A Comparison of Pitfalls after ALPPS Stage 1 or Portal Vein Embolization in Small-for-Size Setting Hepatectomies

The role of ischaemia-reperfusion injury and liver regeneration in hepatic tumour recurrence

The risk of cancer recurrence after liver surgery mainly depends on tumour biology, but preclinical and clinical evidence suggests that the degree of perioperative liver injury plays a role in creating a favourable microenvironment for tumour cell engraftment or proliferation of dormant micro-metastases. Understanding the contribution of perioperative liver injury to tumour recurrence is imperative, as these pathways are potentially actionable. In this review, we examine the key mechanisms of perioperative liver injury, which comprise mechanical handling and surgical stress, ischaemia-reperfusion injury, and parenchymal loss leading to liver regeneration. We explore how these processes can trigger downstream cascades leading to the activation of the immune system and the pro-inflammatory response, cellular proliferation, angiogenesis, anti-apoptotic signals, and release of circulating tumour cells. Finally, we discuss the novel therapies under investigation to decrease ischaemia-reperfusion injury and increase regeneration after liver surgery, including pharmaceutical agents, inflow modulation, and machine perfusion.

[Treatment concepts for hepatic echinococcosis]

The incidence of both cystic (CE) and alveolar echinococcosis (AE) is increasing in Germany. The CE can often be managed with drug treatment and interventional strategies. In contrast, AE shows characteristics of a malignant disease with a high morbidity and mortality. Benzimidazoles are potent drugs for both entities but with the necessity for a lifelong follow-up and the risk of side effects as well as progression under treatment. Therefore, the indications for surgical resection have to be carefully considered; however, the combination of drug treatment and surgery is the only curative approach. Recently, the use of minimally invasive surgery with reduced morbidity and mortality has justified surgical resection for a broader set of patients; however, minimally invasive surgery requires a high level of expertise and optimal perioperative planning. Therefore, treatment strategies, especially for AE require an individual stratified risk-benefit assessment in an interdisciplinary consensus.

Early Outcomes of Extended Hepatectomy: An Experience from the University Hospital of Nepal

Background Extended hepatectomy (≥ 5 liver segments resection) may be required to have a complete surgical resection and provide the best chance of cure of hepatobiliary tumors. It is associated with high morbidity and mortality but with good perioperative care, its outcomes can be improved. This study was conducted to evaluate the early outcomes of extended hepatectomy at a university hospital in Nepal. Methods For this study, prospectively collected data from all patients who underwent extended hepatectomy from October 2012 to April 2022 were reviewed and analyzed retrospectively. Demographic data, liver volume augmentation methods used, intraoperative variables, and postoperative complications were analyzed. Results Seventeen patients underwent extended hepatectomy from October 2012 to April 2022. Among them 11 (64.7%) were female and the mean age was 53.9 ±16.3 years (18-72 years). Right extended hepatectomy was the most commonly performed procedure (n = 15, 88.2%), and left extended hepatectomy was performed in the remaining (n = 2, 11.8%). Six patients underwent liver volume augmentation procedures (35.3%) with portal vein embolization (PVE) in three, portal vein ligation (PVL) in one, and partial associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) in two patients. Overall complications were 70% with major complications (Clavien Dindo ≥ IIIa) constituting 35.3%. The most common hepatectomy-specific complication was post-hepatectomy liver failure (PHLF) in six cases. The 30-day mortality was 17.6% (three patients). Conclusion Extended hepatectomy can be performed with acceptable major complications and mortality rates in selected patients.

Rescue percutaneous transhepatic portal vein embolization after failed associated liver partition and portal vein ligation for staged hepatectomy in a patient with multiple liver metastases of rectal cancer: a case report

Background

Liver metastasis is the most common form of distant spread of colorectal cancer. Despite oncological and surgical advances, only about 25% of patients are eligible to undergo resection. As the liver has a limited resectable volume, tumor reduction and remnant liver hypertrophy are of critical importance in treating initially unresectable colorectal cancer liver metastasis. Associated liver partition and portal vein ligation for staged hepatectomy (ALPPS) allows rapid liver hypertrophy within a short period and has been reported to be useful in recent years.

Case presentation

A 29-year-old woman complaining of bloody stool was referred to our hospital. She was diagnosed with rectal cancer (Rb) with simultaneous multiple liver and lung metastases. The patient was then initially commenced on chemotherapy and completed it with a satisfactory response. Right trisectionectomy was necessary to achieve hepatic clearance; however, the future liver remnant (FLR) volume was insufficient. Therefore, we decided to perform totally laparoscopic ALPPS to obtain enough FLR volume. However, the FLR increase was slow, and FLR did not attain the required volume for right trisectionectomy. Computed tomography showed that right portal venous blood flow was increased via developed collateral vessels around the portal vein. We attempted to induce further liver growth by blocking portal blood flow using additional percutaneous transhepatic portal vein embolization (PTPE), and a rapid increase in FLR was obtained. The patient underwent right trisectionectomy and partial resection of S2 with negative margins, and the patient was discharged without postoperative liver failure.

Conclusions

Resumption of the portal venous blood flow through collateral vessels after ALPPS may have interfered with the planned residual liver hypertrophy. Performing PTPE in addition to ALPPS increased the FLR volume, and radical hepatectomy was completed safely. Remnant portal venous blood flow following ALPPS is an important issue to be considered in surgical planning, and early additional portal vein embolization could be effective.

Current evidence on posthepatectomy liver failure: comprehensive review

INTRODUCTION

Despite important advances in many areas of hepatobiliary surgical practice during the past decades, posthepatectomy liver failure (PHLF) still represents an important clinical challenge for the hepatobiliary surgeon. The aim of this review is to present the current body of evidence regarding different aspects of PHLF.

METHODS

A literature review was conducted to identify relevant articles for each topic of PHLF covered in this review. The literature search was performed using Medical Subject Heading terms on PubMed for articles on PHLF in English until May 2022.

RESULTS

Uniform reporting on PHLF is lacking due to the use of various definitions in the literature. There is no consensus on optimal preoperative assessment before major hepatectomy to avoid PHLF, although many try to estimate future liver remnant function. Once PHLF occurs, there is still no effective treatment, except liver transplantation, where the reported experience is limited.

DISCUSSION

Strict adherence to one definition is advised when reporting data on PHLF. The use of the International Study Group of Liver Surgery criteria of PHLF is recommended. There is still no widespread established method for future liver remnant function assessment. Liver transplantation is currently the only effective way to treat severe, intractable PHLF, but for many indications, this treatment is not available in most countries.

Case Report: Robotic ALPPS Procedure for Hepatocellular Carcinoma in the Right Lobe of the Liver

Introduction: Associating liver partition with portal vein ligation for staged hepatectomy (ALPPS) is a surgical procedure for liver malignancy where the volume of the liver remnant is estimated to be too small. We present the first case of two-stage robotic ALPPS procedure, illustrating the steps and advantages of robotic surgery. Materials and Methods: A 68-year-old man with morbid obesity (BMI 40), portal fibrosis, macrovesicular steatosis, and poor liver function underwent robotic ALPPS for hepatocellular carcinoma in the right lobe of the liver (segments 5, 7, and 8). A video presentation (https://youtu.be/M50Gumf-4pw) of the operative procedure is accompanied by explanation in the text with embedded corresponding video time points. Results: Both stages of the procedure were performed robotically, with negligible blood loss, and rapid surgical recovery. The patient died 3 years later. Discussion: Robotic ALPPS offers reduced morbidity in major liver surgery for malignancy and may extend survival in meticulously selected patients.

Faster Return to Intended Oncologic Treatment (RIOT) After Trisectionectomy Does Not Translate to Better Outcomes

BACKGROUND

Resection with trisectionectomy may necessitate liver molding for adequate future liver remnant (FLR), and subsequent complications can impact return to intended oncologic therapy (RIOT). This study evaluated whether a difference in RIOT exists with the use of molding and between liver molding techniques (associating liver partition and portal vein ligation for staged hepatectomy [ALPPS] and portal vein embolization [PVE]) with trisectionectomy.

METHODS

A retrospective review evaluated trisectionectomies for malignancy. Outcomes were compared with and without molding, and RIOT was determined.

RESULTS

Fifty-one patients underwent trisectionectomy: 11 ALPPS, 14 PVE, 26 without molding. 73% of ALPPS, 64% of PVE, and 58% without molding achieved RIOT (P = .971). There were no differences found in baseline characteristics, R0 rate, length of stay, readmission, complications, or mortality. Time to RIOT was significantly different (ALPPS: 3.3 months; PVE: 5.2 months; none: 2.4 months, P = .0203). There were no differences in recurrence or survival.

CONCLUSIONS

Liver molding should not cause apprehension as there are no differences in achieving RIOT. Although technique alters time to RIOT, this does not translate into improved outcomes, implicating disease biology, and regeneration stimulus.

Short-Term Outcomes of Patients Undergoing Portal Vein Embolization: an ACS-NSQIP Procedure-Targeted Hepatectomy Analysis

BACKGROUND

Preoperative portal vein embolization (PVE) is utilized to induce growth of the future liver remnant volume (FLRV) among patients at elevated risk of post-hepatectomy liver failure (PHLF).

METHODS

The American College of Surgery National Surgical Quality Improvement Program (ACS-NSQIP) database was used to compare short-term outcomes of PVE versus non-PVE patients. A propensity score match (PSM) was used to compare short-term outcomes among PVE and non-PVE patients.

RESULTS

Among the 11,243 patients included in the study, 462 (4.1%) patients had a PVE. Postoperatively, patients who underwent PVE had a higher incidence of overall (PVE, 44% vs. non-PVE, 23%) and liver-specific complications (biliary leak PVE, 16% vs. non-PVE, 7%; post-hepatectomy liver failure [PHLF] PVE, 17% vs. non-PVE, 5%), as well as a longer length of stay (> 7 days PVE, 39% vs. non-PVE, 22%) compared with the non-PVE group (all p < 0.001). After PSM, no differences in mortality or LOS were observed among PVE and non-PVE patients. PVE patients remained more likely to have a bile leak, organ/surgical-site infection, and PHLF versus non-PVE patients (all p < 0.05).

CONCLUSION

Among patients who underwent PVE before hepatectomy, the risk of postoperative complications was 1.6-fold higher than non-PVE patients. After PSM, PVE patients still had an increased risk of complications.

Role of yttrium-90 selective internal radiation therapy in the treatment of liver-dominant metastatic colorectal cancer: an evidence-based expert consensus algorithm

Surgical resection of colorectal liver metastases is associated with greater survival compared with non-surgical treatment, and a meaningful possibility of cure. However, the majority of patients are not eligible for resection and may require other non-surgical interventions, such as liver-directed therapies, to be converted to surgical eligibility. Given the number of available therapies, a general framework is needed that outlines the specific roles of chemotherapy, surgery, and locoregional treatments [including selective internal radiation therapy (SIRT) with Y-90 microspheres]. Using a data-driven, modified Delphi process, an expert panel of surgical oncologists, transplant surgeons, and hepatopancreatobiliary (HPB) surgeons convened to create a comprehensive, evidence-based treatment algorithm that includes appropriate treatment options for patients stratified by their eligibility for surgical treatment. The group coined a novel, more inclusive phrase for targeted locoregional tumor treatment (a blanket term for resection, ablation, and other emerging locoregional treatments): local parenchymal tumor destruction therapy. The expert panel proposed new nomenclature for 3 distinct disease categories of liver-dominant metastatic colorectal cancer that is consistent with other tumor types: (I) surgically treatable (resectable); (II) surgically untreatable (borderline resectable); (III) advanced surgically untreatable (unresectable) disease. Patients may present at any point in the algorithm and move between categories depending on their response to therapy. The broad intent of therapy is to transition patients toward individualized treatments where possible, given the survival advantage that resection offers in the context of a comprehensive treatment plan. This article reviews what is known about the role of SIRT with Y-90 as neoadjuvant, definitive, or palliative therapy in these different clinical situations and provides insight into when treatment with SIRT with Y-90 may be appropriate and useful, organized into distinct treatment algorithm steps.

Defining Benchmark Outcomes for ALPPS

OBJECTIVE

The aim of this study was to use the concept of benchmarking to establish robust and standardized outcome references after the procedure ALPPS (Associating Liver Partition and Portal Vein Ligation for Staged hepatectomy).

BACKGROUND AND AIMS

The recently developed ALPPS procedure, aiming at removing primarily unresectable liver tumors, has been criticized for safety issues with high variations in the reported morbidity/mortality rates depending on patient, disease, technical characteristics, and center experience. No reference values for relevant outcome parameters are available.

METHODS

Among 1036 patients registered in the international ALPPS registry, 120 (12%) were benchmark cases fulfilling 4 criteria: patients ≤67 years of age, with colorectal metastases, without simultaneous abdominal procedures, and centers having performed ≥30 cases. Benchmark values, defined as the 75th percentile of the median outcome parameters of the centers, were established for 10 clinically relevant domains.

RESULTS

The benchmark values were completion of stage 2: ≥96%, postoperative liver failure (ISGLS-criteria) after stage 2: ≤5%, ICU stay after ALPPS stages 1 and 2: ≤1 and ≤2 days, respectively, interstage interval: ≤16 days, hospital stay after ALPPS stage 2: ≤10 days, rates of overall morbidity in combining both stage 1 and 2: ≤65% and for major complications (grade ≥3a): ≤38%, 90-day comprehensive complication index was ≤22, the 30-, 90-day, and 6-month mortality was ≤4%, ≤5%, and 6%, respectively, the overall 1-year, recurrence-free, liver-tumor-free, and extrahepatic disease-free survival was ≥86%, ≥50%, ≥57%, and ≥65%, respectively.

CONCLUSIONS

This benchmark analysis sets key reference values for ALPPS, indicating similar outcome as other types of major hepatectomies. Benchmark cutoffs offer valid tools not only for comparisons with other procedures, but also to assess higher risk groups of patients or different indications than colorectal metastases.

Evaluation of the role of transhepatic flow in postoperative outcomes following major hepatectomy (THEFLOW): study protocol for a single-centre, non-interventional cohort study

INTRODUCTION

Liver resection is the only curative treatment for primary and secondary hepatic tumours. Improvements in perioperative preparation of patients and new surgical developments have made complex liver resections possible. However, small for size and flow syndrome (SFSF) is still a challenging issue, rendering patients inoperable and causing postoperative morbidity and mortality. Although the role of transhepatic flow in the postoperative outcome has been shown in small partial liver transplantation and experimental studies of SFSF, this has never been studied in the clinical setting following liver resection. The aim of this study is to systematically evaluate transhepatic flow changes following major liver resection and its correlation with postoperative outcomes.

METHODS AND ANALYSIS

The TransHEpatic FLOW (THEFLOW) study is a single-centre, non-interventional cohort study, and aims to enrol 50 patients undergoing major hepatectomy (defined as hemihepatectomy or extended hepatectomy based on the Brisbane classification) with or without prior chemotherapy. The portal venous flow, hepatic artery flow and portal venous pressure are measured before and after each resection. All patients are followed-up for 3 months after the operation. During each evaluation, standard clinical data, posthepatectomy liver failure and overall morbidity and mortality will be recorded. THEFLOW study was initiated on 25 March 2018 and is expected to progress for 2 years.

ETHICS AND DISSEMINATION

This protocol study received approval from the Ethics Committee of the University of Heidelberg (registration number: S576/2017). The results of this study will be published in a peer-reviewed journal, and will also be presented at medical meetings.

TRIAL REGISTRATION NUMBER

NCT03762876.

Chance and challenge of associating liver partition and portal vein ligation for staged hepatectomy

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.

Conversion therapy and suitable timing for subsequent salvage surgery for initially unresectable hepatocellular carcinoma: What is new?

AIM

To review the conversion therapy for initially unresectable hepatocellular carcinoma (HCC) patients and the suitable timing for subsequent salvage surgery.

METHODS

A PubMed search was undertaken from 1987 to 2017 to identify articles using the keywords including “unresectable” “hepatocellular carcinoma”, ”hepatectomy”, ”conversion therapy”, “resection”, “salvage surgery” and “downstaging”. Additional studies were investigated through a manual search of the references from the articles. The exclusion criteria were duplicates, case reports, case series, videos, contents unrelated to the topic, comments, and editorial essays. The main and widely used conversion therapies and the suitable timing for subsequent salvage surgery were discussed in detail. Two members of our group independently performed the literature search and data extraction.

RESULTS

Liver volume measurements [future liver remnant (FLR)/total liver volume or residual liver volume/bodyweight ratio] and function tests (scoring systems and liver stiffness) were often performed in order to justify whether patients were suitable candidates for surgery. Successful conversion therapy was usually defined as downstaging the tumor, increasing FLR and providing subsequent salvage surgery, without increasing complications, morbidity or mortality. The requirements for performing salvage surgery after transcatheter arterial chemoembolization were the achievement of a partial remission in radiology, the disappearance of the portal vein thrombosis, and the lack of extrahepatic metastasis. Patients with a standardized FLR (sFLR) > 20% were good candidates for surgery after portal vein embolization, while other predictive parameters like growth rate, kinetic growth rate were treated as an effective supplementary. There was probably not enough evidence to provide a standard operation time after associating liver partition and portal vein ligation for staged hepatectomy or yttrium-90 microsphere radioembolization. The indications of any combinations of conversion therapies and the subsequent salvage surgery time still need to be carefully and comprehensively evaluated.

CONCLUSION

Conversion therapy is recommended for the treatment of initially unresectable HCC, and the suitable subsequent salvage surgery time should be reappraised and is closely related to its previous therapeutic effect.