenitor hepatic cell, were identified. Afterwards, the detection of liver function followed by cluster analysis of functional gene expression were performed to evaluate the maturity.
RESULTS Compared with PHx and sham groups, the proliferation of FLR was significantly higher in ALPPS group (P = 0.023 and 0.001 at second day, P = 0.034 and P < 0.001 at fifth day after stage I). Meanwhile, the increased expression of proliferative markers including Ki-67, proliferating cell nuclear antigen, and cyclin D1 verified the accelerated liver regeneration derived from ALPPS procedure. However, ALPPS-induced Sox9 positive hepatocytes significantly increased beyond the portal triad, which indicated the progenitor hepatic cell was potentially involved. And the characteristics of ALPPS-induced hepatocytes indicated the lower expression of hepatocyte nuclear factor 4 and anti-tryptase in early proliferative stage. Both suggested the immaturity of ALPPS-derived liver regeneration. Additionally, the detection of liver function and functional genes expression confirmed the immaturity of renascent hepatocytes derived in early stage of ALPPS-derived liver regeneration.
CONCLUSION Our study revealed the immaturity of ALPPS-derived proliferation in early regenerative response, which indicated that the volumetric assessment overestimated the functional proliferation. This could be convincing evidence that the stage II of ALPPS should be performed prudently in patients with marginally adequate FLR, as the ALPPS-derived proliferation in volume lags behind the functional regeneration.
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Affiliation(s)
- Yi-Fan Tong
- Department of General Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou 310000, Zhejiang Province, China
| | - Ning Meng
- Department of General Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou 310000, Zhejiang Province, China
- Department of General Surgery, Second Hospital, School of Medicine, Hangzhou Normal University, Hangzhou 310000, Zhejiang Province, China
| | - Miao-Qin Chen
- Department of Biological Treatment Research Center, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou 310000, Zhejiang Province, China
| | - Han-Ning Ying
- Department of General Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou 310000, Zhejiang Province, China
| | - Ming Xu
- Department of General Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou 310000, Zhejiang Province, China
| | - Billy Lu
- National Center for Advancing Translational Science/National Institutes of Health (NIH), Rickville 20850, American Samoa
| | - Jun-Jie Hong
- Department of General Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou 310000, Zhejiang Province, China
| | - Yi-Fan Wang
- Department of General Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou 310000, Zhejiang Province, China
| | - Xiu-Jun Cai
- Department of General Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou 310000, Zhejiang Province, China
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Schnitzbauer AA. A Comparison of Pitfalls after ALPPS Stage 1 or Portal Vein Embolization in Small-for-Size Setting Hepatectomies. Visc Med 2017; 33:435-441. [PMID: 29344517 DOI: 10.1159/000480100] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Background Portal vein embolization (PVE) followed by resection and associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) are tools to enable liver resections in small-for-size settings. Methods A systematic review of the literature and comparison of pitfalls between PVE and resection and after ALPPS stage 1 were performed. Results Evidence levels were as low as 4 for both procedures. 20 publications were identified with reports on post-PVE or post-ALPPS stage 1 pitfalls. A total of 2,758 patients treated with PVE followed by resection and 698 patients undergoing ALPPS were analyzed. Pitfalls identified were failure to advance to resection (PVE: high (20%)/ALPPS: low (1%); p = 0.0001), tumor progression (PVE: high/ALPPS: low); insufficient hypertrophy (PVE: frequent/ALPPS: rare), and inter-stage liver failure (PVE: rare/ALPPS: frequent). However, in-house mortality was still very high after ALPPS (7 vs. 3%, p = 0.0001) in a pooled analysis. Conclusion PVE is a well-established technique to induce hypertrophy in small-for-size settings. The weakness of PVE is that it may fail to advance to resection. Inter-stage liver failure in ALPPS triggers post-stage 2 mortality. Prolongation of the inter-stage interval to overcome liver failure or cancellation of the resection stage combined with adherence to defined indications has the potential to make ALPPS much safer and decrease mortality rates. Level of evidence is low for both techniques.
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Affiliation(s)
- Andreas A Schnitzbauer
- Clinic for General and Visceral Surgery, University Hospital Frankfurt, Goethe-University Frankfurt/Main, Frankfurt/M., Germany
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Alexandrino H, Rolo A, Teodoro JS, Donato H, Martins R, Serôdio M, Martins M, Tralhão JG, Caseiro Alves F, Palmeira C, Castro E Sousa F. Bioenergetic adaptations of the human liver in the ALPPS procedure - how liver regeneration correlates with mitochondrial energy status. HPB (Oxford) 2017; 19:1091-1103. [PMID: 28941575 DOI: 10.1016/j.hpb.2017.08.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2017] [Revised: 08/02/2017] [Accepted: 08/12/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND The Associating Liver Partition and Portal Ligation for Staged Hepatectomy (ALPPS) depends on a significant inter-stages kinetic growth rate (KGR). Liver regeneration is highly energy-dependent. The metabolic adaptations in ALPPS are unknown. AIMS i) Assess bioenergetics in both stages of ALPPS (T1 and T2) and compare them with control patients undergoing minor (miHp) and major hepatectomy (MaHp), respectively; ii) Correlate findings in ALPPS with volumetric data; iii) Investigate expression of genes involved in liver regeneration and energy metabolism. METHODS Five patients undergoing ALPPS, five controls undergoing miHp and five undergoing MaHp. Assessment of remnant liver bioenergetics in T1, T2 and controls. Analysis of gene expression and protein content in ALPPS. RESULTS Mitochondrial function was worsened in T1 versus miHp; and in T2 versus MaHp (p < 0.05); but improved from T1 to T2 (p < 0.05). Liver bioenergetics in T1 strongly correlated with KGR (p < 0.01). An increased expression of genes associated with liver regeneration (STAT3, ALR) and energy metabolism (PGC-1α, COX, Nampt) was found in T2 (p < 0.05). CONCLUSION Metabolic capacity in ALPPS is worse than in controls, improves between stages and correlates with volumetric growth. Bioenergetic adaptations in ALPPS could serve as surrogate markers of liver reserve and as target for energetic conditioning.
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Affiliation(s)
- Henrique Alexandrino
- Serviço de Cirurgia A dos Hospitais da Universidade de Coimbra, Centro Hospitalar e Universitário de Coimbra, Portugal; Clínica Universitária de Cirurgia III, Faculdade de Medicina, Universidade de Coimbra, Portugal.
| | - Anabela Rolo
- Departamento de Ciências da Vida, Faculdade de Ciências e Tecnologia, Universidade de Coimbra, Portugal; Centro de Neurociências e Biologia Celular, Universidade de Coimbra, Portugal
| | - João S Teodoro
- Departamento de Ciências da Vida, Faculdade de Ciências e Tecnologia, Universidade de Coimbra, Portugal; Centro de Neurociências e Biologia Celular, Universidade de Coimbra, Portugal
| | - Henrique Donato
- Serviço de Imagem Médica dos Hospitais da Universidade de Coimbra, Centro Hospitalar e Universitário de Coimbra, Portugal; Clínica Universitária de Radiologia, Faculdade de Medicina, Universidade de Coimbra, Portugal
| | - Ricardo Martins
- Serviço de Cirurgia A dos Hospitais da Universidade de Coimbra, Centro Hospitalar e Universitário de Coimbra, Portugal; Clínica Universitária de Cirurgia III, Faculdade de Medicina, Universidade de Coimbra, Portugal
| | - Marco Serôdio
- Serviço de Cirurgia A dos Hospitais da Universidade de Coimbra, Centro Hospitalar e Universitário de Coimbra, Portugal; Clínica Universitária de Cirurgia III, Faculdade de Medicina, Universidade de Coimbra, Portugal
| | - Mónica Martins
- Serviço de Cirurgia A dos Hospitais da Universidade de Coimbra, Centro Hospitalar e Universitário de Coimbra, Portugal; Clínica Universitária de Cirurgia III, Faculdade de Medicina, Universidade de Coimbra, Portugal
| | - José G Tralhão
- Serviço de Cirurgia A dos Hospitais da Universidade de Coimbra, Centro Hospitalar e Universitário de Coimbra, Portugal; Clínica Universitária de Cirurgia III, Faculdade de Medicina, Universidade de Coimbra, Portugal
| | - Filipe Caseiro Alves
- Serviço de Imagem Médica dos Hospitais da Universidade de Coimbra, Centro Hospitalar e Universitário de Coimbra, Portugal; Clínica Universitária de Radiologia, Faculdade de Medicina, Universidade de Coimbra, Portugal
| | - Carlos Palmeira
- Departamento de Ciências da Vida, Faculdade de Ciências e Tecnologia, Universidade de Coimbra, Portugal; Centro de Neurociências e Biologia Celular, Universidade de Coimbra, Portugal
| | - Francisco Castro E Sousa
- Serviço de Cirurgia A dos Hospitais da Universidade de Coimbra, Centro Hospitalar e Universitário de Coimbra, Portugal; Clínica Universitária de Cirurgia III, Faculdade de Medicina, Universidade de Coimbra, Portugal
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Stavrou GA, Donati M, Fard-Aghaie MH, Zeile M, Huber TM, Stang A, Oldhafer KJ. Did the International ALPPS Meeting 2015 Have an Impact on Daily Practice? The Hamburg Barmbek Experience of 58 Cases. Visc Med 2017; 33:456-461. [PMID: 29344520 DOI: 10.1159/000479476] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Background ALPPS (associating liver partition and portal vein ligation for staged hepatectomy) was introduced only 10 years ago and has gained wide acceptance as a variation of staged procedures in liver surgery. It has been criticized for its high morbidity and mortality, which all centers reported in their initial series. Methods After a world expert meeting in Hamburg in 2015 where all experts in the field met to discuss this method, caveats were extracted and formulated. We researched our complete prospective ALPPS database to see if the recommendations had any impact on outcome. Results In total, we performed 58 ALPPS procedures in our center. 33 patients were operated on before, 25 after the meeting. Results in terms of morbidity and mortality were significantly better after the meeting, as were patient selection and strategy. Conclusion In our own center's experience, the implementation of the meetings' recommendations and the information gathered through this valuable exchange had a dramatic impact on results. Having performed 58 ALPPS procedures in total, we can now conclude that ALPPS has become much safer in our hands since the 2015 meeting and that morbidity and mortality are no longer the issue to be discussed. Future research must focus on oncologic outcomes in these patients.
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Affiliation(s)
- Gregor A Stavrou
- General and Visceral Surgery, Surgical Oncology, Asklepios Hospital Barmbek, Hamburg, Germany.,Semmelweis Medical Faculty, Campus Hamburg, Hamburg, Germany
| | - Marcello Donati
- General and Visceral Surgery, Surgical Oncology, Asklepios Hospital Barmbek, Hamburg, Germany.,Department of Surgery, Vittorio-Emanuele University Hospital Catania, Catania, Italy
| | - Mohammad H Fard-Aghaie
- General and Visceral Surgery, Surgical Oncology, Asklepios Hospital Barmbek, Hamburg, Germany
| | - Martin Zeile
- Semmelweis Medical Faculty, Campus Hamburg, Hamburg, Germany.,Diagnostic and Interventional Radiology, Asklepios Hospital Barmbek, Hamburg, Germany
| | - Tessa M Huber
- General and Visceral Surgery, Surgical Oncology, Asklepios Hospital Barmbek, Hamburg, Germany
| | - Axel Stang
- Semmelweis Medical Faculty, Campus Hamburg, Hamburg, Germany.,Medical Oncology, Asklepios Hospital Barmbek, Hamburg, Germany
| | - Karl J Oldhafer
- General and Visceral Surgery, Surgical Oncology, Asklepios Hospital Barmbek, Hamburg, Germany.,Semmelweis Medical Faculty, Campus Hamburg, Hamburg, Germany
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Risk Adjustment in ALPPS Is Associated With a Dramatic Decrease in Early Mortality and Morbidity. Ann Surg 2017; 266:779-786. [PMID: 28806301 DOI: 10.1097/sla.0000000000002446] [Citation(s) in RCA: 96] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To longitudinally assess whether risk adjustment in Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy (ALPPS) occurred over time and is associated with postoperative outcome. BACKGROUND ALPPS is a novel 2-stage hepatectomy enabling resection of extensive hepatic tumors. ALPPS has been criticized for its high mortality, which is reported beyond accepted standards in liver surgery. Therefore, adjustments in patient selection and technique have been performed but have not yet been studied over time in relation to outcome. METHODS ALPPS centers of the International ALPPS Registry having performed ≥10 cases over a period of ≥3 years were assessed for 90-day mortality and major interstage complications (≥3b) of the longitudinal study period from 2009 to 2015. The predicted prestage 1 and 2 mortality risks were calculated for each patient. In addition, questionnaires were sent to all centers exploring center-specific risk adjustment strategies. RESULTS Among 437 patients from 16 centers, a shift in indications toward colorectal liver metastases from 53% to 77% and a reverse trend in biliary tumors from 24% to 9% were observed. Over time, 90-day mortality decreased from initially 17% to 4% in 2015 (P = 0.002). Similarly, major interstage complications decreased from 10% to 3% (P = 0.011). The reduction of 90-day mortality was independently associated with a risk adjustment in patient selection (P < 0.001; OR: 1.62; 95% CI: 1.36-1.93) and using less invasive techniques in stage-1 surgery (P = 0.019; OR: 0.39; 95% CI: 0.18-0.86). A survey indicated risk adjustment of patient selection in all centers and ALPPS technique in the majority (80%) of centers. CONCLUSIONS Risk adjustment of patient selection and technique in ALPPS resulted in a continuous drop of early mortality and major postoperative morbidity, which has meanwhile reached standard outcome measures accepted for major liver surgery.
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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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Modified ALPPS procedures: more safety through less invasive surgery. Langenbecks Arch Surg 2017; 402:563-574. [PMID: 28493147 DOI: 10.1007/s00423-017-1588-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Accepted: 05/04/2017] [Indexed: 02/06/2023]
Abstract
PURPOSE Although associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) has been advocated for treating advanced liver tumors, increased morbidity and mortality remain serious problems. Many modified procedures have been devised to improve patient safety, but some confusion persists as to benefits and risks. METHODS Modifications to ALPPS as originally reported were reviewed to clarify their contributions to safety and their clinical relevance. RESULTS A variety of modifications are explained and considered. Modifications mainly aim to reduce adhesions, prevent tumor spread, avoid devascularization during liver splitting, and reduce surgical severity. Such changes aiming to increase safety and reduce invasiveness are needed to avoid high morbidity and mortality rates with this innovative procedure. However, these modified procedures still require more meaningful statistical comparisons of outcome. CONCLUSIONS Prospective controlled studies are needed to confirm which modified procedures should be adopted in a standardized manner as an alternative to the original ALPPS. Further, we need to further explore mechanisms of liver regeneration, functional recovery, histopathologic changes of hepatocytes, and blood distribution during ALPPS simultaneously to developing and evaluating modifications of the procedure.
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Manzini G, Henne-Bruns D, Porzsolt F, Kremer M. Is there a standard for surgical therapy of hepatocellular carcinoma in healthy and cirrhotic liver? A comparison of eight guidelines. BMJ Open Gastroenterol 2017; 4:e000129. [PMID: 28405349 PMCID: PMC5372044 DOI: 10.1136/bmjgast-2016-000129] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Revised: 02/08/2017] [Accepted: 02/13/2017] [Indexed: 12/12/2022] Open
Abstract
Background and aims Liver resection (LR) and transplantation are the most reliable treatments for hepatocellular carcinoma (HCC). Aim was to compare different guidelines regarding indication for resection and transplantation because of HCC with and without underlying cirrhosis. Methods We compared the following guidelines published after 1 January 2010: American (American Association for the Study of Liver Diseases (AASLD)), Spanish (Sociedad Espanola de Oncologia Medica (SEOM)), European (European Association for the study of liver-European Organization for Research and Treatment of Cancer (EASL-EORTC) and European Society for Medical Oncology-European Society of Digestive Oncology (ESMO-ESDO)), Asian (Asian Pacific Association for the Study of Liver (APASL)), Japanese (Japan Society of Hepatology (JSH)), Italian (Associazione Italiana Oncologia Medica (AIOM)) and German (S3) guidelines. Results All guidelines recommend resection as therapy of choice in healthy liver. Guidelines based on the Barcelona Clinic Liver Cancer staging system recommend resection for single HCC<2 cm and Child-Pugh A cirrhosis and for HCC≤5 cm with normal bilirubin and portal pressure, whereas transplantation is recommended for multiple tumours between Milan criteria and for single tumours ≤5 cm and advanced liver dysfunction. Patients with HCC and Child-Pugh C cirrhosis are not candidates for transplantation. JSH guidelines recommend LR for patients with Child-Pugh A/B with HCC without tumour size restriction; APASL guidelines in general exclude patients with Child-Pugh A from transplantation. In patients with Child-Pugh B, transplantation is the second-line therapy, if resection is not possible for patients within Milan criteria. German and Italian guidelines recommend transplantation for all patients within Milan criteria. Conclusions Whereas resection is the standard therapy of HCC in healthy liver, a standard regarding the indication for LR and transplantation for HCC in cirrhotic liver does not exist, although nearly all guidelines claim to be evidence based. Surprisingly, despite European guidelines, Germany and Italy use their own national guidelines which partially differ from the European. Possible solutions of the problems are discussed.
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Affiliation(s)
- Giulia Manzini
- Department of General and Visceral Surgery , University of Ulm , Ulm , Germany
| | - Doris Henne-Bruns
- Department of General and Visceral Surgery , University of Ulm , Ulm , Germany
| | - Franz Porzsolt
- Health Care Research Group at the Hospital of General and Visceral Surgery, University Hospital of Ulm , Ulm , Germany
| | - Michael Kremer
- Department of General and Visceral Surgery , University of Ulm , Ulm , Germany
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