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Lu YX, Zhao JP, Zhang WG. Is ALPPS still appropriate for large or locally advanced hepatocellular carcinoma in an era of targeted agents and immunotherapy? Updates Surg 2024; 76:899-910. [PMID: 38526694 DOI: 10.1007/s13304-024-01789-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Accepted: 02/25/2024] [Indexed: 03/27/2024]
Abstract
Therapeutic options for large or locally advanced hepatocellular carcinoma (HCC) have limited efficacy. This study investigated the efficacy and safety of drug-eluting beads trans-arterial chemo-embolization (dTACE), portal vein embolization (PVE), tyrosine kinase inhibitor (TKI), and immune checkpoint inhibitors (ICI) compared to Associating Liver Partition and Portal vein ligation for Staged hepatectomy (ALPPS) for large or locally advanced HCC.Data regarding clinicopathological details, safety, and oncological outcomes were reviewed for the quadruple therapy (dTACE-PVE-TKI-ICI) and compared with ALPPS.From 2019 to 2020, 10 patients with large or locally advanced HCC underwent future remnant liver (FRL) modulation (dTACE-PVE-TKI-ICI: 5; ALPPS: 5). All five dTACE-PVE-TKI-ICI cases responded well, with patients #4 and #5 achieving complete tumor necrosis. The overall response rate (ORR) was 5/5. Patients #1-4 underwent hepatectomy, while #5 declined surgery due to complete tumor necrosis. Mean FRL volume increased by 75.3% (range 60.0%-89.4%) in 2-4 months, compared to 104.6% (range 51.3%-160.8%) in 21-37 days for ALPPS (P = 0.032). Major postoperative complications occurred in 1/5 ALPPS patients. Resection rates were 4/4 for quadruple therapy and 5/5 for ALPPS. 2-year progression free survival for dTACE-PVE-TKI-ICI and ALPPS were 5/5 and 3/5, respectively.Quadruple therapy is a feasible, effective strategy for enhancing resectability by downsizing tumors and inducing FRL hypertrophy, with manageable complications and improved long-term prognosis. In addition, it provokes the re-examination of the application of ALPPS in an era of molecular and immune treatments.
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Affiliation(s)
- Yuan-Xiang Lu
- Hepatic Surgery Center, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Wuhan, 430030, Hubei Province, China
| | - Jian-Ping Zhao
- Hepatic Surgery Center, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Wuhan, 430030, Hubei Province, China
| | - Wan-Guang Zhang
- Hepatic Surgery Center, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Wuhan, 430030, Hubei Province, China.
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Arend J, Franz M, Rose A, March C, Rahimli M, Perrakis A, Lorenz E, Croner R. Robotic Complete ALPPS (rALPPS)-First German Experiences. Cancers (Basel) 2024; 16:1070. [PMID: 38473426 DOI: 10.3390/cancers16051070] [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: 01/25/2024] [Revised: 03/02/2024] [Accepted: 03/04/2024] [Indexed: 03/14/2024] Open
Abstract
BACKGROUND ALPPS leads to fast and effective liver hypertrophy. This enables the resection of extended tumors. Conventional ALPPS is associated with high morbidity and mortality. MILS reduces morbidity and the robot adds technical features that make complex procedures safe. MATERIAL AND METHODS The MD-MILS was screened for patients who underwent rALPPS. Demographic and perioperative data were evaluated retrospectively. Ninety days postoperative morbidity was scored according to the CD classification. The findings were compared with the literature. RESULTS Since November 2021, five patients have been identified. The mean age and BMI of the patients were 50.0 years and 22.7 kg/m2. In four cases, patients suffered from colorectal liver metastases and, in one case, intrahepatic cholangiocarcinoma. Prior to the first operation, the mean liver volume of the residual left liver was 380.9 mL with a FLR-BWR of 0.677%. Prior to the second operation, the mean volume of the residual liver was 529.8 mL with a FLR-BWR of 0.947%. This was an increase of 41.9% of the residual liver volume. The first and second operations were carried out within 17.8 days. The mean time of the first and second operations was 341.2 min and 440.6 min. The mean hospital stay was 27.2 days. Histopathology showed the largest tumor size of 39 mm in diameter with a mean amount of 4.7 tumors. The mean tumor-free margin was 12.3 mm. One complication CD > 3a occurred. No patient died during the 90-day follow up. CONCLUSION In the first German series, we demonstrated that rALPPS can be carried out safely with reduced morbidity and mortality in selected patients.
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Affiliation(s)
- Jörg Arend
- Department of General-, Visceral-, Vascular- and Transplant Surgery, University Hospital Magdeburg, 39120 Magdeburg, Germany
| | - Mareike Franz
- Department of General-, Visceral-, Vascular- and Transplant Surgery, University Hospital Magdeburg, 39120 Magdeburg, Germany
| | - Alexander Rose
- Department of General-, Visceral-, Vascular- and Transplant Surgery, University Hospital Magdeburg, 39120 Magdeburg, Germany
| | - Christine March
- Department of Radiology and Nuclear Medicine, University Hospital Magdeburg, 39120 Magdeburg, Germany
| | - Mirhasan Rahimli
- Department of General-, Visceral-, Vascular- and Transplant Surgery, University Hospital Magdeburg, 39120 Magdeburg, Germany
| | - Aristotelis Perrakis
- Department of General-, Visceral-, Vascular- and Transplant Surgery, University Hospital Magdeburg, 39120 Magdeburg, Germany
| | - Eric Lorenz
- Department of General-, Visceral-, Vascular- and Transplant Surgery, University Hospital Magdeburg, 39120 Magdeburg, Germany
| | - Roland Croner
- Department of General-, Visceral-, Vascular- and Transplant Surgery, University Hospital Magdeburg, 39120 Magdeburg, Germany
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3
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Chandra P, Sacks GD. Contemporary Surgical Management of Colorectal Liver Metastases. Cancers (Basel) 2024; 16:941. [PMID: 38473303 DOI: 10.3390/cancers16050941] [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: 11/27/2023] [Revised: 02/13/2024] [Accepted: 02/19/2024] [Indexed: 03/14/2024] Open
Abstract
Colorectal cancer is the third most common cancer in the United States and the second most common cause of cancer-related death. Approximately 20-30% of patients will develop hepatic metastasis in the form of synchronous or metachronous disease. The treatment of colorectal liver metastasis (CRLM) has evolved into a multidisciplinary approach, with chemotherapy and a variety of locoregional treatments, such as ablation and portal vein embolization, playing a crucial role. However, resection remains a core tenet of management, serving as the gold standard for a curative-intent therapy. As such, the input of a dedicated hepatobiliary surgeon is paramount for appropriate patient selection and choice of surgical approach, as significant advances in the field have made management decisions extremely nuanced and complex. We herein aim to review the contemporary surgical management of colorectal liver metastasis with respect to both perioperative and operative considerations.
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Affiliation(s)
- Pratik Chandra
- Department of Surgery, NYU Grossman School of Medicine, New York, NY 10016, USA
| | - Greg D Sacks
- Department of Surgery, NYU Grossman School of Medicine, New York, NY 10016, USA
- VA New York Harbor Healthcare System, New York, NY 10010, USA
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Bekheit M, Grundy L, Salih AK, Bucur P, Vibert E, Ghazanfar M. Post-hepatectomy liver failure: A timeline centered review. Hepatobiliary Pancreat Dis Int 2023; 22:554-569. [PMID: 36973111 DOI: 10.1016/j.hbpd.2023.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 03/10/2023] [Indexed: 03/29/2023]
Abstract
BACKGROUND Post-hepatectomy liver failure (PHLF) is a leading cause of postoperative mortality after liver surgery. Due to its significant impact, it is imperative to understand the risk stratification and preventative strategies for PHLF. The main objective of this review is to highlight the role of these strategies in a timeline centered way around curative resection. DATA SOURCES This review includes studies on both humans and animals, where they addressed PHLF. A literature search was conducted across the Cochrane Library, Embase, MEDLINE/PubMed, and Web of Knowledge electronic databases for English language studies published between July 1997 and June 2020. Studies presented in other languages were equally considered. The quality of included publications was assessed using Downs and Black's checklist. The results were presented in qualitative summaries owing to the lack of studies qualifying for quantitative analysis. RESULTS This systematic review with 245 studies, provides insight into the current prediction, prevention, diagnosis, and management options for PHLF. This review highlighted that liver volume manipulation is the most frequently studied preventive measure against PHLF in clinical practice, with modest improvement in the treatment strategies over the past decade. CONCLUSIONS Remnant liver volume manipulation is the most consistent preventive measure against PHLF.
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Affiliation(s)
- Mohamed Bekheit
- Department of Surgery, NHS Grampian, Foresterhill Health Campus, Ashgrove Road, AB252ZN Aberdeen, UK; Institute of Medical Sciences, Medical School, Foresterhill Health Campus, Ashgrove Road, AB252ZN Aberdeen, UK; Hépatica, Integrated Center of HPB Care, Elite Hospital, Agriculture Road, Alexandria, Egypt.
| | - Lisa Grundy
- Department of Surgery, NHS Grampian, Foresterhill Health Campus, Ashgrove Road, AB252ZN Aberdeen, UK
| | - Ahmed Ka Salih
- Department of Surgery, NHS Grampian, Foresterhill Health Campus, Ashgrove Road, AB252ZN Aberdeen, UK; Institute of Medical Sciences, Medical School, Foresterhill Health Campus, Ashgrove Road, AB252ZN Aberdeen, UK
| | - Petru Bucur
- Department of Surgery, University Hospital Tours, Val de la Loire 37000, France
| | - Eric Vibert
- Centre Hépatobiliaire, Paul Brousse Hospital, 12 Paul Valliant Couturier, 94804 Villejuif, France
| | - Mudassar Ghazanfar
- Department of Surgery, NHS Grampian, Foresterhill Health Campus, Ashgrove Road, AB252ZN Aberdeen, UK
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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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Heil J, Schiesser M, Schadde E. Current trends in regenerative liver surgery: Novel clinical strategies and experimental approaches. Front Surg 2022; 9:903825. [PMID: 36157407 PMCID: PMC9491020 DOI: 10.3389/fsurg.2022.903825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 07/15/2022] [Indexed: 11/13/2022] Open
Abstract
Liver resections are performed to cure patients with hepatobiliary malignancies and metastases to the liver. However, only a small proportion of patients is resectable, largely because only up to 70% of liver tissue is expendable in a resection. If larger resections are performed, there is a risk of post-hepatectomy liver failure. Regenerative liver surgery addresses this limitation by increasing the future liver remnant to an appropriate size before resection. Since the 1980s, this surgery has evolved from portal vein embolization (PVE) to a multiplicity of methods. This review presents an overview of the available methods and their advantages and disadvantages. The first use of PVE was in patients with large hepatocellular carcinomas. The increase in liver volume induced by PVE equals that of portal vein ligation, but both result only in a moderate volume increase. While awaiting sufficient liver growth, 20%–40% of patients fail to achieve resection, mostly due to the progression of disease. The MD Anderson Cancer Centre group improved the PVE methodology by adding segment 4 embolization (“high-quality PVE”) and demonstrated that oncological results were better than non-surgical approaches in this previously unresectable patient population. In 2012, a novel method of liver regeneration was proposed and called Associating Liver Partition and Portal vein ligation for Staged hepatectomy (ALPPS). ALPPS accelerated liver regeneration by a factor of 2–3 and increased the resection rate to 95%–100%. However, ALPPS fell short of expectations due to a high mortality rate and a limited utility only in highly selected patients. Accelerated liver regeneration, however, was there to stay. This is evident in the multiplicity of ALPPS modifications like radiofrequency or partial ALPPS. Overall, rapid liver regeneration allowed an expansion of resectability with increased perioperative risk. But, a standardized low-risk approach to rapid hypertrophy has been missing and the techniques used and in use depend on local expertise and preference. Recently, however, simultaneous portal and hepatic vein embolization (PVE/HVE) appears to offer both rapid hypertrophy and no increased clinical risk. While prospective randomized comparisons are underway, PVE/HVE has the potential to become the future gold standard.
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Affiliation(s)
- Jan Heil
- Institute of Physiology, University of Zurich, Zurich, Switzerland
- Department of General, Visceral, Transplant and Thoracic Surgery, University Hospital, Goethe University Frankfurt, Frankfurt, Germany
| | - Marc Schiesser
- Chirurgisches Zentrum Zürich (CZZ), Klinik Hirslanden Zurich, Zurich, Switzerland
- Chirurgie Zentrum Zentralschweiz (CZZ), Hirslanden St. Anna, Lucerne, 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, Chicago, IL, United States
- Correspondence: Erik Schadde
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8
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Xiao M, Wang D, Lin GL, Lin X, Tao LY, Li QY. Safely Modified Laparoscopic Liver Resection for Segment VI and/or VII Hepatic Lesions Using the Left Lateral Decubitus Position. Int J Gen Med 2022; 15:6691-6699. [PMID: 36034184 PMCID: PMC9401608 DOI: 10.2147/ijgm.s376919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 08/10/2022] [Indexed: 12/07/2022] Open
Abstract
Purpose To explore the feasibility and safety of using the left lateral decubitus position (LLDP) to perform laparoscopic liver resection (LLR) for the treatment of hepatic lesions in segment VI and/or VII. Patients and Methods Clinical data concerning 50 patients underwent LLR including 25 patients in the LLDP and the other 25 patients in the routine operative position (ROP) at Shulan (Hangzhou) Hospital Affiliated to Zhejiang Shuren University Shulan International Medical College (Hangzhou, China) and Shulan (Quzhou) Hospital between March 2019 and May 2022 were retrospectively analyzed. All of the patients underwent LLR while in the LLDP or the ROP for the treatment of hepatic lesions located in segment VI and/or VII. Results The preoperative clinical and laboratory parameters were comparable between the two groups (P > 0.05). All patients completed the surgery successfully. There were two patients required conversion to open resection in the ROP comparing with zero in the LLDP. The mean operative time was 256.9 ± 132.7 minutes in LLDP and 255.7 ± 92.1 minutes in ROP, while the median perioperative blood loss was 100 mL (range: 50–300 mL) in LLDP and 200 mL (range: 50–425 mL), respectively. The postoperative pathological examination showed that margin-negative resection was achieved all of the cases. The important postoperative parameters all returned to normal within five days after the LLR. The mean postoperative hospital stay (15.6 vs 19.3 days; p < 0.05) and the extraction of the drainage tube time (7.8 vs 10.4 days; p < 0.05) were shorter for patients in LLDP. Conclusion The LLDP represents a safe and feasible position for performing LLR in selected patients with lesions in segment VI and/or VII. LLR in the LLDP is helpful in terms of the exposure of the surgical field and the recovery of the patient.
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Affiliation(s)
- Min Xiao
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Shulan (Hangzhou) Hospital Affiliated to Zhejiang Shuren University Shulan International Medical College, Hangzhou, People's Republic of China
| | - Di Wang
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Zhejiang Chinese Medical University, Hangzhou, People's Republic of China
| | - Guo-Ling Lin
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Shulan (Hangzhou) Hospital Affiliated to Zhejiang Shuren University Shulan International Medical College, Hangzhou, People's Republic of China
| | - Xin Lin
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Zhejiang University School of Medicine, Hangzhou, People's Republic of China
| | - Li-Yan Tao
- Division of Hepatobiliary and Pancreatic Surgery, Department of Nursing, Shulan (Hangzhou) Hospital Affiliated to Zhejiang Shuren University Shulan International Medical College, Hangzhou, People's Republic of China
| | - Qi-Yong Li
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Shulan (Hangzhou) Hospital Affiliated to Zhejiang Shuren University Shulan International Medical College, Hangzhou, People's Republic of China.,Jinan Microecological Biomedicine Shandong Laboratory, Jinan, People's Republic of China
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Evolution of associating liver partition and portal vein ligation for staged hepatectomy from 2012 to 2021: A bibliometric analysis. Review. Int J Surg 2022; 103:106648. [PMID: 35513249 DOI: 10.1016/j.ijsu.2022.106648] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 04/15/2022] [Accepted: 04/19/2022] [Indexed: 02/08/2023]
Abstract
BACKGROUND Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) has become increasingly popular during the past few decades, and its indications have extended from patients with normal liver to post-chemotherapy patients and even patients with cirrhosis. However, few studies have assessed the publications in relation to ALPPS. METHODS Web of Science was searched to identify studies related to ALPPS published from 2012 to 2021. The analysis was performed using the bibliometric package (Version 3.1.0) in R software. RESULTS In total, 486 publications were found. These articles were published in 159 journals and authored by 2157 researchers from 694 organizations. The most prolific journal was Annals of Surgery (24 articles and 1170 citations). The most frequently cited article was published in Annals of Surgery (average citations, 72.7; total citations, 727). China was the most productive country for ALPPS publications but had comparatively less interaction with other countries. Both thematic evolution and co-occurrence network analysis showed low numbers of topics such as failure, resection, and safety among the publications but large numbers of highly cited papers on outcomes, prediction, mechanisms, multicenter analysis, and novel procedures such as liver venous deprivation. A total of 196 studies focused the clinical application of ALPPS, and most studies were IDEAL Stages I and II. The specific mechanism of ALPPS liver regeneration remains unclear. CONCLUSIONS This is the first bibliometric analysis offering an overview of the development of ALPPS research publications. Our findings identified prominent studies, countries, institutions, journals, and authors to indicate the future direction of ALPPS research. The role of ALPPS in liver regeneration and the long-term results of ALPPS need further study. Future research directions include comparison of ALPPS with portal vein embolization, liver venous deprivation, and other two-stage hepatectomies as well as patients' quality of life after ALPPS.
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10
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Current Perspectives on the Surgical Management of Perihilar Cholangiocarcinoma. Cancers (Basel) 2022; 14:cancers14092208. [PMID: 35565335 PMCID: PMC9104954 DOI: 10.3390/cancers14092208] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Revised: 04/21/2022] [Accepted: 04/21/2022] [Indexed: 02/08/2023] Open
Abstract
Cholangiocarcinoma (CCA) represents nearly 15% of all primary liver cancers and 2% of all cancer-related deaths worldwide. Perihilar cholangiocarcinoma (pCCA) accounts for 50-60% of all CCA. First described in 1965, pCCAs arise between the second-order bile ducts and the insertion of the cystic duct into the common bile duct. CCA typically has an insidious onset and commonly presents with advanced, unresectable disease. Complete surgical resection is technically challenging, as tumor proximity to the structures of the central liver often necessitates an extended hepatectomy to achieve negative margins. Intraoperative frozen section can aid in assuring negative margins and complete resection. Portal lymphadenectomy provides important prognostic and staging information. In specialized centers, vascular resection and reconstruction can be performed to achieve negative margins in appropriately selected patients. In addition, minimally invasive surgical techniques (e.g., robotic surgery) are safe, feasible, and provide equivalent short-term oncologic outcomes. Neoadjuvant chemoradiation therapy followed by liver transplantation provides a potentially curative option for patients with unresectable disease. New trials are needed to investigate novel chemotherapies, immunotherapies, and targeted therapies to better control systemic disease in the adjuvant setting and, potentially, downstage disease in the neoadjuvant setting.
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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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Liver Venous Deprivation (LVD) or Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy (ALPPS)?: A Retrospective Multicentric Study. Ann Surg 2021; 274:874-880. [PMID: 34334642 DOI: 10.1097/sla.0000000000005121] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To compare two techniques of remnant liver hypertrophy in candidates for extended hepatectomy: radiological simultaneous portal vein (PVE) and hepatic vein embolization (HVE); namely liver venous deprivation (LVD), and ALPPS. SUMMARY BACKGROUND DATA Recent advances in chemotherapy and surgical techniques have widened indications for extended hepatectomy, before which remnant liver augmentation is mandatory. ALPPS and LVD typically show higher hypertrophy rates than PVE, but their respective places in patient management remain unclear. METHODS All consecutive ALPPS and LVD procedures performed in eight French centers between 2011 and 2020 were included. The main endpoint was the successful resection rate (resection rate without 90-day mortality) analyzed according to an intention-to-treat principle. Secondary endpoints were hypertrophy rates, intra- and post-operative outcomes. RESULTS Among 209 patients, 124 had LVD 37 [13,1015] days before surgery, while 85 underwent ALPPS with an inter-stages period of 10 [6, 69] days. ALPPS was mostly-performed for colorectal liver metastases (CRLM), LVD for CRLM and perihilar cholangiocarcinoma. Hypertrophy was faster for ALPPS. Successful resection rates were 72.6% for LVD ± rescue ALPPS (n=6) versus 90.6% for ALPPS (p<0.001). Operative duration, blood losses and length-of-stay were lower for LVD, while 90-day major complications and mortality were comparable. Results were globally unchanged for CRLM patients, or after excluding the early 2 years of experience (learning-curve effect). CONCLUSIONS This study is the first one comparing LVD versus ALPPS in the largest cohort so far. Despite its retrospective design, it yields original results that may serve as the basis for a prospective study.
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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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Serenari M, Ratti F, Zanello M, Guglielmo N, Mocchegiani F, Di Benedetto F, Nardo B, Mazzaferro V, Cillo U, Massani M, Colledan M, Dalla Valle R, Cescon M, Vivarelli M, Colasanti M, Ettorre GM, Aldrighetti L, Jovine E. Minimally Invasive Stage 1 to Protect Against the Risk of Liver Failure: Results from the Hepatocellular Carcinoma Series of the Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy Italian Registry. J Laparoendosc Adv Surg Tech A 2020; 30:1082-1089. [PMID: 32907480 DOI: 10.1089/lap.2020.0563] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Introduction: Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) has been described to treat hepatocellular carcinoma (HCC) but burdened, in its pioneering phase, by high morbidity and mortality. With the advent of minimally invasive (MI) techniques in liver surgery, surgical complications, including posthepatectomy liver failure (PHLF), have been dramatically reduced. The primary endpoint of this study was to compare the short-term outcomes of MI- versus open-ALPPS for HCC, with specific focus on PHLF. Methods: Data of patients submitted to ALPPS for HCC between 2012 and 2020 were identified from the ALPPS Italian Registry. Patients receiving an MI Stage 1 (MI-ALPPS) constituted the study group, whereas the patients who received an open Stage 1 (open-ALPPS) constituted the control group. Results: Sixty-six patients were enrolled from 12 Italian centers. Stage 1 of ALPPS was performed in 14 patients using an MI approach (21.2%). MI-ALPPS patients were discharged after Stage 1 at a significantly higher rate compared with open-ALPPS (78.6% versus 9.6%, P < .001). After Stage 2, major morbidity after MI-ALPPS was 8.3% compared with 28.6% reported after open-ALPPS. Mortality was nil after MI-ALPPS. Length of hospital stay was significantly shorter in MI-ALPPS (12 days versus 22 days, P < .001). Univariate logistic regression analysis (Firth method) found that both MI-ALPPS (odds ratio [OR] = 0.05, P = .040) and partial parenchymal transection (OR = 0.04, P = .027) were protective against PHLF. Conclusion: This national multicenter study showed that a less invasive approach to ALPPS first stage was associated with a lower overall risk of PHLF.
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Affiliation(s)
- Matteo Serenari
- General Surgery and Transplantation Unit, Azienda Ospedaliero-Universitaria di Bologna, Sant'Orsola-Malpighi Hospital, Bologna, Italy
| | - Francesca Ratti
- Hepatobiliary Surgery Division, San Raffaele Hospital, Milan, Italy
| | - Matteo Zanello
- Department of General Surgery, Azienda Ospedaliero-Universitaria di Bologna, Maggiore Hospital, Bologna, Italy
| | - Nicola Guglielmo
- Division of General Surgery and Liver Transplantation, S. Camillo Hospital, Rome, Italy
| | - Federico Mocchegiani
- HPB Surgery and Transplantation Unit, Department of Clinical and Experimental Medicine, Polytechnic University of Marche, Ancona, Italy
| | - Fabrizio Di Benedetto
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University of Modena and Reggio Emilia, Modena, Italy
| | - Bruno Nardo
- Department of Surgery, UOC Chirurgia Generale "Falcone," Cosenza, Italy
| | - Vincenzo Mazzaferro
- Division of HPB, General Surgery and Liver Transplantation, Department of Surgery, Fondazione IRCCS Istituto Nazionale Tumori di Milano, Milan, Italy
| | - Umberto Cillo
- Hepatobiliary and Liver Transplantation Unit, University of Padua, Padua, Italy
| | - Marco Massani
- Regional Center for HPB Surgery, Regional Hospital of Treviso, Treviso, Italy
| | - Michele Colledan
- Unit of Hepato-biliary Surgery and Liver Transplantation, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Raffaele Dalla Valle
- Hepatobiliary Surgery Unit, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Matteo Cescon
- General Surgery and Transplantation Unit, Azienda Ospedaliero-Universitaria di Bologna, Sant'Orsola-Malpighi Hospital, Bologna, Italy
| | - Marco Vivarelli
- HPB Surgery and Transplantation Unit, Department of Clinical and Experimental Medicine, Polytechnic University of Marche, Ancona, Italy
| | - Marco Colasanti
- Division of General Surgery and Liver Transplantation, S. Camillo Hospital, Rome, Italy
| | | | - Luca Aldrighetti
- Hepatobiliary Surgery Division, San Raffaele Hospital, Milan, Italy
| | - Elio Jovine
- Department of General Surgery, Azienda Ospedaliero-Universitaria di Bologna, Maggiore Hospital, Bologna, Italy
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Kabir T, Syn N, Goh BKP. Current status of laparoscopic liver resection for the management of colorectal liver metastases. J Gastrointest Oncol 2020; 11:526-539. [PMID: 32655931 PMCID: PMC7340801 DOI: 10.21037/jgo.2020.02.05] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2019] [Accepted: 01/22/2020] [Indexed: 12/11/2022] Open
Abstract
Colorectal cancer (CRC) is one of the most prevalent malignancies worldwide. The commonest site of spread is the liver, with up to 40% of patients developing colorectal liver metastasis (CLRM) during the course of their lifetime. Significant advances in surgical techniques, as well as breakthroughs in chemotherapy and biologic agents, have resulted in dramatic improvements in prognosis. A multimodal approach comprising of liver resection coupled with systemic therapy offers these patients the best chance of cure. The arrival of laparoscopic liver resection (LLR) within the last 3 decades has added a whole new dimension to the management of this condition. Today, CLRM is one of the most frequent indications for LLR globally. Meta-analyses of retrospective studies and two randomized trials have demonstrated superior short-term outcomes following LLR, with no differences in mortality rates. Oncologically, R0 resection rates are comparable to the open approach, while overall and disease-free survival rates are also similar. As surgeons gain confidence, boundaries are pushed even further. High-volume centers have published their early experiences with complex LLR of recurrent CLRM as well as totally laparoscopic synchronous resection of CRC and liver metastases, with very encouraging results. In the presence of extensive bilobar CLRM, two-stage hepatectomy (TSH) and associating liver partition with portal vein ligation (ALPPS) may be adopted to augment an inadequate future liver remnant to facilitate metastasectomy. Interestingly, the adoption of LLR for these techniques also seem to confer additional benefits. Despite the plethora of advantages, LLR comes with its own unique set of limitations such as a steep learning curve and high cost. The surgical world eagerly awaits the results of prospective trials currently underway in order to further advance the management of this disease.
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Affiliation(s)
- Tousif Kabir
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore, Singapore
- Department of General Surgery, Sengkang General Hospital, Singapore, Singapore
| | - Nicholas Syn
- Yong Loo Lin School of Medicine, Singapore, Singapore
| | - Brian K. P. Goh
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore, Singapore
- Duke NUS Medical School, Singapore, Singapore
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Truant S, Baillet C, Fulbert M, Olivier A, Sergent G, Turpin A, Boleslawski E, El Amrani M, Huglo D, Pruvot FR. Asymmetric kinetics of volume and function of the remnant liver after major hepatectomy as a key for postoperative outcome - A case-matched study. HPB (Oxford) 2020; 22:855-863. [PMID: 31669198 DOI: 10.1016/j.hpb.2019.10.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Revised: 08/22/2019] [Accepted: 10/01/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND The kinetics of remnant liver (RL) function is unknown after major hepatectomy (MH), especially in case of post-hepatectomy liver failure (PHLF). This study investigated the change in RL function after MH using 99mTc-labelled-mebrofenin SPECT-scintigraphy and its correlation with RL volume and PHLF. METHODS From 2011 to 2015, 125 patients undergoing MH had volumetric assessment by CT and functional SPECT-scintigraphy preoperatively and at day 7 (POD7) and 1 month (1M). RL volume and function changes were compared in (i) overall population and (ii) 17 patients with vs. 42 without PHLF (ISGLS) matched on preoperative RL function. RESULTS Increase in RL function correlated poorly with volume increase at POD7 (r = 0.035, p = 0.43) and 1M (r = 0.394, p < 0.0001). Overall, function increase on POD7 (+38.8%) was lower than volume (+49.4%), but comparable at 1M (+78.8% vs. +73%). PHLF patients showed lower function increase on POD7 (+2.1% [-89%-77.8%] vs. +50% [-39%-218%]; p = 0.006). At 1M, 4 PHLF patients died with no function increase despite significant volumetric gain. CONCLUSIONS We first showed via sequential SPECT-scintigraphy that RL function increase after MH is slower than volume increase. A poor kinetic of function was correlated with PHLF as early as POD7, contrasting with substantial volume gain in PHLF patients.
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Affiliation(s)
- Stéphanie Truant
- Department of Digestive Surgery and Transplantation, CHU, Univ Nord de France, F-59000 Lille, France.
| | - Clio Baillet
- Department of Nuclear Medicine, CHU, Univ Nord de France, F-59000 Lille, France
| | - Maxence Fulbert
- Department of Digestive Surgery and Transplantation, CHU, Univ Nord de France, F-59000 Lille, France
| | - Anais Olivier
- Department of Nuclear Medicine, CHU, Univ Nord de France, F-59000 Lille, France
| | - Géraldine Sergent
- Department of Radiology, CHU, Univ Nord de France, F-59000 Lille, France
| | - Anthony Turpin
- Department of Medical Oncology, CHU, Univ Nord de France, F-59000 Lille, France
| | - Emmanuel Boleslawski
- Department of Digestive Surgery and Transplantation, CHU, Univ Nord de France, F-59000 Lille, France
| | - Mehdi El Amrani
- Department of Digestive Surgery and Transplantation, CHU, Univ Nord de France, F-59000 Lille, France
| | - Damien Huglo
- Department of Nuclear Medicine, CHU, Univ Nord de France, F-59000 Lille, France
| | - François-René Pruvot
- Department of Digestive Surgery and Transplantation, CHU, Univ Nord de France, F-59000 Lille, France
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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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18
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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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Affiliation(s)
- Hauke Lang
- Department of General, Visceral, and Transplant Surgery, University Medical Center, Mainz, Germany.
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20
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Yoshida H, Taniai N, Yoshioka M, Hirakata A, Kawano Y, Shimizu T, Ueda J, Takata H, Nakamura Y, Mamada Y. Current Status of Laparoscopic Hepatectomy. J NIPPON MED SCH 2019; 86:201-206. [PMID: 31204380 DOI: 10.1272/jnms.jnms.2019_86-411] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Before the first laparoscopic hepatectomy (LH) was described in 1991, open hepatectomy (OH) was the only choice for surgical treatment of liver tumors. LH indications were initially based solely on tumor location, size, and type. Use of LH has spread rapidly worldwide because it reduces incision size. This review systematically assesses the current status of LH. As compared with OH, LH is significantly less complicated, requires shorter hospital stays, and results in less blood loss. The long-term survival rates of LH and OH are comparable. Development of new techniques and instruments will improve the conversion rate and reduce complications. Furthermore, development of surgical navigation will improve LH safety and efficacy. Laparoscopic major hepatectomy for HCC remains a challenging procedure and should only be performed by experienced surgeons. In the near future, a training system for young surgeons will become mandatory for standardization of LH, and LH will likely become better standardized and have broader applications.
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Affiliation(s)
- Hiroshi Yoshida
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School
| | - Nobuhiko Taniai
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School
| | - Masato Yoshioka
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School
| | - Atsushi Hirakata
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School
| | - Youichi Kawano
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School
| | - Tetsuya Shimizu
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School
| | - Junji Ueda
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School
| | - Hideyuki Takata
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School
| | - Yoshiharu Nakamura
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School
| | - Yasuhiro Mamada
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School
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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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