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Kawaguchi Y, De Bellis M, Panettieri E, Duwe G, Vauthey JN. Debate: Improvements in Systemic Therapies for Liver Metastases Will Increase the Role of Locoregional Treatments. Hematol Oncol Clin North Am 2025; 39:207-220. [PMID: 39510674 DOI: 10.1016/j.hoc.2024.08.009] [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] [Indexed: 11/15/2024]
Abstract
The benefit of resection of liver metastases depends on primary diseases. Neuroendocrine tumors are associated with favorable prognosis after resection of liver metastases. Gastric cancer has worse tumor biology, and resection of gastric liver metastases should be performed in selected patients. A multidisciplinary approach is well established for colorectal liver metastases (CLMs). Resection remains the only curative treatment of CLM. Chemotherapy and molecular-targeted therapy have improved survival in unresectable metastatic colorectal cancer. Understanding of the following two strategies, conversion therapy and two-stage hepatectomy, are important to make this patient group to be candidates for curative-intent surgery.
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Affiliation(s)
- Yoshikuni Kawaguchi
- Department of Surgical Oncology, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA; Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, the University of Tokyo, Tokyo, Japan
| | - Mario De Bellis
- Department of Surgical Oncology, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - Elena Panettieri
- Department of Surgical Oncology, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - Gregor Duwe
- Department of Surgical Oncology, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - Jean-Nicolas Vauthey
- Department of Surgical Oncology, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA.
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Shimizu T, Aoki T, Ishizuka M, Sakamoto K, Beppu T, Honda G, Kotake K, Yamamoto M, Takahashi K, Endo I, Hasegawa K, Itabashi M, Hashiguchi Y, Kotera Y, Kobayashi S, Yamaguchi T, Natsume S, Tabuchi K, Kobayashi H, Yamaguchi K, Tani K, Morita S, Miyazaki M, Sugihara K, Ajioka Y. Evaluation of two-stage hepatectomy using portal vein embolization for colorectal liver metastasis: a retrospective nationwide cohort survey in Japan. Int J Surg 2024; 110:6691-6701. [PMID: 38869986 PMCID: PMC11486952 DOI: 10.1097/js9.0000000000001811] [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: 01/24/2024] [Accepted: 05/28/2024] [Indexed: 06/15/2024]
Abstract
INTRODUCTION Two-stage hepatectomy (TSH) enables patients to undergo surgery for colorectal liver metastasis (CRLM), which one-stage hepatectomy cannot remove. Although the outcome of TSH has been reported, there is no original report from Japan. The aim of this retrospective study was to evaluate the outcome of TSH in Japanese patients with CRLM. METHODS The authors conducted a retrospective cohort study using the nationwide database that included clinical information of 12 519 patients treated with CRLM between 2005 and 2017 in Japan. The primary outcome measure was overall survival. The second outcome measure was progression-free survival. Fisher's exact test, χ 2 test and Mann-Whitney U test were conducted to examine an intergroup difference. Univariate and multivariate analyses were performed using Cox regression model. Survival analysis was performed by Kaplan-Meier method and log-rank test. RESULTS Of the database, 53 patients undergoing TSH using portal vein embolization (PVE) were identified and analyzed. Their morbidity and in-hospital mortality rates at the second hepatectomy were 26.4% and 0.0%. The mean observation period was 21.8 months. The estimated 1-, 3- and 5-year overall survival rate were 92.5%, 70.8% and 34.7%. Multivariate analyses showed that more than 10 liver nodules significantly increased the mortality risk by 4.2-fold (95% CI 1.224-14.99, P = 0.023). Survival analysis revealed that repeat hepatectomy for disease progression after TSH was superior to chemotherapy in overall survival (mean: 49.6 vs. 18.7, months, P = 0.004). CONCLUSION In the Japanese cohort, TSH was confirmed to be a safety procedure with an acceptable survival outcome. More than 10 liver nodules may be a predictor for unfavorable outcomes of patients with CRLM undergoing TSH. Furthermore, repeat hepatectomy can be a salvage treatment for resectable intrahepatic recurrence after TSH.
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Affiliation(s)
- Takayuki Shimizu
- Joint Committee for National Survey on Colorectal Liver Metastasis, Tokyo
- Department of Hepato-Biliary-Pancreatic Surgery, Dokkyo Medical University, Tochigi
| | - Taku Aoki
- Joint Committee for National Survey on Colorectal Liver Metastasis, Tokyo
- Department of Hepato-Biliary-Pancreatic Surgery, Dokkyo Medical University, Tochigi
| | - Mitsuru Ishizuka
- Joint Committee for National Survey on Colorectal Liver Metastasis, Tokyo
- Department of Hepato-Biliary-Pancreatic Surgery, Dokkyo Medical University, Tochigi
| | - Katsunori Sakamoto
- Joint Committee for National Survey on Colorectal Liver Metastasis, Tokyo
- Department of Hepato-Biliary-Pancreatic and Breast Surgery, Ehime University Graduate School of Medicine, Ehime
| | - Toru Beppu
- Joint Committee for National Survey on Colorectal Liver Metastasis, Tokyo
- Department of Surgery, Yamaga City Medical Center, Kumamoto
| | - Goro Honda
- Joint Committee for National Survey on Colorectal Liver Metastasis, Tokyo
- Department of Surgery, Institute of Gastroenterology, Tokyo Women’s Medical, Tochigi
| | - Kenjiro Kotake
- Joint Committee for National Survey on Colorectal Liver Metastasis, Tokyo
- Department of Surgery, Sano City Hospital, Sano, Tochigi
| | - Masakazu Yamamoto
- Joint Committee for National Survey on Colorectal Liver Metastasis, Tokyo
- Department of Surgery, Utsunomiya Memorial Hospital, Utsunomiya, Tochigi
| | - Keiichi Takahashi
- Joint Committee for National Survey on Colorectal Liver Metastasis, Tokyo
- Department of Surgery, Tokyo Metropolitan Health and Hospitals Corporation Ohkubo Hospital, Tokyo
| | - Itaru Endo
- Joint Committee for National Survey on Colorectal Liver Metastasis, Tokyo
- Department of Gastroenterological Surgery, Yokohama City University Graduate School of Medicine, Kanagawa
| | - Kiyoshi Hasegawa
- Joint Committee for National Survey on Colorectal Liver Metastasis, Tokyo
- Department of Surgery, Hepato-Biliary-Pancreatic Surgery Division, Graduate School of Medicine, The University of Tokyo
| | - Michio Itabashi
- Joint Committee for National Survey on Colorectal Liver Metastasis, Tokyo
- Department of Surgery, Institute of Gastroenterology, Tokyo Women’s Medical, Tochigi
| | - Yojiro Hashiguchi
- Joint Committee for National Survey on Colorectal Liver Metastasis, Tokyo
- Department of Surgery, Teikyo University School of Medicine Tokyo
| | - Yoshihito Kotera
- Joint Committee for National Survey on Colorectal Liver Metastasis, Tokyo
- Department of Surgery, Institute of Gastroenterology, Tokyo Women’s Medical, Tochigi
| | - Shin Kobayashi
- Joint Committee for National Survey on Colorectal Liver Metastasis, Tokyo
- Department of Hepatobiliary and Pancreatic Surgery, National Cancer Center Hospital East, Chiba
| | - Tatsuro Yamaguchi
- Joint Committee for National Survey on Colorectal Liver Metastasis, Tokyo
- Department of Surgery, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Tokyo
| | - Soichiro Natsume
- Joint Committee for National Survey on Colorectal Liver Metastasis, Tokyo
- Department of Surgery, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Tokyo
| | - Ken Tabuchi
- Joint Committee for National Survey on Colorectal Liver Metastasis, Tokyo
- Department of Pediatrics, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Tokyo
| | - Hirotoshi Kobayashi
- Joint Committee for National Survey on Colorectal Liver Metastasis, Tokyo
- Department of Surgery, Teikyo University Hospital, Kanagawa
| | - Kensei Yamaguchi
- Joint Committee for National Survey on Colorectal Liver Metastasis, Tokyo
- Department of Gastrointestinal Chemotherapy, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo
| | - Kimitaka Tani
- Joint Committee for National Survey on Colorectal Liver Metastasis, Tokyo
- Department of Surgery, Institute of Gastroenterology, Tokyo Women’s Medical, Tochigi
| | - Satoshi Morita
- Joint Committee for National Survey on Colorectal Liver Metastasis, Tokyo
- Department of Biomedical Statistics and Bioinformatics, Graduate School of Medicine, Kyoto University, Kyoto
| | - Masaru Miyazaki
- International University of Health and Welfare, Narita Hospital, Tokyo
| | | | - Yoichi Ajioka
- Joint Committee for National Survey on Colorectal Liver Metastasis, Tokyo
- Division of Molecular and Diagnostic Pathology, Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan
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Turk S, Plahuta I, Magdalenic T, Spanring T, Laufer K, Mavc Z, Potrc S, Ivanecz A. Two-stage hepatectomy in resection of colorectal liver metastases - a single-institution experience with case-control matching and review of the literature. Radiol Oncol 2023; 57:270-278. [PMID: 37341198 DOI: 10.2478/raon-2023-0026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2023] [Accepted: 05/15/2023] [Indexed: 06/22/2023] Open
Abstract
BACKGROUND Two-stage hepatectomy (TSH) has been proposed for patients with bilateral liver tumours who have a high risk of posthepatectomy liver failure after one-stage hepatectomy (OSH). This study aimed to determine the outcomes of TSH for extensive bilateral colorectal liver metastases. PATIENTS AND METHODS A retrospective review of a prospectively maintained database of liver resections for colorectal liver metastases was conducted. The TSH group was compared to the OSH group in terms of perioperative outcomes and survival. Case-control matching was performed. RESULTS A total of 632 consecutive liver resections for colorectal liver metastases were performed between 2000 and 2020. The study group (TSH group) consisted of 15 patients who completed TSH. The control group included 151 patients who underwent OSH. The case-control matching-OSH group consisted of 14 patients. The major morbidity and 90-day mortality rates were 40% and 13.3% in the TSH group, 20.5% and 4.6% in the OSH group and 28.6% and 7.1% in the case-control matching-OSH group, respectively. The recurrence-free survival, median overall survival, and 3- and 5-year survival rates were 5 months, 21 months, 33% and 13% in the TSH group; 11 months, 35 months, 49% and 27% in the OSH group; and 8 months, 23 months, 36% and 21%, respectively, in the case-control matching-OSH group, respectively. CONCLUSIONS TSH used to be a favourable therapeutic choice in a select population of patients. Now, OSH should be preferred whenever feasible because it has lower morbidity and equivalent oncological outcomes to those of completed TSH.
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Affiliation(s)
- Spela Turk
- Clinical Department of Abdominal and General Surgery, University Medical Centre Maribor, Maribor, Slovenia
- Department of Surgery, Faculty of Medicine, University of Maribor, Maribor, Slovenia
| | - Irena Plahuta
- Clinical Department of Abdominal and General Surgery, University Medical Centre Maribor, Maribor, Slovenia
- Department of Surgery, Faculty of Medicine, University of Maribor, Maribor, Slovenia
| | - Tomislav Magdalenic
- Clinical Department of Abdominal and General Surgery, University Medical Centre Maribor, Maribor, Slovenia
| | - Tajda Spanring
- Clinical Department of Abdominal and General Surgery, University Medical Centre Maribor, Maribor, Slovenia
- Department of Surgery, Faculty of Medicine, University of Maribor, Maribor, Slovenia
| | - Kevin Laufer
- Clinical Department of Abdominal and General Surgery, University Medical Centre Maribor, Maribor, Slovenia
- Department of Surgery, Faculty of Medicine, University of Maribor, Maribor, Slovenia
| | - Zan Mavc
- Clinical Department of Abdominal and General Surgery, University Medical Centre Maribor, Maribor, Slovenia
| | - Stojan Potrc
- Clinical Department of Abdominal and General Surgery, University Medical Centre Maribor, Maribor, Slovenia
- Department of Surgery, Faculty of Medicine, University of Maribor, Maribor, Slovenia
| | - Arpad Ivanecz
- Clinical Department of Abdominal and General Surgery, University Medical Centre Maribor, Maribor, Slovenia
- Department of Surgery, Faculty of Medicine, University of Maribor, Maribor, Slovenia
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Bozkurt E, Sijberden JP, Abu Hilal M. Safety and Feasibility of Laparoscopic Right or Extended Right Hemi Hepatectomy Following Modulation of the Future Liver Remnant in Patients with Colorectal Liver Metastases: A Systematic Review. J Laparoendosc Adv Surg Tech A 2023. [PMID: 37015071 DOI: 10.1089/lap.2022.0609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/06/2023] Open
Abstract
Background: Major hepatectomies after future liver remnant (FLR) modulation are technically demanding procedures, especially when performed as minimally invasive surgery. The aim of this systematic review is to assess current evidence regarding the safety and feasibility of laparoscopic right or extended right hemihepatectomies after FLR modulation. Materials and Methods: The Medline, PubMed, Cochrane Library, and Embase databases were searched for studies involving laparoscopic right or extended right hemihepatectomies after FLR modulation, from their inception to December 2021. Two reviewers independently selected eligible articles and assessed their quality using the Newcastle-Ottawa Quality Assessment Scale (NOS). Baseline characteristics and outcomes were extracted from the included studies and summarized. Results: Six studies were included. In these studies, the median length of stay after the second stage ranged from 4.5 to 15.5 days and postoperative complication rates between 4.5% and 42.8%. Overall, 7.4% of patients developed liver failure, and 90-day mortality occurred in 3.2% of patients. The R0 resection rate was 93.5%. Only one study reported long-term outcomes, describing comparable 3-year overall survival rates following laparoscopic and open surgery (80% versus 54%, P = .154). Conclusions: The current evidence is scarce, but it suggests that in experienced centers, laparoscopic right or extended right hemihepatectomy, following FLR modulation, is a safe and feasible procedure.
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Affiliation(s)
- Emre Bozkurt
- Department of Surgery, Poliambulanza Foundation Hospital, Brescia, Italy
- Hepatopancreatobiliary Surgery Division, Department of Surgery, Koç University Hospital, Istanbul, Turkey
| | - Jasper P Sijberden
- Department of Surgery, Poliambulanza Foundation Hospital, Brescia, Italy
- Department of Surgery, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Mohammad Abu Hilal
- Department of Surgery, Poliambulanza Foundation Hospital, Brescia, Italy
- Department of Surgery, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
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Omichi K, Inoue Y, Mise Y, Oba A, Ono Y, Sato T, Ito H, Takahashi Y, Saiura A. Hepatectomy with Perioperative Chemotherapy for Multiple Colorectal Liver Metastases is the Available Option for Prolonged Survival. Ann Surg Oncol 2022; 29:3567-3576. [PMID: 35118524 DOI: 10.1245/s10434-022-11345-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 01/05/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Hepatic resection combined with perioperative chemotherapy is the standard of care for patients with multiple colorectal liver metastases (CLMs). However, the optimal surgical strategy for treating advanced CLMs remains unclear. The role of the two-stage hepatectomy (TSH) strategy in the management of multiple CLMs remains challenging. This study aimed to compare the outcomes of one-step hepatectomy (OSH)-treated and TSH-treated patients with multiple CLMs. METHODS This single-institution study included 742 consecutive patients who underwent initial liver resection for histologically confirmed CLMs. The study enrolled patients with 10 or more tumors (n = 106). Clinicopathologic characteristics and long-term outcomes were compared between patients who underwent OSH and those who underwent TSH for 10 or more CLMs. RESULTS The study planned OSH for 67 patients (63%) and TSH for 39 patients (37%). One of the OSH-planned patients and two of the TSH-planned patients underwent a trial laparotomy because of non-curative factors. Five patients (13%) did not progress to the second stage of TSH. In the entire cohort, the cumulative 3-year overall survival rate was 58.4% for the patients who had 10 or more CLMs treated with OSH compared with 61.1% for the patients treated with TSH (P = 0.746). In the curative resection cohort, the cumulative 1-year recurrence-free survival rate was 18.2% for the patients treated with OSH and 17.9% for the patients treated with TSH (P = 0.640). CONCLUSIONS Hepatectomy with perioperative chemotherapy for advanced CLMs with 10 or more tumors is feasible and effective. To prolong survival, TSH is a promising option when curative resection with OSH is impossible.
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Affiliation(s)
- Kiyohiko Omichi
- Department of Hepato-Biliary-Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Yosuke Inoue
- Department of Hepato-Biliary-Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan.
| | - Yoshihiro Mise
- Department of Hepato-Biliary-Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan.,Department of Hepatobiliary-Pancreatic Surgery, Juntendo University School of Medicine, Hongo, Tokyo, Japan
| | - Atsushi Oba
- Department of Hepato-Biliary-Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Yoshihiro Ono
- Department of Hepato-Biliary-Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Takafumi Sato
- Department of Hepato-Biliary-Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Hiromichi Ito
- Department of Hepato-Biliary-Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Yu Takahashi
- Department of Hepato-Biliary-Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Akio Saiura
- Department of Hepato-Biliary-Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan.,Department of Hepatobiliary-Pancreatic Surgery, Juntendo University School of Medicine, Hongo, Tokyo, Japan
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6
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Bolhuis K, Grosheide L, Wesdorp NJ, Komurcu A, Chapelle T, Dejong CHC, Gerhards MF, Grünhagen DJ, van Gulik TM, Huiskens J, De Jong KP, Kazemier G, Klaase JM, Liem MSL, Molenaar IQ, Patijn GA, Rijken AM, Ruers TM, Verhoef C, de Wilt JHW, Punt CJA, Swijnenburg RJ. Short-Term Outcomes of Secondary Liver Surgery for Initially Unresectable Colorectal Liver Metastases Following Modern Induction Systemic Therapy in the Dutch CAIRO5 Trial. ANNALS OF SURGERY OPEN 2021; 2:e081. [PMID: 37635815 PMCID: PMC10455233 DOI: 10.1097/as9.0000000000000081] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 06/14/2021] [Indexed: 12/15/2022] Open
Abstract
Objective To present short-term outcomes of liver surgery in patients with initially unresectable colorectal liver metastases (CRLM) downsized by chemotherapy plus targeted agents. Background The increase of complex hepatic resections of CRLM, technical innovations pushing boundaries of respectability, and use of intensified induction systemic regimens warrant for safety data in a homogeneous multicenter prospective cohort. Methods Patients with initially unresectable CRLM, who underwent complete resection after induction systemic regimens with doublet or triplet chemotherapy, both plus targeted therapy, were selected from the ongoing phase III CAIRO5 study (NCT02162563). Short-term outcomes and risk factors for severe postoperative morbidity (Clavien Dindo grade ≥ 3) were analyzed using logistic regression analysis. Results A total of 173 patients underwent resection of CRLM after induction systemic therapy. The median number of metastases was 9 and 161 (93%) patients had bilobar disease. Thirty-six (20.8%) 2-stage resections and 88 (51%) major resections (>3 liver segments) were performed. Severe postoperative morbidity and 90-day mortality was 15.6% and 2.9%, respectively. After multivariable analysis, blood transfusion (odds ratio [OR] 2.9 [95% confidence interval (CI) 1.1-6.4], P = 0.03), major resection (OR 2.9 [95% CI 1.1-7.5], P = 0.03), and triplet chemotherapy (OR 2.6 [95% CI 1.1-7.5], P = 0.03) were independently correlated with severe postoperative complications. No association was found between number of cycles of systemic therapy and severe complications (r = -0.038, P = 0.31). Conclusion In patients with initially unresectable CRLM undergoing modern induction systemic therapy and extensive liver surgery, severe postoperative morbidity and 90-day mortality were 15.6% and 2.7%, respectively. Triplet chemotherapy, blood transfusion, and major resections were associated with severe postoperative morbidity.
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Affiliation(s)
- Karen Bolhuis
- From the Department of Medical Oncology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, The Netherlands
| | - Lodi Grosheide
- From the Department of Medical Oncology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, The Netherlands
| | - Nina J. Wesdorp
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, VU University Amsterdam, The Netherlands
| | - Aysun Komurcu
- The Netherlands Netherlands Comprehensive Cancer Center, Utrecht, The Netherlands
| | - Thiery Chapelle
- Department of Hepatobiliary, Transplantation, and Endocrine Surgery, University of Antwerp, Belgium
| | - Cornelis H. C. Dejong
- Maastricht University Medical Center, Department of Surgery, Maastricht, The Netherlands and Universitätsklinikum Aachen, Aachen, Germany
| | | | - Dirk J. Grünhagen
- Erasmus MC Cancer Institute, Department of Surgery, Rotterdam, The Netherlands
| | - Thomas M. van Gulik
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, The Netherlands
| | | | - Koert P. De Jong
- Department of Hepatobiliary Surgery and Liver Transplantation, University Medical Center Groningen, Groningen
| | - Geert Kazemier
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, VU University Amsterdam, The Netherlands
| | - Joost M. Klaase
- Department of Hepatobiliary Surgery and Liver Transplantation, University Medical Center Groningen, Groningen
| | - Mike S. L. Liem
- Department of Surgery, Medical Spectrum Twente, Enschede, the Netherlands
| | - I. Quintus Molenaar
- Regional Academic Cancer Center Utrecht, Department of Surgery, University Medical Center Utrecht and St Antonius Hospital Nieuwegein, The Netherlands
| | | | - Arjen M. Rijken
- Amphia hospital, Department of Surgery, Breda, The Netherlands
| | - Theo M. Ruers
- Amphia hospital, Department of Surgery, Breda, The Netherlands
| | - Cornelis Verhoef
- Erasmus MC Cancer Institute, Department of Surgery, Rotterdam, The Netherlands
| | | | - Cornelis J. A. Punt
- From the Department of Medical Oncology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, The Netherlands
- Julius Center for Health Sciences and Primary Care, University Medical Center, Utrecht University, Department of Epidemiology, Utrecht, The Netherlands
| | - Rutger-Jan Swijnenburg
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, The Netherlands
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Imai K, Allard M, Baba H, Adam R. Optimal patient selection for successful two-stage hepatectomy of bilateral colorectal liver metastases. Ann Gastroenterol Surg 2021; 5:634-638. [PMID: 34585048 PMCID: PMC8452472 DOI: 10.1002/ags3.12465] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Revised: 03/18/2021] [Accepted: 03/29/2021] [Indexed: 12/13/2022] Open
Abstract
Two-stage hepatectomy (TSH) is one of the specific surgical techniques that can expand the pool of resectable patients with initially unresectable colorectal liver metastases (CRLM). The indication of TSH for CRLM is only bilateral, multinodular disease, which cannot be resected by a single hepatectomy. TSH is nowadays considered an effective treatment for selected patients, with acceptable morbidity/mortality rates and promising long-term outcomes. However, not all eligible patients can benefit from the TSH strategy. One of the most important issues is dropout from the strategy (failure to complete both of the two sequential procedures), because the survival of such patients is drastically worse compared with patients who can complete both stages. Another important issue is the early recurrence rate and subsequent poor survival even after completion of TSH. Thus, the selection of appropriate patients who can really benefit from the TSH strategy is crucial. This review discusses the optimal patient selection for TSH, which should be helpful for the development of treatment strategies for patients with extensive CRLM.
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Affiliation(s)
- Katsunori Imai
- Centre Hépato‐BiliaireAP‐HPHôpital Universitaire Paul BrousseVillejuifFrance
- Department of Gastroenterological SurgeryGraduate School of Life SciencesKumamoto UniversityKumamotoJapan
| | - Marc‐Antoine Allard
- Centre Hépato‐BiliaireAP‐HPHôpital Universitaire Paul BrousseVillejuifFrance
| | - Hideo Baba
- Department of Gastroenterological SurgeryGraduate School of Life SciencesKumamoto UniversityKumamotoJapan
| | - René Adam
- Centre Hépato‐BiliaireAP‐HPHôpital Universitaire Paul BrousseVillejuifFrance
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Rocca A, Cipriani F, Belli G, Berti S, Boggi U, Bottino V, Cillo U, Cescon M, Cimino M, Corcione F, De Carlis L, Degiuli M, De Paolis P, De Rose AM, D'Ugo D, Di Benedetto F, Elmore U, Ercolani G, Ettorre GM, Ferrero A, Filauro M, Giuliante F, Gruttadauria S, Guglielmi A, Izzo F, Jovine E, Laurenzi A, Marchegiani F, Marini P, Massani M, Mazzaferro V, Mineccia M, Minni F, Muratore A, Nicosia S, Pellicci R, Rosati R, Russolillo N, Spinelli A, Spolverato G, Torzilli G, Vennarecci G, Viganò L, Vincenti L, Delrio P, Calise F, Aldrighetti L. The Italian Consensus on minimally invasive simultaneous resections for synchronous liver metastasis and primary colorectal cancer: A Delphi methodology. Updates Surg 2021; 73:1247-1265. [PMID: 34089501 DOI: 10.1007/s13304-021-01100-9] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 05/12/2021] [Indexed: 12/17/2022]
Abstract
At the time of diagnosis synchronous colorectal cancer, liver metastases (SCRLM) account for 15-25% of patients. If primary tumour and synchronous liver metastases are resectable, good results may be achieved performing surgical treatment incorporated into the chemotherapy regimen. So far, the possibility of simultaneous minimally invasive (MI) surgery for SCRLM has not been extensively investigated. The Italian surgical community has captured the need and undertaken the effort to establish a National Consensus on this topic. Four main areas of interest have been analysed: patients' selection, procedures, techniques, and implementations. To establish consensus, an adapted Delphi method was used through as many reiterative rounds were needed. Systematic literature reviews were conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses instructions. The Consensus took place between February 2019 and July 2020. Twenty-six Italian centres participated. Eighteen clinically relevant items were identified. After a total of three Delphi rounds, 30-tree recommendations reached expert consensus establishing the herein presented guidelines. The Italian Consensus on MI surgery for SCRLM indicates possible pathways to optimise the treatment for these patients as consensus papers express a trend that is likely to become shortly a standard procedure for clinical pictures still on debate. As matter of fact, no RCT or relevant case series on simultaneous treatment of SCRLM are available in the literature to suggest guidelines. It remains to be investigated whether the MI technique for the simultaneous treatment of SCRLM maintain the already documented benefit of the two separate surgeries.
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Affiliation(s)
- Aldo Rocca
- Department of Medicine and Health Sciences "V. Tiberio", University of Molise, Campobasso, Italy.
- Center for Hepatobiliary and Pancreatic Surgery, Pineta Grande Hospital, Castel Volturno, Italy.
| | - Federica Cipriani
- Hepatobiliary Surgery Division, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
| | - Giulio Belli
- Department of General and HPB Surgery, Loreto Nuovo Hospital, Naples, Italy
| | - Stefano Berti
- Department of Surgery, Hospital S Andrea La Spezia, La Spezia, Italy
| | - Ugo Boggi
- Division of General and Transplant Surgery, Pisa University Hospital, Pisa, Italy
| | - Vincenzo Bottino
- Department of Obesity and Metabolic Surgery, Ospedale Evangelico Betania, Naples, Italy
| | - Umberto Cillo
- Hepatobiliary Surgery and Liver Transplantation Unit, Department of Surgery, Oncology and Gastroenterology, Padova University Hospital, Padua, Italy
| | - Matteo Cescon
- General Surgery and Transplant Unit, IRCCS AOU Sant'Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Matteo Cimino
- Division of Hepatobiliary and General Surgery, Department of Surgery, Humanitas Clinical and Research Center, IRCCS, Humanitas University, Rozzano, MI, Italy
| | - Francesco Corcione
- Department of Public Health, School of Medicine, University of Naples Federico II, Naples, Italy
| | - Luciano De Carlis
- Division of General Surgery and Abdominal Transplantation, ASST Grande Ospedale Metropolitano Niguarda, School of Medicine, University of Milano-Bicocca, Milan, Italy
| | - Maurizio Degiuli
- Department of Oncology, Digestive and Surgical Oncology, San Luigi University Hospital, University of Torino, Orbassano, Italy
| | - Paolo De Paolis
- General Surgery Department, Ospedale Gradenigo, Turin, Italy
| | - Agostino Maria De Rose
- Hepatobiliary Surgery Unit, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Catholic University of the Sacred Heart, Rome, Italy
| | - Domenico D'Ugo
- General Surgery Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Catholic University, Rome, Italy
| | - Fabrizio Di Benedetto
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University of Modena and Reggio Emilia, Modena, Italy
| | - Ugo Elmore
- Vita-Salute San Raffaele University, Milan, Italy
- Division of Gastrointestinal Surgery, San Raffaele Scientific Institute, Milan, Italy
| | - Giorgio Ercolani
- General and Oncologic Surgery, Morgagni-Pierantoni Hospital, Forli, Italy
| | - Giuseppe M Ettorre
- Department of General Surgery and Transplantation, San Camillo-Forlanini General Hospital, Rome, Italy
| | - Alessandro Ferrero
- Department of HPB and Digestive Surgery, Ospedale Mauriziano Umberto I, Turin, Italy
| | - Marco Filauro
- General and Hepatobiliopancreatic Surgery Unit, Department of Abdominal Surgery, E.O. Galliera Hospital, Genoa, Italy
| | - Felice Giuliante
- Hepatobiliary Surgery Unit, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Catholic University of the Sacred Heart, Rome, Italy
| | - Salvatore Gruttadauria
- Abdominal Surgery and Organ Transplantation Unit, Department for the Treatment and Study of Abdominal Diseases and Abdominal Transplantation, ISMETT, Palermo, Italy
| | - Alfredo Guglielmi
- Unit of HPB Surgery, Department of Surgery, GB Rossi University Hospital, Verona, Italy
| | - Francesco Izzo
- Divisions of Hepatobiliary Surgery, Istituto Nazionale Dei Tumori IRCCS "Fondazione G. Pascale", Naples, Italy
| | - Elio Jovine
- Department of Surgery, AOU Sant'Orsola Malpighi, IRCCS, Bologna, Italy
| | - Andrea Laurenzi
- General and Oncologic Surgery, Morgagni-Pierantoni Hospital, Forli, Italy
| | - Francesco Marchegiani
- Hepatobiliary Surgery and Liver Transplantation Unit, Department of Surgery, Oncology and Gastroenterology, Padova University Hospital, Padua, Italy
| | - Pierluigi Marini
- The Department of General and Emergency Surgery, San Camillo-Forlanini Regional Hospital, Rome, Italy
| | - Marco Massani
- Department of Surgery, Regional Hospital of Treviso, Treviso, Italy
| | - Vincenzo Mazzaferro
- Department of Gastrointestinal Surgery and Liver Transplantation, Fondazione IRCCS Istituto Nazionale Tumori di Milano, Milan, Italy
| | - Michela Mineccia
- Department of General Surgery and Transplantation, San Camillo-Forlanini General Hospital, Rome, Italy
| | - Francesco Minni
- Division of Pancreatic Surgery, Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Andrea Muratore
- General Surgery Unit, E. Agnelli Hospital, Pinerolo, TO, Italy
| | - Simone Nicosia
- Department of Surgery, AOU Sant'Orsola Malpighi, IRCCS, Bologna, Italy
| | - Riccardo Pellicci
- General Surgery Unit, Santa Corona Hospital, Pietra Ligure, SV, Italy
| | - Riccardo Rosati
- Vita-Salute San Raffaele University, Milan, Italy
- Division of Gastrointestinal Surgery, San Raffaele Scientific Institute, Milan, Italy
| | - Nadia Russolillo
- Department of HPB and Digestive Surgery, Ospedale Mauriziano Umberto I, Turin, Italy
| | - Antonino Spinelli
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20090, Pieve Emanuele, MI, Italy
- Division of Colon and Rectal Surgery, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano, MI, Italy
| | - Gaya Spolverato
- Surgery Unit, Department of Surgical Oncology and Gastroenterology Sciences (DiSCOG), University of Padua, Padua, Italy
| | - Guido Torzilli
- Division of Hepatobiliary and General Surgery, Department of Surgery, Humanitas Clinical and Research Center, IRCCS, Humanitas University, Rozzano, MI, Italy
| | - Giovanni Vennarecci
- Laparoscopic, Hepatic, and Liver Transplant Unit, AORN A. Cardarelli, Naples, Italy
| | - Luca Viganò
- Division of Hepatobiliary and General Surgery, Department of Surgery, Humanitas Clinical and Research Center, IRCCS, Humanitas University, Rozzano, MI, Italy
| | - Leonardo Vincenti
- Medical Oncology Unit, National Cancer Research Centre, Istituto Tumori Giovanni Paolo II, Bari, Italy
| | - Paolo Delrio
- Colorectal Surgical Oncology-Abdominal Oncology Department, Istituto Nazionale per lo Studio e la Cura dei Tumori, 'Fondazione Giovanni Pascale' IRCCS, 80131, Naples, Italy
| | - Fulvio Calise
- Center for Hepatobiliary and Pancreatic Surgery, Pineta Grande Hospital, Castel Volturno, Italy
| | - Luca Aldrighetti
- Hepatobiliary Surgery Division, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
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9
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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: 18] [Impact Index Per Article: 4.5] [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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10
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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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11
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Kawaguchi Y, De Bellis M, Panettieri E, Duwe G, Vauthey JN. Debate: Improvements in Systemic Therapies for Liver Metastases Will Increase the Role of Locoregional Treatments. Surg Oncol Clin N Am 2021; 30:205-218. [PMID: 33220806 PMCID: PMC7709757 DOI: 10.1016/j.soc.2020.08.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The benefit of resection of liver metastases depends on primary diseases. Neuroendocrine tumors are associated with favorable prognosis after resection of liver metastases. Gastric cancer has worse tumor biology, and resection of gastric liver metastases should be performed in selected patients. A multidisciplinary approach is well established for colorectal liver metastases (CLMs). Resection remains the only curative treatment of CLM. Chemotherapy and molecular-targeted therapy have improved survival in unresectable metastatic colorectal cancer. Understanding of the following two strategies, conversion therapy and two-stage hepatectomy, are important to make this patient group to be candidates for curative-intent surgery.
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Affiliation(s)
- Yoshikuni Kawaguchi
- Department of Surgical Oncology, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA; Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, the University of Tokyo, Tokyo, Japan
| | - Mario De Bellis
- Department of Surgical Oncology, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - Elena Panettieri
- Department of Surgical Oncology, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - Gregor Duwe
- Department of Surgical Oncology, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - Jean-Nicolas Vauthey
- Department of Surgical Oncology, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA.
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12
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Petrowsky H, Linecker M, Raptis DA, Kuemmerli C, Fritsch R, Kirimker OE, Balci D, Ratti F, Aldrighetti L, Voskanyan S, Tomassini F, Troisi RI, Bednarsch J, Lurje G, Fard-Aghaie MH, Reese T, Oldhafer KJ, Ghamarnejad O, Mehrabi A, Abraham MET, Truant S, Pruvot FR, Hoti E, Kambakamba P, Capobianco I, Nadalin S, Fernandes ESM, Kron P, Lodge P, Olthof PB, van Gulik T, Castro-Benitez C, Adam R, Machado MA, Teutsch M, Li J, Scherer MN, Schlitt HJ, Ardiles V, de Santibañes E, Brusadin R, Lopez-Lopez V, Robles-Campos R, Malagó M, Hernandez-Alejandro R, Clavien PA. First Long-term Oncologic Results of the ALPPS Procedure in a Large Cohort of Patients With Colorectal Liver Metastases. Ann Surg 2020; 272:793-800. [PMID: 32833765 DOI: 10.1097/sla.0000000000004330] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVES To analyze long-term oncological outcome along with prognostic risk factors in a large cohort of patients with colorectal liver metastases (CRLM) undergoing ALPPS. BACKGROUND ALPPS is a two-stage hepatectomy variant that increases resection rates and R0 resection rates in patients with primarily unresectable CRLM as evidenced in a recent randomized controlled trial. Long-term oncologic results, however, are lacking. METHODS Cases in- and outside the International ALPPS Registry were collected and completed by direct contacts to ALPPS centers to secure a comprehensive cohort. Overall, cancer-specific (CSS), and recurrence-free (RFS) survivals were analyzed along with independent risk factors using Cox-regression analysis. RESULTS The cohort included 510 patients from 22 ALPPS centers over a 10-year period. Ninety-day mortality was 4.9% and median overall survival, CSS, and RFS were 39, 42, and 15 months, respectively. The median follow-up time was 38 months (95% confidence interval 32-43 months). Multivariate analysis identified tumor-characteristics (primary T4, right colon), biological features (K/N-RAS status), and response to chemotherapy (Response Evaluation Criteria in Solid Tumors) as independent predictors of CSS. Traditional factors such as size of metastases, uni versus bilobar involvement, and liver-first approach were not predictive. When hepatic recurrences after ALPPS was amenable to surgical/ablative treatment, median CSS was significantly superior compared to chemotherapy alone (56 vs 30 months, P < 0.001). CONCLUSIONS This large cohort provides the first evidence that patients with primarily unresectable CRLM treated by ALPPS have not only low perioperative mortality, but achieve appealing long-term oncologic outcome especially those with favorable tumor biology and good response to chemotherapy.
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Affiliation(s)
- Henrik Petrowsky
- Swiss HPB and Transplantation Center, Department of Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Michael Linecker
- Swiss HPB and Transplantation Center, Department of Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Dimitri A Raptis
- Department of HPB- and Liver Transplantation Surgery, University College London, Royal Free Hospitals, London, UK
| | - Christoph Kuemmerli
- Swiss HPB and Transplantation Center, Department of Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Ralph Fritsch
- Department of Medical Oncology and Hematology, University Hospital Zurich, Zurich, Switzerland
| | | | - Deniz Balci
- Department of Surgery, Ankara University, Ankara, Turkey
| | - Francesca Ratti
- Hepatobiliary Surgery Division, Department of Surgery, IRCCS San Raffaele Hospital, School of Medicine, Milan, Italy
| | - Luca Aldrighetti
- Hepatobiliary Surgery Division, Department of Surgery, IRCCS San Raffaele Hospital, School of Medicine, Milan, Italy
| | - Sergey Voskanyan
- Department of Surgery, A.I. Burnazyan FMBC Russian State Scientific Center of FMBA, Moscow, Russia
| | - Federico Tomassini
- Department of Human Structure and Repair, Ghent University Faculty of Medicine, Ghent, Belgium
| | - Roberto I Troisi
- Department of Human Structure and Repair, Ghent University Faculty of Medicine, Ghent, Belgium
- Department of Clinical Medicine and Surgery, Division of HPB, Minimally Invasive and Robotic Surgery, Federico II University Hospital Naples, Naples, Italy
| | - Jan Bednarsch
- Department of General, Visceral and Transplantation Surgery, University Hospital Aachen, RWTH Aachen, Germany
| | - Georg Lurje
- Department of General, Visceral and Transplantation Surgery, University Hospital Aachen, RWTH Aachen, Germany
- Department of Surgery, Charité Universitätsmedizin Berlin, Campus Charité Mitte and Campus Virchow Klinikum, Berlin, Germany
| | - Mohammad-Hossein Fard-Aghaie
- Department of Surgery, Division of Hepatobiliary and Pancreatic Surgery, Asklepios Hospital Barmbek, Hamburg, Germany
- Semmelweis University Budapest, Campus Hamburg, Hamburg, Germany
| | - Tim Reese
- Department of Surgery, Division of Hepatobiliary and Pancreatic Surgery, Asklepios Hospital Barmbek, Hamburg, Germany
- Semmelweis University Budapest, Campus Hamburg, Hamburg, Germany
| | - Karl J Oldhafer
- Department of Surgery, Division of Hepatobiliary and Pancreatic Surgery, Asklepios Hospital Barmbek, Hamburg, Germany
- Semmelweis University Budapest, Campus Hamburg, Hamburg, Germany
| | - Omid Ghamarnejad
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Arianeb Mehrabi
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Mauro E Tun Abraham
- Department of Surgery, Division of HPB Surgery and Liver Transplantation, London Health Sciences Centre, London, Ontario, Canada
| | - Stéphanie Truant
- Department of Digestive Surgery and Transplantation, University Hospital, Lille, France
| | - Francois-René Pruvot
- Department of Digestive Surgery and Transplantation, University Hospital, Lille, France
| | - Emir Hoti
- Department of Hepatobiliary and Liver Transplant Surgery, St. Vincents University Hospital, Dublin, Ireland
| | - Patryk Kambakamba
- Department of Hepatobiliary and Liver Transplant Surgery, St. Vincents University Hospital, Dublin, Ireland
| | - Ivan Capobianco
- Department of General, Visceral and Transplant Surgery, University Hospital Tübingen, Germany
| | - Silvio Nadalin
- Department of General, Visceral and Transplant Surgery, University Hospital Tübingen, Germany
| | - Eduardo S M Fernandes
- Department of General Surgery and Transplantation, Hospital Adventista Silvestre, and Department of Surgery, Faculty of Medicine, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
- Department of Surgery, Rio de Janeiro Federal University, Rio de Janeiro, Brazil
| | - Philipp Kron
- Swiss HPB and Transplantation Center, Department of Surgery, University Hospital Zurich, Zurich, Switzerland
- HPB and Transplant Unit, St. James's University Hospital, Leeds, UK
| | - Peter Lodge
- HPB and Transplant Unit, St. James's University Hospital, Leeds, UK
| | - Pim B Olthof
- Department of Surgery, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Thomas van Gulik
- Department of Surgery, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | | | - René Adam
- Centre Hépato-Biliaire, Hôpital Paul Brousse, Villejuif, France
| | | | - Martin Teutsch
- Department of Hepatobiliary Surgery and Transplantation University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jun Li
- Department of Hepatobiliary Surgery and Transplantation University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Marcus N Scherer
- Department of Surgery and Transplantation, University Hospital Regensburg, Regensburg, Germany
| | - Hans J Schlitt
- Department of Surgery and Transplantation, University Hospital Regensburg, Regensburg, Germany
| | - Victoria Ardiles
- Department of Surgery, Division of HPB Surgery, Liver Transplant Unit, Italian Hospital of Buenos Aires, Buenos Aires, Argentina
| | - Eduardo de Santibañes
- Department of Surgery, Division of HPB Surgery, Liver Transplant Unit, Italian Hospital of Buenos Aires, Buenos Aires, Argentina
| | - Roberto Brusadin
- Department of Surgery and Liver and Pancreas Transplantation, Virgen de la Arrixaca Clinic and University Hospital and IMIB, Murcia, Spain
| | - Victor Lopez-Lopez
- Department of Surgery and Liver and Pancreas Transplantation, Virgen de la Arrixaca Clinic and University Hospital and IMIB, Murcia, Spain
| | - Ricardo Robles-Campos
- Department of Surgery and Liver and Pancreas Transplantation, Virgen de la Arrixaca Clinic and University Hospital and IMIB, Murcia, Spain
| | - Massimo Malagó
- Department of HPB- and Liver Transplantation Surgery, University College London, Royal Free Hospitals, London, UK
| | - Roberto Hernandez-Alejandro
- Department of Surgery, Division of HPB Surgery and Liver Transplantation, London Health Sciences Centre, London, Ontario, Canada
- Division of Transplantation, Hepatobiliary Surgery, University of Rochester, Rochester, New York
| | - Pierre-Alain Clavien
- Swiss HPB and Transplantation Center, Department of Surgery, University Hospital Zurich, Zurich, Switzerland
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13
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Zhang L, Yang Z, Zhang S, Wang W, Zheng S. Conventional Two-Stage Hepatectomy or Associating Liver Partitioning and Portal Vein Ligation for Staged Hepatectomy for Colorectal Liver Metastases? A Systematic Review and Meta-Analysis. Front Oncol 2020; 10:1391. [PMID: 32974141 PMCID: PMC7471772 DOI: 10.3389/fonc.2020.01391] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Accepted: 07/01/2020] [Indexed: 12/14/2022] Open
Abstract
Background: Pushing the surgical limits for initially unresectable colorectal liver metastases (CRLM) are two approaches for sequential liver resection: two-stage hepatectomy (TSH) and associating liver partitioning and portal vein ligation for staged hepatectomy (ALPPS). However, the role of each treatment modality remains ill-defined. The present meta-analysis was designed to compare the safety, efficacy, and oncological benefits between ALPPS and TSH in the management of advanced CRLM. Methods: A systematic literature search was conducted from online databases through to February 2020. Single-arm synthesis and cumulative meta-analysis were performed. Results: Eight studies were included, providing a total of 409 subjects for analysis (ALPPS: N = 161; TSH: N = 248). The completions of the second stage of the hepatectomy [98 vs. 78%, odds ratio (OR) 5.75, p < 0.001] and R0 resection (66 vs. 37%; OR 4.68; p < 0.001) were more frequent in patients receiving ALPPS than in those receiving TSH, and the waiting interval was dramatically shortened in ALPPS (11.6 vs. 45.7 days, weighted mean difference = −35.3 days, p < 0.001). Nevertheless, the rate of minor complications was significantly higher in ALPPS (59 vs. 18%, OR 6.5, p < 0.001) than in TSH. The two treatments were similar in 90-day mortality (7 vs. 5%, p = 0.43), major complications (29 vs. 22%, p = 0.08), posthepatectomy liver failure (PHLF; 9 vs. 9%, p = 0.3), biliary leakage (11 vs. 14%, p = 0.86), length of hospital stay (27.95 vs. 26.88 days, p = 0.8), 1-year overall survival (79 vs. 84%, p = 0.61), 1-year recurrence (49 vs. 39%, p = 0.32), and 1-year disease-free survival (34 vs. 39%, p = 0.66). Cumulative meta-analyses indicated chronological stability for the pooled effect sizes of resection rate, 90-day mortality, major complications, and PHLF. Conclusions: Compared with TSH, ALPPS for advanced CRLM resulted in superior surgical efficacy with comparable perioperative mortality rate and short-term oncological outcomes, while this was at the cost of increased perioperative minor complications.
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Affiliation(s)
- Liang Zhang
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, School of Medicine, The First Affiliated Hospital, Zhejiang University, Hangzhou, China
- NHC Key Laboratory of Combined Multi-Organ Transplantation, Key Laboratory of the Diagnosis and Treatment of Organ Transplantation, CAMS, Hangzhou, China
| | - Zhentao Yang
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, School of Medicine, The First Affiliated Hospital, Zhejiang University, Hangzhou, China
- NHC Key Laboratory of Combined Multi-Organ Transplantation, Key Laboratory of the Diagnosis and Treatment of Organ Transplantation, CAMS, Hangzhou, China
| | - Shiyu Zhang
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, School of Medicine, The First Affiliated Hospital, Zhejiang University, Hangzhou, China
- NHC Key Laboratory of Combined Multi-Organ Transplantation, Key Laboratory of the Diagnosis and Treatment of Organ Transplantation, CAMS, Hangzhou, China
| | - Wenchao Wang
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, School of Medicine, The First Affiliated Hospital, Zhejiang University, Hangzhou, China
- NHC Key Laboratory of Combined Multi-Organ Transplantation, Key Laboratory of the Diagnosis and Treatment of Organ Transplantation, CAMS, Hangzhou, China
| | - Shusen Zheng
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, School of Medicine, The First Affiliated Hospital, Zhejiang University, Hangzhou, China
- NHC Key Laboratory of Combined Multi-Organ Transplantation, Key Laboratory of the Diagnosis and Treatment of Organ Transplantation, CAMS, Hangzhou, China
- *Correspondence: Shusen Zheng
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14
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Lehwald-Tywuschik N, Vaghiri S, Schulte Am Esch J, Alaghmand S, Klosterkemper Y, Schimmöller L, Lachenmayer A, Ashmawy H, Krieg A, Topp SA, Rehders A, Knoefel WT. In situ split plus portal vein ligation (ISLT) - a salvage procedure following inefficient portal vein embolization to gain adequate future liver remnant volume prior to extended liver resection. BMC Surg 2020; 20:63. [PMID: 32252737 PMCID: PMC7333278 DOI: 10.1186/s12893-020-00721-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Accepted: 03/23/2020] [Indexed: 02/07/2023] Open
Abstract
Background Right extended liver resection is frequently required to achieve tumor-free margins. Portal venous embolization (PVE) of the prospective resected hepatic segments for conditioning segments II/III does not always induce adequate hypertrophy in segments II and III (future liver remnant volume (FLRV)) for extended right-resection. Here, we present the technique of in situ split dissection along segments II/III plus portal disruption to segments IV-VIII (ISLT) as a salvage procedure to overcome inadequate gain of FLRV after PVE. Methods In eight patients, FLRV was further pre-conditioned following failed PVE prior to hepatectomy (ISLT-group). We compared FLRV changes in the ISLT group with patients receiving extended right hepatectomy following sufficient PVE (PVEres-group). Survival of the ISLT-group was compared to PVEres patients and PVE patients with insufficient FLRV gain or tumor progress who did not receive further surgery (PVEnores-group). Results Patient characteristics and surgical outcome were comparable in both groups. The mean FLRV-to-body-weight ratio in the ISLT group was smaller than in the PVEres-group pre- and post-PVE. One intraoperative mortality due to a coronary infarction was observed for an ISLT patient. ISLT was successfully completed in the remaining seven ISLT patients. Liver function and 2-year survival of ~ 50% was comparable to patients with extended right hepatectomy after efficient PVE. Patients who received a PVE but who were not subsequently resected (PVEnores) demonstrated no survival beyond 4 months. Conclusion Despite extended embolization of segments I and IV-VIII, ISLT should be considered if hypertrophy was not adequate. Liver function and overall survival after ISLT was comparable to patients with trisectionectomy after efficient PVE.
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Affiliation(s)
- Nadja Lehwald-Tywuschik
- Department of Surgery A, University Hospital Duesseldorf, Duesseldorf, Germany.,Department of General, Visceral, Thorax and Pediatric Surgery,Heinrich-Heine-University Hospital, Moorenstr. 5, 40225, Duesseldorf, Germany
| | - Sascha Vaghiri
- Department of Surgery A, University Hospital Duesseldorf, Duesseldorf, Germany.,Department of General, Visceral, Thorax and Pediatric Surgery,Heinrich-Heine-University Hospital, Moorenstr. 5, 40225, Duesseldorf, Germany
| | - Jan Schulte Am Esch
- Present address: Center of Visceral Medicine, Department of Visceral Surgery, Protestant Hospital of Bethel Foundation, Bielefeld, Germany
| | - Salman Alaghmand
- Department of Surgery A, University Hospital Duesseldorf, Duesseldorf, Germany
| | - Yan Klosterkemper
- Department of Diagnostic and Interventional Radiology, University Hospital Duesseldorf, Duesseldorf, Germany
| | - Lars Schimmöller
- Department of Diagnostic and Interventional Radiology, University Hospital Duesseldorf, Duesseldorf, Germany
| | - Anja Lachenmayer
- Present ccaddress: Department of Visceral Surgery and Medicine, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Hany Ashmawy
- Department of Surgery A, University Hospital Duesseldorf, Duesseldorf, Germany.,Department of General, Visceral, Thorax and Pediatric Surgery,Heinrich-Heine-University Hospital, Moorenstr. 5, 40225, Duesseldorf, Germany
| | - Andreas Krieg
- Department of Surgery A, University Hospital Duesseldorf, Duesseldorf, Germany.,Department of General, Visceral, Thorax and Pediatric Surgery,Heinrich-Heine-University Hospital, Moorenstr. 5, 40225, Duesseldorf, Germany
| | - Stefan A Topp
- Present address: Department of Surgery, Ameos Hospital, Bremerhaven, Germany
| | - Alexander Rehders
- Department of Surgery A, University Hospital Duesseldorf, Duesseldorf, Germany.,Department of General, Visceral, Thorax and Pediatric Surgery,Heinrich-Heine-University Hospital, Moorenstr. 5, 40225, Duesseldorf, Germany
| | - Wolfram Trudo Knoefel
- Department of Surgery A, University Hospital Duesseldorf, Duesseldorf, Germany. .,Department of General, Visceral, Thorax and Pediatric Surgery,Heinrich-Heine-University Hospital, Moorenstr. 5, 40225, Duesseldorf, Germany.
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15
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Jouffret L, Ewald J, Marchese U, Garnier J, Gilabert M, Mokart D, Piana G, Delpero JR, Turrini O. Is progression in the future liver remnant a contraindication for second-stage hepatectomy? HPB (Oxford) 2019; 21:1478-1484. [PMID: 30962135 DOI: 10.1016/j.hpb.2019.03.357] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Revised: 02/25/2019] [Accepted: 03/10/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Two-stage hepatectomy (TSH) strategy is used to treat patients with bilobar colorectal liver metastasis (CLM). However, many patients do not undergo the second hepatectomy owing to disease progression in the future liver remnant (FLR) after portal vein embolization (PVE). This study aimed to assess the impact of disease progression in the FLRs of patients who completed the first hepatectomy. METHODS 68 consecutive patients underwent the first hepatectomy followed by PVE. Six patients (9%) dropped out after the PVE (two-stage failed [TSF] group) because of unresectable hepatic or general disease progression. Seventeen patients (25%) completed their second hepatectomy despite disease progression in the FLR (new CLM [nCLM] group) as it was considered resectable, while 45 patients (66%) underwent the second hepatectomy (control group). RESULTS The 5-year overall survival rates in the TSF, nCLM, and control groups were 0%, 7%, and 60%, respectively (P < 0.001). The median overall survival times between the TSF and nCLM groups were 26 months and 42 months (P = 0.005). Patients in the nCLM group whose hepatic disease progression was detected preoperatively versus intraoperatively had comparable survival rates. CONCLUSION Resectable hepatic disease progression in the FLR after PVE should not be considered a contraindication for the second hepatectomy.
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Affiliation(s)
- Lionel Jouffret
- Department of Surgery, Institut Paoli-Calmettes, Marseille, France.
| | - Jacques Ewald
- Department of Surgery, Institut Paoli-Calmettes, Marseille, France
| | - Ugo Marchese
- Department of Surgery, Institut Paoli-Calmettes, Marseille, France
| | - Jonathan Garnier
- Department of Surgery, Institut Paoli-Calmettes, Marseille, France
| | - Marine Gilabert
- Aix-Marseille University, Institut Paoli-Calmettes, Department of Oncology, CNRS, Inserm, CRCM, Marseille, France
| | - Djamel Mokart
- Department of Reanimation, Institut Paoli-Calmettes, Marseille, France
| | - Gilles Piana
- Department of Radiology, Institut Paoli-Calmettes, Marseille, France
| | | | - Olivier Turrini
- Aix-Marseille University, Institut Paoli-Calmettes, Department of Surgery, CNRS, Inserm, CRCM, Marseille, France
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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: 9] [Impact Index Per Article: 1.5] [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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17
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Quénet F, Pissas MH, Gil H, Roca L, Carrère S, Sgarbura O, Rouanet P, de Forges H, Khellaf L, Deshayes E, Ychou M, Bibeau F. Two-stage hepatectomy for colorectal liver metastases: Pathologic response to preoperative chemotherapy is associated with second-stage completion and longer survival. Surgery 2019; 165:703-711. [DOI: 10.1016/j.surg.2018.10.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Revised: 09/21/2018] [Accepted: 10/09/2018] [Indexed: 12/17/2022]
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Kawaguchi Y, Lillemoe HA, Vauthey JN. Dealing with an insufficient future liver remnant: Portal vein embolization and two-stage hepatectomy. J Surg Oncol 2019; 119:594-603. [PMID: 30825223 DOI: 10.1002/jso.25430] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Accepted: 02/09/2019] [Indexed: 12/18/2022]
Abstract
Colorectal liver metastases (CLM) are not always resectable at the time of diagnosis. An insufficient future liver remnant is a factor excluding patients from curative intent resection. To deal with this issue, two-stage hepatectomy was introduced approximately 20 years ago. It is a sequential treatment strategy for bilateral CLM, which consists of preoperative chemotherapy, portal vein embolization, and planned first and second liver resections. This study reviews current evidence supporting use of two-stage hepatectomy.
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Affiliation(s)
- Yoshikuni Kawaguchi
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Heather A Lillemoe
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jean-Nicolas Vauthey
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
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19
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Mor E, Al-Kurd A, Yaacov AB, Aderka D, Nissan A, Ariche A. Surgical outcomes of two-stage hepatectomy for colorectal liver metastasis: comparison to a benchmark procedure. Hepatobiliary Surg Nutr 2019; 8:29-36. [PMID: 30881963 DOI: 10.21037/hbsn.2018.12.02] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Background Two-stage hepatectomy (TSH) with portal vein embolization (PVE) is associated with high morbidity and mortality and may result in liver failure due to insufficient future liver remnant. The objectives of this investigation were to evaluate the short-term outcomes of patients with colorectal cancer liver metastasis who underwent TSH with PVE, and to critically review the selection criteria for TSH-PVE. Methods A retrospective review of all patients who were operated due to bi-lobar CRLM during the years 2007-2017 was performed. Patients who underwent TSH-PVE were compared to those who underwent right hepatectomy (RH) only. Results Twenty-nine patient underwent TSH, 25 of whom (86.2%) completed both stages. These patients demonstrated a major complication rate of 17%, and a 90-day mortality rate of 3.4%. Most complications (80%) were related to the colonic resection, and one patient developed liver failure. Patients who suffered complications had a trend towards more baseline comorbidities and more liver lesions. Ablative techniques were utilized in 76%. When compared to 35 patients who underwent sole RH, no significant difference was demonstrated in major complication rate (20%) or mortality (0%). Conclusions TSH is a relatively safe procedure in selected patients. Ablative techniques can reduce the occurrence of liver insufficiency and should be used liberally when possible. Factors such as number of lesions, comorbidities and the timing of colonic resection should be considered and evaluated in order to improve the outcomes of the procedure.
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Affiliation(s)
- Eyal Mor
- Department of General and Oncological Surgery, Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel
| | - Abbas Al-Kurd
- Department of Surgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Almog Ben Yaacov
- Department of General and Oncological Surgery, Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel
| | - Dan Aderka
- Department of Oncology, Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel
| | - Aviram Nissan
- Department of General and Oncological Surgery, Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel
| | - Arie Ariche
- Department of Surgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel.,Department of Hepatobiliary Surgery, Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel
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20
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Torzilli G, Viganò L, Cimino M, Imai K, Vibert E, Donadon M, Mansour D, Castaing D, Adam R. Is Enhanced One-Stage Hepatectomy a Safe and Feasible Alternative to the Two-Stage Hepatectomy in the Setting of Multiple Bilobar Colorectal Liver Metastases? A Comparative Analysis between Two Pioneering Centers. Dig Surg 2018; 35:323-332. [PMID: 29439275 DOI: 10.1159/000486210] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Accepted: 12/10/2017] [Indexed: 12/19/2022]
Abstract
BACKGROUND Two-stage hepatectomy (TSH) is the present standard for multiple bilobar colorectal metastases (CLM). As alternative, ultrasound-guided one-stage hepatectomy (E-OSH) has been proposed even for deep-located nodules to compare TSH and E-OSH. METHODS All consecutive TSH at the Paul Brousse Hospital and E-OSH at the Humanitas Research Hospital were considered. The inclusion criteria were ≥6 CLM, ≥3 CLM in the left liver, and ≥1 lesion with vascular contact. A total of 74 TSH and 35 E-OSH were compared. RESULTS The 2 groups had similar characteristics. Drop-out rate of TSH was 40.5%. In comparison with the cumulated hepatectomies of TSH, E-OSH had lower blood loss (500 vs. 1,100 mL, p = 0.009), overall morbidity (37.1 vs. 70.5%, p = 0.003), severe morbidity (14.3 vs. 36.4%, p = 0.04), and liver-specific morbidity (22.9 vs. 40.9%, p = 0.02). R0 resection rate was similar between groups. E-OSH and completed TSH had similar overall survival (5-year 38.2 vs. 31.8%), recurrence-free survival (3-year 17.6 vs. 17.7%), and recurrence sites. CONCLUSIONS E-OSH is a safe alternative to TSH for multiple bilobar deep-located CLM. Whenever feasible, E-OSH should even be considered the preferred option because it has excellent safety and oncological outcomes equivalent to completed TSH, without the drop-out risk.
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Affiliation(s)
- Guido Torzilli
- Division of Hepatobiliary and General Surgery, Department of Surgery, Humanitas University, School of Medicine, Humanitas Research Hospital, Milan, Italy
| | - Luca Viganò
- Division of Hepatobiliary and General Surgery, Department of Surgery, Humanitas University, School of Medicine, Humanitas Research Hospital, Milan, Italy
| | - Matteo Cimino
- Division of Hepatobiliary and General Surgery, Department of Surgery, Humanitas University, School of Medicine, Humanitas Research Hospital, Milan, Italy
| | - Katsunori Imai
- AP-HP Hôpital Paul Brousse, Centre Hépato-Biliaire, University of Paris, Paris, France
| | - Eric Vibert
- AP-HP Hôpital Paul Brousse, Centre Hépato-Biliaire, University of Paris, Paris, France
| | - Matteo Donadon
- Division of Hepatobiliary and General Surgery, Department of Surgery, Humanitas University, School of Medicine, Humanitas Research Hospital, Milan, Italy
| | - Doaa Mansour
- Division of Hepatobiliary and General Surgery, Department of Surgery, Humanitas University, School of Medicine, Humanitas Research Hospital, Milan, Italy
| | - Denis Castaing
- AP-HP Hôpital Paul Brousse, Centre Hépato-Biliaire, University of Paris, Paris, France
| | - Ren Adam
- AP-HP Hôpital Paul Brousse, Centre Hépato-Biliaire, University of Paris, Paris, France
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21
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Regimbeau JM, Cosse C, Kaiser G, Hubert C, Laurent C, Lapointe R, Isoniemi H, Adam R. Feasibility, safety and efficacy of two-stage hepatectomy for bilobar liver metastases of colorectal cancer: a LiverMetSurvey analysis. HPB (Oxford) 2017; 19:396-405. [PMID: 28343889 DOI: 10.1016/j.hpb.2017.01.008] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Revised: 12/29/2016] [Accepted: 01/04/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND The combination of liver resection and chemotherapy has become the standard of care for colorectal liver metastases (LM). The objective of the present study was to evaluate the impact of two-stage hepatectomy (TSH) on the long-term survival of patients with bilobar LM. METHODS We included adult (over-18) patients from the LiverMetSurvey registry with confirmed multiple colorectal LM and having undergone either one-stage hepatectomy or TSH with curative intent. The "TSH (2/2)" group (n = 625) comprised patients having completed both stages of TSH; the "TSH (1/2)" group (n = 244) comprised patients having undergone only the first stage of TSH; the "hepatectomy" group. The primary outcome criterion was the overall survival (OS). The secondary outcomes were the morbidity and mortality rates. RESULTS The 30- and 90-day mortality rates were respectively 3.8% and 9.3% in the TSH (2/2) group, 9.4% and 16.4% in the TSH (1/2) group, and 5.4% and 9.1% in the "hepatectomy" group. The three-year OS rate was 45% in the TSH (2/2) group, 30% in the TSH (1/2) group and 50.7% in the hepatectomy group. CONCLUSION The LiverMetSurvey registry's data indicate that TSH is associated with rather good long-term survival and acceptable morbidity and mortality rates.
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Affiliation(s)
- Jean Marc Regimbeau
- Digestive and Oncological Surgery Department, Amiens University Medical Center, Amiens, France; EA 4292, Jules Verne University of Picardy, Amiens, France; Clinical Research Center, Amiens University Medical Center, Amiens, France.
| | - Cyril Cosse
- Digestive and Oncological Surgery Department, Amiens University Medical Center, Amiens, France; Clinical Research Center, Amiens University Medical Center, Amiens, France
| | | | | | | | | | - Helen Isoniemi
- Transplantation and Liver Surgery Helsinki University Hospital, Helsinki, Finland
| | - Rene Adam
- Centre Hépato-Biliaire, Assistance Publique - Hôpitaux de Paris (APHP), Hôpital Universitaire Paul Brousse, Villejuif, France; Institut National de la Santé et de la Recherche Médicale (INSERM), Unité 935, Villejuif, France
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22
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Two-stage hepatectomy in two regional district community hospitals: perioperative safety and long-term survival. TUMORI JOURNAL 2016; 103:170-176. [PMID: 28058712 DOI: 10.5301/tj.5000589] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/15/2016] [Indexed: 01/15/2023]
Abstract
INTRODUCTION Surgical resection offers the best chance of cure for patients with colorectal liver metastases (CRLMs). Two-stage hepatectomy (TSH) has been demonstrated to be safe and effective to obtain curative resection in patients with multiple, bilobar CRLMs that are unresectable in a single procedure. Up to now TSH has been the prerogative of dedicated liver surgery centers. The aim of this study was to assess the safety and effectiveness of TSH also in community hospitals. METHODS Of 294 patients operated on for CRLMs between September 1997 and June 2012 in 2 district community hospitals (belonging to the same regional healthcare district), 43 (14.6%) were scheduled for TSH. Thirty-eight/43 received neoadjuvant and/or bridge chemotherapy (2 neoadjuvant only, 4 neoadjuvant and bridge, 32 bridge only). RESULTS The mean follow-up was 35.74 ± 29.53 months. Five-year overall survival (OS) was 31.4%, with a median survival time of 31 months. Twenty-nine patients completed the planned procedure (OS: 42.9%; median 47 months), while 14 did not because of disease progression (OS: 0%; median 13 months). No operative mortality occurred within the first 90 days either after the first or second stage. CONCLUSIONS Our results suggest good efficacy and safety of TSH even when performed in a community hospital setting. Shifting patient selection from neoadjuvant to bridge chemotherapy had no impact on outcome once the clearing of the liver had been achieved. In patients presenting with synchronous CRLMs, simultaneous colorectal resection and clearing of the less involved hemiliver as the first surgical step is feasible without any negative impact on outcome.
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23
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Torzilli G, Adam R, Viganò L, Imai K, Goransky J, Fontana A, Toso C, Majno P, de Santibañes E. Surgery of Colorectal Liver Metastases: Pushing the Limits. Liver Cancer 2016; 6:80-89. [PMID: 27995092 PMCID: PMC5159716 DOI: 10.1159/000449495] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND The recent advent of more effective chemotherapy and the development of surgical procedures have expanded the pool of resectable patients with colorectal liver metastases (CLM). Two-stage hepatectomy (TSH), associated liver partition and portal vein ligation for staged hepatectomy (ALPPS), and ultrasound-guided enhanced one-stage hepatectomy (e-OSH) are the surgical solutions proposed for these patients, but the range of indications for these procedures vary from institution to institution. SUMMARY The advantages and disadvantages of each approach are herein discussed. Patients who drop out between the staged operations of TSH limit its success rate, although predictive scores may help with patient selection and thereby optimize the results. Safety and oncological suitability are concerns to be addressed when considering ALPPS. These concerns notwithstanding, ALPPS has introduced an innovative concept in surgery: the monosegmental remnant liver. Studies involving e-OSH have proven the oncological suitability of tumor exposure once the CLM is detached from major intrahepatic vessels. This finding could expand the indications for e-OSH, although the technical challenges that it entails limit its spread among the surgical community. The liver-first approach involves the clearance of tumors from the liver before the colorectal primary is tackled. This approach fully justifies the complexity of e-OSH. KEY MESSAGES Predictive scores limiting the interstage dropout of TSH, partial and monosegmental ALPPS, and R1 vascular e-OSH justified by solid long-term results represent new insights that could help refne the patient assignment to each of these approaches. Additionally, liver transplantation is an emerging treatment for CLM that should be taken into account.
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Affiliation(s)
- Guido Torzilli
- Department of Surgery, Division of Hepatobiliary and General Surgery, Humanitas University, Hu-manitas Clinical and Research Hospital, Rozzano, Italy,*Guido Torzilli, MD, PhD Department of Surgery, Division of Hepatobiliary and General Surgery, Humanitas University, Humanitas Clinical and Research Hospital, Via Manzoni, 56, IT–20089, Rozzano, Milano (Italy), Tel. +39 02 8224 4769, E-Mail
| | - René Adam
- Centre Hépato-Biliaire, AP-HP, Hôpital Universitaire Paul Brousse, Villejuif, France
| | - Luca Viganò
- Department of Surgery, Division of Hepatobiliary and General Surgery, Humanitas University, Hu-manitas Clinical and Research Hospital, Rozzano, Italy
| | - Katsunori Imai
- Centre Hépato-Biliaire, AP-HP, Hôpital Universitaire Paul Brousse, Villejuif, France
| | - Jeremias Goransky
- Department of General Surgery, Division of Hepatobiliary and Pancreatic Surgery, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Andrea Fontana
- Department of Surgery, Division of Hepatobiliary and General Surgery, Humanitas University, Hu-manitas Clinical and Research Hospital, Rozzano, Italy
| | - Christian Toso
- Department of Visceral and Transplantation Surgery, University Hospitals of Geneva, Geneva, Switzerland
| | - Pietro Majno
- Department of Visceral and Transplantation Surgery, University Hospitals of Geneva, Geneva, Switzerland
| | - Eduardo de Santibañes
- Department of General Surgery, Division of Hepatobiliary and Pancreatic Surgery, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
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24
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A literature review of associating liver partition and portal vein ligation for staged hepatectomy (ALPPS): so far, so good. Updates Surg 2016; 69:9-19. [DOI: 10.1007/s13304-016-0401-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2016] [Accepted: 09/29/2016] [Indexed: 12/24/2022]
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Eshmuminov D, Raptis DA, Linecker M, Wirsching A, Lesurtel M, Clavien PA. Meta-analysis of associating liver partition with portal vein ligation and portal vein occlusion for two-stage hepatectomy. Br J Surg 2016; 103:1768-1782. [PMID: 27633328 DOI: 10.1002/bjs.10290] [Citation(s) in RCA: 103] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Revised: 07/04/2016] [Accepted: 07/06/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND Discussion is ongoing regarding whether associating liver partition with portal vein ligation for staged hepatectomy (ALPPS) or portal vein occlusion is better in staged hepatectomy. The aim of this study was to compare available strategies using a two-stage approach in extended hepatectomy. METHODS A literature search was performed in MEDLINE, Scopus, the Cochrane Library and Embase, and additional articles were identified by hand searching. Data from the international ALPPS registry were extracted. Clinical studies reporting volumetric changes, mortality, morbidity, feasibility of the second stage and tumour-free resection margins (R0) in two-stage hepatectomy were included. RESULTS Ninety studies involving 4352 patients, including 320 from the ALPPS registry, met the inclusion criteria. Among these, nine studies (357 patients) reported on comparisons with other strategies. In the comparison of ALPPS versus portal vein embolization (PVE), ALPPS was associated with a greater increase in the future liver remnant (76 versus 37 per cent; P < 0·001) and more frequent completion of stage 2 (100 versus 77 per cent; P < 0·001). Compared with PVE, ALPPS had a trend towards higher morbidity (73 versus 59 per cent; P = 0·16) and mortality (14 versus 7 per cent; P = 0·19) after stage 2. In the non-comparative studies, complication rates were 39 per cent in the PVE group, 47 per cent in the portal vein ligation (PVL) group and 70 per cent in the ALPPS group. After stage 2, mortality rates were 5, 7 and 12 per cent respectively. CONCLUSION ALPPS is associated with greater future liver remnant hypertrophy and a higher rate of completion of stage 2, but this may be at the price of greater morbidity and mortality.
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Affiliation(s)
- D Eshmuminov
- Department of Surgery, Swiss HPB and Transplantation Centre, University Hospital Zurich, Zurich, Switzerland
| | - D A Raptis
- Department of Surgery, Swiss HPB and Transplantation Centre, University Hospital Zurich, Zurich, Switzerland
| | - M Linecker
- Department of Surgery, Swiss HPB and Transplantation Centre, University Hospital Zurich, Zurich, Switzerland
| | - A Wirsching
- Department of Surgery, Swiss HPB and Transplantation Centre, University Hospital Zurich, Zurich, Switzerland
| | - M Lesurtel
- Department of Surgery, Swiss HPB and Transplantation Centre, University Hospital Zurich, Zurich, Switzerland.,Department of General Surgery and Liver Transplantation, Croix-Rousse University Hospital, Hospices Civils de Lyon, Lyon, France
| | - P-A Clavien
- Department of Surgery, Swiss HPB and Transplantation Centre, University Hospital Zurich, Zurich, Switzerland
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Drop-out between the two liver resections of two-stage hepatectomy. Patient selection or loss of chance? Eur J Surg Oncol 2016; 42:1385-93. [DOI: 10.1016/j.ejso.2016.03.020] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2015] [Revised: 02/22/2016] [Accepted: 03/21/2016] [Indexed: 12/25/2022] Open
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Dervenis C, Xynos E, Sotiropoulos G, Gouvas N, Boukovinas I, Agalianos C, Androulakis N, Athanasiadis A, Christodoulou C, Chrysou E, Emmanouilidis C, Georgiou P, Karachaliou N, Katopodi O, Kountourakis P, Kyriazanos I, Makatsoris T, Papakostas P, Papamichael D, Pechlivanides G, Pentheroudakis G, Pilpilidis I, Sgouros J, Tekkis P, Triantopoulou C, Tzardi M, Vassiliou V, Vini L, Xynogalos S, Ziras N, Souglakos J. Clinical practice guidelines for the management of metastatic colorectal cancer: a consensus statement of the Hellenic Society of Medical Oncologists (HeSMO). Ann Gastroenterol 2016; 29:390-416. [PMID: 27708505 PMCID: PMC5049546 DOI: 10.20524/aog.2016.0050] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Accepted: 03/10/2016] [Indexed: 12/12/2022] Open
Abstract
There is discrepancy and failure to adhere to current international guidelines for the management of metastatic colorectal cancer (CRC) in hospitals in Greece and Cyprus. The aim of the present document is to provide a consensus on the multidisciplinary management of metastastic CRC, considering both special characteristics of our Healthcare System and international guidelines. Following discussion and online communication among the members of an executive team chosen by the Hellenic Society of Medical Oncology (HeSMO), a consensus for metastastic CRC disease was developed. Statements were subjected to the Delphi methodology on two voting rounds by invited multidisciplinary international experts on CRC. Statements reaching level of agreement by ≥80% were considered as having achieved large consensus, whereas statements reaching 60-80% moderate consensus. One hundred and nine statements were developed. Ninety experts voted for those statements. The median rate of abstain per statement was 18.5% (range: 0-54%). In the end of the process, all statements achieved a large consensus. The importance of centralization, care by a multidisciplinary team, adherence to guidelines, and personalization is emphasized. R0 resection is the only intervention that may offer substantial improvement in the oncological outcomes.
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Affiliation(s)
- Christos Dervenis
- General Surgery, "Konstantopouleio" Hospital of Athens, Greece (Christos Dervenis)
| | - Evaghelos Xynos
- General Surgery, "InterClinic" Hospital of Heraklion, Greece (Evangelos Xynos)
| | | | - Nikolaos Gouvas
- General Surgery, "METROPOLITAN" Hospital of Piraeus, Greece (Nikolaos Gouvas)
| | - Ioannis Boukovinas
- Medical Oncology, "Bioclinic" of Thessaloniki, Greece (Ioannis Boukovinas)
| | - Christos Agalianos
- General Surgery, Athens Naval & Veterans Hospital, Greece (Christos Agalianos, Ioannis Kyriazanos, George Pechlivanides)
| | - Nikolaos Androulakis
- Medical Oncology, "Venizeleion" Hospital of Heraklion, Greece (Nikolaos Androulakis)
| | | | | | - Evangelia Chrysou
- Radiology, University Hospital of Heraklion, Greece (Evangelia Chrysou)
| | - Christos Emmanouilidis
- Medical Oncology, "Interbalkan" Medical Center, Thessaloniki, Greece (Christos Emmanoulidis)
| | - Panagiotis Georgiou
- Colorectal Surgery, Chelsea and Westminster NHS Foundation Trust, London, UK (Panagiotis Georgiou, Paris Tekkis)
| | - Niki Karachaliou
- Medical Oncology, Dexeus University Institut, Barcelona, Spain (Niki Carachaliou)
| | - Ourania Katopodi
- Medical Oncology, "Iaso" General Hospital, Athens, Greece (Ourania Katopoidi)
| | - Panteleimon Kountourakis
- Medical Oncology, Oncology Center of Bank of Cyprus, Nicosia, Cyprus (Pandelis Kountourakis, Demetris Papamichael)
| | - Ioannis Kyriazanos
- General Surgery, Athens Naval & Veterans Hospital, Greece (Christos Agalianos, Ioannis Kyriazanos, George Pechlivanides)
| | - Thomas Makatsoris
- Medical Oncology, University Hospital of Patras, Greece (Thomas Makatsoris)
| | - Pavlos Papakostas
- Medical Oncology, "Ippokrateion" Hospital of Athens, Greece (Pavlos Papakostas)
| | - Demetris Papamichael
- Medical Oncology, Oncology Center of Bank of Cyprus, Nicosia, Cyprus (Pandelis Kountourakis, Demetris Papamichael)
| | - George Pechlivanides
- General Surgery, Athens Naval & Veterans Hospital, Greece (Christos Agalianos, Ioannis Kyriazanos, George Pechlivanides)
| | | | - Ioannis Pilpilidis
- Gastroenterology, "Theageneion" Cancer Hospital, Thessaloniki, Greece (Ioannis Pilpilidis)
| | - Joseph Sgouros
- Medical Oncology, "Agioi Anargyroi" Hospital of Athens, Greece (Joseph Sgouros)
| | - Paris Tekkis
- Colorectal Surgery, Chelsea and Westminster NHS Foundation Trust, London, UK (Panagiotis Georgiou, Paris Tekkis)
| | | | - Maria Tzardi
- Pathology, University Hospital of Heraklion, Greece (Maria Tzardi)
| | - Vassilis Vassiliou
- Radiation Oncology, Oncology Center of Bank of Cyprus, Nicosia, Cyprus (Vassilis Vassiliou)
| | - Louiza Vini
- Radiation Oncology, "Iatriko" Center of Athens, Greece (Lousa Vini)
| | - Spyridon Xynogalos
- Medical Oncology, "George Gennimatas" General Hospital, Athens, Greece (Spyridon Xynogalos)
| | - Nikolaos Ziras
- Medical Oncology, "Metaxas" Cancer Hospital, Piraeus, Greece (Nikolaos Ziras)
| | - John Souglakos
- Medical Oncology, University Hospital of Heraklion, Greece (John Souglakos)
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Cai YL, Song PP, Tang W, Cheng NS. An updated systematic review of the evolution of ALPPS and evaluation of its advantages and disadvantages in accordance with current evidence. Medicine (Baltimore) 2016; 95:e3941. [PMID: 27311006 PMCID: PMC4998492 DOI: 10.1097/md.0000000000003941] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
The main obstacle to achieving an R0 resection after a major hepatectomy is inability to preserve an adequate future liver remnant (FLR) to avoid postoperative liver failure (PLF). Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) is a novel technique for resecting tumors that were previously considered unresectable, and this technique results in a vast increase in the volume of the FLR in a short period of time. However, this technique continues to provoke heated debate because of its high mortality and morbidity.The evolution of ALPPS and its advantages and disadvantages have been systematically reviewed and evaluated in accordance with current evidence. Electronic databases (PubMed and Medline) were searched for potentially relevant articles from January 2007 to January 2016.ALPPS has evolved into various modified forms. Some of these modified techniques have reduced the difficulty of the procedure and enhanced its safety. Current evidence indicates that the advantages of ALPPS are rapid hypertrophy of the FLR, the feasibility of the procedure, and a higher rate of R0 resection in comparison to other techniques. However, ALPPS is associated with worse major complications, more deaths, and early tumor recurrence.Hepatobiliary surgeons should carefully consider whether to perform ALPPS. Some modified forms of ALPPS have reduced the mortality and morbidity of the procedure, but they cannot be recommended over the original procedure currently. Portal vein embolization (PVE) is still the procedure of choice for patients with a tumor-free FLR, and ALPPS could be used as a salvage procedure when PVE fails. More persuasive evidence needs to be assembled to determine whether ALPPS or two-stage hepatectomy (TSH) is better for patients with a tumor involving the FLR. Evidence with regard to long-term oncological outcomes is still limited. More meticulous comparative studies and studies of the 5-year survival rate of ALPPS could ultimately help to determine the usefulness of ALPPS. Indications and patient selection for the procedure need to be determined.
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Affiliation(s)
- Yu-Long Cai
- Department of Bile Duct Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Pei-Pei Song
- Graduate School of Frontier Sciences, The University of Tokyo, Kashiwa-shi, Chiba, Japan
| | - Wei Tang
- Department of Bile Duct Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Nan-Sheng Cheng
- Department of Bile Duct Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
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Li J, Ewald F, Gulati A, Nashan B. Associating liver partition and portal vein ligation for staged hepatectomy: From technical evolution to oncological benefit. World J Gastrointest Surg 2016; 8:124-133. [PMID: 26981186 PMCID: PMC4770166 DOI: 10.4240/wjgs.v8.i2.124] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Revised: 10/08/2015] [Accepted: 12/11/2015] [Indexed: 02/06/2023] Open
Abstract
Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) is a novel approach in liver surgery that allows for extensive resection of liver parenchyma by inducing a rapid hypertrophy of the future remnant liver. However, recent reports indicate that not all patients eligible for ALPPS will benefit from this procedure. Therefore, careful patient selection will be necessary to fully exploit possible benefits of ALPPS. Here, we provide a comprehensive overview of the technical evolution of ALPPS with a special emphasis on safety and oncologic efficacy. Furthermore, we review the contemporary literature regarding indication and benefits, but also limitations of ALPPS.
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Passot G, Chun YS, Kopetz SE, Zorzi D, Brudvik KW, Kim BJ, Conrad C, Aloia TA, Vauthey JN. Predictors of Safety and Efficacy of 2-Stage Hepatectomy for Bilateral Colorectal Liver Metastases. J Am Coll Surg 2016; 223:99-108. [PMID: 26968325 DOI: 10.1016/j.jamcollsurg.2015.12.057] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2015] [Revised: 12/14/2015] [Accepted: 12/14/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND In patients with bilateral colorectal liver metastases (CLM) not resectable in 1 operation, 2-stage hepatectomy is the standard surgical approach. The objective of this study was to determine factors associated with safety and efficacy of 2-stage hepatectomy. STUDY DESIGN The study included all 109 patients for whom 2-stage hepatectomy for CLM was planned during 2003 to 2014. The RAS mutation status and other clinicopathologic factors were evaluated for association with major complications and survival using multivariate analysis. RESULTS Two-stage hepatectomy was completed in 89 of 109 patients (82%). Reasons for dropout after the first stage were disease progression (n = 12), insufficient liver growth (n = 5), and complications after first stage or portal vein embolization (n = 3). More than 6 cycles of preoperative chemotherapy were associated with failure to proceed to the second stage (p = 0.009). Rates of major complications (26% vs 6%; p < 0.001) and 90-day mortality (7% vs 0%; p = 0.006) were higher after the second stage. The cumulative rate of major complications was 15% (n = 29). Factors independently associated with major complications were rectal primary tumor, metachronous CLM, and more than 1 lesion resected at first stage. At median follow-up of 29.5 months, 3-year (68% vs 6%; p < 0.001) and 5-year overall survival rates (49% vs 0%; p < 0.001) were better after 2-stage hepatectomy completion than noncompletion. Factors independently associated with poor overall survival were rectal primary tumor (p = 0.044), more than 5 CLMs (p = 0.043), need for chemotherapy after first stage (p = 0.046), and RAS mutation (p < 0.001). CONCLUSIONS The RAS mutation independently predicts the oncologic efficacy of 2-stage hepatectomy and may help guide patient selection for this aggressive surgical strategy.
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Affiliation(s)
- Guillaume Passot
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Yun Shin Chun
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Scott E Kopetz
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Daria Zorzi
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - Bradford J Kim
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Claudius Conrad
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Thomas A Aloia
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Jean-Nicolas Vauthey
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX.
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31
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Staged resection of bilobar colorectal liver metastases: surgical strategies. Langenbecks Arch Surg 2015; 400:633-40. [PMID: 26049744 DOI: 10.1007/s00423-015-1310-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2015] [Accepted: 05/28/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND Radical resection is the treatment of choice for colorectal liver metastases (CLM). Unfortunately, only about 20 % of patients present with initially resectable disease, in most cases due to bilobar disease. In the last two decades, major achievements have been made to extend surgical indications to patients with bilobar CLM, such as two-stage hepatectomy with or without portal vein occlusion and associating liver partition and portal vein ligation for staged hepatectomy (ALPPS). PURPOSE The purpose of this review article was to summarize current surgical approaches and their safety and efficacy for patients with initially unresectable bilobar CLM. CONCLUSION In selected patients, two-stage hepatectomy and ALPPS are efficient and safe to convert unresectable to resectable CLM. Further studies are required to evaluate long-term outcome of these procedures.
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Bertens KA, Hawel J, Lung K, Buac S, Pineda-Solis K, Hernandez-Alejandro R. ALPPS: challenging the concept of unresectability--a systematic review. Int J Surg 2014; 13:280-287. [PMID: 25496851 DOI: 10.1016/j.ijsu.2014.12.008] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2014] [Accepted: 12/07/2014] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Hepatic resection for malignancy is limited by the amount of liver parenchyma left behind. As a result, two-staged hepatectomy and portal vein occlusion (PVO) have become part of the treatment algorithm. Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) has been recently described as a method to stimulate rapid and profound hypertrophy. MATERIALS AND METHODS A systematic review of the literature pertaining to ALPPS was undertaken. Peer-reviewed articles relating to portal vein ligation (PVL) and in situ split (ISS) of the parenchyma were included. RESULTS To date, ALPPS has been employed for a variety of primary and metastatic liver tumors. In early case series, the perioperative morbidity and mortality was unacceptably high. However with careful patient selection and improved technique, many centers have reported a 0% 90-day mortality. The benefits of ALPPS include hypertrophy of 61-93% over a median 9-14 days, 95-100% completion of the second stage, and high likelihood of R0 resection (86-100%). DISCUSSION ALPPS is only indicated when a two-stage hepatectomy is necessary and the future liver remnant (FLR) is deemed inadequate (<30%). Use in patients with poor functional status, or advanced age (>70 years) is cautioned. Discretion should be used when considering this in patients with pathology other than colorectal liver metastases (CRLM), especially hilar tumors requiring biliary reconstruction. Biliary ligation during the first stage and routine lymphadenectomy of the hepatoduodenal ligament should be avoided. CONCLUSIONS A consensus on the indications and contraindications for ALPPS and a standardized operative protocol are needed.
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Affiliation(s)
- Kimberly A Bertens
- Department of Surgery, Schulich School of Medicine & Dentistry, University of Western Ontario, 339 Windermere Road, London, ON, Canada N6A 5A5
| | - Jeffrey Hawel
- Department of Surgery, Schulich School of Medicine & Dentistry, University of Western Ontario, 339 Windermere Road, London, ON, Canada N6A 5A5
| | - Kalvin Lung
- Department of Surgery, Schulich School of Medicine & Dentistry, University of Western Ontario, 339 Windermere Road, London, ON, Canada N6A 5A5
| | - Suzana Buac
- Department of Surgery, Schulich School of Medicine & Dentistry, University of Western Ontario, 339 Windermere Road, London, ON, Canada N6A 5A5
| | - Karen Pineda-Solis
- Department of Surgery, Schulich School of Medicine & Dentistry, University of Western Ontario, 339 Windermere Road, London, ON, Canada N6A 5A5; Multi-Organ Transplant Program, London Health Sciences Centre, 339 Windermere Road, London, ON, Canada N6A 5A5
| | - Roberto Hernandez-Alejandro
- Department of Surgery, Schulich School of Medicine & Dentistry, University of Western Ontario, 339 Windermere Road, London, ON, Canada N6A 5A5; Multi-Organ Transplant Program, London Health Sciences Centre, 339 Windermere Road, London, ON, Canada N6A 5A5.
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Faitot F, Soubrane O, Wendum D, Sandrini J, Afchain P, Balladur P, de Gramont A, Scatton O. Feasibility and survival of 2-stage hepatectomy for colorectal metastases: definition of a simple and early clinicopathologic predicting score. Surgery 2014; 157:444-53. [PMID: 25633729 DOI: 10.1016/j.surg.2014.09.033] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2013] [Revised: 08/13/2014] [Accepted: 09/18/2014] [Indexed: 12/29/2022]
Abstract
INTRODUCTION Bilobar colorectal metastases may be treated by a 2-stage surgical strategy. The risk of drop out after the first stage hepatectomy remains high and is associated with a nearly zero survival rate at 3 years. Our goal was to evaluate the factors predictive of the feasibility of the strategy and long-term survival, based on simple clinical and histologic features obtained from the first stage specimen. PATIENTS AND METHODS Patients who underwent a first stage hepatectomy with curative intent were included. Preoperative clinical parameters and histologic features of the primary neoplasm and metastases obtained at the first stage hepatectomy were analyzed and compared between patients who did or did not undergo the second stage operation. A group of comparable patients treated only by chemotherapy was used as a control group. RESULTS The feasibility rate of this 2-stage resection was 76% (38/50 patients). Median survival was greater in patients treated with chemotherapy alone than for those who failed the second stage. A clinicopathologic score including male sex, segment 1 metastasis, need for >3 resection(s)/radiofrequency ablation(s), vascular invasion in the primary, need for change in type of chemotherapy, and microscopic biliary invasion by the metastasis was predictive of feasibility of the second stage and disease-free survival in patients achieving the second stage. CONCLUSION Combining preoperative clinical parameters with pathologic features of the primary and the metastatic lesions obtained during first stage hepatectomy predicted accurately patients who failed the second stage, and the long-term outcomes. Considering both clinical and pathologic parameters may help to define the best oncologic strategy by choosing between an exclusive chemotherapeutic or a surgical strategy.
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Affiliation(s)
- Francois Faitot
- Departments of Hepatobiliary Surgery and Liver Transplantation, Hôpital Saint Antoine, Paris, France
| | - Olivier Soubrane
- Departments of Hepatobiliary Surgery and Liver Transplantation, Hôpital Saint Antoine, Paris, France
| | | | | | | | | | | | - Olivier Scatton
- Departments of Hepatobiliary Surgery and Liver Transplantation, Hôpital Saint Antoine, Paris, France.
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Hernandez-Alejandro R, Bertens KA, Pineda-Solis K, Croome KP. Can we improve the morbidity and mortality associated with the associating liver partition with portal vein ligation for staged hepatectomy (ALPPS) procedure in the management of colorectal liver metastases? Surgery 2014; 157:194-201. [PMID: 25282528 DOI: 10.1016/j.surg.2014.08.041] [Citation(s) in RCA: 93] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2014] [Accepted: 08/15/2014] [Indexed: 02/06/2023]
Abstract
BACKGROUND Meticulous selection of patients who can undergo the associating liver partition with portal vein ligation for staged hepatectomy (ALPPS) procedure safely will be paramount to minimize the associated morbidity and mortality. METHODS We collected data prospectively on 14 consecutive patients who underwent the ALPPS procedure for planned resection of colorectal liver metastases at London Health Sciences Centre, Canada, between April 2012 and November 2013. RESULTS The median relative increase of the standardized future liver remnant after the ALPPS procedure was 93 ± 28%. The standardized future liver remnant rate of volume increase was 35 ± 13 mL/day. Biopsies of the FLR were taken during stage 1 and 2. These biopsies showed a mean preregeneration Ki-67 index of 0% and a postregeneration index of 14 ± 3%. All 14 ALPPS patients completed the 2-stage hepatectomy. No complications occurred after ALPPS stage 1. After ALPPS stage 2, 5 patients had complications (36%), with 2 patients (14%) having a severe complication (Clavien-Dindo ≥ IIIB). Median follow-up was 9 months. Overall survival at the time of follow-up was 100%. Recurrence developed in 2 patients. One patient had recurrence in the liver and lungs 5 months after stage 2 and was offered more chemotherapy. The other patient developed recurrence in the liver remnant 9 months after stage 2 and underwent additional chemotherapy with a possible future resection of the recurrence. CONCLUSION Low morbidity and negligible mortality can be achieved with the ALPPS procedure, and the high rates published in previous reports can be improved with refinements in technique and patient selection. The ALPPS approach may be a valid option to enable resection in selected patients with colorectal liver metastases considered unresectable previously by standard techniques.
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Affiliation(s)
| | - Kimberly A Bertens
- Department of Surgery, Division of General Surgery, Western University, London, Ontario, Canada
| | - Karen Pineda-Solis
- Department of Surgery, Division of General Surgery, Western University, London, Ontario, Canada
| | - Kristopher P Croome
- Department of Surgery, Division of General Surgery, Western University, London, Ontario, Canada; Division of Gastroenterologic and General Surgery, Mayo Clinic, Rochester, MN
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Giuliante F, Ardito F, Ferrero A, Aldrighetti L, Ercolani G, Grande G, Ratti F, Giovannini I, Federico B, Pinna AD, Capussotti L, Nuzzo G. Tumor progression during preoperative chemotherapy predicts failure to complete 2-stage hepatectomy for colorectal liver metastases: results of an Italian multicenter analysis of 130 patients. J Am Coll Surg 2014; 219:285-94. [PMID: 24933714 DOI: 10.1016/j.jamcollsurg.2014.01.063] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2013] [Revised: 12/09/2013] [Accepted: 01/09/2014] [Indexed: 02/08/2023]
Abstract
BACKGROUND We aimed to evaluate the feasibility and long-term results of 2-stage hepatectomy (TSH) in patients with bilobar colorectal liver metastases (CRLM). STUDY DESIGN We performed a retrospective multicenter study including 4 Italian hepatobiliary surgery units. One hundred thirty patients were selected for TSH between 2002 and 2011. The primary endpoint was feasibility of TSH and analysis of factors associated with failure to complete the procedure. The secondary endpoint was the long-term survival analysis. RESULTS Patients presented with synchronous CRLM in 80.8% of cases, with a mean number of 8.3 CRLM and with concomitant extrahepatic disease in 20.0% of cases. The rate of failure to complete TSH was 21.5% and tumor progression was the most frequent reason for failure (18.5% of cases). Primary tumor characteristics, type, number, and distribution of CRLM were not associated with significantly different risks of disease progression. Multivariable logistic regression analysis showed that tumor progression during prehepatectomy chemotherapy was the only independent risk factor for failure to complete TSH. The 5- and 10-year overall survival rates for patients who completed TSH were 32.1% and 24.1%, respectively, with a median survival of 43 months. Duration of prehepatectomy chemotherapy ≥6 cycles was found to be the only independent predictor of overall and disease-free survival. CONCLUSIONS This study showed that selection of patients by response to prehepatectomy chemotherapy may be extremely important before planning TSH because tumor progression while receiving prehepatectomy chemotherapy was associated with significantly higher risk of failure to complete the second stage. For patients who completed the TSH strategy, long-term outcomes can be achieved with results similar to those observed after single-stage hepatectomy.
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Affiliation(s)
- Felice Giuliante
- Hepatobiliary Surgery Unit, A. Gemelli Hospital, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Francesco Ardito
- Hepatobiliary Surgery Unit, A. Gemelli Hospital, Università Cattolica del Sacro Cuore, Rome, Italy.
| | - Alessandro Ferrero
- Department of Digestive and Hepatobiliary Surgery, Mauriziano Umberto I Hospital, Turin, Italy
| | | | - Giorgio Ercolani
- Department of Surgery and Transplantation, Sant'Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Gennaro Grande
- Hepatobiliary Surgery Unit, A. Gemelli Hospital, Università Cattolica del Sacro Cuore, Rome, Italy
| | | | - Ivo Giovannini
- Hepatobiliary Surgery Unit, A. Gemelli Hospital, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Bruno Federico
- Faculty of Health and Sport Sciences, University of Cassino, Cassino, Italy
| | - Antonio D Pinna
- Department of Surgery and Transplantation, Sant'Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Lorenzo Capussotti
- Department of Digestive and Hepatobiliary Surgery, Mauriziano Umberto I Hospital, Turin, Italy
| | - Gennaro Nuzzo
- Hepatobiliary Surgery Unit, A. Gemelli Hospital, Università Cattolica del Sacro Cuore, Rome, Italy
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Settmacher U, Scheuerlein H, Rauchfuss F. [Assessment of resectability of colorectal liver metastases and extended resection]. Chirurg 2014; 85:24-30. [PMID: 24317339 DOI: 10.1007/s00104-013-2566-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Most patients with colorectal liver metastases are treated within a multimodal therapy regime whereby liver resection is a key point in the curative treatment concept. The achievement of an R0 situation is of vital importance for long-term survival. Besides general operability and the assessment of comorbidities, resection depends on the quality of liver parenchyma (functional resectability) and the anatomical position of the tumor (oncological resectability). The improvement of operation techniques and perioperative medicine nowadays allow complex surgical procedures for metastasis surgery. This article presents the methods for the assessment of resectability and modern strategies of preoperative conditioning as well as approaches for extended liver resection.
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Affiliation(s)
- U Settmacher
- Klinik für Allgemein-, Viszeral- und Gefäßchirurgie, Universitätsklinikum Jena, Erlanger Allee 101, 07740, Jena, Deutschland,
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Lam VWT, Laurence JM, Johnston E, Hollands MJ, Pleass HCC, Richardson AJ. A systematic review of two-stage hepatectomy in patients with initially unresectable colorectal liver metastases. HPB (Oxford) 2013; 15:483-91. [PMID: 23750490 PMCID: PMC3692017 DOI: 10.1111/j.1477-2574.2012.00607.x] [Citation(s) in RCA: 137] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2012] [Accepted: 09/19/2012] [Indexed: 12/12/2022]
Abstract
OBJECTIVES Selected patients with unresectable colorectal liver metastases (CLM) may be rendered resectable using the two-stage hepatectomy (TSH) approach. This review was conducted with the aim of collating and evaluating published evidence for TSH in patients with initially unresectable CLM. METHODS Searches of the MEDLINE and EMBASE databases were undertaken to identify studies of TSH in patients with initially unresectable CLM. Studies were required to focus on the perioperative treatment regimen, operative strategy, morbidity, technical success and survival outcomes. RESULTS Ten observational studies were reviewed. A total of 459 patients with initially unresectable CLM were selected for the first stage of TSH. Preoperative chemotherapy was used in 88% of patients and achieved partial and stable response rates of 59% and 39%, respectively. Postoperative morbidity and mortality after the first stage of TSH were 17% and 0.5%, respectively. Portal vein embolization (PVE) was used in 76% of patients. Ultimately, 352 of the initial 459 (77%) patients underwent the second stage of TSH. Major liver resection was undertaken in 84% of patients; the negative margin (R0) resection rate was 75%. Postoperative morbidity and mortality after the second stage of TSH were 40% and 3%, respectively. Median overall survival was 37 months (range: 24-44 months) in patients who completed both stages of TSH. In patients who did not complete both stages of TSH, median survival was 16 months (range: 10-29 months). The 3-year disease-free survival rate was 20% (range: 6-27%). CONCLUSIONS Two-stage hepatectomy is safe and effective in selected patients with initially unresectable CLM. Further studies are required to better define patient selection criteria for TSH and the exact roles of PVE and preoperative and interval chemotherapy.
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Affiliation(s)
- Vincent W T Lam
- Department of Surgery, Westmead HospitalWestmead, NSW, Australia,Discipline of Surgery, Sydney Medical SchoolSydney, NSW, Australia
| | | | - Emma Johnston
- Department of Surgery, Westmead HospitalWestmead, NSW, Australia,Discipline of Surgery, Sydney Medical SchoolSydney, NSW, Australia
| | - Michael J Hollands
- Department of Surgery, Westmead HospitalWestmead, NSW, Australia,Discipline of Surgery, Sydney Medical SchoolSydney, NSW, Australia
| | - Henry C C Pleass
- Department of Surgery, Westmead HospitalWestmead, NSW, Australia,Discipline of Surgery, Sydney Medical SchoolSydney, NSW, Australia
| | - Arthur J Richardson
- Department of Surgery, Westmead HospitalWestmead, NSW, Australia,Discipline of Surgery, Sydney Medical SchoolSydney, NSW, Australia
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Gauzolino R, Castagnet M, Blanleuil ML, Richer JP. The ALPPS technique for bilateral colorectal metastases: three "variations on a theme". Updates Surg 2013; 65:141-8. [PMID: 23690242 DOI: 10.1007/s13304-013-0214-3] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2013] [Accepted: 05/04/2013] [Indexed: 12/11/2022]
Abstract
The aim of this study was to assess feasibility of technical variations of the associating liver partition and portal vein ligation for staged hepatectomy technique (ALPPS) with regard to three different ways of liver splitting. The ALPPS technique was applied in the classic form consisting in ligation of the right portal vein, limited resections on the left lobe and splitting along the umbilical fissure; the right lobe was removed 1 week later. The first variation was "left ALPPS": ligation of the left portal vein, multiple resections on the right hemiliver and splitting along the main portal fissure. The second variation was "rescue ALPPS", consisting in simple splitting of the liver along the main portal fissure several months after a radiological portal vein embolization that did not allow satisfactory liver hypertrophy. The third variation was "right ALPPS", consisting in ligation of the posterolateral branch of right portal vein, left lateral sectionectomy, multiple resections on the right anterior and left medial section and splitting along the right portal fissure. In all cases auxiliary deportalized liver was removed 1 week later. 4 patients with colorectal metastases were included. Morbidity was defined according to the Clavien-Dindo classification: grade I (2 events), grade IIIb (1 event). Postoperative mortality was nil. Median follow-up was 4 months and to date all patients are still alive. ALPPS technique, in its "classical" and modified forms, is a good option for selected patients with bilateral colorectal metastases and represents a feasible alternative to classical two-stage hepatectomy.
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